Rosacea is more common in women than men and occurs more frequently in fair-skinned individuals, usually in the middle years of life. It tends to localise to the cheeks, forehead, chin and nose, sometimes showing marked...Rosacea is more common in women than men and occurs more frequently in fair-skinned individuals, usually in the middle years of life. It tends to localise to the cheeks, forehead, chin and nose, sometimes showing marked asymmetry. Only very occasionally does it involve areas other than the face. Rosacea is usually characterised by erythematous papules, pustules, and occasionally plaques (papulopustular rosacea), which fluctuate in severity, typically on a background of erythema and telangiectasia. In some individuals, facial redness can be prominent and permanent (erythematotelangiectatic rosacea). Important distinguishing features from acne are a lack of comedones, absence of involvement of extra-facial areas, and the presence of flushing. Hypertrophy of facial sebaceous glands, sometimes with fibrotic changes, may result in unsightly thickening of the skin. Men, in particular, may develop marked enlargement and distortion of the nose. Occasionally, the predominant feature of rosacea is swelling of the eyelids and firm oedematous changes elsewhere on the face. Involvement of the eyes is an important, underdiagnosed complication that may result in significant ocular morbidity. Involvement of the external eye surfaces by rosacea usually necessitates ophthalmological advice. There is often no correlation between the degree of ocular and cutaneous rosacea, and ocular rosacea may occur alone. Rosacea is a disfiguring condition that can have a major psychosocial impact, and its detrimental effect on emotional health and quality of life is often overlooked.
Inherited heart conditions are the most common cause of sudden cardiac death in those under the age of 35 and the leading cause of non-traumatic death in young athletes. Hypertrophic cardiomyopathy (HCM) is the most comm...Inherited heart conditions are the most common cause of sudden cardiac death in those under the age of 35 and the leading cause of non-traumatic death in young athletes. Hypertrophic cardiomyopathy (HCM) is the most common inherited heart disease affecting 1 in 500 of the population. Some patients may exhibit severe left ventricular hypertrophy, others may show nothing more than an abnormal ECG. Left ventricular hypertrophy most commonly manifests in the second decade of life. Sudden death is rare and usually affects patients in the first three decades whereas older patients present with heart failure, atrial fibrillation and stroke. Arrhythmogenic right ventricular cardiomyopathy is a rare, autosomal dominant heart muscle disorder which affects between 1 in 1,000 and 1 in 5,000 of the population. Dilated cardiomyopathy (DCM) is characterised by a dilated left ventricle with impaired function that cannot be explained by ischaemic heart disease, hypertension or valvular heart disease. At least 25% of cases of DCM are familial. DCM may be associated with multisystem conditions such as muscular dystrophy. Chemotherapy and certain other drugs, alcohol abuse and myocarditis may also lead to a dilated and poorly contracting left ventricle. In many cases the first manifestation of an inherited cardiomyopathy can be a sudden cardiac arrest. Other presentations include chest pain or breathlessness during exertion, palpitations and syncope. In many of the cardiomyopathies, the diagnosis can be made with a standard ECG and echocardiogram. However if the diagnosis is not certain or the cardiologist wishes to look at the heart structure in greater detail, a cardiac MRI may be performed.
The lifetime risk of atrial fibrillation (AF) for men and women over the age of 40 is about 25%. The condition affects around 800,000 people in the UK, of which it is estimated that 250,000 are undiagnosed. A rapid heart...The lifetime risk of atrial fibrillation (AF) for men and women over the age of 40 is about 25%. The condition affects around 800,000 people in the UK, of which it is estimated that 250,000 are undiagnosed. A rapid heart rate may result in palpitations, dyspnoea or chest tightness, whereas loss of atrial contractility may lead to fatigue and reduced exercise capacity. There is a five-fold increased risk of ischaemic stroke, transient ischaemic attack or systemic embolism. AF strokes are larger, more disabling and have a higher mortality rate than those with other causes. The risk of stroke is not related to the presence or absence of symptoms, or whether the AF is paroxysmal or persistent. When an irregular pulse is detected it should precipitate further assessment with a 12-lead ECG. In patients with intermittent palpitations that may represent AF, prolonged ECG monitoring can be used to increase the chance of diagnosis. In patients with a confirmed diagnosis of AF, three areas need to be considered, stroke risk, symptoms, and risk of tachycardia cardiomyopathy. The CHA2DS2-VASc score is used to assess the stroke risk in patients with AF. Oral anticoagulation should be offered to those with a CHA2DS2-VASc score of 2 or more, and considered for men with a score of 1. The risk of severe bleeding with warfarin should also be assessed using the HAS-BLED score. A score of 3 or more indicates that caution is required when starting any anticoagulant therapy. Oral anticoagulant therapy can reduce the risk of stroke by around 50-70%. It should be started when the patient reaches 65 or if he/she develops any of the risk factors for stroke.
The UK has one of the highest death rates in Europe from asthma, with more than 20 people dying from the disease each week. Across the UK there is a five-fold variation in the number of hospital admissions for asthma alm...The UK has one of the highest death rates in Europe from asthma, with more than 20 people dying from the disease each week. Across the UK there is a five-fold variation in the number of hospital admissions for asthma almost certainly explained in part by variations in delivery, uptake and organisation of care. Deaths from asthma are frequently avoidable the findings from the National Review of Asthma Deaths have confirmed. A total of 276 cases were considered by the confidential enquiry panels and 195 confirmed as asthma deaths. Major avoidable factors were judged to be present in 60% of cases. Key findings from the report include: Almost half the patients (45%) died without seeking medical help or before help could be provided; 10% died within 28 days of discharge from hospital; 21% had attended A&E with asthma in the previous year; and only 23% had a personal asthma action plan. Over-prescription of short-acting bronchodilators and under-prescription of preventer inhalers was common. Every general practice should have a designated, named clinical lead for asthma services. Patients with asthma should be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids, oral or injected, in the previous 12 months or management using BTS steps 4 or 5 to achieve control. Any patient admitted to hospital or attending A&E with asthma should be reviewed, and control optimised, within a week of discharge. All asthma patients should have a written personal asthma action plan and should have a structured review by a healthcare professional with training. in asthma at least annually.
Migraine is a common neurovascular disorder characterised by attacks of head pain that are typically unilateral and often described as severe and throbbing in association with nausea and sensitivity to sensory input, i.e...Migraine is a common neurovascular disorder characterised by attacks of head pain that are typically unilateral and often described as severe and throbbing in association with nausea and sensitivity to sensory input, i.e. light, sound and head movement. The headaches typically last 4-72 hours, up to 31% of migraineurs have aura on some occasions. Migraine is commonly episodic. With an increasing intake of painkillers, patients often complain of an escalation of migraine attacks or a transformation to a chronic daily background pain with exacerbations. Acute painkiller use, both prescription and OTC, should be enquired about in all cases and medication overuse headache suspected and managed if patients are taking any acute painkiller excessively. Migraineurs should be encouraged to have regular habits. Regular sleep, exercise, meals, work habits and relaxation will be rewarded by a reduction in headache frequency. NICE guidelines recommend adopting the stepped-down approach to management. They suggest a combination of a triptan, NSAID or paracetamol, and an anti-emetic taken as early as possible during the headache. The decision to commence a preventative agent should depend on a combination of attack frequency, duration and severity, as well as response to abortive therapy and patient preference.
Although the patient's goal is often complete pain relief, this is rarely a realistic outcome, so the role of the physician in managing chronic pain involves optimising pain relief as far as possible. Careful explanation...Although the patient's goal is often complete pain relief, this is rarely a realistic outcome, so the role of the physician in managing chronic pain involves optimising pain relief as far as possible. Careful explanation and education may be needed to enable the focus to shift from cure to better management of pain, and improvement of function and quality of life. Chronic pain is defined as pain continuing beyond the normal time for tissue healing. Pain may be broadly classified on the basis of mechanism, as neuropathic, nociceptive or mixed. A thorough biopsychosocial assessment is essential so that an individualised multidisciplinary approach to management can be developed. The aims of assessment of chronic pain are to rule out any underlying serious pathology, identify the pain mechanism and identify and evaluate risk factors that contribute to chronicity. SIGN emphasises the need for a multidisciplinary team approach to improve outcomes, and highlights five broad categories of care: supported self-management, drug treatment, psychologically-based interventions, physical therapies and complementary therapies. Exercise, regardless of its type and the source of pain, is recommended for the management of chronic pain. In chronic low back pain, exercise therapy can improve strength and range of motion across joints, cardiorespiratory fitness and sense of wellbeing. Pain management programmes reduce anxiety and depressive symptoms, increase function and improve mood. They may be considered in patients with poor functional capacity, pain-related social and occupational problems and in cases where other management strategies have failed.
In England there has been a sharp increase in the prevalence of overweight and obesity in adults. In 1993 58% of men and 49% of women were classified as overweight or obese compared with 65% and 58% respectively in 2011;...In England there has been a sharp increase in the prevalence of overweight and obesity in adults. In 1993 58% of men and 49% of women were classified as overweight or obese compared with 65% and 58% respectively in 2011; 24% of men and 26% of women were classed as obese in 2011. Body mass index (BMI) is the most commonly used measure to classify people into weight categories. While the use of BMI has limitations, as it does not take into account the difference between muscle and fat, it is a good quick indicator of increased risks. Obesity increases the risk of hypertension, coronary heart disease, deep vein thrombosis and pulmonary embolism. It is also associated with an increased risk of certain cancers. Obesity is an important risk factor for non-alcoholic fatty liver disease which if left untreated can progress to severe forms of liver disease, such as non-alcoholic steatohepatitis, fibrosis and cirrhosis. The risk of sleep apnoea is raised in obese individuals as is that for gastro-oesophageal reflux and gallstones, stress incontinence in women and erectile dysfunction in men. Lifestyle weight management programmes should be multicomponent, developed by a multidisciplinary team, and delivered by individuals who have undergone appropriate training. They should focus on long-term weight loss and prevention of weight regain and continue for a minimum of three months. Effective programmes include setting dietary targets, such as specific reductions in energy intake. Other options that GPs and practice nurses might offer within the practice, over and above referral to lifestyle programmes, include help with intermittent or regular motivational support, and/or drug therapy.
Gastric cancer often presents late and the mortality ratio remains one of the highest compared with more common cancers. Early diagnosis improves survival in this potentially curable cancer. Men are twice as likely as wo...Gastric cancer often presents late and the mortality ratio remains one of the highest compared with more common cancers. Early diagnosis improves survival in this potentially curable cancer. Men are twice as likely as women to develop gastric cancer. The vast majority (96%) of cases occur in people above the age of 55. Dysphagia, weight loss and age over 55 are significant predictors of cancer. All patients presenting with dyspepsia and either alarm features or known conditions that increase the risk of gastric cancer should be referred for urgent endoscopy. Given that the majority of gastric 0032-6518 cancer cases occur in people over 55, urgent endoscopy is also recommended in this group with new uncomplicated dyspepsia prior to treatment, even without alarm symptoms or if the symptoms respond to treatment. Upper GI endoscopy with biopsy is the recommended investigation to confirm gastric cancer. Patients deemed medically fit should undergo surgical resection to cure early gastric cancer and chemotherapy followed by surgical resection for higher stage tumours. More than half of all patients with gastric cancer present with incurable advanced disease; palliative chemotherapy has a small but significant effect on survival.
Cirrhosis is a condition that arises as a result of chronic liver damage, typically over many years. It is characterised by fibrosis and nodularity of the liver parenchyma. Cirrhosis interferes with the normal functions...Cirrhosis is a condition that arises as a result of chronic liver damage, typically over many years. It is characterised by fibrosis and nodularity of the liver parenchyma. Cirrhosis interferes with the normal functions of the liver, reducing its ability to produce proteins, which can lead to coagulopathy, low serum albumin and raised bilirubin. The incidence of cirrhosis is rising in the UK, this can primarily be attributed to increasing levels of alcohol consumption and obesity. Mortality from cirrhosis is also rising. Common causes of chronic liver disease include alcohol, non-alcoholic fatty liver disease and chronic viral hepatitis. Nearly half of patients with cirrhosis are asymptomatic. As a result the condition may only be discovered incidentally as a result of abnormalities in liver function tests or imaging of the abdomen performed for other reasons. Alternatively patients may present with signs and symptoms of the complications of cirrhosis e.g. jaundice, ascites, variceal bleeding, hepatic encephalopathy or hepatocellular carcinoma. Detecting patients with cirrhosis in primary care usually relies on identifying common risk factors. Currently, there are no standard criteria for the investigation of patients with suspected cirrhosis. If a patient is suspected of having cirrhosis, most GPs will arrange for blood tests and an ultrasound of the liver to be performed. The gold standard test for the diagnosis of cirrhosis remains a liver biopsy. Staging of liver fibrosis is an important predictor of prognosis and is necessary to guide management.