If a child under the age of 5 has asthma that is not being controlled by a short-acting beta agonist (SABA) and a low dose of inhaled corticosteroids (ICS), then a leukotriene receptor antagonist should be added to their asthma management plan.

Managing Asthma in Children: NICE Guidelines

Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.

It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.

Transient Synovitis in Childhood: the Causes and Diagnosis

Transient synovitis is a prevalent cause of hip pain in children, but it is crucial to rule out other more severe causes before diagnosing it. The exact cause of this condition is still unknown, but it is believed to be associated with viral infections, allergic reactions, or trauma.

Transient synovitis is a self-limiting condition that typically resolves within a few days to weeks. However, it is essential to differentiate it from other conditions that may require urgent medical attention, such as septic arthritis or Legg-Calve-Perthes disease. Therefore, a thorough medical history, physical examination, and imaging studies are necessary to make an accurate diagnosis.

In conclusion, transient synovitis is a common cause of hip pain in childhood, but it is crucial to exclude other more serious conditions before diagnosing it. Parents should seek medical attention if their child experiences hip pain, limping, or difficulty walking to ensure prompt and appropriate treatment.

Risk Factors for Pancreatic Cancer

Pancreatic cancer is a serious condition that can be caused by various risk factors. One of the most common risk factors is chronic pancreatitis, which is often caused by excessive alcohol intake. Other risk factors include smoking, diabetes mellitus, and obesity.

In the case of a patient with weight loss and painless jaundice, pancreatic cancer is the most likely diagnosis. This is supported by the patient’s history of repeated acute pancreatitis due to alcohol abuse, which can lead to chronic pancreatitis and increase the risk of developing pancreatic cancer.

COPD, on the other hand, is caused by smoking but is not a direct risk factor for pancreatic cancer. Obesity is also a risk factor for pancreatic cancer, as it increases the risk of developing diabetes mellitus, which in turn increases the risk of pancreatic cancer. Hypertension, however, is not a recognised risk factor for pancreatic cancer.

It is important to identify and address these risk factors in order to prevent the development of pancreatic cancer. Quitting smoking, reducing alcohol intake, maintaining a healthy weight, and managing diabetes mellitus and hypertension can all help to reduce the risk of developing this serious condition.

Understanding Gene Transcription: Promoters, Silencers, Exons, Introns, and Enhancers

Gene transcription is the process by which genetic information is copied from DNA to RNA. This process involves several key elements, including promoters, silencers, exons, introns, and enhancers.

Promoters are specialized sequences found upstream of a gene that serve as binding sites for RNA polymerase, the enzyme responsible for RNA synthesis from DNA. Silencers, on the other hand, are sequences found upstream or downstream of a gene that can prevent RNA polymerase from binding, thereby inhibiting gene transcription.

Following transcription, an RNA transcript is produced that contains both introns and exons. Exons are the sections of the RNA transcript that will be translated to protein, while introns are non-coding sections that are spliced out prior to translation.

Enhancers are sequences found upstream or downstream of a gene that promote transcription when bound by specific transcription factors. They can be located thousands of base pairs from the promoter region of the gene in question.

Understanding these key elements of gene transcription is essential for understanding how genetic information is expressed and regulated in cells.

Proteins Associated with Neurodegenerative Diseases

Neurodegenerative diseases are characterized by the progressive loss of neurons in the brain and spinal cord. Several proteins have been identified as being associated with these diseases. For example, Alzheimer’s disease is associated with both amyloid precursor protein (APP) and tau proteins. Lewy body disease and Parkinson’s disease are associated with alpha-synuclein, while fronto-temporal dementia and ALS are associated with TARDBP-43 and tau protein. Additionally, Huntington’s disease is associated with huntingtin. Other changes, such as bunina bodies and Pick bodies, are also seen in certain neurodegenerative diseases and can serve as markers of neuronal degeneration. Understanding the role of these proteins in disease pathology is crucial for developing effective treatments for these devastating conditions.

Hypertension Treatment in Patients with Type 2 Diabetes

Patients with type 2 diabetes and sustained hypertension require treatment. The first-line treatment for hypertension in diabetes is ACE inhibitors. These medications have no adverse effects on glucose tolerance or lipid profiles and can delay the progression of microalbuminuria to nephropathy. Additionally, ACE inhibitors can reduce morbidity and mortality in patients with vascular disease and diabetes.

However, bendroflumethiazide should be avoided in patients with a history of gout as it may provoke an attack. Beta-blockers should also be avoided for routine treatment of uncomplicated hypertension in patients with diabetes. They can precipitate bronchospasm and should be avoided in patients with asthma. In cases where there is no alternative, a cardioselective beta blocker should be selected and initiated at a low dose by a specialist, with close monitoring for adverse effects.

Alpha-blockers, such as doxazosin, are reserved for the treatment of resistant hypertension in conjunction with other antihypertensives. It is important to follow guidelines, such as those provided by NICE and the British National Formulary, for the diagnosis and management of hypertension in adults with diabetes. A treatment algorithm for hypertension can also be helpful in guiding treatment decisions.

Distinguishing between Acute Kidney Injury and Chronic Kidney Disease

One of the most effective ways to differentiate between acute kidney injury (AKI) and chronic kidney disease (CKD) is through the use of renal ultrasound. In most cases, patients with CKD will have small kidneys that are bilateral. However, there are some exceptions to this rule, including individuals with autosomal dominant polycystic kidney disease, diabetic nephropathy in its early stages, amyloidosis, and HIV-associated nephropathy.

In addition to renal ultrasound, there are other features that can suggest CKD rather than AKI. For example, individuals with CKD may experience hypocalcaemia due to a lack of vitamin D. By identifying these distinguishing factors, healthcare professionals can more accurately diagnose and treat patients with kidney disease. Proper diagnosis is crucial, as the treatment and management of AKI and CKD differ significantly.

Understanding Postpartum Mental Health Problems

Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.

‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.

Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.

Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.

Arteries of the Stomach and Duodenum: Potential Sites of Haemorrhage

The gastrointestinal tract is supplied by a network of arteries that can be vulnerable to erosion and haemorrhage in cases of ulceration. Here are some of the key arteries of the stomach and duodenum to be aware of:

Gastroduodenal artery: This branch of the common hepatic artery travels to the first part of the duodenum, where duodenal ulcers often occur. If the ulceration erodes through the gastroduodenal artery, it can cause a catastrophic haemorrhage and present as haematemesis.

Left gastric artery: Arising from the coeliac artery, the left gastric artery supplies the distal oesophagus and the lesser curvature of the stomach. Gastric ulceration can cause erosion of this artery and lead to a massive haemorrhage.

Left gastroepiploic artery: This artery arises from the splenic artery and runs along the greater curvature of the stomach. If there is gastric ulceration, it can be eroded and lead to a massive haemorrhage.

Right gastroepiploic artery: Arising from the gastroduodenal artery, the right gastroepiploic artery runs along the greater curvature of the stomach and anastomoses with the left gastroepiploic artery.

Short gastric arteries: These branches arise from the splenic artery and supply the fundus of the stomach, passing through the gastrosplenic ligament.

Knowing the potential sites of haemorrhage in the gastrointestinal tract can help clinicians to identify and manage cases of bleeding effectively.

Common Foot Injuries and Their Causes

March fracture, Lisfranc injury, Hallux Rigidus, Jones fracture, and proximal fifth metatarsal avulsion fracture are all common foot injuries that can cause significant pain and discomfort. A March fracture is a stress fracture of one of the metatarsal bones caused by repetitive stress, often seen in soldiers and hikers. Lisfranc injury occurs when one or more metatarsal bones are displaced from the tarsus due to excessive kinetic energy, such as in a traffic collision. Hallux Rigidus is degenerative arthritis that causes bone spurs at the metatarsophalangeal joint of the big toe, resulting in stiffness and pain. Jones fracture is a fracture in the fifth metatarsal of the foot, while proximal fifth metatarsal avulsion fracture is caused by forcible inversion of the foot in plantar flexion.

Based on the onset of symptoms and tenderness over the distal portion of the second metatarsal, a March fracture is the most likely diagnosis. It is important to seek medical attention for any foot injury to prevent further damage and ensure proper healing.