Practitioner最新文献

Polymyalgia rheumatica (PMR) is a common inflammatory condition of unknown aetiology with a prevalence of 1 in 133 in the over 50s, and a female to male ratio of 2:1. Symptoms develop over a matter of weeks; typically bilateral shoulder or pelvic girdle pain and stiffness, that is worse in the mornings. Associated symptoms include low-grade fever, malaise, fatigue, low mood, poor appetite, and weight loss. There is no specific diagnostic test for PMR but the usual pattern is a commensurate rise in CRP and ESR. A small proportion of PMR patients will have normal inflammatory markers. PMR is associated with giant cell arteritis (GCA). Half of patients with GCA will have some PMR symptoms and up to one fifth of patients with PMR will have evidence of GCA. Other conditions that can mimic PMR include: rheumatic disease in the elderly e.g. rheumatoid arthritis; inflammatory muscle diseases; thyroid disease; malignancy; infection; bilateral shoulder capsulitis; osteoarthritis, Parkinsonism and depressive illness. At diagnosis and each follow-up visit it is imperative to consider the potential for associated GCA. The patient should be asked about headaches, jaw claudication and visual disturbance. If there is any suspicion of GCA, urgent discussion with the rheumatologist should take place that day.

Osteoarthritis has become a major chronic pain condition. It affects more than 10% of adults and accounts for almost 10% of health service resources. The impact of osteoarthritis is amplified by underuse of effective muscle strengthening exercises and a focus on often less effective and poorly tolerated analgesic therapies. Although traditionally considered to be primarily a disease of cartilage, there is now ample evidence that typical clinical osteoarthritis involves multiple tissue pathologies. Increased BMI is associated with a higher incidence of knee osteoarthritis. Anatomical abnormalities such as valgus alignment or previous joint trauma including meniscectomy, anterior cruciate ligament rupture and fracture through the joint are also associated with increased incidence of osteoarthritis. Pain is the main presenting symptom. However, we still have a poor understanding of the causes of pain in osteoarthritis. In patients aged 45 or over the diagnosis should be made clinically without investigations if the patient has activity-related joint pain in addition to early morning joint stiffness lasting less than 30 minutes. Muscle strengthening and aerobic exercise have been shown to improve joint pain and function. Weight loss not only improves joint pain and function but has a myriad of other health benefits, reducing the incidence of lifestyle associated diseases such as cardiovascular disease and type 2 diabetes, and mechanical stress on the joints.

The close proximity of contraceptive implant placement to the course of the ulnar nerve can result in injury. Several factors have been implicated in this complication including: low BMI, erroneous placement of the implant, implantation over the brachial groove, and migration of the implant from its original insertion. Clinicians should familiarise themselves with the vulnerable neurovascular structures in the area and refer promptly to a specialist if any neurological symptoms develop during placement or removal of these devices. The prognosis following nerve injury is related to the anatomical site, pathophysiological depth of injury and delay between injury and treatment. Minor injury (neurapraxia) results from ischaemia or oedema within the nerve. In more severe injuries there is axonal damage resulting in Wallerian degeneration. The axonal damage affects all nerve fibre subtypes and as a result there is usually neuropathic pain and loss of autonomic sudomotor and vasomotor function in the cutaneous territory of the affected nerve. Loss of these autonomic supplies results in disruption of function of sweat glands and blood flow regulation which manifests as dry erythematous skin. High-grade nerve injury with axonal degeneration should be suspected when there is neuropathic pain, autonomic dysfunction and a positive Tinel’s sign (pain in the territory of the nerve elicited by gently tapping over the site of suspected injury). The British Orthopaedic Association recommends prompt referral for specialist assessment when there is motor or sensory dysfunction in the territory of a nerve following an intervention in proximity to the nerve. Early recognition and intervention may prevent further degeneration and improve outcomes.

More than 25% of the world population has been infected with tuberculosis (TB), however only 10% of those infected will ever develop active disease. Clinically significant disease occurs through progression of primary infection or through later reactivation of latent TB infection (LTBI); this is most likely to occur in the first few years following infection, although late reactivation can occur several decades later, particularly in individuals who become immunosuppressed. Risk of TB acquisition is increased in people who have come to the UK from high incidence countries or who are born in the UK but come from high-risk ethnic minority groups. In 2015, 73% of those diagnosed with active TB were born outside the UK. Other risk groups include those who are homeless, in prison or who misuse drugs or alcohol. Once infected people who are immunosuppressed are at greater risk of progression to active disease. Infants below the age of 12 months can develop rapidly progressive and potentially fatal infection. Initial clinical assessment with chest radiography and the collection of three deep respiratory samples for smear microscopy and culture remain the standard of care. The management of active TB has not changed significantly over many years. The most significant changes in the 2016 NICE guidance relate to screening for LTBI in individuals who are contacts of a patient with active TB, or who are recent entrants to the UK from a high incidence country. NICE recommends that only contacts of patients with active pulmonary or laryngeal TB be screened.