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History taking the key to diagnosing food allergy in children

25 Jul 2018Paid-up subscribers

Allergy to milk and egg are the two most prevalent food allergies in children. They are typically diagnosed in infancy and carry a good prognosis with the majority of cases resolving before the child reaches school age. Other allergies may present later in childhood and are more likely to persist. There is evidence of a causal link between early onset severe and widespread eczema that is unresponsive to moderate topical steroids and development of IgE mediated food allergy, in particular peanut allergy. The EAT study showed that infants who were weaned early and exposed to egg and peanut had a significant reduction in allergy to both foods.



Tailor BP targets to the older patient with hypertension

25 Jun 2018Paid-up subscribers

The prevalence of hypertension increases with age and older people are likely to benefit more from BP reduction because of their high baseline cardiovascular risk. However, older people are a very heterogeneous group and a single BP target will not be appropriate for all. Current evidence is based on ambulatory or healthy older populations as patients with significant complex conditions were not represented in randomised clinical trials. 

Diagnosis and management of migraine in primary care

22 May 2018Registered users

Migraine is common, with a global prevalence of 14.7% and a lifetime prevalence in the UK of 20-25%. A UK study found that there were 4.44 consultations for headache per 100 registered patients aged ≥ 15 years per annum. The Landmark study, from 15 countries, reported that 94% of patients attending a GP with episodic disabling headache had migraine.

Early treatment vital in pelvic inflammatory disease

23 Apr 2018Paid-up subscribers

Pelvic inflammatory disease (PID) is caused by infection ascending from the cervix. It can affect the uterus, fallopian tubes, ovaries, and peritoneum. Important sequelae include infertility, ectopic pregnancy and tubo-ovarian abscess. PID is associated with sexually transmitted infections. These are more prevalent in younger women. A diagnosis of PID should be considered in any sexually active woman with recent onset pelvic pain associated with tenderness on bimanual examination where other differentials have been excluded. Delay in commencing treatment for PID has been shown to increase the risk of long-term complications.

Pruritus may be a symptom of underlying systemic disease

22 Mar 2018Registered users

Itch is a common symptom of many dermatological conditions (e.g. eczema, urticaria and lichen planus) but can also be a manifestation of underlying systemic, neurological and psychological disorders, or an adverse reaction to medication. The assessment of patients with generalised itch but no rash requires a detailed history and examination to narrow the spectrum of potential causes. Examination should include inspection of the entire skin. Physical examination should include palpation for lymphadenopathy and organomegaly.

Diagnosis and management of oesophageal cancer

22 Feb 2018Registered users

Oesophageal cancer commonly presents with dysphagia or odynophagia and can be associated with weight loss and vomiting. Referral for urgent endoscopy should always be considered in the presence of dysphagia regardless of previous history or medication. NICE recommends urgent referral (within 2 weeks) for direct access for upper GI endoscopy in patients with dysphagia and those aged 55 years or over with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.

Diagnosing and managing sepsis in children

23 Jan 2018Paid-up subscribers

The clinical features of sepsis are: fever; tachycardia, with no other explanation; tachypnoea, with no other explanation; leukocytosis or leucopenia. To meet the International Pediatric Sepsis Consensus Conference definition, a patient should have two of these features, one of which should be fever or abnormal white cell count, in the presence of infection. Every time a child who has symptoms or signs suggestive of infection is assessed, it is important to consider whether this could be sepsis. This may seem obvious in a child presenting with fever, but not all children with sepsis present with high fever or focal signs.

Non-motor symptoms may herald Parkinson’s disease

20 Dec 2017Paid-up subscribers

While the three cardinal motor symptoms of Parkinson’s disease (PD), bradykinesia, rigidity and tremor, are key to the diagnosis of the condition, there is evidence that non-motor symptoms start long before motor features arise. Two of these in particular, REM sleep behaviour disorder and olfactory dysfunction, have been strongly associated with the development of PD. Non-motor symptoms are increasingly recognised as main features of PD with a high impact on quality of life. Their progression has been shown to be independent of motor deterioration. Sleep, GI and attention/memory problems become more prevalent over time, whereas psychiatric and cardiovascular problems become less prevalent.

Recognising the pattern of hair loss key to managing alopecia

23 Nov 2017Registered users

Alopecia affects up to 50% of men and women at some time in their lives. In primary care the first step is to establish whether hair loss is focal or diffuse and if focal whether it is scarring or non scarring. It is usually possible to establish the pattern of hair loss from a combination of the history and clinical examination. Dermatoscopic examination and pull testing can be useful in confirming the diagnosis. If hair loss is accompanied by scaling or significant inflammation it is important to exclude infective causes.

Have a high index of suspicion for sepsis in primary care

23 Oct 2017Paid-up subscribers

The incidence of sepsis in the UK is estimated at 200,000 cases a year. Around 70% of cases of sepsis originate in the community. Most infections are self-limiting and can be managed outside hospital. However, patients with sepsis will deteriorate rapidly and each hour of delay to antibiotic administration is linked to decreased survival by 7.6%. Infants (< 1 year) and the elderly (> 75 years) seem to be far more likely to progress to sepsis than others. The assessment of sepsis in primary care should be standardised and include measurement of temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults.

Diagnosing childhood eczema can be challenging

25 Sep 2017Registered users

Atopic eczema is the most common endogenous type of eczema in infants and children and affects around 15-20% of school-age children in the UK. Its prevalence is highest in children under the age of two and subsequently diminishes with age. It has a chronic, relapsing course. An emergency referral to a dermatologist or paediatrician should be made via telephone when there is a suspicion of eczema herpeticum or eczema coxsackium. Other indications for referral include diagnostic uncertainty, recurrent secondary infection, when control remains poor despite topical treatments, and for patients with emotional distress or significant sleep disturbance.

Timely diagnosis of heart failure can improve prognosis

28 Jul 2017Paid-up subscribers

Heart failure is a common, complex clinical syndrome resulting from the impaired ability of the heart to cope with the metabolic needs of the body, leading to breathlessness, fatigue and fluid retention. It is a progressive disease characterised by high levels of morbidity and mortality. Measuring plasma levels of natriuretic peptides is recommended for ruling out heart failure, as patients with normal levels are unlikely to have heart failure. An echocardiogram is indicated if the natriuretic peptides are elevated, or natriuretic peptide testing is not available.

Aerobic exercise can improve sleep and pain in fibromyalgia

22 Jun 2017Paid-up subscribers

Fibromyalgia is a chronic condition characterised by regional pain at multiple sites, non-restorative sleep and fatigue. In the UK, it is a common cause of musculoskeletal pain and significant disability, affecting around 2% of the population. It has a female preponderance with a female to male ratio of 7:1. Self-help strategies are important. There is strong evidence of benefit from a slow graded increase in daily aerobic exercise which can increase delta sleep and restore descending pain inhibition mechanisms. Sleep hygiene should also be considered to promote delta sleep.

Early referral improves long-term outcomes in rheumatoid arthritis

23 May 2017Paid-up subscribers

Rheumatoid arthritis is a common, chronic systemic inflammatory disease of unclear aetiology leading to synovial hypertrophy and joint inflammation. It typically presents with symmetrical polyarthritis of small joints of the hands or feet, but can also involve larger joints, and have associated extra-articular manifestations. Diagnosis is based on duration of symptoms, joint distribution, level of inflammatory markers and autoantibodies. The presence of synovitis or effusion is essential for diagnosis. Early referral of patients with suspected synovitis results in significant improvements in long-term outcomes.

Improving pain control in diabetic neuropathy

22 Mar 2017Paid-up subscribers

Diabetic neuropathy is thought to affect 1.9% of the world’s population and 50% of patients with a diagnosis of diabetes mellitus which would equate to 2.25 million people in the UK. The term diabetic neuropathy includes multiple distinct clinical entities that have been classified under the broad headings of focal and multifocal neuropathies and symmetrical neuropathies. Peripheral diabetic neuropathy, a chronic distal symmetrical predominantly sensory neuropathy, is the most common form of diabetic neuropathy. The common presentation is of painful symptoms originating in the feet, that then spread to the knees before involving the distal portion of the upper limbs in a ‘glove and stocking’ distribution.

Be vigilant for skin manifestations of inherited cancer syndromes

23 Jan 2017Registered users

More than 200 hereditary cancer susceptibility syndromes have been described, and it is thought that they account for 5-10% of all cancers. Many have dermatological manifestations (usually lesions, occasionally rashes) which frequently precede other systemic pathology. Dermatological signs are usually non-specific and often trivial in appearance, making their significance easy to overlook and a clinical diagnosis challenging.

Improving the identification and monitoring of cirrhosis

23 Nov 2016Paid-up subscribers

Morbidity and mortality associated with cirrhosis are on the increase. Cirrhosis generally results from chronic liver damage over many years. Common causes include: alcohol misuse, hepatitis B (± delta) and hepatitis C and non-alcoholic fatty liver disease. Patients with confirmed cirrhosis should be assessed for potential complications (ascites, encephalopathy, oesophageal varices or hepatocellular carcinoma). Reviewing cirrhotic patients regularly in primary care provides a valuable opportunity to ensure hepatocellular carcinoma and variceal surveillance is being undertaken and to give advice on losing weight or reducing alcohol intake.

Managing actinic keratosis in primary care

24 Oct 2016Registered users

Actinic, or solar, keratosis is caused by chronic ultraviolet-induced damage to the epidermis. In the UK, 15-23% of individuals have actinic keratosis lesions. Dermatoscopy can be helpful in excluding signs of basal cell carcinoma when actinic keratosis is non-keratotic. It is always important to consider the possibility of squamous cell carcinoma. The principal indication for referral to secondary care is the possibility of cutaneous malignancy. However, widespread and severe actinic damage in immunosuppressed patients also warrants referral.

Set individualised targets for patients with type 2 diabetes

23 Sep 2016Paid-up subscribers

In type 2 diabetes regular physical activity totalling 30 minutes most days of the week improves muscle insulin sensitivity, lipid profile and blood pressure although a total of 60-75 minutes a day is required for weight reduction and better metabolic profiles. NICE guidelines acknowledge the need for individualised treatment targets. Lowering HbA1c is beneficial in reducing microvascular complications and may have macrovascular benefits in the long term. However, intensive glycaemic control in the elderly with more advanced disease may not have similar benefits and poses a risk due to hypoglycaemia.

Have a high index of suspicion for meningitis in adults

01 Aug 2016Registered users

Bacterial meningitis and meningococcal sepsis are rare in adults. Any diagnostic delays with subsequent delay to treatment can have disastrous consequences. The classic triad of neck stiffness, fever and altered consciousness is present in < 50% of cases of bacterial meningitis. Patients with viral meningitis also present with signs of meningism (headache, neck stiffness and photophobia) possibly with additional non-specific symptoms such as diarrhoea or sore throat. Suspected cases of meningitis or meningococcal sepsis must be referred for further assessment and consideration of a lumbar puncture.

Identifying patients with complex PTSD

01 Aug 2016Registered users

Type 2 or complex trauma results from multiple or repeated traumatic events occurring over extended periods. Complex trauma is often associated with other adversity and stressors such as neglect, loss or deprivation. For many individuals these traumas occur at a developmentally vulnerable time with the perpetrator often in a caregiving role. Patients who have experienced complex trauma should be assessed for the core symptoms of PTSD. In addition, patients should be assessed for disturbances in the three domains of emotional dysregulation, negative self-concept and interpersonal disturbances.

Erectile dysfunction heralds onset of cardiovascular disease

23 Jun 2016Registered users

Erectile dysfunction (ED) has been shown to share risk factors with cardiovascular disease including age, diabetes mellitus, smoking, hypertension and hypercholesterolaemia, suggesting an underlying vascular pathology. Evidence reveals that there is a potential link between ED and subsequent development of coronary artery disease. ED itself may also increase cardiovascular risk. As ED often predates the development of coronary artery disease this provides GPs with a valuable window of opportunity for risk assessment, subsequent primary prevention and early referral to a cardiologist.

Careful assessment the key to diagnosing adolescent heel pain

23 May 2016Registered users

The most common cause of adolescent heel pain is calcaneal apophysitis also known as Sever’s disease. Sever’s disease, Osgood Schlatter’s disease (tibial tuberosity) and Sinding-Larsen Johansson syndrome (distal patella) are all overuse syndromes brought about by repetitive submaximal loading and microtrauma. They are, however, entirely self-limiting and resolve at skeletal maturity or earlier. Careful assessment is required to differentiate them from other rare pathologies.

Managing patients with hidradenitis suppurativa

23 May 2016Paid-up subscribers

Hidradenitis suppurativa affects the apocrine-bearing areas of the skin. The onset is variable but usually occurs in the second and third decades of life, coinciding with development of the apocrine glands. The condition is characterised by painful, inflammatory papules and nodules which frequently progress to form abscesses, sinus tracts and hypertrophic scars.The most important non-genetic factors implicated in hidradenitis suppurativa are obesity and smoking.

Rapid diagnosis vital in thunderclap headache

25 Apr 2016Registered users

Thunderclap headache is a severe and acute headache that reaches maximum intensity in under one minute and lasts for more than five minutes. Thunderclap headaches may be associated with symptoms such as photophobia, nausea, vomiting, neck pain, focal neurological symptoms or loss of consciousness. Subarachnoid haemorrhage (SAH) accounts for 10-25% of all thunderclap headaches and, despite advances in medical technology, has a 90-day mortality of 30%. Up to a quarter of cases of SAH are misdiagnosed, often through failure to follow guidance.

 

Early diagnosis of oesophageal cancer improves outcomes

21 Mar 2016

There are two main types of oesophageal cancer, oesophageal squamous cell carcinoma and oesophageal adenocarcinoma. They present in the same manner and both carry a five-year survival of only 16%. Oesophageal cancer commonly presents with dysphagia or odynophagia. This can be associated with weight loss and vomiting. All patients with recent onset dysphagia should be referred for rapid access endoscopy. Referral for urgent endoscopy should still be considered in the presence of dysphagia regardless of previous history or medication. Dysphagia is not always present so all patients with alarm symptoms should be considered for endoscopy.

Tailor systemic therapy to the patient with severe psoriasis

22 Feb 2016Paid-up subscribers

There is no standard definition regarding the severity of psoriasis, and a number of factors should be considered, including the extent and stability of skin disease, involvement of joints, response to treatment, and impact on quality of life. Erythrodermic psoriasis and pustular psoriasis are severe conditions and the patient may be systemically unwell and febrile.

Improving the detection and management of type 1 diabetes

25 Jan 2016Registered users

Type 1 diabetes affects around 370,000 adults in the UK, about 10% of all those diagnosed with diabetes. In type 1 diabetes there is a lack of beta cell insulin secretion as a result of autoimmune destruction of the beta cells. However, patients are not affected by insulin resistance, and so do not routinely experience the features of metabolic syndrome that occur in type 2 diabetes. It is therefore important to classify the type of diabetes correctly and to recognise that type 1 diabetes is a condition with its own management requirements. Structured education is the cornerstone of care providing tools to allow effective self-management.