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Five-minute Practitioner: November 2007

Only got five minutes? Then just read these key points on: tuberculosis, asthma, cystic fibrosis and obsessive-compulsive disorder

Only got five minutes? Then just read these key points on: tuberculosis, asthma, cystic fibrosis and obsessive-compulsive disorder

Tuberculosis

Nearly 8,200 cases of TB were reported in England, Northern Ireland and Wales in 2006. London accounted for the highest proportion of cases (42%) and the Midlands the second highest (12%). In 2005, TB was responsible for 357 deaths in the UK.

Membership of a disadvantaged socioeconomic group, independent of ethnicity or country of origin, is a risk factor for TB, especially when combined with a problem such as drug misuse, homelessness or a period in prison.

TB is not highly contagious and it usually requires prolonged close contact with a person with TB for the risk of transmission to be high. Only pulmonary TB is potentially infectious.

Drugs should be prescribed by specialists and dispensed from the hospital but GPs have a crucial role in helping with the early identification of possible drug side-effects.

Asthma

In the UK, approximately 5.2 million patients (1.1 million children and 4.1 million adults) are currently receiving treatment for asthma. The UK has the highest frequency of self-reported asthma symptoms among children aged 13-14 years in the world.

One in six people receiving emergency treatment for asthma will need emergency treatment again within two weeks and, on average, one person dies of asthma every seven hours in the UK. The reasons for this continuing morbidity and mortality may involve the mistaken view held by some patients and doctors that asthma only requires treatment when there are symptoms.

Inhaled corticosteroids remain the most effective drugs for the prevention of asthma attacks in adults and older children. They should now be considered for patients who are:
• Using short-acting beta-agonists three or more times per week
• Symptomatic three or more times per week
• Waking one night or more per week with respiratory symptoms.

Cystic fibrosis

Cystic fibrosis (CF) is becoming a chronic disease of adults rather than a fatal disease of childhood. One in 2,500 newborn babies are affected by CF, giving a UK population of around 7,000 patients. Median survival is currently 34 years but has been increasing every year, with recent data suggesting that someone born with CF in 2000 can expect to live into their fifties or sixties.

Long-term use of rhDNase is associated with reductions in long-term decline of lung function. The use of long-term maintenance therapy with azithromycin improves lung function and reduces exacerbations.

Antibiotic therapy is targeted against the key pathogens that infect the airway in patients with CF. Pulmonary exacerbations of chronic Pseudomonas infection can be treated with oral ciprofloxacin if symptoms are mild but otherwise require therapy with two iv antipseudomonal antibiotics, usually an aminoglycoside and a beta-lactam. Such treatment does not necessarily require hospital admission, as all CF centres support home iv therapies.

The absence or blockage of the vas deferens results in infertility in 98% of men with CF. Intracytoplasmic sperm injection may be an option.

OCD

OCD is characterised by intrusive unwanted thoughts (obsessions) and ritualistic behaviours (compulsions). Common obsessions include fears and concerns about contamination, symmetry and order. Compulsions include checking, handwashing, cleaning and counting. As the severity of symptoms increases, OCD can consume the patient's daily life.

OCD is often comorbid with other common psychiatric conditions. Guided self-help can be effective in mild OCD and this can be offered by GPs. In adults, CBT or an SSRI is recommended. If unsuccessful, a combination of CBT and SSRI is suggested.

Clinical trials have proved that SSRIs are effective in treating OCD in children and adults. Benefits continue to accrue for up to six months. Available evidence suggests that treatment with an SSRI in children and young people carries little risk.

On relapsing, many patients respond promptly to ‘top-up' CBT or restarting medication and it is important that they have prompt access to services and treatment.

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