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International Primary Care Association
 
 
 

Clinical Focus Primary Care

Primary care professionals are amongst the most frequent users of the National Poisons Information Service in the United Kingdom. This paper provides an up-to-date review on the management of acute poisoning in this setting.

Depression is a common mental health disorder in children and adolescents and presents relatively frequently to primary care. Early recognition, assessment and treatment of depression is important to alleviate distress, improve functioning and later outcome, and manage risks. Primary care and tier 1 professionals may manage mild depression whilst moderate to severe depression is usually managed by specialist mental health services. Treatment of depression is dependent on severity and individual circumstances; interventions include supportive measures, addressing stressors, psychological therapy, and antidepressant edication in selected cases.

Hip pain is a common presentation in GP practices across the country. It can be caused by a multitude of different pathologies ranging from simple muscle spasms, to fractures. It is vital that health professionals can differentiate between benign causes, which can be treated in the community setting, to symptoms that warrant specialist input.

Perianal dermatoses and pruritus ani are common and socially embarrassing conditions that are often poorly managed. Perianal dermatoses encompass a variety of inflammatory diseases affecting the anal region, of which eczema, of various aetiologies, is the most common. 

Pruritus ani is a chronic itch of perianal skin without rash and is poorly understood. There is a knowledge gap in understanding the pathophysiology and management of pruritus ani as there has been little research. 

The aim of this article is to present an overview of perianal dermatoses and their management.

Eye problems account for 4.5 million GP consultations yearly, in the United Kingdom, and evidence shows that 50% of sight loss could be avoided through improved eye care and early detection. While often it is obvious when an eye condition needs referral (for example the red, painful eye, or sudden loss of vision), there are a number of potentially blinding or even lifethreatening conditions which may present atypically or with subtle signs that may be missed. Such misdiagnoses can have serious implications. 

This article examines common presentations in ophthalmology and suggest some important ‘red flags’ in each which merit urgent attention. We have placed emphasis on conditions which can be life or sight-threatening, which can present atypically, and whose ‘red flags’ are aspects of history or examination which are easily and quickly elicited in the GP consultation. 

It is worth noting that while many of the conditions discussed frequently present with eye symptoms (and indeed may be seen in eye casualty), they may in fact reflect other underlying disease processes (e.g. raised intracranial pressure). Having the conviction to refer such patients directly to the medical or neurology team for treatment results in a safer and faster patient journey.

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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