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International Primary Care Association
 
 
 

Clinical Focus Volume 8 N3

Volume 11 Issue 1 - 2017

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.  

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.

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.

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