In type 2 diabetes, tight glucose control/HbA1c does not improve survival. Blood pressure control is more important. Metformin is drug of choice if obesity present.
Diuretics are still firstline treatment in all patients, including diabetics and other coexisting risk factors for cardiovascular disease. Reduced risk of cardiovascular events, same reduction in bp, less intolerance cf other agents. Max 25 mg hydrochlorothiazide.
Salt - RCTs of moderate reductions in salt intake show a dose dependent relation with hypertension and lack of a threshold effect within usual levels of salt intake. Independent of age, sex, baseline blood pressure. Prospective studies, with one exception, indicate that higher salt intake predicts cardiovascular events. But lack of large, long trials of salt reduction on clinical outcomes! TOHP I and II (n of 3000) randomized non-hypertensives to reduced intake for 18-48 months - 30% lower incidence of cardiovascular events in the next 10-15 years. In the West, most salt comes from hidden sources, hence legislation on industry is required.
For chronic neck pain, light exercise is of no use, high intensity exercise is no better, relaxation may be useful. Ordinary activity may be as good as anything else!
Non-operative methods for prolapsed intervertebral disc eg manipulation, physio have little effect on course of sciatica. Equally, no reliable predictors of time scale (except possibly psychosocial). Surgery on the other hand is effective - 90% of leg pain eased, but 70% continue to have back pain. Up to 10% find their back pain worsens. Surgery does not have any benefit on recurrence. Early surgery ie at 8 weeks improves leg pain faster, but benefit lost by 6 months. Still, may add up to significant benefit.
Highly effective for hot flushes and vaginal atrophy and prevention of osteoporotic fractures. Since the latter requires long term treatment, its use must be balanced against potential harm (increased risk of breast cancer in combined products used for 5+yrs, increased dementia in over 65s, increased DVT). Oestrogen only may protect against breast cancer! Coronary heart disease risk is complicated - on subgroup analysis, suggestion of reduced risk within 10 yrs of menopause, whereas increased risk beyond 20yrs. Difficult to confirm/refute this timing hypothesis as risk in perimenopausal women is very low. So treat with the lowest effective dose for the shortest possible time!
Oxybutinin more effective than tolterodine for overactive bladder; but more dry mouth.
2 trials now show that reducing homocysteine levels with vitamins and folic acid do not help. Presumably a marker rather than a cause?
3 large trials of ACE inhibitors in patients with atherosclerosis but no evidence of heart failure or left ventricular dysfunction (HOPE, EUROPA, PEACE) showed benefit but most pronounced for diabetics or patients with uncontrolled lipids or other risk factors. More debatable if any extra benefit if alreay on aspirin, beta blockers and statins.
Prescribe the cheapest anti-depressant. Trial of second line (after SSRI) found no difference between buproprion, sertraline or venlafaxine.
New mental health laws in England and Scotland. Drug and alcohol use are excluded from compulsory detention, but sexual disorders eg paedophilia are not. The idea that treatment must alleviate or prevent deterioration has been replaced by the need for appropriate treatment to be available. Main problem remains that government sees the law as a tool for public protection rather than care/treatment. Danger is that as definition of mental disorder and treatability widens, criminals will be less willing to pursue medical care eg anger management since they risk compulsory detention.
The rate of violent behaviour in mentally disordered reflects the prevalence of such behaviour in the community they come from. As a predictor of serious violence, mental health carries much less weight than other social factors. The proportion of homicides perpetrated by those with mental illness has changed little in 50yrs, care in the community and changes in law notwithstanding.
Drugs for migraine work better if started early! Dihydroergotamine, subcut sumatriptan, metoclopramide (and prochlorperazine, chlorpromazine), ketorolac are all effective. Narcotic analgesics are recommended only as rescue drugs, yet are commonly prescribed. Single dose IV dexamethasone is effetive at reducing early recurrence, not acute pain.
Beware the industry promoting a silent but deadly epidemic. Bone densitometry can under or overestimate by 20-50%. Not surprisingly, it is not a good predictor of fractures. 80% of low trauma fractures occur in people without osteoporosis (defined as T <2.5). The Fracture Index (age, previous fracture, maternal hip fracture, weight, smoking, ability to rise from chair without hands) can predict fractures just as well! Preventing falls is probably more important, especially in institutions, although evidence for preventing fractures is lacking.
Cognitive Reserve theory of dementia – higher educational attainment seem to cope better with brain pathology (can even have normal cognition).
No evidence for magnets in pain relief (meta-analysis).
Best evidence is for arthritis of the knee and back pain.
Sham acupuncture appears to have benefit above that of placebo. This has been demonstrated physiologically through the mechanism of target directed expectation. In a systematic review of sham vs true acupuncture there was a significant added benefit from the true treatment but wide heterogeneity (perhaps not surprising, since all indications were lumped together).
Primary angioplasty is better than thrombolysis for ST elevation MI if present within 12 hours. Also provides information about potential bypass surgery. Support with unfractionated heparin, aspirin, clopidogrel. Adding Abciximab (GP IIb/IIIa inhibitor) BEFORE angioplasty reduces reinfarction rates further (ADMIRAL study). Stenting also improves outcome, esp drug-eluting.
The best approach for patients with non-ST-segment-elevation myocardial infarction and unstable angina is less certain. The results of ten randomised trials so far collectively show a significant improvement in survival and recurrent ischaemia with invasive rather than conservative management ie early angiography in an attempt to cure underlying lesion. But possibly more early infarcts, due to procedure related complications. Certainly for moderate/high risk patients, current evidence supports the use of aspirin, clopidogrel (with full loading before angiography), and bivalirudin monotherapy, with glycoprotein IIb/IIIa inhibitors reserved for breakthrough ischaemia. Heparin and glycoprotein IIb/IIIa inhibitors may be considered for the patient not loaded with clopidogrel, which might decrease ischaemic events at the expense of increased major bleeding.
For lower risk patients or atypical symptoms, aspirin, clopidogrel, and fondaparinux (if an antithrombin agent is required) would be expected to minimise ischaemic and haemorrhagic complications. Inadequate though if catheter is required, due to potential thrombotic complications.
Beta blockers reduce mortality after MI (not early on, where heart failure and shock offset any benefit) and improve prognosis in heart failure. Also reduce adverse outcomes in perioperative management of high risk patients. ASCOT trial suggests that atenolol is inferior to amlodipine for cardiac outcomes of BP control, but actually, the data suggests that better control (including tackling other risk factors) is the main influence, rather than the type of drug. Atenolol may not be as good as other beta blockers for cardiovascular outcomes in hypertension - not clear yet. Seem to prevent progression of coronary artery disease but clinical benefit? Older patients get less benefit - presumably less sympathetic tone.
In isolated LADA disease, internal mammary grafting (using minimally invasive technique) is as effective and probably more cost effective than stenting. Stenting has a higher risk of recurrent angina and reintervention. In multivessel disease CABG is much better than stenting, esp with diabetes; indeed, the additional benefit of stenting over medical treatment is probably too small to justify its additional costs. Even drug eluting stents may not have that much advantage, since they offer no protection against new lesions - hence the lack of mortality and MI benefit. Plus such stents may suffer from late thrombosis, which also means that prolonged clopidogrel may be needed.
With or without ST elevation. If myocardial necrosis is documented (cardiac troponin T, troponin I, CK MB), then myocardial infarction is diagnosed. Q wave changes are reported later.
Muscle enzymes take 6-8hrs to go up. If normal at presentation, repeat at 8hrs if clinical suspicion. If still negative, consider early stress test. Wall motion abnormalities on echo and CT may be part of the diagnostic work up in future.
Treat with:
Should all get angiography? Higher early mortality hazard but trend towards lower mortality during longer term follow up (see Cochrane) before newer protocols developed including more effective antiplatelet therapy. If a conservative approach is used, consider pre-discharge stress testing.
Should intervention happen straightaway or should there be initial stabilisation? No clear answer yet.
After discharge, aspirin, beta blocker, statin, ACE inhibitor should be continued.
About half embolic, some venous occlusion, some due to shock for other reasons. CT angiography is investigation of choice for acute ischaemia, MR angiography shows venous anatomy well, but less good for distal emboli. Surgery indicated if peritoneal signs, recurrent fever, symptoms for more than 2-3 weeks. Surgical embolectomy is standard but intraarterial thrombolysis is effective within 12 hours of onset. In non-occlusive (low flow) states, intra-arterial papaverine is useful.
LMW heparin is as effective as normal heparin in treating PE (studied in patients with symptomatic DVT). Rates of bleeding similar.
Factors potentially associated with recurrent venous thromboembolism in patients with idiopathic venous thromboembolism:
But all of these are pretty soft - very small odds ratios.
Do bloods esp glucose, platelets (for consideration of thrombolysis). Do ECG. CXR not much use.
Findings suggesting intracerebral haemorrhage:
Emergency, non-contrast CT of the head identifies haemorrhage and can help distinguish non-vascular causes of neurological symptoms such as tumour. CT is not ideal, however, because of the difficulty in detecting acute or small infarcts and artifact in the brainstem area. Loss of grey-white differentiation and hemispheric sulcal effacement can be detected within 6 h of ischaemia. A hyperdense middle cerebral artery sign is indicative of embolus or thrombus in the vessel. All correlate with poor outcomes. A clearly visible hypodensity on CT is rarely seen within 3 h of onset of stroke and the presence of such a finding should prompt a reappraisal of the time of onset.
MRI is better for detection of acute ischaemia than CT, even within minutes of symptom onset. The ischaemic penumbra is the area of normal diffusion but delayed perfusion on MRI (diffusion–perfusion mismatch - although some will be reversible).
Fever carries a worse prognosis, conversely hypothermia improves prognosis! Look for cause and treat aggressively.
ECG changes include atrial fibrillation, QT prolongation, ST depression and inverted T waves. Myocardial infarction is possible (catecholamine release.
Low glucose may mimic stroke; high glucose worsens prognosis.
Hypertension is common, and rarely treated in case perfusion pressure is compromised. Consider if BP>220/120/. Excessive hyperension though is a risk factor for haemorrhage after thrombolysis so treat if %gt;185/110 post thrombolysis.
rt-PA was approved for use in acute ischaemic stroke in 1996. Neurological improvement did not differ after 24 h but outcomes were significantly better at 3 months, persisting to 1 year. Symptomatic intracerebral haemorrhage occurred in 6·4% of patients treated with rt-PA compared with 0·6% of those given placebo. NNT=3, NNH=30. Stroke subtype is irrelevant.
Mild or minor neurological deficits should still be considered, as prognosis is not necessarily favourable, and treatment can result in more favourable outcomes. Conversely, severe deficits do not appear to be at greater risk of haemorrhage.
rt-PA (0·9 mg/kg, max 90 mg, 10% bolus, remaining infused for more than 1 h) should be given to patients with acute ischaemic stroke who meet criteria (within 3 hr, clear deficit, imaging to exclude haemorrhage) - the earlier the better! Contraindications are not all absolute eg minor GI bleeding, platelets= 90:
Anticoagulants are often used but benefit is far from proven. Aspirin does appear to be of benefit so should be used if thrombolysis is contraindicated (increases haemorrhage risk with rtPA).
Aspirin with Dipyridamole is better than aspirin alone for secondary prevention (ESPRIT trial), hazard ratio 0.8 - no excess of major bleeding but less compliance due to side effects esp headache (usually settles by 1-2 weeks). £100 per year. Lancet? Volume 367, Issue 9523 , 1665-1673
In the event of haemorrhage after thrombolysis, check coag, do CT - if confirmed, stop rtPA and give cryo and FFP to reverse. Other important side effect is oral angioedema. Haemorrhagic transformation can occur even without rtPA; other complications are RICP (maximal at 3-5 days), seizures.
Early mobilization, DVT prophylaxis, early nutrition and surveillance for infection esp pneumonia/UTI important.
Lancet 2007
Patent Foramen Ovale (rare cause of stroke) - non-randomised trials support anticoagulation for patients with patent foramen ovale and atrial septal aneurysm, and at least antiplatelet treatment for patients with patent foramen ovale without atrial septal aneurysm. The recurrence rate of stroke after transcatheter closure of patent foramen ovale is lower compared with trials that used medical treatment (esp Amplatzer). By contrast with medical treatment, the initial presence of atrial septal aneurysm during closure of patent foramen ovale does not influence long-term outcome. Hence, especially for patients with atrial septal aneurysm or those with recurrent cryptogenic ischaemic events, closure of patent foramen ovale should be considered to provide a lower recurrence rate for ischaemic events and to preclude anticoagulation with potential long-term bleeding risk.
Jack Russells are one of the most common offenders. And most bites happen in the home, not the park. Lack of supervision is a common factor in children. Facial bites can often be closed primarily, whereas extremities are best left unsutured (elevated and Immobilised) unless adequately debrided and toileted. Suture only when considered clean and free of infection.
Children should not run or scream near a dog, should not pet unless first sniffed, should avoid eye contact, and should avoid if dog is sleeping, eating or looking after puppies.
Associated with postmenopausal obesity. No link with specific dietary components otherwise. HRT is a risk (combined worse than oestrogen only). Tamoxifen taken for 5+ years reduces the risk of invasive breast cancer in high risk, similarly for Raloxifene, but no improvement in overall mortality - prob underpowered, but perhaps only prevents the most responsive tumours. BRCA1&2 have a lifetime risk of up to 80% - no data on Tamoxifen, bilat ooporectomy reduces risk by 50% (and reduces risk of ovarian cancer by up to 85%), bilat mastectomy almost completely removes risk.
Mammography has a NNT of 2000 (and 10years) to prevent 1 death. At the same time, 10 clinically occult tumours will be diagnosed! Combining with MRI increases sensitivity to 94%, but specificity falls to 77%. Particularly good for ductal in situ. NICE currently recommends for high risk women from age 30, but cost?
Staging with PET is not routine. MRI can define local spread. Wide local excision is now standard; if not possible, downstaging with chemo or hormone therapy may allow for more conservative surgery. In early disease, sentinel lymph node (ie the single closest one) biopsy and analysis during surgery can prevent need for full clearance; false negative rate is less than 10%. Current research compares full clearance vs radiotherapy, endoscopic techniques.
After breast conserving surgery all require radiotherapy. Accelerated course over 3 weeks gives same rates as standard 5 week course. Traditionally radiotherapy would be given post mastectomy if lymph node mets but local recurrence rates are less now so arguably not necessary for <4 nodes.
Lord Crisp's report Global Health Partnerships looks at strengthening UK contribution to health in developing countries.
Donating hospital equipment: most useful medical are beds, spectacles, anaesthetic machines, hoists for othopaedic patients, cannulae, suction machines, sar moitors, mattresses, centrifuges, chairs, incubators, feeding tubes. Keep equipment simple, build network with local and national connections, regularly update your hospital eg through magazine, enlist support of chief executive, give feecback to donors and individuals concerned, register as a charity trust, do not insure (to save money), liaise with appropriate government department abroad to help with customs.
Rural Nepalese women given albendazole in the second trimester of pregnancy had a lower rate of severe anaemia during the third trimester. Birthweight of infants of women who had received two doses of albendazole rose by 59 g (95% CI 19-98), and infant mortality at 6 months fell by 41% (RR 0.59; 95% CI 0.43-0.82). Lancet. 2004 Sep 11;364
Oral misoprostol was associated with significant decreases in the rate of acute postpartum haemorrhage and mean blood loss. The drug's low cost, ease of administration, stability, and a positive safety profile make it a good option in resource-poor settings.
Phenobarbitone is relatively well tolerated in developing countries. Apart from its low cost, its other advantages are efficacy against all seizure types except absences, starting dose within effective range, once daily dosing. Its efficacy is comparable with more modern drugs. But once started, important not to discontinue suddenly; associated with status.
Vitamin A/D - see Nutrition.
Hyperemesis: avoid iron suppls. Antihistamine/phenothiazines are safe treatments, ondansetron has limited safety data, Pyridoxine reduces nausea but not vomiting, some evidence for acupressure, ginger. If ketones and postural drop are present, then rehydration, thiamine, and DVT prophylaxis are required. Role for steroids? Differential diagnosis is important: UTI, thyrotoxicosis, molar pregnancy. So n of 1 trial (patient centred symptom diary, paired treatment periods - ?number, ?duration, ?carry over effects).
Coffee and pregnancy - some scary research findings out there, but lots of confounding, plus variation in caffeine content, clearance (P450 polymorphisms). But Mums who drink 3+ cups coffee per day do not benefit from switching to decaf. Early miscarriage more common In those who drink substantial amounts In early pregnancy - but lack of aversion to coffee Is a marker for a failing pregnancy!? Some evidence of Increased fetal loss In 2nd half of pregnancy for 4+ cups a day.
Risk factors are
Bed rest and progesterone supplements are often used but little evidence. Remember Rhesus Ig.
Due to ischaemia of uterine wall with lactate accumulation. Pethidine is not rated as highly by women as it is by doctors… Mobile epidural includes fentanyl and less bupivicaine, giving less paralysis. Beware urinary retention. If postural headache develops (1%), autologous blood patch may cure. Higher rates of instrumental delivery probably related to painful malpositions! Spinal lasts about 2 hours. Pudendal block plus local infiltration good for ventouse, forceps except Keillands. Massage and relaxation are helpful, warm water baths are good for first and early second stages. TENS helps very good pain relief in 25%, but none in 25%.
Safety of LSCS related to availability of doctors skilled at difficult deliveries out of hours… Previous LSCS – 66% try vaginal the next time, of which 66% succeed. Only CPD will prohibit. Classical LSCS only needed for fibroids, transverse fetal lie with back inferior, pre 28/40 (subsequent rupture more common, and bleeding more serious). Remember antibiotic prophylaxis (cost effective) and heparin.
Kiellands rotational forceps are straight, Wrigley’s and Simpson’s are curved for lower and midcavity respectively. Ventouse is safer and less painful for mum but more scalp trauma for baby (avoid under 34/40). Episiotomy used for fetal distress in second stage, forceps/ventouse (to help line of traction), to avoid tear. Skin closure not necessary if muscle well closed.
In preterm labour with a multiple gestation, delayed delivery of the remaining fetus(es) before 30 weeks of gestation for 2 or more days was associated with improved infant survival. Am J Obstet Gynecol. 2004 Aug;191
Corpus luteum function seems to be impaired in IVF after a GnRH agonist. You therefore have to support the corpus luteum with HCG, to help ripen the oocytes in readiness for collection, and/or give on-going luteal support with progesterone (with less risk of OHSS than HCG). IM progesterone gives higher levels than vaginal, but is painful and does not seem to have a better success rate. The other option is to trigger a mid-cycle LH surge using a single bolus of GnRH agonist, reducing the risk of developing ovarian hyperstimulation syndrome (OHSS) in high responders.
Private GP services may encourage innovation, but not innovation that is likely to be shared, except by other branches of the same corporation. Doctor patient relationships will suffer (increasing convenience/access requires flexibility in which doctor is seen), professional autonomy is likely to suffer (doctor as shift worker).
Conflict between increasing range of providers (to improve access) and rising demand for co-ordinated care for people with multiple chronic conditions.
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