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IPCA

International Primary Care Association
 
 
 

Clinical Focus Volume 8 N3

Editor Admin

Editor Admin

Women with epilepsy have specific needs during their reproductive years. It is imperative that their general practitioner is familiar with the relevant issues and aware of how to address these, as well as knowing what to anticipate and expect from specialist joint neurology/obstetric care.

Diabetic Neuropathy (DN) is the most common complication of diabetes and represents a heterogeneous group of neurological conditions. Although any nerve in the body may be affected, the length dependent distal symmetrical sensory predominant neuropathy is the most common presentation. Diabetic neuropathy often develops insidiously and often remains asymptomatic until well established. Important complications of DN include the development of neuropathic pain, autonomic features, foot deformities and ulceration all which lead to considerable morbidity. Furthermore, it is also considered to represent an increased mortality risk.

Pathogenic triggers apart from hyperglycaemia, such as cardiometabolic and vascular factors, are being increasingly recognised to play a significant role in DN development. Newer putative agents have shown promise in experimental diabetic neuropathy but are yet to be clinically proven. Thus, glucose control remains the only proven strategy to delay the development of DN. Management of neuropathic pain and foot risk assessment and ulcer prevention strategies are important clinical considerations. In this review, I discuss the classification, diagnosis and management of the DN.

15% of new or recurrent asthma in adulthood is due to workplace exposures. Occupational asthma occurs due to an allergic reaction to an airborne allergen whereas ‘work exacerbated (pre-existing) asthma’ is a response to non-specific irritants. If detected early, occupational asthma is curable but a false positive diagnosis can have devastating consequences.

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.

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