Chronic hepatitis C (HCV) infection affects 0.8-1.0% of the UK population, with up to 70% having ongoing chronic infection. HCV is curable but if left untreated can progress to end stage liver disease and potentially hep...Chronic hepatitis C (HCV) infection affects 0.8-1.0% of the UK population, with up to 70% having ongoing chronic infection. HCV is curable but if left untreated can progress to end stage liver disease and potentially hepatocellular carcinoma. HCV management options have changed dramatically over the past five years, with improvement in cure rates and tolerability; cure rates of more than 90% can now be achieved. The main risk factors for acquiring HCV infection in the UK are injecting drug use and sharing drug using equipment. Other risk factors include receipt of blood products in the UK before 1991; tattooing or acupuncture with non-sterile equipment; medical procedures; needlestick injuries and contact with blood from an infected person. Acute hepatitis C infection has mild symptoms only and is likely to go undiagnosed. The estimated diagnosis rate in England is 35%, suggesting that 65% of the total HCV-positive population remains undiagnosed. The most common method of detecting HCV is case finding in high- risk groups. Those who test positive for HCV antibodies should be tested for persisting viral presence through HCV PCR testing - a positive result confirms active infection. GPs can play a major role in identifying those at risk of the disease, which includes patients with known risk factors and those with unexplained abnormal liver function tests, providing information and arranging testing. Patients with confirmed active HCV infection should be referred to the local specialist hepatology or infectious disease service in accordance with locally agreed pathways.
Asthma affects 5.4 million people in the UK, around 1 in 12 of the population. Between 5 and 10% of asthma (depending on the definition used) is categorised as difficult asthma, a term which generally refers to patients...Asthma affects 5.4 million people in the UK, around 1 in 12 of the population. Between 5 and 10% of asthma (depending on the definition used) is categorised as difficult asthma, a term which generally refers to patients who continue to experience symptoms and frequent exacerbations despite the prescription of high-dose asthma therapy. Difficult asthma is an indication for specialist review by an appropriate respiratory physician, but close liaison between primary, secondary and tertiary care is critical and it is therefore important that primary care health professionals should be aware of the principles of management. One of the most important questions to ask is whether the individual with difficult asthma is taking their treatment Identifying this, however, is not easy. GPs could assess prescription uptake, looking for low use of preventers and excess use of short-acting bronchodilators. Newer means of assessing adherence have been developed. Inhaler devices that can monitor completion and timing of actuations have been produced. Meters that measure FeNO are available. A recent UK study found that 12 out of 100 patients referred for difficult asthma did not have reversible airflow obstruction or a history suggestive of asthma. Diagnoses included COPD, cystic fibrosis, cardiomyopathy, respiratory muscle dysfunction and severe anxiety with vocal cord dysfunction.
COPD is a progressive condition. Therefore, earlier diagnosis allows earlier intervention in particular smoking cessation. Stopping smoking in early middle age where an individual has relatively mild COPD is associated w...COPD is a progressive condition. Therefore, earlier diagnosis allows earlier intervention in particular smoking cessation. Stopping smoking in early middle age where an individual has relatively mild COPD is associated with a slower decline in lung function and reduced mortality. Spirometry should be performed in symptomatic current or former smokers (typically ≥ 10 pack years) who are aged at least 35 where COPD is a likely differential diagnosis. Once airflow obstruction is proven and a diagnosis of COPD established then a measure of COPD severity can be made based on FEV1 expressed as a percentage of predicted value. When an individual with COPD is assessed it is vital that comorbid conditions are considered and management optimised. Cardiovascular disease and diabetes were seen most commonly in people enrolled in the active and sometimes sleep. The COPD Assessment Tool is a simple measure of health status that takes under five minutes to complete. Performing spirometry each year can identify patients with a rapid, progressive decline in lung function and allow this to be addressed. Inhaler technique should be checked at this review and also when a new type of inhaler is commenced.
Dermatophyte fungi are confined to the keratin layer of the epidermis and include three genera: Microsporum, Epidermophyton and Trichophyton. These infections can be transmitted by human contact (anthropophilic), from th...Dermatophyte fungi are confined to the keratin layer of the epidermis and include three genera: Microsporum, Epidermophyton and Trichophyton. These infections can be transmitted by human contact (anthropophilic), from the soil (geophilic) and by animal (zoophilic) spread. Dermatophyte infections usually present as an erythematous, scaly eruption, which may or may not be itchy. Asymmetry is an important clinical clue to fungal infection, as is annular morphology. Examination under ultraviolet (Wood's light) can be helpful. The gold standard for diagnosing cutaneous fungal infections is microscopy and culture of scale, hair or nail, and a definite diagnosis is desirable before commencing treatment, especially with oral therapy. Any dermatophyte species affecting the body can affect the hands. The most common organism is T. rubrum. Tinea corporis infection affects the trunk mainly in children and adolescents, and all genera of dermatophyte can cause it. Tinea cruris infection involves the groin region and is more common in men than women. T. rubrum is the most common causative dermatophyte. The clinical features of tinea capitis include patchy hair loss with varying degrees of scale, erythema and pustules. Infected hairs tend to break at the base, leaving stubble. Occasionally, there is invasion of the visible epidermis, resulting in a boggy, painful swelling with associated alopecia and regional lymphadenopathy known as a kerion.
Webb J, Jackson T, Claridge S
… +3 more, Sammut E, Behar J, Carr-White G
Practitioner
· 2015 Oct · PMID 26738248
Heart failure affects nearly one million people in the UK. Half of these patients have normal, or near normal, left ventricular ejection fraction and are classified as heart failure with preserved ejection fraction (HFpE...Heart failure affects nearly one million people in the UK. Half of these patients have normal, or near normal, left ventricular ejection fraction and are classified as heart failure with preserved ejection fraction (HFpEF). Newer imaging techniques have confirmed that systolic function in HFpEF patients is not completely normal, with reduced long axis function and extensive but subtle changes on exercise. Patients are likely to be older women with a history of hypertension. Other cardiovascular risk factors, such as diabetes mellitus, atrial fibrillation and coronary artery disease are prevalent in the HFpEF population. Clinical symptoms and signs in HFpEF are often nonspecific although the primary symptoms are breathlessness, fatigue and fluid retention. There is still no single diagnostic test for HFpEF and the cornerstone in the assessment remains a thorough medical history and physical examination. The duration and extent of the symptoms are relevant and it is useful to classify patients according to the NYHA functional assessment. Physical examination should include the patient's BMI and weight, heart rate and rhythm, lying and standing blood pressure and auscultation to rule out valvular disease and pulmonary congestion. Estimating the jugular venous pressure and the presence of peripheral oedema allows assessment of the patient's volume status. Patients with heart failure should be referred to heart failure nurses and have follow-up with local cardiology services as these have both been shown to reduce mortality.
Regular physical activity controls acquired cardiovascular risk factors such as obesity, diabetes mellitus, hypertension and hyperlipidaemia. Exercise is generally associated with a 50% reduction in adverse events from c...Regular physical activity controls acquired cardiovascular risk factors such as obesity, diabetes mellitus, hypertension and hyperlipidaemia. Exercise is generally associated with a 50% reduction in adverse events from coronary artery disease (CAD). The benefits of exercise extend well beyond the cardiovascular system. Recent evidence suggests that exercise prevents cell senescence, and active individuals are at lower risk of developing certain malignancies including cancer of the prostate and the colon, osteoporosis, depression and dementia. Individuals who exercise regularly extend their life expectancy by three to seven years. Healthy individuals should engage in 150 minutes of moderate-intensity, aerobic exercise per week. Recent studies have demonstrated that even lower volumes of exercise below these recommendations confer health benefits, which is highly relevant to individuals with established cardiac disease including heart failure. Sudden cardiac death in athletes under 35 is rare with.estimates ranging from 1 in 50,000 to 1 in 200,000. Hereditary and congenital abnormalities of the heart are the most common cause of nontraumatic death during sport in young athletes. In middle-aged recreational athletes more than 90% of sudden cardiac deaths occur in males and more than 90% are caused by atherosclerotic CAD. The AHA and the ESC advocate pre-participation screening of young athletes. The ECG has the ability to detect congenital accessory pathways and ion channelopathies, and is frequently abnormal in individuals with cardiomyopathy. Screening with a 12-lead ECG in older athletes is of limited value given the overwhelming contribution of atherosclerotic CAD to sudden cardiac death.
It is important to distinguish between diverticulosis, the presence of asymptomatic diverticula, and diverticular disease which refers to symptomatic cases which can present with acute or chronic symptoms. Chronic sympto...It is important to distinguish between diverticulosis, the presence of asymptomatic diverticula, and diverticular disease which refers to symptomatic cases which can present with acute or chronic symptoms. Chronic symptoms range from mild intermittent abdominal cramps to the more severe picture of chronic abdominal pain and occasional rectal bleeding. In contrast, acute diverticulitis refers to acute inflammation in the diverticula. Low dietary fibre intake is reported to increase the risk of diverticular disease. In the UK, the prevalence rises from approximately 5% of people in their 40s to almost 50% of those above the age of 80. It is estimated that 20% of patients with diverticulosis will develop symptoms at some point in their lifetime. Diverticular disease can be confirmed radiologically or endoscopically. Referral of patients with symptomatic diverticular disease to secondary care is not indicated unless: the symptoms affect their quality of life; the pain is not controlled by paracetamol; new symptoms develop which require further investigation; there are concerns about the possibility of an alternative diagnosis or patients develop red flag symptoms. Even in patients with established diverticulosis, a change in the clinical picture with development of red flag symptoms warrants urgent referral to rule out lower gastrointestinal malignancy. Patients with suspected uncomplicated acute diverticulitis should be assessed according to their level of pain and associated systemic features of sepsis. In those where pain is controlled and there are no signs of systemic sepsis or multiple comorbidities, the patient may be treated in primary care.
In around 85% of cases, multiple sclerosis (MS) starts with an acute neurological episode, a clinically isolated syndrome, which is considered to be the first clinical episode of relapsing-remitting MS (RRMS). It is char...In around 85% of cases, multiple sclerosis (MS) starts with an acute neurological episode, a clinically isolated syndrome, which is considered to be the first clinical episode of relapsing-remitting MS (RRMS). It is characterised by the presence of acute relapses, after which there is normally good functional recovery. About 15-20 years after symptom onset, most patients develop secondary progressive MS, characterised by a gradual and irreversible neurological decline. MS affects women more frequently than men, with a ratio of 2-3:1. In RRMS the disease generally starts in the late 20s. Symptom onset in those with primary progressive MS occurs around the age of 40. Clinical relapses in RRMS reflect acute inflammation in the CNS, resulting in specific clinical syndromes including optic neuritis, myelitis, brainstem/cerebellum syndrome and supratentorial syndrome. In progressive MS, progression generally presents with gradual loss of power in the lower limbs, which may be asymmetric. It is often accompanied by sensory disturbances in the lower limbs, bladder and bowel symptoms. Investigations need to rule out conditions that can mimic an inflammatory-demyelinating disease of the CNS and determine the presence of dissemination in space and dissemination in time of the inflammatory-demyelinating disease. There is no confirmatory test for MS and it remains essentially a clinical diagnosis.
The diagnosis of epilepsy carries significant implications for physical, psychosocial and financial wellbeing as well as a small but significant increased risk of mortality. The diagnosis is often incorrect, potentially...The diagnosis of epilepsy carries significant implications for physical, psychosocial and financial wellbeing as well as a small but significant increased risk of mortality. The diagnosis is often incorrect, potentially in up to 20% of cases, so should be revisited if seizures are not responding to treatment. Evidence indicates that misdiagnosis is significantly more common among nonspecialists. SIGN recommends that the diagnosis of epilepsy should be made by an epilepsy specialist, ideally in the setting of a dedicated first seizure or epilepsy clinic. An incorrect diagnosis of epilepsy can be harmful. There is an exhaustive list of epilepsy mimics that can result in misdiagnosis and expose patients to unnecessary treatment with antiepileptic drugs. Diagnosis relies primarily on the history. Investigations can support the diagnosis but cannot make it in isolation, and negative investigation findings are common in epilepsy. Brain imaging will be undertaken in most patients with epilepsy, but is not routinely required in those with a definite diagnosis of genetic generalised epilepsy. The EEG has limitations and can sometimes cloud rather than clarify the diagnostic picture. Distinguishing between a genetic generalised epilepsy and a focal epilepsy is vital as this influences investigation, treatment and prognosis. Generally medication should not be started following a single seizure except in specific circumstances or in cases where the risk of recurrence is high.