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62081. Measles, Mumps and Rubella (MMR) Vaccination

the second dose less than three months after the first dose and at less than 18 months of age then the routine preschool dose (a third dose) should be given in order to ensure full protection. The catch-up campaign Between 25 April 2013 and 31 March 2014, there was an MMR catch-up campaign in England in response to local measles outbreaks. From 1 April 2014, patients aged between 16-18, who have no record of vaccination and who self-present to practices requesting vaccination, were offered the vaccine (...) . To confer longer-term protection, MMR should then be repeated after three months. Pregnancy - but note that the Department of Health does not recommend termination, as studies failed to demonstrate a link between rubella immunisation in early pregnancy and fetal damage. Note that the following are NOT contra-indications: Family history of any adverse reactions following immunisation. Previous history of infection with pertussis, measles, rubella or mumps. Contact with an infectious disease. Asthma

2008 Mentor

62082. Mucosa-associated Lymphoid Tissue (MALT) Lymphoma

causative agent in ocular adnexal lymphomas. [ ] Borrelia burgdorferi infection has been linked to skin MALT lymphomas. [ ] Campylobacter jejuni has been linked to small bowel MALT lymphomas. [ ] There is also a possible link between hepatitis C and HIV and MALT lymphomas. [ ] Autoimmune diseases such as Hashimoto's thyroiditis and Sjögren's syndrome have also been linked to MALT lymphomas in the thyroid and salivary glands. There are certain karyotypic abnormalities associated with MALT lymphoma. A t (...) aggressive form of lymphoma. Relapses of MALT lymphoma may be late and lifelong observation may be required. [ ] Investigations General assessment: FBC, renal function tests, electrolytes, LFTs. Phenotyping of circulating lymphocytes, bone marrow lymphocytes or biopsy specimens. Imaging studies for disease staging: Barium contrast studies of the upper and lower gastrointestinal tract. CT scan and MRI scan. Endoscopy. Bone marrow aspiration. Management Management is different for gastric and non-gastric

2008 Mentor

62083. Neonatal Examination

motion with extremities well flexed Reflex irritability (response to plantar stimulation) No response Grimace Cry Heart rate Absent Slow (<100 bpm) Fast (>100 bpm) Although UK practice still includes recording Apgar scores, it is not recommended that Apgar scoring be used to predict mortality or neurological outcome. Only a small proportion of babies with a very low Apgar score have significant neurodisability [ ] . All personnel attending deliveries in the UK are trained in neonatal life support (...) . Observe whether there is any evidence of or pilonidal sinus hidden by flesh creases or dimples. Palpate the spine gently. Hips : Specifically test for congenital dislocation of the hip (aka ) using a combination of Barlow and Ortolani manoeuvres (follow the link for more detail). Legs : Watch movements at each joint. Check for any evidence of . Count toes and check their shape. CNS : Observe tone, behaviour, movements and posture. Elicit newborn reflexes only if there is cause for concern. Further

2008 Mentor

62084. Underperforming Doctors

deliver the appraisal and revalidation process to nationally agreed criteria. See the separate article. Underperformance of a colleague The GMC guidance 'Good Medical Practice' states: [ ] If you have concerns that a colleague may not be fit to practise and may be putting patients at risk, you must ask for advice from a colleague, your defence body or from the GMC. If you are still concerned, you must report this, in line with GMC guidance and your workplace policy, and make a record of the steps you (...) welcome an opportunity to 'offload'; or, they may see the approach as an unwarranted intrusion into their private and professional life. Other options - which should be considered if there is the slightest risk to patient safety - would include approaching other members of the practice team (eg, the practice manager or the senior partner), reporting the matter to the Primary Care Organisation or contacting the GMC. This situation is never easy and an unwarranted accusation unsupported by evidence may

2008 Mentor

62085. Tropical Spastic Paraparesis

. You may find one of our more useful. This page has been archived. It has not been updated since 20/04/2011. External links and references may no longer work. In this article In This Article Tropical Spastic Paraparesis In this article There are two types of tropical myeloneuropathies that are different in aetiology and clinical features. They both occur predominantly in tropical countries, although tropical spastic paraparesis (TSP) has been described in temperate southern Japan. [ ] TSP (...) and necrotic lesions in the spinal cord. It is a progressive disease involving the degeneration of neurons in the spinal cord, leading to a gradual paralysis of the lower limbs. Pathogenesis HAM/TSP is associated with . However, there have been some cases of TSP where evidence of HTLV-1 infection has not been found. [ ] Although a form of chronic myeloneuropathy found in the West Indies had been recognised as a distinct entity for over a hundred years, it was not until 1985 that a link was first made

2008 Mentor

62086. Toxoplasmosis

Empirical anti-toxoplasmosis treatment is accepted practice for immunocompromised patients with multiple ring-enhancing brain lesions; patients usually improve within 7-10 days [ ] . Management There may be life-threatening illness (usually in immunocompromised patients), with encephalitis, pneumonitis, or myocarditis. Patients may require stabilisation and treatment of acute symptoms such as seizures, respiratory failure and cardiovascular compromise [ ] . Specific treatment against T. gondii is given (...) infections may present in four main ways: Acquired infection in immunocompetent adults and children This is asymptomatic in most cases. It is said that 10% have symptoms - eg, nonspecific illness or isolated lymphadenopathy (of occipital or cervical nodes, usually resolving within six weeks). However, studies have reported subtle changes in behaviour, personality and psychomotor performance in infected individuals, so the incidence of symptomatic toxoplasmosis may be higher [ ] . Studies suggest a link

2008 Mentor

62087. Stillbirth and Neonatal Death

factor for stillbirth. A 2012 study of stillbirths in England showed the risk to be significantly higher where the growth restriction was not detected antenatally, suggesting this as an important avenue for reducing stillbirth rates in the future. [ ] It concluded strategy should focus on improving antenatal detection of growth restriction, and subsequent management of pregnancy and delivery. Preterm birth: [ ] This is the biggest risk factor for neonatal death. Obstetric and neonatal care can have (...) it is often left out of analyses. Fewer than 10% of stillbirths are caused by congenital abnormalities. [ ] Low birth weight: Strongly linked with neonatal death and infant mortality. Inter-related with other factors, such as prematurity, multiple pregnancy, smoking. In 2012, there were 173 deaths per 1,000 live births for very low birth weight babies (<1500 g), 35.2 per 1,000 for low birthweight babies (<2500 g), compared to 1.3 per 1,000 for normal birth weight babies. These ONS figures are for infant

2008 Mentor

62088. Steroids and the Skin

of corticosteroids - for example, scabies, bacterial infection (suggested by crusting and weeping), herpes infection (suggested by vesicles or punched-out erosions). Consider wider management issues: Aggravating factors. Previous treatments. Impact on quality of life. Other medications. Growth chart in children. [ ] When should referral be considered? Referral might be considered occasionally before treatment if: Diagnosis is unclear. There are certain diagnoses where distribution and severity require referral (...) Severe infection is suspected - eg, eczema herpeticum (same day referral). There is lack of response to treatment of the primary condition (see under 'Guidance', below) There is failure of treatment for secondary infection. There is contact dermatitis requiring patch testing. Additional advice or treatment is required, Use of immunomodulatory agents is to be considered (such as tacrolimus and pimecrolimus). [ ] Dietary factors are suspected. Topical steroid prescribing guidance Guidance

2008 Mentor

62089. Thalassaemia Full Text available with Trip Pro

, as giving more iron will only aggravate the condition. Screening Pre-conceptual testing for haemoglobinopathies is recommended in at-risk groups. [ ] Policies for antenatal and neonatal screening vary throughout the UK (for further information, see link to UK Screening Portal under 'Further reading & references', below). [ ] Laboratories performing antenatal screening should utilise methods capable of detecting significant variants and be capable of quantitating haemoglobins A 2 and F. Differential (...) are usually found on the 24-hour ECG. Stage III patients have symptoms ranging from palpitations to congestive heart failure. The ejection fraction on echocardiography is decreased. There is normal or decreased ejection fraction on cineangiogram at rest, and it falls on exercise. The 24-hour ECG reveals atrial and ventricular premature beats, often in pairs or in runs. Management The general principles of management include: [ ] Asymptomatic carriers: require no specific treatment but should be protected

2008 Mentor

62090. Termination of Pregnancy

personal beliefs concerning TOP. Current General Medical Council (GMC) guidance states: [ ] " You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient's lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor (...) Act does not apply. Abortion is unlawful other than in restricted circumstances. Termination of pregnancy in girls under 16 years [ ] GMC guidelines state that girls under the age of 16 may be able to make an informed decision without parental consent if they are deemed to have capacity to do so. The guidance states that abortion can be provided without parental knowledge or consent if: The girl understands all aspects of the advice and its implications. You cannot persuade her to tell her parents

2008 Mentor

62091. Telephone Consultations Full Text available with Trip Pro

more useful. This page has been archived. It has not been updated since 12/06/2009. External links and references may no longer work. In this article In This Article Telephone Consultations In this article In British medical practice we have been slow to embrace the use of the telephone, but now, over a century on from its invention, a quarter of primary care contacts are by telephone and likely to grow further. The proportion of direct versus telephone contacts varies considerably between (...) ". There is an increasing trend for calls to OOH centres to be recorded and it may seem prudent to record telephone consultations in daytime practice as well. In such cases it is usually recommended to seek express consent to recording, and offer a non-recorded option. [ ] Appropriateness and safety Always ask yourself, "Is telephone management appropriate in this situation?". Revisit this question several times during the consultation. Be guided as to the need to convert to a direct encounter by factors including

2008 Mentor Controlled trial quality: predicted high

62092. Tackling Foundation Years (House Jobs)

and European Guidelines. You may find one of our more useful. This page has been archived. It has not been updated since 19/02/2010. External links and references may no longer work. In this article In This Article Tackling Foundation Years House Jobs In this article Modernising medical careers saw the introduction of the Foundation Programme for the training of newly qualified doctors in 2005. The idea is that this training will be a stepping stone bridging the gap between medical training and speciality (...) medical graduates with core clinical skills that are necessary to deal with acutely unwell patients. [ ] Starting right Typically, the two foundation years consist of 6 four-month posts. These usually consist of medical and surgical specialities and other recognised specialities - for example, haematology, anaesthetics, and general practice. When applying for foundation year posts, consider the factors that are most important to you; for example, location, family commitments, and previous jobs you

2008 Mentor

62093. Surgical Emergencies in Childhood

. Management Paediatric surgeons will undertake repair soon after diagnosis, regardless of age or weight, in healthy full-term infant boys with asymptomatic reducible . Emergency surgery is twenty times more likely to cause complications than an elective procedure. Premature infants with inguinal hernias are usually repaired prior to discharge from the neonatal intensive care unit (NICU) but this practice is changing, as infants are now being discharged home at much lower weights. Some surgeons prefer (...) . You may find one of our more useful. This page has been archived. It has not been updated since 22/06/2011. External links and references may no longer work. In this article In This Article Surgical Emergencies in Childhood In this article [ ] This is where a segment of bowel becomes invaginated into the immediately distal bowel. [ ] It is the most common cause of obstruction in children aged 5 months to 3 years. It accounts for 25% of all abdominal surgical emergencies in children aged younger

2008 Mentor

62094. Surgical Correction of Refractive Errors Full Text available with Trip Pro

and European Guidelines. You may find one of our more useful. This page has been archived. It has not been updated since 22/06/2011. External links and references may no longer work. In this article In This Article Surgical Correction of Refractive Errors In this article Background [ ] The purpose of the globe is to receive light from the outside world and transmit it to the brain for processing. There are two aspects to this function. In the first instance, the light rays have to be correctly focused (...) . [ ] (Conversely, those who have had laser surgery may experience complications in non-refractive surgery and so should make their history known and be managed by more senior surgeons.) Systemic considerations The patient must be aged over 21. Pregnant or breast-feeding women as well as patients with certain medical conditions (eg , , ) will not be able to go ahead with surgery. This also applies to those on certain medications, such as steroids and . [ ] Assessment [ ] Patients will be carefully assessed

2008 Mentor

62095. Superficial Spreading Malignant Melanoma of Skin

Quality Standard, September 2016 ; Cancer Research UK ; The role of BRAF V600 mutation in melanoma. J Transl Med. 2012 Jul 910:85. doi: 10.1186/1479-5876-10-85. ; Melanoma--Part 1: epidemiology, risk factors, and prevention. BMJ. 2008 Nov 20337:a2249. doi: 10.1136/bmj.a2249. ; Epidemiology of invasive cutaneous melanoma. Ann Oncol. 2009 Aug20 Suppl 6:vi1-7. ; NICE Clinical Guideline (2015 - last updated July 2017) ; NICE Guidance (July 2015) ; Melanoma: ESMO Clinical Practice Guidelines for diagnosis (...) Guidance, Mar 2013 ; NICE Technology Appraisal Guidance, October 2014 ; NICE Technology Appraisal Guidance, December 2012 ; NICE Technology Appraisal Guidance, December 2012 ; Melanoma--part 2: management. BMJ. 2008 Dec 1337:a2488. doi: 10.1136/bmj.a2488. ; Multiple primary melanoma: two-year results from a population-based study. Arch Dermatol. 2006 Apr142(4):433-8. Hello, I am a 25 year old male, I've searched the internet high and low but there doesn't seem to be any reassurance out there for me. I

2008 Mentor

62096. Thyroid Eye Disease Full Text available with Trip Pro

biochemical thyroid dysfunction at all. Management is challenging and requires a team approach. Medical management is only available in the active, early phase. When the disease becomes inactive (no acute inflammation), surgery is the only option. TED is sight-threatening in up to 5% of patients, although most cases are mild and self-limiting. [ ] See also separate articles , , , , , and . Description TED is an organ-specific idiopathic autoimmune disease. It usually begins with an active inflammatory (...) . Features suggesting optic neuropathy (and necessitating urgent referral) include: Blurred vision. Impaired colour perception. Reduced visual acuity. A relative afferent papillary defect. Visual field defect. See separate article. See also below under urgent referral. Systemic features These depend on the thyroid status and the underlying disease. See the links at the beginning of this article for more information about dysthyroid states. Diagnosis This is straightforward in patients with obvious

2008 Mentor

62097. Thrombophilia

find the article more useful, or one of our other . In this article In This Article Thrombophilia In this article Definition Thrombophilia refers to a predisposition to thromboembolism. In practice, the term is used to describe patients who are at significantly increased long-term risk of venous thromboembolism (VTE). Heritable thrombophilia is an inherited tendency for venous thrombosis [ ] . Epidemiology [ ] Thrombophilia may be heritable, acquired or mixed. Heritable causes [ ] Heritable (...) thrombosis. May be primary (venous or arterial thrombosis, or recurrent first-trimester miscarriages) or secondary (linked to other conditions - eg, , collagenosis). Acquired antithrombin deficiency: Due to liver disease, nephrotic syndrome, disseminated intravascular coagulation or pregnancy. Myeloproliferative disorders, or . Cancer. Certain inflammatory conditions - eg, . , including . [ ] . . , recent or . Possibly, [ ] . The presence of a central catheter is the most important risk factor

2008 Mentor

62098. Tinnitus

demonstrate that they are at an intensity that is only just louder than the softest sound audible at that frequency - usually above 3 kHz. Management General measures Explanation and reassurance that the condition will not progress and that there are no sinister findings. There is a strong association between tinnitus and stress; relaxation techniques or relaxing background music can distract or mask some tinnitus. Tinnitus retraining therapy shows improvement in 75-82% of patients. It links negative (...) tentative suggestions that selective serotonin reuptake inhibitors (SSRIs), tricyclics or nasal lidocaine can help tinnitus [ ] but many of the proposed treatments, when subjected to placebo-controlled trials, were found to be ineffective. This led to 2014 guidance from a US tinnitus development group to recommend against : Antidepressants Anti-convulsants Anxiolytics Intratympanic medication Ginkgo biloba Melatonin Zinc Transcranial magnetic stimulation Surgical Small case series have shown equivocal

2008 Mentor

62099. Dental and Periodontal Diseases Full Text available with Trip Pro

challenges in managing their oral health. Problems may be experienced due to: Barriers in accessing adequate oral care due to lack of perceived need, inability by the individual to express need and a lack of ability to self-care. Fear and anxieties, which are also significant contributors to poor access to oral care providers. The knowledge and skills of carers may be inadequate. Concurrent illness may take priority and oral healthcare takes a back seat. Detailed guidance for these specific patient (...) frequently. In this article, you will find basic information on the presentation and initial management of dental and periodontal disease as well as notes on systemic conditions that affect the teeth and gums. You may also want to refer to the separate articles and . Dental disease Toothache Local causes - this usually arises as a result of irritation of the nerve supplying the affected tooth. This can be due to a number of local problems, including inflammation of the pulp (pulpitis), infection

2008 Mentor

62100. Deep Vein Thrombosis

Oct 31343:d5916. doi: 10.1136/bmj.d5916. ; NICE Technology Appraisal Guidance, December 2014 ; NICE Technology Appraisal Guidance, June 2015 ; NICE Technology Appraisal Guidance, July 2012 ; New oral anticoagulants: their advantages and disadvantages compared with vitamin K antagonists in the prevention and treatment of patients with thromboembolic events. Ther Clin Risk Manag. 2015 Jun 2411:967-77. doi: 10.2147/TCRM.S84210. eCollection 2015. ; Thrombolysis for acute deep vein thrombosis. Cochrane (...) of DVT is likely if the score is two or more, and unlikely if the score is one or less. D-dimers These are specific cross-linked products of fibrin degradation and are raised in patients with VTE. Sensitivity is high but specificity poor. High concentrations occur in other disorders, such as malignancy and pregnancy and in other conditions where clots form, as after surgery. The investigation of VTE in pregnancy is fraught with many difficulties [ ] . Several D-dimer assays are available - eg, ELISA

2008 Mentor

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