Dianette has a VTE risk that is approximately 1.5-2.0 times higher than that of typical COCPs.

Co-cyprindiol (Dianette) – Updated Guidance

Co-cyprindiol, also known as Dianette, is a medication licensed for the treatment of severe acne in women who are unresponsive to prolonged oral antibacterial therapy and moderately severe hirsutism. It is also an effective contraceptive, which has contributed to its popularity. However, some post-marketing studies have shown that some women were being prescribed additional hormonal contraception alongside co-cyprindiol, which is unnecessary and increases the risk of venous thromboembolism (VTE).

The duration of co-cyprindiol treatment is limited due to concerns about VTE. Interestingly, the increased risk of VTE associated with co-cyprindiol is similar to that of combined oral contraceptive pills (COCPs) containing desogestrel, gestodene, or drospirenone, compared to COCPs containing levonorgestrel. The current evidence suggests that the VTE risk is about 1.5-2.0 times higher. Therefore, it is important to consider the risks and benefits of co-cyprindiol and other COCPs when prescribing them to women.

Lymphoproliferative diseases, especially lymphoma, are more likely to occur in individuals with RA. Additionally, RA increases the risk of infection by about two-fold, with chest infections and sepsis being particularly concerning. Furthermore, those with RA have a higher likelihood of developing cardiovascular disease compared to the general population.

Complications of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease that affects the joints, causing inflammation and pain. However, it can also lead to a variety of extra-articular complications. These complications can affect different parts of the body, including the respiratory system, eyes, bones, heart, and mental health.

Respiratory complications of RA include pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, and pleurisy. Ocular complications can include keratoconjunctivitis sicca, episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, and chloroquine retinopathy. RA can also lead to osteoporosis, ischaemic heart disease, and an increased risk of infections. Depression is also a common complication of RA.

Less common complications of RA include Felty’s syndrome, which is characterized by RA, splenomegaly, and a low white cell count, and amyloidosis, which is a rare condition where abnormal proteins build up in organs and tissues.

In summary, RA can lead to a variety of complications that affect different parts of the body. It is important for patients with RA to be aware of these potential complications and to work closely with their healthcare providers to manage their condition and prevent or treat any complications that may arise.

The positive predictive value (PPV) is calculated by dividing the number of true positives by the total number of positive results. In this case, the total number of positive blood tests is 120, with 90 true positives. Therefore, the PPV is 0.75.
The sensitivity of the test is the proportion of patients with the condition who have a positive test result. In this scenario, out of the 150 people with the disease identified on CTPA, 90 have a positive blood result, resulting in a sensitivity of 0.6.
The negative predictive value (NPV) is the proportion of true negative results out of all negative results. In this case, there are 180 negative blood results, with 120 being truly negative as per the disease being absent on CTPA. Therefore, the NPV is 0.67.
The figure of 0.7 is not relevant to this scenario.

Precision refers to the consistency of a test in producing the same results when repeated multiple times. It is an important aspect of test reliability and can impact the accuracy of the results. In order to assess precision, multiple tests are performed on the same sample and the results are compared. A test with high precision will produce similar results each time it is performed, while a test with low precision will produce inconsistent results. It is important to consider precision when interpreting test results and making clinical decisions.

Perioral dermatitis can be treated with either topical or oral antibiotics. However, before starting treatment, it is important to evaluate any underlying factors and advise the patient to avoid using cosmetics, cleansers, and moisturizers on the affected area.

For milder cases, a topical antibiotic such as clindamycin, erythromycin, or metronidazole can be used. However, for more severe cases, a systemic antibiotic such as oxytetracycline, lymecycline, doxycycline, or erythromycin should be used for a period of 4-6 weeks.

It is important to note that the use of topical steroids should be avoided as they can cause or exacerbate perioral dermatitis. The exact cause of this condition is unknown, but it can be associated with the use of topical steroids for minor skin problems.

Referral to a dermatologist is not necessary at this stage, as perioral dermatitis can be effectively treated in primary care. However, if the condition doesn’t respond to treatment or alternative diagnoses are being considered, referral to a dermatologist may be appropriate.

Understanding Periorificial Dermatitis

Periorificial dermatitis is a skin condition that is commonly observed in women between the ages of 20 and 45 years old. The use of topical corticosteroids, and to a lesser extent, inhaled corticosteroids, is often linked to the development of this condition. The symptoms of periorificial dermatitis include the appearance of clustered erythematous papules, papulovesicles, and papulopustules, which are typically found in the perioral, perinasal, and periocular regions. However, the skin immediately adjacent to the vermilion border of the lip is usually spared.

When it comes to managing periorificial dermatitis, it is important to note that steroids may actually worsen the symptoms. Instead, the condition should be treated with either topical or oral antibiotics. By understanding the features and management of periorificial dermatitis, individuals can take the necessary steps to address this condition and improve their skin health.

Before initiating an ACE inhibitor in patients with heart failure with a reduced ejection fraction, it is recommended to seek specialist advice if the potassium level is above 5 mmol/L. The current NICE CKS guidance suggests starting bisoprolol and ramipril for such patients. However, if the potassium level is high, it is advisable to repeat the urea and electrolytes in 2-3 weeks and seek specialist advice before starting an ACE inhibitor. As the patient is asymptomatic, increasing the dose of furosemide would not be beneficial. There is no need for same-day medical assessment as the patient is currently stable. Although bendroflumethiazide may be suitable for hypertension, NICE CKS recommends ACEi for heart failure treatment.

Angiotensin-converting enzyme (ACE) inhibitors are commonly used as the first-line treatment for hypertension and heart failure in younger patients. However, they may not be as effective in treating hypertensive Afro-Caribbean patients. ACE inhibitors are also used to treat diabetic nephropathy and prevent ischaemic heart disease. These drugs work by inhibiting the conversion of angiotensin I to angiotensin II and are metabolized in the liver.

While ACE inhibitors are generally well-tolerated, they can cause side effects such as cough, angioedema, hyperkalaemia, and first-dose hypotension. Patients with certain conditions, such as renovascular disease, aortic stenosis, or hereditary or idiopathic angioedema, should use ACE inhibitors with caution or avoid them altogether. Pregnant and breastfeeding women should also avoid these drugs.

Patients taking high-dose diuretics may be at increased risk of hypotension when using ACE inhibitors. Therefore, it is important to monitor urea and electrolyte levels before and after starting treatment, as well as any changes in creatinine and potassium levels. Acceptable changes include a 30% increase in serum creatinine from baseline and an increase in potassium up to 5.5 mmol/l. Patients with undiagnosed bilateral renal artery stenosis may experience significant renal impairment when using ACE inhibitors.

The current NICE guidelines recommend using a flow chart to manage hypertension, with ACE inhibitors as the first-line treatment for patients under 55 years old. However, individual patient factors and comorbidities should be taken into account when deciding on the best treatment plan.

Managing Nephropathy Progression

Tight control of blood pressure and glucose levels is crucial in managing the progression of nephropathy. The recommended target for systolic blood pressure is 130 or less, while the HbA1c target should be less than 53 mmol/mol. Although BMI, diastolic blood pressure, and cholesterol are relevant factors, they are less significant compared to blood pressure and glucose control.

Among all antihypertensives, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have the strongest evidence for reducing nephropathy progression. Therefore, it is important to prioritize these medications in the management of nephropathy. Proper management of blood pressure and glucose levels, along with the use of ACE inhibitors and ARBs, can significantly slow down the progression of nephropathy.

The probable reason for the patient’s condition is Clostridium difficile, which could have been caused by the administration of broad-spectrum antibiotics during the operation. According to NICE guidelines, patients undergoing clean surgery with prosthesis or implant placement, clean-contaminated surgery, contaminated surgery, or surgery on a dirty or infected wound should receive antibiotics to prevent surgical site infections. In cases of contaminated or infected wounds, prophylaxis should be accompanied by antibiotic treatment.

Clostridioides difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.

To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.

Helicobacter pylori: A Bacteria Associated with Gastrointestinal Problems

Helicobacter pylori is a type of Gram-negative bacteria that is commonly associated with various gastrointestinal problems, particularly peptic ulcer disease. This bacterium has two primary mechanisms that allow it to survive in the acidic environment of the stomach. Firstly, it uses its flagella to move away from low pH areas and burrow into the mucous lining to reach the epithelial cells underneath. Secondly, it secretes urease, which converts urea to NH3, leading to an alkalinization of the acidic environment and increased bacterial survival.

The pathogenesis mechanism of Helicobacter pylori involves the release of bacterial cytotoxins, such as the CagA toxin, which can disrupt the gastric mucosa. This bacterium is associated with several gastrointestinal problems, including peptic ulcer disease, gastric cancer, B cell lymphoma of MALT tissue, and atrophic gastritis. However, its role in gastro-oesophageal reflux disease (GORD) is unclear, and there is currently no role for the eradication of Helicobacter pylori in GORD.

The management of Helicobacter pylori infection involves a 7-day course of treatment with a proton pump inhibitor, amoxicillin, and either clarithromycin or metronidazole. For patients who are allergic to penicillin, a proton pump inhibitor, metronidazole, and clarithromycin are used instead.

To manage hyperlipidaemia, it is important to address any accompanying hyperglycaemia. The patient’s abnormal cholesterol levels could be a result of his deteriorating diabetic condition. Therefore, the best course of action would be to maintain the current statin dosage and adjust the metformin dosage accordingly. By treating the hyperglycaemia, there is a possibility of improving the patient’s cholesterol levels.

Management of Hyperlipidaemia: NICE Guidelines

Hyperlipidaemia, or high levels of lipids in the blood, is a major risk factor for cardiovascular disease (CVD). In 2014, the National Institute for Health and Care Excellence (NICE) updated their guidelines on lipid modification, which caused controversy due to the recommendation of statins for a significant proportion of the population over the age of 60. The guidelines suggest a systematic strategy to identify people over 40 years who are at high risk of CVD, using the QRISK2 CVD risk assessment tool. A full lipid profile should be checked before starting a statin, and patients with very high cholesterol levels should be investigated for familial hyperlipidaemia. The new guidelines recommend offering a statin to people with a QRISK2 10-year risk of 10% or greater, with atorvastatin 20 mg offered first-line. Special situations, such as type 1 diabetes mellitus and chronic kidney disease, are also addressed. Lifestyle modifications, including a cardioprotective diet, physical activity, weight management, alcohol intake, and smoking cessation, are important in managing hyperlipidaemia.

If a patient with hypertension is already taking an ACE inhibitor and has a history of gout, it would be more appropriate to prescribe a calcium channel blocker as the next step instead of a thiazide. This is because thiazide-type diuretics should be used with caution in individuals with gout as it may worsen the condition. Therefore, a calcium channel blocker should be considered as a second-line Antihypertensive medication.

It would be incorrect to make no changes to the patient’s medication, especially if their blood pressure readings are consistently high. In this case, a second-line Antihypertensive medication is necessary.

Stopping the patient’s current medication, ramipril, is also not recommended as it is providing some Antihypertensive effects. Instead, a second medication should be added to further manage the patient’s hypertension.

Hypertension, or high blood pressure, is a common condition that can lead to serious health problems if left untreated. The National Institute for Health and Care Excellence (NICE) has published updated guidelines for the management of hypertension in 2019. Some of the key changes include lowering the threshold for treating stage 1 hypertension in patients under 80 years old, allowing the use of angiotensin receptor blockers instead of ACE inhibitors, and recommending the use of calcium channel blockers or thiazide-like diuretics in addition to ACE inhibitors or angiotensin receptor blockers.

Lifestyle changes are also important in managing hypertension. Patients should aim for a low salt diet, reduce caffeine intake, stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more, and lose weight.

Treatment for hypertension depends on the patient’s blood pressure classification. For stage 1 hypertension with ABPM/HBPM readings of 135/85 mmHg or higher, treatment is recommended for patients under 80 years old with target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 10% or greater. For stage 2 hypertension with ABPM/HBPM readings of 150/95 mmHg or higher, drug treatment is recommended regardless of age.

The first-line treatment for patients under 55 years old or with a background of type 2 diabetes mellitus is an ACE inhibitor or angiotensin receptor blocker. Calcium channel blockers are recommended for patients over 55 years old or of black African or African-Caribbean origin. If a patient is already taking an ACE inhibitor or angiotensin receptor blocker, a calcium channel blocker or thiazide-like diuretic can be added.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, NICE recommends seeking expert advice or adding a fourth drug. Blood pressure targets vary depending on age, with a target of 140/90 mmHg for patients under 80 years old and 150/90 mmHg for patients over 80 years old. Direct renin inhibitors, such as Aliskiren, may be used in patients who are intolerant of other antihypertensive drugs, but their role is currently limited.

Treatment for High-Risk Wounds

This man’s wound poses a high risk of contamination from horse manure, and we do not know his vaccination status. Immediate action is necessary to prevent tetanus infection. Tetanus immunoglobulin can provide short-term protection, but it takes several months to achieve long-term immunity after the first dose of tetanus vaccine and up to a week after a booster. Therefore, the patient should receive both tetanus immunoglobulin and a full course of five tetanus vaccinations, with intervals of at least four weeks between doses. The standard dose of tetanus immunoglobulin is 250 IU IM, but if the wound is heavily contaminated, or if there is a delay in seeking treatment, a dose of 500 IU is recommended.

Diagnosis of Diabetes: Interpreting Plasma Glucose Concentrations

The diagnosis of diabetes is based on interpreting plasma glucose concentrations. To diagnose diabetes mellitus, a fasting plasma glucose above 7 mmol/L or a random glucose above 11.1 mmol/L is required. However, it is important to note that two plasma glucose readings are needed according to these parameters in an asymptomatic patient to make the diagnosis. In a symptomatic patient, only one reading is needed.

It is crucial to pay attention to the details of the question and not misinterpret any of the options. For instance, candidates may misread or misinterpret the threshold of 7.0 mmol/L and argue that 7.1 mmol/L cannot be the correct answer. Therefore, using good examination technique, it is recommended to go over the options again to ensure that the question has been read correctly.

Urgent Referral for Unexplained Haematuria and Previous DVT

This patient presents with unexplained haematuria and a history of previous DVT. It is important to consider the possibility of underlying occult neoplasia of the renal tract. Therefore, an urgent referral to the urologists is the most appropriate course of action.

It is important to note that in cases where the patient is on therapeutic INR with warfarin, the haematuria should not be attributed to the medication. Warfarin may unmask a potential neoplasm, and it is crucial to investigate the underlying cause of the haematuria. Early detection and treatment of neoplasia can significantly improve patient outcomes.

Exclusion of agranulocytosis is necessary when using carbimazole.

Carbimazole is a medication used to treat thyrotoxicosis, a condition where the thyroid gland produces too much thyroid hormone. It is usually given in high doses for six weeks until the patient’s thyroid hormone levels become normal, after which the dosage is reduced. The drug works by blocking thyroid peroxidase, an enzyme that is responsible for coupling and iodinating the tyrosine residues on thyroglobulin, which ultimately leads to a reduction in thyroid hormone production. In contrast, propylthiouracil has a dual mechanism of action, inhibiting both thyroid peroxidase and 5′-deiodinase, which reduces the peripheral conversion of T4 to T3.

However, carbimazole is not without its adverse effects. One of the most serious side effects is agranulocytosis, a condition where the body’s white blood cell count drops significantly, making the patient more susceptible to infections. Additionally, carbimazole can cross the placenta and affect the developing fetus, although it may be used in low doses during pregnancy under close medical supervision. Overall, carbimazole is an effective medication for managing thyrotoxicosis, but its potential side effects should be carefully monitored.

Managing Insulin Use in Unwell Diabetic Patients

When it comes to managing diabetic patients taking insulin, Diabetes Specialist Nurses (DSNs) play a crucial role. However, as a healthcare professional, you may not always have exposure to this type of clinical problem, which can lead to de-skilling. Additionally, the Royal College of General Practitioners (RCGP) has identified this area as a particular weakness in past AKT exams, making it important to stay up-to-date on the topic.

One key aspect of counselling diabetic patients who have started insulin is knowing what to do if they become unwell. For type I diabetics, it is essential to check their blood glucose and ketone levels regularly, at least every 4 hours. If the blood glucose level is less than 13 mmol/L and there are no ketones present in the urine (or ketone levels are less than 1.5 mmol/L on blood ketone testing), then insulin should be taken as normal. However, if the blood glucose level is greater than 13 mmol/L and urinary ketones are present (or blood ketone level greater than 1.5mmol/L), then insulin adjustment is necessary. In such cases, the patient requires an additional 10% of their daily insulin dose as rapid-acting insulin every 4 hours, followed by 4-hourly glucose and ketone monitoring to guide ongoing management.

Antibiotics for Prophylaxis and Treatment of Infectious Diseases

Public Health England recommends ciprofloxacin as the preferred antibiotic for prophylaxis and treatment of meningococcal disease in all age groups, including pregnant women. Ciprofloxacin has advantages over rifampicin, such as being a single-dose medication, not interfering with oral contraceptives, and being more easily accessible in community pharmacies. However, it should not be used in patients with ciprofloxacin hypersensitivity. Although historically not recommended for children due to the risk of arthropathy, studies have shown that the risk is low and transient.

Co-trimoxazole is the drug of choice for prophylaxis and treatment of Pneumocystis jirovecii pneumonia, as well as toxoplasmosis and nocardiasis. Vancomycin can be used orally to treat Clostridium difficile infection, with metronidazole as an alternative. Ceftriaxone can be used for prophylaxis of meningococcal and Haemophilus influenza type b disease, but its use is unlicensed and requires intramuscular administration. Benzylpenicillin is given intravenously or intramuscularly in the prehospital treatment of patients with suspected meningococcal disease.

Antibiotics for Prophylaxis and Treatment of Infectious Diseases

Shingles Vaccination: Who Should Get It and When?

The national shingles immunisation programme aims to reduce the incidence and severity of shingles in older people. The vaccine is recommended for routine administration to those aged 70 years, but can be given up until the 80th birthday. Vaccination is most effective and cost-effective in this age group, as the burden of shingles disease is generally more severe in older ages. The vaccine is not routinely offered below 70 years of age, as the duration of protection is not known to last more than ten years and the need for a second dose is not known.

Zostavax® is the only shingles vaccine available in the UK, and is contraindicated in immunosuppressed individuals. Previous shingles is also a contraindication, as there is a natural boosting of antibody levels after an attack of shingles.

Clinical trials have shown that the vaccine reduces the incidence of shingles and post-herpetic neuralgia in those aged 60 and 70 years and older. However, it is important to note that the vaccine is only effective in reducing neuralgia.

In summary, the shingles vaccine is recommended for routine administration to those aged 70 years, but can be given up until the 80th birthday. It is contraindicated in immunosuppressed individuals and those with a history of shingles. While the vaccine is effective in reducing neuralgia, it is not a guarantee against shingles.

Managing Acute Coronary Syndrome: A Summary of NICE Guidelines

Acute coronary syndrome (ACS) is a common and serious medical condition that requires prompt management. The management of ACS has evolved over the years, with the development of new drugs and procedures such as percutaneous coronary intervention (PCI). The National Institute for Health and Care Excellence (NICE) has updated its guidelines on the management of ACS in 2020.

ACS can be classified into three subtypes: ST-elevation myocardial infarction (STEMI), non ST-elevation myocardial infarction (NSTEMI), and unstable angina. The management of ACS depends on the subtype. However, there are common initial drug therapies for all patients with ACS, such as aspirin and oxygen therapy if the patient has low oxygen saturation.

For patients with STEMI, the first step is to assess eligibility for coronary reperfusion therapy, which can be either PCI or fibrinolysis. Patients with NSTEMI or unstable angina require a risk assessment using the Global Registry of Acute Coronary Events (GRACE) tool. Based on the risk assessment, decisions are made regarding whether a patient has coronary angiography (with follow-on PCI if necessary) or conservative management.

This summary provides an overview of the NICE guidelines on the management of ACS. However, it is important to note that emergency departments may have their own protocols based on local factors. The full NICE guidelines should be reviewed for further details.

Differentiating Types of Arthritis: A Brief Overview

Arthritis is a common condition that affects millions of people worldwide. However, not all types of arthritis are the same. Here, we will briefly discuss some of the most common types of arthritis and their distinguishing features.

Osteoarthritis is the most prevalent form of arthritis and is associated with older age. It typically affects the knee and hip joints, as well as the DIP joints in the hands, where it causes bony lumps known as Heberden nodes.

Pseudogout is caused by the deposition of calcium pyrophosphate dihydrate crystals in the joints, particularly in the knees. It can cause acute monoarticular or oligoarticular arthritis, similar to gout but milder.

Psoriatic arthritis affects the DIP joints and is almost always associated with nail dystrophy. It is often accompanied by psoriatic skin lesions, which are absent in this patient’s case.

Reactive arthritis follows a gastrointestinal or venereal infection and typically affects young adults, causing lower-limb asymmetrical oligoarthritis, lower back pain, and heel pain. This patient doesn’t fit these criteria.

Rheumatoid arthritis is characterised by symmetrical arthralgia and synovitis of the small joints of the hands, feet, and wrists, with swelling of the metacarpophalangeal and PIP joints.

In summary, understanding the distinguishing features of different types of arthritis can help clinicians make an accurate diagnosis and provide appropriate treatment.

Viral labyrinthitis may cause hearing loss, while vestibular neuronitis doesn’t typically result in hearing loss. However, both conditions can cause symptoms such as nausea and vomiting, vertigo, and nystagmus. Therefore, the options stating that these symptoms are exclusive to one condition or the other are incorrect.

Vertigo is a condition characterized by a false sensation of movement in the body or environment. There are various causes of vertigo, each with its own unique characteristics. Viral labyrinthitis, for example, is typically associated with a recent viral infection, sudden onset, nausea and vomiting, and possible hearing loss. Vestibular neuronitis, on the other hand, is characterized by recurrent vertigo attacks lasting hours or days, but with no hearing loss. Benign paroxysmal positional vertigo is triggered by changes in head position and lasts for only a few seconds. Meniere’s disease, meanwhile, is associated with hearing loss, tinnitus, and a feeling of fullness or pressure in the ears. Elderly patients with vertigo may be experiencing vertebrobasilar ischaemia, which is accompanied by dizziness upon neck extension. Acoustic neuroma, which is associated with hearing loss, vertigo, and tinnitus, is also a possible cause of vertigo. Other causes include posterior circulation stroke, trauma, multiple sclerosis, and ototoxicity from medications like gentamicin.

Understanding Autoantibody Screening: ANA and Anti-dsDNA Antibodies

Autoantibodies are antibodies that mistakenly attack the body’s own tissues. Antinuclear antibodies (ANA) are a type of autoantibody that bind to the contents of the cell nucleus. ANA screening is a useful tool in diagnosing autoimmune disorders. However, a positive ANA test alone is not enough to diagnose a specific autoimmune disorder.

A positive ANA test with titres of 1:160 or higher is strongly associated with autoimmune disorders, but it can also be found in 5% of healthy individuals, particularly older people. In addition to ANA, other autoantibodies are tested, including antibodies to double-stranded DNA (anti-dsDNA) and other extractable nuclear antigens such as anti-Ro, anti-La, and anti-Sm antibodies.

Anti-dsDNA antibodies are highly specific for systemic lupus erythematosus (SLE) and are present in more than 50% of cases. However, nearly 50% of people with SLE will test negative for dsDNA. Anti-Ro antibodies occur in 30-50% of SLE patients and in 70-90% of patients with Sjögren syndrome. Anti-Sm antibodies occur in 20-30% of SLE patients and are quite specific for SLE. Anti-La antibodies are found in 10-15% of SLE patients but in 60-90% of patients with Sjögren syndrome.

In summary, autoantibody screening is a useful tool in diagnosing autoimmune disorders, but a positive ANA test alone is not enough to diagnose a specific autoimmune disorder. Testing for other autoantibodies, such as anti-dsDNA, anti-Ro, anti-La, and anti-Sm antibodies, can help in making a more accurate diagnosis.

Dactylitis is a common symptom of reactive arthritis, which is strongly suggested by this patient’s history. The fact that his mother has psoriatic arthritis may indicate a hereditary HLA-B27 genotype, which is also associated with reactive arthritis. Achilles tendinitis is more commonly associated with ankylosing spondylitis, another seronegative arthritis linked to HLA-B27. Erythema multiforme is a skin reaction caused by various infections and is not specifically associated with reactive arthritis. Herberden’s nodes are bony nodules at the distal interphalangeal joints associated with osteoarthritis, which is a non-inflammatory condition. Although the patient’s positive family history suggested psoriatic arthritis, the rest of his history was more consistent with reactive arthritis, making that option incorrect.

Dactylitis is a condition characterized by inflammation of a finger or toe. The causes of this condition include spondyloarthritis, such as Psoriatic and reactive arthritis, sickle-cell disease, and other rare causes like tuberculosis, sarcoidosis, and syphilis.

The Importance of Appraisal for GPs

Appraisal is a crucial process that has been mandatory for GPs since 2002. Its primary purpose is to identify areas for development rather than performance management. With the introduction of revalidation by the GMC, appraisals have become even more important as they provide a structured system for recording progress towards revalidation and identifying development needs.

After the Primary Care Trusts were disbanded, NHS England took on the responsibility for appraisals. The appraiser should be another GP who has been properly trained in appraisal. It is recommended that a doctor should have no more than three consecutive appraisals by the same appraiser in the same revalidation cycle. The average time commitment for appraisal is a minimum of 4.5 to 6.5 hours, including between 2 and 4 hours for preparation.

The content of appraisal is based on the 4 key domains set out in the GMC’s Good Medical Practice document. These domains include knowledge, skills, and performance, contributing and complying with systems to protect patients, communication, partnership, and teamwork, and maintaining trust. It is essential for GPs to participate in appraisal regularly to ensure they are providing the best possible care to their patients and maintaining their professional standards.

Sjogren’s Syndrome: A Multi-System Diagnosis

This patient’s chest symptoms, along with systemic symptoms and dry eyes and mouth, suggest a possible multi-system diagnosis. Sjogren’s syndrome is a condition that should be considered, especially if the patient is a woman in her 5th or 6th decade. Men and younger people can also be affected.

Sjogren’s syndrome is characterized by various symptoms, including pulmonary fibrosis, sicca symptoms (dry eyes and mouth), Raynaud’s phenomenon, and arthralgia. Anti-Ro and anti-La antibodies are useful diagnostic tools in identifying this condition.

It is important to recognize the potential for a multi-system diagnosis in patients presenting with a combination of symptoms. In this case, Sjogren’s syndrome should be considered and appropriate testing should be performed to confirm the diagnosis.

A brain tumour can cause local brain invasion, compression of adjacent structures, and increased intracranial pressure (ICP), leading to symptoms such as severe unilateral headache, nausea, and vomiting. However, a sudden onset of weakness that resolves quickly is unlikely to be caused by a brain tumour.

MS typically presents with temporary vision loss in a woman in her 20s, but a new presentation may be mistaken for a TIA and have longer-lasting neurological deficits. Other symptoms are usually present in a patient of this age.

While central retinal vein occlusion can cause unilateral vision loss, it usually presents with blurred vision, and the presence of amaurosis fugax or an altitudinal field defect suggests an arterial pathology. A normal fundoscopic examination also makes central retinal vein occlusion unlikely.

A stroke is characterized by an acute neurological deficit lasting more than 24 hours due to cerebrovascular aetiology. However, in this case, the weakness has resolved, and the MRI shows only age-related changes, making a TIA diagnosis more appropriate.

A TIA is a transient episode of neurological dysfunction without acute infarction. Given the patient’s presentation of amaurosis fugax, past medical history of coronary artery disease, and normal MRI scan, a TIA is the most likely diagnosis.

A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, sudden transient loss of vision in one eye (amaurosis fugax), diplopia, and homonymous hemianopia.

NICE recommends immediate antithrombotic therapy, giving aspirin 300 mg immediately unless the patient has a bleeding disorder or is taking an anticoagulant. If aspirin is contraindicated, management should be discussed urgently with the specialist team. Specialist review is necessary if the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis. Urgent assessment within 24 hours by a specialist stroke physician is required if the patient has had a suspected TIA in the last 7 days. Referral for specialist assessment should be made as soon as possible within 7 days if the patient has had a suspected TIA more than a week previously. The person should be advised not to drive until they have been seen by a specialist.

Neuroimaging should be done on the same day as specialist assessment if possible. MRI is preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies. Carotid imaging is necessary as atherosclerosis in the carotid artery may be a source of emboli in some patients. All patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy.

Antithrombotic therapy is recommended, with clopidogrel being the first-line treatment. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel. Carotid artery endarterectomy should only be considered if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be recommended if carotid stenosis is greater

Managing Constipation in a Patient on Analgesia

The patient’s constipation is not a mystery as it coincides with the prescription of codeine phosphate, which slows down bowel transit. There are no other concerning symptoms in the patient’s history or examination that would warrant an urgent referral to a lower gastrointestinal specialist for suspected cancer.

To manage the patient’s constipation, the healthcare provider should provide advice on diet and lifestyle, review the patient’s medication to identify any contributing factors, and counsel the patient on red flags. The patient has already undergone blood tests to investigate secondary causes of constipation, such as hypothyroidism or hypercalcaemia. The healthcare provider can also discuss the use of laxatives with the patient.

Overall, managing constipation in a patient on analgesia involves identifying contributing factors, providing lifestyle advice, and discussing treatment options with the patient.

The usual progression of rheumatoid arthritis involves experiencing pain first, followed by stiffness. However, in this particular case, the patient is experiencing both pain and stiffness simultaneously. The condition commonly causes swelling, stiffness, and pain in the small joints of the hands and feet.

Understanding Polymyalgia Rheumatica

Polymyalgia rheumatica (PMR) is a condition commonly seen in older individuals that is characterized by muscle stiffness and elevated inflammatory markers. Although it is closely related to temporal arteritis, the underlying cause is not fully understood, and it doesn’t appear to be a vasculitic process. PMR typically affects individuals over the age of 60 and has a rapid onset, with symptoms appearing in less than a month. Patients experience aching and morning stiffness in proximal limb muscles, along with mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, and night sweats. Weakness is not considered a symptom of PMR.

To diagnose PMR, doctors look for elevated inflammatory markers, such as an ESR greater than 40 mm/hr. Creatine kinase and EMG are typically normal. Treatment for PMR involves the use of prednisolone, with a typical dose of 15mg/od. Patients usually respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis. Understanding the symptoms and treatment options for PMR can help individuals manage their condition and improve their quality of life.

Causes of Jaundice and their Characteristics

Jaundice can be caused by various conditions, each with their own unique characteristics. Cancer of the pancreas, particularly in the head, can cause painless jaundice. On the other hand, cancer in the body or tail of the pancreas can present with dull, unremitting central abdominal pain or back pain. Smoking is a known risk factor for pancreatic cancer.

Gilbert’s syndrome, a familial condition, can also cause jaundice. However, the jaundice in this case is pale yellow and the patient typically feels well. While Gilbert’s syndrome is not uncommon, it is important to consider other potential causes of jaundice, especially if the patient has significant weight loss. As a wise surgeon once said, People with IBS get Ca bowel too – never forget that.

Hepatitis A is more commonly seen in adolescents and young adults. Primary biliary cirrhosis, on the other hand, has its peak incidence in the fifth decade of life and often presents with generalized pruritus or asymptomatic hepatomegaly. Understanding the characteristics of different causes of jaundice can help in making an accurate diagnosis and providing appropriate treatment.

The risk of osteoporosis increases with over-replacement of thyroxine. Elevated T4 and suppressed TSH levels in blood tests indicate over-replacement with levothyroxine, which can cause confusion in biochemistry abnormalities, although this is more commonly observed in hypothyroidism. Constipation is a symptom of hypothyroidism, not over-replacement with levothyroxine. Muscle weakness and reduced reflexes are also associated with hypothyroidism, not hyperthyroidism. Over-replacement with thyroxine would result in weight loss rather than weight gain.

Managing Hypothyroidism: Dosage, Goals, and Side-Effects

Hypothyroidism is a condition where the thyroid gland doesn’t produce enough thyroid hormone. The management of hypothyroidism involves the use of levothyroxine, a synthetic form of thyroid hormone. The initial starting dose of levothyroxine should be lower in elderly patients and those with ischaemic heart disease. For patients with cardiac disease, severe hypothyroidism, or patients over 50 years, the initial starting dose should be 25mcg od with dose slowly titrated. Other patients should be started on a dose of 50-100 mcg od. After a change in thyroxine dose, thyroid function tests should be checked after 8-12 weeks. The therapeutic goal is to achieve a ‘normalisation’ of the thyroid stimulating hormone (TSH) level, with a TSH value of 0.5-2.5 mU/l being the preferred range.

Women with established hypothyroidism who become pregnant should have their dose increased ‘by at least 25-50 micrograms levothyroxine’* due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. There is no evidence to support combination therapy with levothyroxine and liothyronine.

Levothyroxine therapy may cause side-effects such as hyperthyroidism due to over-treatment, reduced bone mineral density, worsening of angina, and atrial fibrillation. Interactions with iron and calcium carbonate may reduce the absorption of levothyroxine, so they should be given at least 4 hours apart.

In summary, the management of hypothyroidism involves careful dosage adjustment, regular monitoring of thyroid function tests, and aiming for a TSH value in the normal range. Women who become pregnant should have their dose increased, and combination therapy with levothyroxine and liothyronine is not recommended. Patients should also be aware of potential side-effects and interactions with other medications.

*source: NICE Clinical Knowledge Summaries

Occupational Asthma and its Diagnosis

The history of a patient who works as a baker raises concerns about occupational asthma, which is often caused by sensitizing agents found in plant products. It is estimated that 10-15% of adults with new or recurrent asthma have an occupational element to their symptoms. If a patient reports that their symptoms improve when away from the workplace, occupational asthma should be strongly suspected.

To diagnose occupational asthma, the most useful approach is to have the patient perform serial peak expiratory flow rate (PEFR) measurements. The Oxford Handbook of Respiratory Medicine recommends that the patient record a PEFR every two hours from waking to sleep for four weeks, with no changes to their treatment. The patient should document home, work, and holiday periods, and an expert should interpret the results.

If you suspect work-related asthma, it is important to arrange PEFR measurements and refer the patient to a chest physician or occupational physician for assessment and interpretation of the PEFR diary. Early diagnosis and management of occupational asthma can prevent long-term respiratory damage and improve the patient’s quality of life.