Practitioner最新文献

Thunderclap headache is a severe and acute headache that reaches maximum intensity in under one minute and lasts for more than five minutes. 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. Thunderclap headaches may be associated with symptoms such as photophobia, nausea, vomiting, neck pain, focal neurological symptoms or loss of consciousness. SAH is more likely if there are neurological abnormalities or reduced consciousness. Loss of consciousness at onset is a poor prognostic indicator with a 2.8-fold increase in risk of death. All patients with suspected SAH should undergo a non-contrast CT brain scan as soon as possible after the onset of pain as the sensitivity of CT drops with time. A negative CT is not sensitive enough to exclude SAH and must be followed with lumbar puncture at least 12 hours after onset of the headache. If SAH is excluded then further investigations, in particular MRI brain and vascular imaging with MRI or CT angiography, should be considered to exclude other aetiologies. Headaches, caused by cervical artery dissection are most commonly of gradual onset but up to 20% of patients complain of thunderclap headache.

The prostate specific antigen (PSA) test clearly provides the opportunity for clinically relevant prostate cancer to be detected at a stage when treatment options are greater and outcomes may be improved. However, in some patients the PSA test may lead to investigations which can identify clinically insignificant cancers which would not have become evident in a man's lifetime. In addition, a raised PSA may often indicate benign prostatic enlargement, and this may provide an opportunity for treatment of this condition before complications develop. The lack of sensitivity and specificity that characterises PSA testing in the initial diagnosis of prostate cancer largely disappears after treatment of localised prostate cancer, especially after surgery. Three monthly PSA measurement is usually recommended for the first year after primary treatment. Subsequently less frequent testing is required. A PSA rise after primary treatment usually indicates biochemical recurrence and often the need for further therapy. There are two promising urinary RNA biomarkers, prostate cancer antigen 3 (PCA3) and fusion gene TMPRSS2:ERG, both of which aim to distinguish between men with low-risk (indolent) and those with aggressive (clinically significant) cancers.

Male lower urinary tract symptoms (LUTS) are common and increase in prevalence with age. Up to 90% of men aged 50 to 80 may suffer from troublesome LUTS. Men may attend expressing direct concern about micturition, describing one or more LUTS and the related impact on their quality of life. Frequently men may present for other medical or urological reasons such as concern regarding their risk of having prostate cancer or erectile dysfunction but on taking a history bothersome LUTS are identified. Men may present late in the community with urinary retention: the inability to pass urine. A thorough urological history is essential to inform management. It is important to determine whether men have storage or voiding LUTS or both. All patients must have a systematic comprehensive examination including genitalia and a digital rectal examination. Investigations performed in primary care should be guided by the history and examination findings, taking into account the impact of the LUTS on the individual's quality of life. Current NICE guidelines recommend the following to be performed at initial assessment: frequency volume chart (FVC); urine dipstick to detect blood, glucose, protein, leucocytes and nitrites; and prostate specific antigen. Men should be referred for urological review if they have: bothersome LUTS which have not responded to conservative management or medical therapy; LUTS in association with recurrent or persistent UTIs; urinary retention; renal impairment suspected to be secondary to lower urinary tract dysfunction; or suspected urological malignancy. All patients not meeting criteria for immediate referral to urology can be managed initially in primary care. Based on history, examination and investigation findings an individualised management plan should be formulated. Basic lifestyle advice should be given regarding reduction or avoidance of caffeinated products and alcohol. The FVC should guide advice regarding fluid intake management and all medications should be reviewed.

There are two main types of oesophageal cancer, oesophageal squamous cell carcinoma (OSCC) and oesophageal adenocarcinoma (OAC). They present in the same manner and both carry a five-year survival of only 16%. In the UK there is a 2:1 male to female ratio for oesophageal cancer. Peak incidence at presentation is in the 65-75 age group, with 95% of cases presenting in those over 50. Smoking is a major risk factor for both types and is linked to an estimated 66% of cases in the UK. OSCC is linked to alcohol, smoking, and chewing betel quid. OAC is associated with the presence of GORD, and its duration, and obesity (especially increased waist circumference). 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. NICE recommends referral for urgent direct access upper GI endoscopy to assess for oesophageal cancer for patients with dysphagia or aged 55 and over with weight loss and any of the following: upper abdominal pain; reflux; dyspepsia.

CVD remains the most common cause of mortality in women. In 2007, the annual mortality in women secondary to CAD was 4.7 times that of breast cancer. Around 2.8 million women are living with CVD in the UK. There has been an increase in the prevalence of MI in women aged 35 to 54, while a decline in prevalence was observed in age-matched men. Difficulty in evaluating symptoms of ischaemic heart disease in women is well documented and remains challenging because of their atypical nature. The main gender difference is that women tend to present less frequently with exertional symptoms of chest pain before an AMI. Although men and women share classic cardiovascular risk factors the relative importance of each risk factor may be gender specific. The impact of smoking is greater in women than men, especially in those under 50. Diabetes is a more potent risk factor for fatal CHD in women than men. Risk factors specific to women include postmenopausal status, hysterectomy and complications during pregnancy. Women who develop gestational diabetes mellitus or pre-eclampsia more than double their risk of CVD later in life. Transition to the menopause is associated with a worsening CHD risk profile. After the menopause women may experience an increase in weight, alteration in fat distribution and an increase in other CVD risk factors such as diabetes and a more adverse lipid profile. Pharmacological stress testing is preferred for diagnosing CAD in females with lower exercise capacity. Stress cardiomyopathy is triggered by intense, unexpected emotional or physical stress and is characterised by transient apical systolic dysfunction or ballooning of the left ventricle. The syndrome predominantly affects postmenopausal women. Women presenting with STEMI have worse outcomes compared with men. However, in those presenting with NSTEMI there were no differences in outcomes.