New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

Meniere’s disease is characterized by sensorineural hearing loss, which can worsen over time and eventually result in profound bilateral hearing loss.

Meniere’s disease is a condition that affects the inner ear and its cause is unknown. It is more commonly seen in middle-aged adults but can occur at any age and affects both men and women equally. The condition is characterized by the excessive pressure and progressive dilation of the endolymphatic system. The main symptoms of Meniere’s disease are recurrent episodes of vertigo, tinnitus, and sensorineural hearing loss. Vertigo is usually the most prominent symptom, but patients may also experience a sensation of aural fullness or pressure, nystagmus, and a positive Romberg test. These episodes can last from minutes to hours and are typically unilateral, but bilateral symptoms may develop over time.

The natural history of Meniere’s disease is that symptoms usually resolve in the majority of patients after 5-10 years. However, most patients will be left with some degree of hearing loss, and psychological distress is common. ENT assessment is required to confirm the diagnosis, and patients should inform the DVLA as the current advice is to cease driving until satisfactory control of symptoms is achieved. Acute attacks can be managed with buccal or intramuscular prochlorperazine, and admission to the hospital may be required. Prevention strategies include the use of betahistine and vestibular rehabilitation exercises, which may be beneficial.

According to current NICE guidelines, patients with gout who experience two or more attacks per year should receive urate-lowering therapy (ULT). When starting ULT, it is recommended to also prescribe colchicine cover for up to six months. If colchicine is not suitable, an alternative option is to consider NSAID cover.

While high-dose prednisolone can effectively treat acute gout, low-dose prednisolone is not recommended for gout prevention due to the negative effects of long-term corticosteroid use.

Although NSAIDs like naproxen or ibuprofen can be used to treat gout, this may not be the best option for someone with a history of hiatus hernia. Unlike xanthine oxidase inhibitors such as allopurinol or febuxostat, NSAIDs are not considered ULT and are therefore not suitable for gout prevention.

Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with a delayed start recommended until inflammation has settled. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Other options for refractory cases include febuxostat, uricase, and pegloticase.

Genetic Conditions and Their Diagnostic Features

Neurofibromatosis type 1 (NF1) is an autosomal-dominant condition characterized by numerous café au lait spots and skin tumors. Hypertension can also be caused by this condition, along with other complications such as optic glioma, vertebral dysplasia, and intracranial tumors. Marfan syndrome, on the other hand, is not associated with café au lait macules or hypertension, but scoliosis is a common feature. Cushing’s disease can cause increased skin pigmentation but not café au lait macules, and it is a cause of secondary hypertension. Hypertrophic cardiomyopathy can also cause hypertension and is associated with dark skin spots in LEOPARD syndrome. Tuberous sclerosis is characterized by oval or leaf-shaped white macules, facial angiofibromas, and shagreen patches, along with other features such as epilepsy and learning disability.

Diagnosing Depression: ICD-10 and DSM-IV Classifications

In diagnosing depression, both ICD-10 and DSM-IV classifications can be used alongside questionnaires. The ICD-10 classification requires four out of 10 depressive symptoms for a diagnosis, while the DSM-IV classification requires five out of nine symptoms. Common symptoms include loss of interest and pleasure, loss of energy, and low mood, which must be present most of every day to be counted.

However, the NICE guidelines on depression acknowledge that many people may fall just below these criteria. This is known as sub-threshold depressive symptoms, which allows for only one of the key features to be present for less time than is necessary for the major depressive classification.

It is important to note that once depression is diagnosed or suspected, patients should be offered help and support.

Propranolol is a beta-blocker that can help manage symptoms in new cases of Graves’ disease. It is particularly effective in reducing tremors and palpitations associated with thyrotoxicosis.

Carbimazole is the primary treatment for inducing remission in most cases of Graves’ disease. However, it may take some time to take effect, and patients may require short-term symptomatic relief with a beta-blocker like propranolol.

Bisoprolol is a beta-blocker used to treat hypertension, angina, and heart failure, but it is not typically used for Graves’ disease.

Ivabradine is a cardiac medication that targets the sino-atrial node to regulate heart rate. It is commonly used to treat angina and heart failure.

Management of Graves’ Disease

Despite numerous trials, there is no clear consensus on the optimal management of Graves’ disease. Treatment options include anti-thyroid drugs (ATDs), radioiodine treatment, and surgery. In recent years, ATDs have become the most popular first-line therapy for Graves’ disease. This is particularly true for patients with significant symptoms of thyrotoxicosis or those at risk of hyperthyroid complications, such as elderly patients or those with cardiovascular disease.

To control symptoms, propranolol is often used to block the adrenergic effects. NICE Clinical Knowledge Summaries recommend that patients with Graves’ disease be referred to secondary care for ongoing treatment. If symptoms are not controlled with propranolol, carbimazole should be considered in primary care.

ATD therapy involves starting carbimazole at 40 mg and gradually reducing it to maintain euthyroidism. This treatment is typically continued for 12-18 months. The major complication of carbimazole therapy is agranulocytosis. An alternative regime, called block-and-replace, involves starting carbimazole at 40 mg and adding thyroxine when the patient is euthyroid. This treatment typically lasts for 6-9 months. Patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime.

Radioiodine treatment is often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment. Contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition. The proportion of patients who become hypothyroid depends on the dose given, but as a rule, the majority of patients will require thyroxine supplementation after 5 years.

Screening and Testing for Hepatitis C Infection

Hepatitis C is a viral infection that can cause liver damage and other serious health problems. It is important to screen and test for hepatitis C in certain individuals, particularly those with unexplained abnormal liver function tests or who have undergone procedures with unsterilized equipment.

Testing for anti-hepatitis C virus (anti-HCV) serology is recommended for those suspected of having HCV infection, although false negatives can occur in the acute stage of infection. A liver ultrasound (US) may be used to look for evidence of cirrhosis, but is not a diagnostic tool for hepatitis C.

Screening for hepatitis C is necessary for those who have undergone tattooing, ear piercing, body piercing, or acupuncture with unsterile equipment, as these procedures can put a person at risk of acquiring the infection.

Testing for HCV deoxyribonucleic acid (DNA) is necessary to confirm ongoing hepatitis C infection in those with positive serology. Chronic hepatitis C is considered in those in whom HCV RNA persists, which occurs in approximately 80% of cases. Normal liver function tests do not exclude hepatitis C infection, and deranged LFTs should be a reason to consider screening for the virus.

In summary, screening and testing for hepatitis C is important for those at risk of infection or with unexplained abnormal liver function tests. Testing for HCV DNA is necessary to confirm ongoing infection, and normal LFTs do not exclude the possibility of hepatitis C.

Management of Iron Deficiency Anaemia

Iron deficiency anaemia is a common condition that can present with symptoms such as fatigue, weakness, and shortness of breath. In a 28-year-old woman with normal menses and no signs of gastrointestinal bleeding, a trial of iron supplementation for three months is appropriate to establish whether ferritin levels increase and haemoglobin normalises. Although a negative anti-TTG test is possible in patients with selective IgA deficiency, the absence of bowel symptoms makes underlying coeliac disease unlikely.

If there are no other symptoms and signs, urgent referral to colorectal under the two-week wait is necessary for unexplained iron deficiency anaemia in a male with a Hb of <120 g/L or a non-menstruating female with a Hb of <100 g/L. Upper and lower GI endoscopy would only be considered if there is a failure of ferritin level and anaemia to respond to iron supplementation. Proper management of iron deficiency anaemia is crucial to prevent complications and improve quality of life.

Common Causes of Death in People with Learning Disabilities

People with learning disabilities are at a higher risk of premature death compared to the general population. The most common cause of death in this group is circulatory or cardiovascular disease, accounting for 22.9% of deaths. Regular health check-ups can help promote long-term health and prevent such diseases.

Cancer is another major cause of death, responsible for 13.1% of deaths in people with learning disabilities. While it is a significant cause of death, it is not the most common.

Aspiration pneumonitis, a potentially preventable cause of death, accounts for 3.6% of deaths in people with learning disabilities. It is important to be aware of this cause of death and take necessary precautions to prevent it.

Epilepsy is responsible for 3.9% of deaths in people with learning disabilities. Like aspiration pneumonitis, it is a preventable cause of death, and awareness can help reduce the risk.

Respiratory disease is the second most common cause of death in people with learning disabilities, accounting for 17.1% of deaths. It is crucial to monitor and manage respiratory conditions in this population to prevent premature deaths.

The most likely diagnosis for this case is motor neurone disease, which is characterized by the degeneration of neurones in the motor cortex, motor cranial nuclei, and anterior horn cells. This condition presents with a combination of upper and lower motor neurone signs, such as weakness, spasticity, hyper-reflexia, up-going plantars, wasting, and fasciculation. However, there are no sensory changes.

Alcohol can cause an acute alcoholic myopathy after binge drinking, which can lead to acute renal tubular necrosis due to the precipitation of myoglobin in the renal tubules. Chronic myopathy associated with gradual progressive weakness and atrophy, usually involving the hip and shoulder girdle without myoglobinuria, can also occur.

Diabetic amyotrophy is a diabetic proximal neuropathy that causes weakness, wasting, and pain, typically in the quadriceps, and progresses distally.

Cervical spondylosis can result in nerve root compression (radiculopathy) or cord compression (myelopathy). Radiculopathy presents with unilateral neck, shoulder, or arm pain, possibly with changes in sensation or weakness in related muscles. Myelopathy results in progressive spastic quadriparesis and sensory loss with decreased position and vibration sense, and a sensory level develops.

Syringomyelia is characterized by a fluid-filled tubular cyst (syrinx) within the central spinal cord, usually in the cervical region. The syrinx enlarges, compressing the corticospinal and spinothalamic tracts and the anterior horn cells. This condition typically presents in the 20s and 30s, and progress is slow. Symptoms depend on the site of the lesion, but early signs often include wasting and weakness of the hands, with decreased pain and temperature sensation in the trunk and arms.

Trinucleotide repeat disorders are genetic conditions that occur due to an abnormal number of repeats of a repetitive sequence of three nucleotides. These expansions are unstable and may enlarge, leading to an earlier age of onset in successive generations, a phenomenon known as anticipation. In most cases, an increase in the severity of symptoms is also observed. It is important to note that these disorders are predominantly neurological in nature. Examples of such disorders include Fragile X, Huntington’s, myotonic dystrophy, Friedreich’s ataxia, spinocerebellar ataxia, spinobulbar muscular atrophy, and dentatorubral pallidoluysian atrophy. It is interesting to note that Friedreich’s ataxia is an exception to the rule and doesn’t demonstrate anticipation.

Different Types of Heart Blocks: A Comparison

Heart block is a condition where the electrical signals that control the heartbeat are disrupted, leading to an abnormal heart rhythm. There are different types of heart blocks, each with its own characteristic features. Here is a comparison of four types of heart blocks:

Complete Heart Block:
In this type of heart block, there is a complete absence of atrioventricular conduction, resulting in no supraventricular impulses being conducted to the ventricles. The perfusing rhythm is maintained by a junctional or ventricular escape rhythm. On the ECG, this appears as a rhythm with regular P waves that are completely unconnected to the rhythm of the QRS complexes. The rate of the QRS complex may be < 45 bpm, and the patient may be overtly symptomatic or haemodynamically unstable. Second-Degree Mobitz Type II Block:
In this type of heart block, there are intermittent non-conducted P waves without progressive prolongation of the PR interval. A significant proportion of atrial activations will still lead to ventricular activation.

Atrial Fibrillation:
In this type of heart block, the ECG will show the absence of P waves and irregularly irregular QRS complexes. The heart rate will usually be normal or high, rather than low, as seen on this ECG.

First-Degree Heart Block:
In this type of heart block, the PR interval is prolonged at > 0.2 seconds. However, each atrial activation will still lead to a ventricular activation, with a 1:1 correspondence. On this ECG, there is no correspondence between the P waves and the QRS complex.

Second-Degree Mobitz Type I Block:
In this type of heart block, the ECG shows progressive prolongation of the PR interval, culminating in a non-conducted P wave. However, the majority of atrial activations will still lead to ventricular activation.

According to NICE, women who are at a high risk of developing VTE and are seeking HRT should be referred to haematology before starting any treatment, even if it is transdermal.

While there is no evidence to suggest that transdermal HRT preparations such as patches or gels increase the risk of VTE, it is recommended to seek specialist advice before starting treatment if there are any risk factors present.

For patients with a high risk of VTE, oral HRT, whether it is combined or oestrogen-only, would be risky. Although per vaginal oestrogen would be a safer option, it would only provide local relief and may not alleviate all of the patient’s symptoms.

Adverse Effects of Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a treatment that involves the use of a small dose of oestrogen, often combined with a progestogen, to alleviate menopausal symptoms. However, this treatment can have side-effects such as nausea, breast tenderness, fluid retention, and weight gain.

Moreover, there are potential complications associated with HRT. One of the most significant risks is an increased likelihood of breast cancer, particularly when a progestogen is added. The Women’s Health Initiative (WHI) study found that the relative risk of developing breast cancer was 1.26 after five years of HRT use. The risk of breast cancer is related to the duration of HRT use, and it begins to decline when the treatment is stopped. Additionally, HRT use can increase the risk of endometrial cancer, which can be reduced but not eliminated by adding a progestogen.

Another potential complication of HRT is an increased risk of venous thromboembolism (VTE), particularly when a progestogen is added. However, transdermal HRT doesn’t appear to increase the risk of VTE. Women who are at high risk for VTE should be referred to haematology before starting any HRT treatment, even transdermal. Finally, HRT use can increase the risk of stroke and ischaemic heart disease if taken more than ten years after menopause.

In conclusion, while HRT can be an effective treatment for menopausal symptoms, it is essential to be aware of the potential adverse effects and complications associated with this treatment. Women should discuss the risks and benefits of HRT with their healthcare provider before starting any treatment.

Management of Gout with Febuxostat

In the management of gout, NICE recommends febuxostat as a second-line therapy if allopurinol is not tolerated or contraindicated. It is important to start febuxostat 1-2 weeks after inflammation has settled and adjust the dose according to the serum uric acid level. Urate-lowering medication is usually Lifelong and requires monitoring. Patients should not stop taking febuxostat during acute attacks if it has already been started. However, ibuprofen should not be used if the patient is taking warfarin.

It is important to note that if the patient is already taking febuxostat, switching back to allopurinol would not be indicated. A rheumatology referral is not necessary at this stage unless complications arise or febuxostat is not tolerated or ineffective. For more information on the management of gout, please refer to the NICE guidelines.

Transgender males who are on testosterone therapy should be aware that this treatment doesn’t prevent pregnancy. In the event that a patient becomes pregnant, testosterone therapy is not recommended as it can have harmful effects on the developing fetus. Instead, emergency contraception should be prescribed and the patient should be advised against continuing testosterone therapy during pregnancy. It is important to note that emergency contraception is still safe for patients on testosterone therapy. While discussing the risk of sexually transmitted infections is important, it is not a substitute for effective contraception. While a future pregnancy test may be necessary, the immediate priority is to provide emergency contraception. It is also important to note that testosterone therapy is not a form of emergency contraception and that other options, such as a copper intrauterine device or specific medications, should be considered.

Contraceptive and Sexual Health Guidance for Transgender and Non-Binary Individuals

The Faculty of Sexual & Reproductive Healthcare has released guidance on contraceptive choices and sexual health for transgender and non-binary individuals. The guidance emphasizes the importance of sensitive communication and offering options that consider personal preferences, co-morbidities, and current medications or therapies. For those engaging in vaginal sex, condoms and dental dams are recommended to prevent sexually transmitted infections. Cervical screening and HPV vaccinations should also be offered. Those at risk of HIV transmission should be advised of pre-exposure prophylaxis and post-exposure prophylaxis.

For individuals assigned female at birth with a uterus, testosterone therapy doesn’t provide protection against pregnancy, and oestrogen-containing regimens are not recommended as they can antagonize the effect of testosterone therapy. Progesterone-only contraceptives are considered safe, and non-hormonal intrauterine devices may also suspend menstruation. Emergency contraception may be required following unprotected vaginal intercourse, and either oral formulation or the non-hormonal intrauterine device may be considered.

In patients assigned male at birth, hormone therapy may reduce or cease sperm production, but the variability of its effects means it cannot be relied upon as a method of contraception. Condoms are recommended for those engaging in vaginal sex to avoid the risk of pregnancy. The guidance stresses the importance of offering individuals options that take into account their personal circumstances and preferences.

Managing Urge Incontinence

Urge incontinence is a condition where urine leakage occurs involuntarily, often preceded by a sudden urge to urinate. According to NICE guidance on Urinary incontinence (CG171), women with urge incontinence or mixed incontinence should be offered bladder training as a first-line treatment for at least six weeks. This involves learning techniques to control the urge to urinate and gradually increasing the time between visits to the toilet. If bladder training is not effective, immediate release oxybutynin may be offered as an alternative treatment.

Women with a positive pregnancy test and abdominal, pelvic or cervical motion tenderness should be immediately referred for assessment to exclude ectopic pregnancy, which could be fatal. Referral should be made even if an ultrasound cannot be arranged immediately, as the patient may require monitoring in hospital. Serial hCG measurements should not be done in secondary care, and referral to a sexual health clinic alone is not appropriate.

Bleeding in the First Trimester: Causes and Management

Bleeding in the first trimester of pregnancy is a common concern for women, often leading them to seek medical attention. The main causes of bleeding during this time include miscarriage, ectopic pregnancy, implantation bleeding, cervical ectropion, vaginitis, trauma, and polyps. Of these causes, ectopic pregnancy is the most important to rule out as it can be life-threatening if missed.

To manage early bleeding, the National Institute for Health and Care Excellence (NICE) released guidelines in 2019. If a woman has a positive pregnancy test and experiences pain, abdominal or pelvic tenderness, or cervical motion tenderness, she should be referred immediately to an early pregnancy assessment service. If the pregnancy is over six weeks gestation or of uncertain gestation and the woman experiences bleeding, she should also be referred to an early pregnancy assessment service. A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.

For pregnancies under six weeks gestation and no pain or risk factors for ectopic pregnancy, expectant management is appropriate. Women should be advised to return if bleeding continues or pain develops, to repeat a urine pregnancy test after 7-10 days and to return if it is positive. A negative pregnancy test indicates a miscarriage. By following these guidelines, healthcare providers can effectively manage bleeding in the first trimester and ensure the safety of both the mother and the developing fetus.

Thromboprophylaxis for Pregnant Women during Air Travel

Low-molecular-weight heparin (LMWH) is not necessary for pregnant women who are traveling by air, unless they have additional risk factors for thrombosis such as a history of deep vein thrombosis (DVT), known thrombophilia, or morbid obesity. Aspirin is not recommended for thromboprophylaxis during pregnancy and air travel. According to the Royal College of Obstetricians and Gynaecologists (RCOG), medium to long-haul flights lasting more than 4 hours pose an increased risk for pregnant women. Therefore, it is important to consider the duration of the flight when assessing the need for thromboprophylaxis.

Understanding the Causes of Macroscopic Haematuria by Age

Macroscopic haematuria, or visible blood in the urine, can be a concerning symptom that may indicate a serious underlying condition. The causes of macroscopic haematuria can vary depending on the age and gender of the patient. In general, painless macroscopic haematuria in an adult should be considered a potential sign of renal tract cancer until proven otherwise.

For patients under 20 years old, glomerulopathies (especially IgA nephropathy), thin basement membrane disease, urinary infection, congenital malformation, hereditary nephritis (Alport’s Syndrome), and sickle cell disease are the most likely causes.

For patients between 20 and 60 years old, urinary infection, nephrolithiasis, endometriosis, bladder, prostate, and renal cancers are the most common causes. The risk of cancer increases significantly after the age of 35-50.

For patients over 60 years old, the most likely causes of macroscopic haematuria differ by gender. In males, cancer and prostatitis are the most common causes, while in females, cancer and urinary infection are the most common causes.

It is important to note that while these age-related trends can be helpful in guiding diagnostic testing and treatment, almost any disease can affect anyone at any age. Therefore, a thorough evaluation by a healthcare professional is necessary to determine the underlying cause of macroscopic haematuria.

Post-Treatment Surveillance Strategies for Colorectal Cancer: The Role of CEA Monitoring, Colonoscopy, and CT Scans

Carcinoembryonic antigen (CEA) is a protein that is elevated in the serum of patients with colorectal cancer. While not suitable for screening, CEA levels can be used to monitor disease burden and predict prognosis in patients with established disease. Additionally, elevated preoperative CEA levels should return to baseline after complete resection, and failure to do so may indicate residual disease. Serial CEA testing can also aid in the early detection of recurrences, which can increase the likelihood of a complete resection.

The National Institute for Health and Care Excellence recommends regular serum CEA tests (at least every six months in the first three years) and a minimum of two CT scans of the chest, abdomen, and pelvis in the first three years after treatment. Surveillance colonoscopy should be performed one year after initial treatment, and if normal, another colonoscopy should be performed at five years. The timing of colonoscopy after adenoma should be determined by the risk status of the adenoma.

While periodic colonoscopy is beneficial for detecting metachronous cancers and preventing further cancers via removal of adenomatous polyps, trials have failed to show a survival benefit from annual or shorter intervals compared to less frequent intervals (three or five years) for detecting anastomotic recurrences. Routine fecal occult blood testing is not recommended in post-treatment surveillance guidelines.

In summary, post-treatment surveillance strategies for colorectal cancer should include serial CEA monitoring, CT scans, and colonoscopy at recommended intervals. These strategies can aid in the early detection of recurrences and improve the likelihood of a complete resection.

Patients who consume more than 50 units of alcohol per week (males) or more than 35 units per week (females) should be referred for an ELF test or FibroScan, even if their liver function tests are normal, according to current NICE CKS guidance. This is because patients may have significant cirrhosis despite normal liver function tests, and FibroScan is the most accurate method for screening for cirrhosis.

While monitoring liver function is important, the next appropriate step would be to assess using a FibroScan, as patients can have advanced cirrhosis with normal liver function tests. Waiting 2 or 4 years to repeat liver function tests is too long, as the disease may progress significantly in the meantime.

Liver ultrasound may be helpful, but it is not sufficient for detecting cirrhosis in all cases. Ultrasound screening for liver cirrhosis alone is not recommended, as patients may have cirrhosis without evidence on liver ultrasound.

Taking no further action is not appropriate, given the potential for liver disease despite normal liver function tests.

Alcoholic liver disease is a range of conditions that includes alcoholic fatty liver disease, alcoholic hepatitis, and cirrhosis. When investigating this disease, gamma-GT levels are typically elevated, and a ratio of AST:ALT greater than 3 strongly suggests acute alcoholic hepatitis. In terms of management, glucocorticoids like prednisolone are often used during acute episodes of alcoholic hepatitis. Maddrey’s discriminant function is used to determine who would benefit from glucocorticoid therapy, and pentoxyphylline may also be used. The STOPAH study compared the effectiveness of pentoxyphylline and prednisolone and found that prednisolone improved survival at 28 days, while pentoxyphylline did not improve outcomes.

Taking Blood Specimens from Incapacitated Drivers

The BMA has provided clear guidance on the subject of taking blood specimens from incapacitated drivers. According to the 2010 document, the law allows for a blood specimen to be taken for future testing for alcohol or other drugs from a person involved in an accident who is unable to give consent due to medical reasons. A police constable must believe the person to be incapable of giving valid consent before a forensic physician is asked to take the sample. If this is not possible, another doctor may be asked, but not one who has any responsibility for the patient’s clinical care. The doctor to whom the request is made must take the specimen, and the doctor in charge of the patient’s care must be notified before the sample is taken. The specimen cannot be tested until the person regains competence and gives valid consent for it to be tested.

Under the Police Reform Act, it is no longer necessary to obtain consent from unconscious or incapacitated drivers. However, the sample is not tested until the person regains competence and gives valid consent to it being tested. A competent person who refuses to allow their sample to be tested may be liable to prosecution. It is important to note that the police have no powers to take and test blood specimens that were taken as part of the patient’s care in hospital. The new law recognises the duty to justice.

Immunisations in Pregnancy

Pregnant women are advised to get immunised against influenza and pertussis, but there are some differences to note. The influenza vaccine is recommended during flu season and can be taken at any stage of pregnancy. On the other hand, the pertussis vaccine is recommended from 16 weeks and can be taken at any time of the year.

It is important for candidates to understand these differences and advise their patients accordingly. While there is no specific recommendation to immunise healthy pregnant women against HPV, MenACWY or pneumococcus, it is always best to consult with a healthcare professional to determine the best course of action for each individual case. By staying informed and up-to-date on immunisation recommendations, candidates can provide the best care for their patients during pregnancy.

Chloasma, also known as melasma, is a skin condition characterized by brown pigmentation that typically develops across the cheeks. It is more common in women and in people with darker skin, and commonly presents between the ages of 30-40. Hormonal contraceptives, pregnancy, sun exposure, and certain cosmetics are well-documented triggers for developing the condition.

It is important to note that other conditions can cause facial rashes, but they would not fit into the description of chloasma. Acne rosacea causes papules and pustules, as well as facial flushing. Dermatomyositis causes a heliotrope rash across the face, eyelids, and light-exposed areas. Perioral dermatitis, also known as muzzle rash, causes papules that are usually seen around the mouth. Seborrhoeic dermatitis causes a scaling, flaky rash.

Overall, chloasma is a common skin condition that can be triggered by hormonal changes and sun exposure.

Squinting is a common occurrence in children, and the Hirschberg test is a useful tool for determining if their eyes are properly aligned. This test involves shining a light at the eyes and observing where the light reflex is located in relation to the pupil. In a person with normal ocular alignment, the light reflex will be slightly nasal from the center of the cornea. By comparing the light reflexes of both eyes, an examiner can detect if there is an abnormality such as exotropia, esotropia, hypertropia, or hypotropia.

It is normal for babies to occasionally cross their eyes, especially when tired, but any child with a suspected or confirmed squint should be referred to a local pediatric eye service. This will allow for proper assessment of the type and severity of the squint, accurate determination of visual acuity, and diagnosis of any underlying causes. Early treatment is important to prevent or stop the progression of amblyopia.

Treatment options for a squint may include corrective glasses, occlusion with an eye patch, and eye exercises. These treatments are typically initiated in secondary care by an orthoptist in conjunction with an ophthalmologist.

Understanding Squint (Strabismus)

Squint, also known as strabismus, is a condition where the visual axes are misaligned. There are two types of squint: concomitant and paralytic. Concomitant squint is more common and is caused by an imbalance in the extraocular muscles, while paralytic squint is rare and is caused by paralysis of the extraocular muscles. It is important to detect squint early as it may lead to amblyopia, where the brain fails to fully process inputs from one eye and over time favours the other eye.

To detect squint, the corneal light reflection test can be used. This involves holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils. The cover test is also used to identify the nature of the squint. The child is asked to focus on an object, one eye is covered, and the movement of the uncovered eye is observed. The test is then repeated with the other eye covered.

Management of squint involves referral to secondary care and eye patches may be used to prevent amblyopia.

Emergency Contraception after Childbirth

Levonorgestrel and ulipristal acetate are safe options for emergency contraception after childbirth, regardless of whether a woman is breastfeeding or not. Levonorgestrel has been shown to have no adverse effects on breastfeeding or infant outcomes, so women can continue to breastfeed after taking it.

However, ulipristal acetate is excreted in breast milk, and its effects on infants are not fully understood. Therefore, it is recommended that women do not breastfeed for seven days after taking it. To maintain lactation, women should express and discard breast milk during this time. Overall, emergency contraception is a viable option for women after childbirth, and healthcare providers can help them make informed decisions about which method to use.

A patient with severe acne, including scarring, hyperpigmentation, and widespread pustules, should be referred to a dermatologist for specialized treatment. In this case, the patient has nodules, pustules, and scarring, indicating the need for consideration of oral isotretinoin. A trial of low-strength topical benzoyl peroxide would not be appropriate for severe and widespread acne, but may be suitable for mild to moderate cases. Same-day hospital admission is unnecessary for a patient with normal observations and no other health concerns. A review in 2 months is not appropriate for severe acne, which should be managed with topical therapies, oral antibiotics, or referral to a dermatologist. Topical antibiotics are also not recommended for severe and widespread acne, and a dermatology referral is necessary for this patient with lesions on the face, neck, and trunk.

Acne vulgaris is a common skin condition that usually affects teenagers and is characterized by the obstruction of hair follicles with keratin plugs, resulting in comedones, inflammation, and pustules. The severity of acne can be classified as mild, moderate, or severe, depending on the number and type of lesions present. Treatment for acne typically involves a step-up approach, starting with single topical therapy and progressing to combination therapy or oral antibiotics if necessary. Tetracyclines are commonly used but should be avoided in certain populations, and a topical retinoid or benzoyl peroxide should always be co-prescribed to reduce the risk of antibiotic resistance. Combined oral contraceptives can also be used in women, and oral isotretinoin is reserved for severe cases under specialist supervision. Dietary modification has no role in the management of acne.

Understanding Eating Disorders: Differential Diagnosis

Eating disorders are complex mental health conditions that can have serious physical and psychological consequences. When a patient presents with symptoms of an eating disorder, it is important to consider a range of differential diagnoses to ensure appropriate treatment. Here, we explore the key features of several eating disorders and related conditions, including anorexia nervosa, personality disorders, avoidant restrictive food intake disorder (ARFID), bulimia nervosa, and depression. By understanding the unique characteristics of each disorder, healthcare professionals can make an accurate diagnosis and provide effective support for patients with eating disorders.

Prenatal Screening Tests: Overview and Differences

Prenatal screening tests are offered to pregnant women to assess the risk of chromosomal abnormalities in the fetus. There are several types of tests available, each with its own advantages and limitations.

Combined Test: This test is offered to all pregnant women between ten and 14 weeks gestation. It involves the measurement of nuchal translucency on ultrasound, serum beta-human chorionic gonadotropin (B-HCG), and pregnancy-associated plasma protein-A. The test allows risk stratification of the likelihood of the baby having Down, Patau, or Edward’s syndrome.

Amniocentesis: This invasive test is usually offered to women who are found to be at higher risk of carrying a baby with a chromosomal abnormality. It carries a 1% risk of miscarriage and is not offered routinely to all pregnant women.

Nuchal Translucency: This measurement is part of the combined test and is routinely offered to all pregnant women. However, if performed alone, it cannot be used as a reliable screening test.

Quadruple Test: This blood test for alpha fetaprotein (AFP), HCG, unconjugated oestriol (uE3), and inhibin A can be offered to women at 15–20 weeks gestation who have missed the chance for the combined test.

Triple Test: This blood test for AFP, HCG, and uE3 can also be offered to women at 15–20 weeks gestation who have missed the chance for the combined test. However, for a patient who is only 11 weeks pregnant, the combined test is indicated instead of the triple test.

In summary, prenatal screening tests can help identify the risk of chromosomal abnormalities in the fetus. The choice of test depends on the gestational age and individual risk factors of the patient.

Medication Review for an Atopic Child with Asthma

When reviewing the medication of an atopic child with asthma, it is important to consider the dosage of inhaled corticosteroids, the potency of topical corticosteroids, and the effectiveness of antihistamines and rescue courses of prednisolone. In this case, the child is using a medium dose of budesonide, which suggests the need for specialist care. The use of mild hydrocortisone for atopic eczema may not be sufficient, and a larger tube may be needed. Loratadine is an effective non-sedating antihistamine for allergic rhinitis and conjunctivitis, and repeat prescriptions are appropriate. Short courses of prednisolone may be necessary for acute exacerbations, and sodium cromoglicate can be used intermittently for allergic conjunctivitis. Overall, careful consideration of medication is crucial for managing the symptoms of an atopic child with asthma.