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International Primary Care Association
 
 
 

Clinical Focus Volume 6 N3

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Editor Admin

Febrile seizures affect about one in 30 pre-school children. The peak incidence is at 18 months and they are most common between the ages of 6 months and 6 years. Causation is probably multifactorial with environmental factors and genetic factors playing a part. The immaturity of both the immune system and brain probably contribute to the phenomenon. Most febrile seizures are generalised tonic-clonic seizures, and about 30-35% have one or more complex features (focal onset, duration >10 minutes, or multiple seizures during one illness episode). Complex seizures augment both recurrence risk and the chance of developing a future epilepsy. Rarely, recurrent febrile seizures may point to a family with genetic susceptibility genes (eg GEFS+) often involving mutations in sodium channel genes, important for neurotransmission. Most children with febrile seizures do not require hospital admission. Clinical assessment should include scrutiny of risk factors for central nervous system infection.

The mainstay of management in the acute stage is first-aid management of the airway, calming the situation and subsequently offering the family information. If they understand more it will add to their confidence in managing a possibly recurrence. An approach is suggested here on how a simple biological model might be used to aid understanding. There is no evidence-base to support the use of either prophylactic antipyretic or antiepileptic drugs to reduce recurrence risk. Rescue treatment in the form of buccal midazolam or rectal diazepam should be prescribed for those with a high recurrence risk. Rescue treatment should be used if the motor component of the seizure is lasting longer than 5 minutes or if the time of seizure onset is not known.

Parents should be reassured that having a single simple febrile seizure does not pose a threat to a child’s cognitive development. Recurrent seizures may be associated with language or memory impairment but there is no association with behaviour disorder or cognition. These risks can be discussed in an encouraging context as early identification can lead to the provision of early intervention and support, saving distress for the child.

The quality of prescribing would benefit patients and GPs as antidepressant prescriptions have doubled to 61 million in the last 10 years. The “net ingredients cost” (NIC) of drugs to treat depression was £284.7 million in 2015., the Health and Social Care Information Centre (HSCIC) figures show.

We would all like to promote evidence based treatments and hence aim to disregard emotive rhetoric as we move forward in to the realm of seamless care between physical and mental health. During our attempt below, we touched on specific advice in certain the age groups, though we recommend specialist advice for all groups. We did not discuss precautions needed for special patient groups, which may require antidepressant medication (e.g. poststroke depression, depression with psychotic features, somatisation/hypochondriasis, acute or enduring mental health presentations etc.) as we believe such complex categories would require specialist attention.

Recent literature demonstrates the reduction in suicide attempts following introduction of an antidepressant and the rates are statistically lower, than in untreated depression. This is a welcome addition to the discussions we have with our patients and their families. In this article we looked at the most common classes of antidepressants, their interactions and side effects, onset of action timeline, swapping and stopping, suicidality and prescribing in other age groups such as the young and the elderly. We recommend specialist advice and input when unsure of the best way forward.

We shall be through a month or so of 2017 by the time this issue is published. Donald Trump will have been inaugurated. The Supreme Court in UK will probably have decided as to whether Parliamentary consent is required to trigger Article 50 for Britain’s exit from the EU…………………The runes are not good reading.  

Abstract

Urinary tract infections (UTIs) are one of the commonest infections encountered in general practice .One in three women will have a UTI by the age of 24 years and one in two will be treated for a symptomatic UTI in their life time.

The antimicrobial management of these infections is so crucial in determining not only individual outcomes of adults with UTIs but also whether resistant organisms will emerge or not and, therefore be more difficult to treat in subsequent infections. Furthermore, there is a wider dimension of potential spread of such resistant organisms whether in the community or hospital setting. Indeed these resistant, including multi-antimicrobial resistant, organisms are common causes of healthcare associated infections not only in the form of UTIs but as other types of infections. As the title suggests clinicians need to ensure that the use of antimicrobials is mindful of the collateral damage incurred and harm to patients in general practice and the hospital setting.

There are different types of UTIs and therefore the way they are managed vary. The good practice approach is to rely heavily on the clinical side and make a working diagnosis and then decide whether a urine sample needs to be obtained for dipstick testing, when appropriate, followed by culture and sensitivity.

Traditionally the cut-off diagnosis of a UTI was the presence of significant growth of bacteria in urine i.e. more than 100,000 bacteria per ml of urine, and this was the gold standard whether to treat or not. The current practice has changed in terms of not necessarily treating a significant bacteriuria unless the symptoms are significant enough and causing suffering to the patient. However, in the absence of symptoms treatment would still be warranted if there is a urological abnormality, renal impairment, or immunosuppression.

In pregnancy asymptomatic bacteriuria should be treated because of the 20-40% risk of progressing towards a UTI subsequently. In recurrent UTIs treatment is the same as other UTIs except that referral should be considered and actions taken to prevent further infections including the use of least broad-spectrum long-term antimicrobial prophylaxis. With indwelling catheters, the risk of UTIs is higher and best management is to avoid them when possible or resort to self-catheterisation. Once in place, a gold standard aseptic technique should be followed. Antimicrobials should only be used in the presence of clinical symptoms, renal abnormality or immunosuppression. Change of catheter should also be considered when in place longer than seven days and in the presence of a genuine UTI and not only bacteriuria.

It is imperative that the Microbiology request form is fully completed in addition to checking for previous microbiology culture results and their sensitivity patterns as this will guide to more appropriate antimicrobial prescribing. Equally important is looking for previous colonization or infection with an alert organism such as MRSA (Methicillin Resistant Staphylococcus Aureus), ESBL (Extended Spectrum Beta Lactamase) or C.diff. This will guide the choice of an antimicrobial with the least collateral damaging effect.

Therefore, the most appropriate antimicrobials to be used are those with the least broad-spectrum activity. The choice of antimicrobials should also be based on current or recent microbiological evidence including sensitivity to infective agents and duration should usually be short i.e. 3 days and only longer when indicated.

The Hippocratic Corpus is reiterated: “First do no harm”.

Abstract

Severe symptoms while taking statins are distressing not only for the patients suffering them but also for the doctors wanting to prevent heart attacks and strokes. In this article, we discuss how symptoms during statin treatment statins can be commonly reported and yet be no more common on real statins than placebo in patients participating in randomised controlled trials. If a patient (and their doctor) wants to know the true symptomatic effect of statins there is now a way to achieve this. We describe how an individual can use a prepared set of statin, placebo and tablet free periods to separate the three components of side effects potentially attributable to statins: ever-present background symptoms, nocebo effect, and pharmacological sideeffects. This approach may enable general practitioners to provide low cost, scientifically secure, personalised medicine.

 
 

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