Although generally considered a childhood ailment, 38% of patients with atopic eczema in the UK are adults. The condition often has a significant detrimental effect on the quality of life of affected individuals and their families. The majority of care for atopic eczema is undertaken by the primary healthcare team. However, despite national evidence-based guidelines in the UK, standards of care in the community setting can vary, and there is still a tendency to undertreat and not follow up and monitor some patients adequately.

Movement disorders are a common cause of neurological disability in older people. Idiopathic Parkinson’s disease (IPD), caused by degradation of dopaminergic neurones in the nigrostriatal pathways of the brain leading to a triad of tremor, rigidity and bradykinesia, is probably the most well known. This article focuses on the most common non-parkinson’s movement disorders seen in older people.

Autism, like most psychiatric disorders, covers a spectrum of severity from severely disabling classic autism to milder forms of Asperger’s syndrome which border on normality. The term autism spectrum disorder (ASD) includes autism, atypical autism and Asperger’s syndrome. Some parents consult their GP worried that their child might have autism. Others may attend with a range of concerns that might point to the condition such as problems with hearing, vision, hypersensitivity to sensory stimuli, behaviour management, language impairment or repetitive behaviour. Autism conditions often co-exist with neurological disorders (particularly those including epilepsy), and more than 300 syndromes which include autism have been described.The new NICE guidelines, launched in September 2011, cover children, from birth up to 19 years, on the autism spectrum and build on the guidance published by SIGN in 2007.ASD was once believed to be relatively rare but is now thought to occur in about 1% of children. There is certainly increasing demand for diagnostic services for children and young people. Whether the apparent increasing prevalence signifies an epidemic or an epidemic of discovery is debatable.

The average age at hip fracture is 83 for women and 84 for men, with around 80% of cases in women. The reported 30% mortality and 20% new institutionalisation rates at 12 months reflect the high prevalence of comorbidity and to some extent suboptimal management at the time of the fracture. With timely intervention and better clinical management many fractures can be prevented and even when they do occur their human and economic costs can be greatly reduced.  Prevention and management span a full spectrum of typical need from primary prevention through acute an rehabilitative management to secondary prevention and long-term and palliative care. Changing what happens in acute hospitals is fundamental to this challenge, but the achievement of seamless clinical continuity across primary, secondary and social care is equally important.

Ovarian cancer is the fifth most common cancer in women. The incidence has increased over the past 20-25 years, particularly in the 65 and over age group. The outcome for women with ovarian cancer is generally poor, with an overall five-year survival rate of less than 35%. The survival rates for women with ovarian cancer in the UK are significantly lower than the European average. Despite recommendations, published by NICE in 2005, on referral of patients with suspected cancer, the majority of women diagnosed with ovarian cancer are not electively referred via the ovarian cancer two-week pathway. They are often referred to the wrong specialty or present as emergencies. NICE has now published a clinical guideline on the diagnosis and initial management of ovarian cancer.

The term men who have sex with men (MSM) encompasses a diverse group of men of all ages, ethnicities and cultural backgrounds. Their sexual behaviour is equally diverse: while some MSM have exclusively male partners, others have partners of both genders or identify themselves as heterosexual but have occasional casual sexual encounters with men. MSM may be involved in the commercial gay scene, may visit cruising environments in public places or may be in monogamous sexual relationships. There were an estimated 415,600 MSM aged 15-44 in the UK in 2007. The estimated prevalence of HIV in this group was 5.2%. Of 60,050 people aware of their HIV-positive diagnosis in the UK, 26,050 (43%) were MSM. A further 9,000 MSM in the UK are estimated to be infected with HIV but unaware of their diagnosis.

Currently the vast majority of people with familial hyper-cholesterolaemia (FH) in the UK remain undiagnosed, probably 85% of the predicted 120,000 cases.In FH families, patients sometimes feel guilty about passing on a defective gene, and there are often concerns about confidentiality surrounding genetic diagnoses. However, in general most people find that knowing the cause of the early heart disease in their family and, more importantly, that the risk can be very significantly reduced by adherence to statins, means that anxiety is easily dealt with and is very shortlived.  It is important that all members of the primary healthcare team have a good working knowledge of the simple Mendelian inheritance of FH, and can explain the elevated risk and how it can be reduced through medication and lifestyle changes.

NICE has updated its guideline on the management of chronic heart failure. The principal changes from the 2003 guideline include more directive advice on how to improve the quality and timeliness of diagnosis. There is greater encouragement to use beta-blockers, more emphasis on rehabilitation and better access to specialist advice - particularly at the time of diagnosis, admission to hospital, and where symptoms do not respond to first-line therapy with diuretics, ACE inhibitors and beta-blockers. 'A new recommendation is that patients with stable heart failure should be offered a supervised group exercise-based rehabilitation programme designed for such patients. This should include a psychological and educational component, and could be incorporated within an existing cardiac rehabilitation programme. This recommendation is likely to be picked up in the, as yet unpublished, ‘Commissioning Pack' for Cardiac Rehabilitation, and will lead to pressure locally on services to include heart failure patients. It is helpful that NHS Improvement has identified both heart failure and cardiac rehabilitation as priorities for 2010/11, but ultimately much of the responsibility for commissioning this new service will fall to primary care.'

 

Infection is usually asymptomatic. Sexually active people aged under 20 in the UK are the group most likely to have a positive result if tested. This is probably because this group changes partners more frequently. However, there also appear to be immunological factors which make infection more persistent in the young. Transmission occurs through vaginal, rectal or oral sex. It can also be vertically transmitted. Untreated chlamydia infection can result in complications including pelvic inflammatory disease (potentially leading to infertility or ectopic pregnancy), sexually acquired reactive arthritis and epididymo-orchitis. There is controversy over important questions such as the likelihood of complications developing and, hence, what sort of control measures are appropriate. Some countries, for example England, have set up screening programmes while others, such as Scotland, have elected not to.

In England in 2008, 66% of men and 57% of women had a BMI >25 kg/m²; within this 24% of men and 25% of women were obese with a BMI >30 kg/m². The relative risk of diabetes in overweight men is 2.40 and in obese men 6.74 compared with men with a BMI in the normal range. The respective relative risks in women are 3.92 and 12.41.There is a 40% increased risk of death from cardiovascular disease for every 5 kg/m² increase in BMI above 25 kg/m². While trying to tackle obesity may seem like very hard work for little gain, having a structured approach to dealing with overweight and obese patients will make it easier to broach the subject and enable evidence-based advice to be given that will be helpful to all patients.

The incidence of melanoma has risen over the past 30 years but most of this increase involves early melanomas which have less impact on mortality. This may explain why mortality has not changed in parallel with incidence as flat rates and even downturns have been observed in most Caucasian populations.