www.MedicalAtoZ.co.uk

DBPs in tap water

2012-02-08T04:14:00.000-08:00

disinfection byproducts (DBPs) found in most treated water supplies, such as trihalomethanes (THMs) and haloacetic acids (HAAs).

These DBPs form when water treatment disinfectants such as chlorine, chloramines, and chlorine dioxide react with natural organic matter in the source water.

Researchers have now discovered that DBPs are over 10,000 times more toxic than chlorine

http://www.biophysica.com/chlorine.html

Thirty second wait

2012-02-08T03:54:00.000-08:00

http://buywaternow.com/drinkingtapwater.shtml

Water that has sat in a faucet overnight or longer will be the most heavily polluted with metals

allowing your tap water to stand in an open container (with a wide mouth, such as a cooking pot) for two or three days will remove most of the residual chlorine

boiling also removes any remaining chlorine and other volatile pollutants

If you are going to boil your drinking water, use a stainless steel, glass or porcelain pot. Don't use aluminum. Trace aluminum in drinking water has been linked to increased rates of disease, Alzheimer's disease

Guardian article on tap v bottled water

2012-02-08T03:50:00.000-08:00

http://www.guardian.co.uk/lifeandstyle/wordofmouth/2008/jun/25/whatsinyourtapwater

Q Do most cancers originate during mitosis ?

2012-02-08T03:04:00.000-08:00

Cancer stem cell theory
http://en.wikipedia.org/wiki/Cancer_stem_cell
self-renewal and differentiation into multiple cell types
differentiated cells (constrained by the Hayflick Limit) cannot divide indefinitely
The first conclusive evidence for CSCs was published in 1997 in Nature Medicine. Bonnet and Dick[2] isolated a subpopulation of leukaemic cells that express a specific surface marker CD34, but lacks the CD38 marker
In human acute myeloid leukemia the frequency of these cells is less than 1 in 10,000
recently been identified in several solid tumors

'Some researchers favor the theory that the cancer stem cell is caused by a mutation in stem cell niche populations during development. The logical progression claims that these developing stem populations are mutated and then expand such that the mutation is shared by many of the descendants of the mutated stem cell. These daughter stem cells are then much closer to becoming tumors, and since there are many of them there is more chance of a mutation that can cause cancer'

with tissues with a high rate of cell turnover (such as the skin or gut). In these tissues, it has long been expected that stem cells are responsible for tumor formation. This is a consequence of the frequent cell divisions of these stem cells (compared to most adult stem cells) in conjunction with the extremely long lifespan of adult stem cells. This combination creates the ideal set of circumstances for mutations to accumulate; accumulation of mutations is the primary factor that drives cancer initiation.

potential de-differentiation of mutated cells such that these cells acquire stem cell like characteristics

Sonic hedgehog (SHH) and Wnt pathways are commonly hyperactivated in tumors and are required to sustain tumor growth

http://en.wikipedia.org/wiki/Hayflick_Limit
40-60 due to telomere shortening
Cancer cells turn on an enzyme called telomerase which is able to restore telomere length

http://en.wikipedia.org/wiki/Carnosine
In animal models carnosine has been shown to retard cancer growth[19] and protect against alcohol-induced oxidative stress[20] as well as ethanol-induced chronic liver damage.[21] Carnosine is also neuroprotective against permanent cerebral ischemia in mice.[22]

Carnosine can increase the Hayflick limit in human fibroblasts,[23] as well as appearing to reduce the telomere shortening rate.[24] This could potentially favor the growth of certain cancers that thrive due to telomere preservation

Useful websites

2012-02-07T14:55:00.000-08:00

www.healthtalkonline.org (great resource for patients and doctors)

www.qtdrugs.org

British Assoc Dermatology info leaflets
http://www.bad.org.uk/site/792/default.aspx

http://www.fpa.org.uk/
Family Planning assoc leaflets

HSGP 3Feb 2012 meeting

2012-02-07T13:00:00.000-08:00

Any acute infection will drop Hb by about 1-2 units, takes 3months to get back to normal

Dabigatran and rivoxibam for AF:
cost £2-4 / day, much more than warfarin
renal function monitoring with the newer agents but nothing else. Half life of about 24hr so stop about 2days pre-op and start again the day after

1 in 20 carry a genetic blood clotting defect

paraproteins
10% in > 80 years
5% in > 65years
IgM paraprotein >10 consider low grade lymphoma

sweating (drenching) is a late Sx of lymphoma
Low grade lymphomas probably aren't really curable, they occassionally become high grade but generally grumble on for years. Bit like CLL, the vast majority never need Rx.

Ectopic pregnancy tips

2012-02-07T12:16:00.000-08:00

Do a pregnancy test even if on contraception, and having a 'period'. (I normally do, but its nice to see the advice in black and white)

Patient safety newsletter Jan 2012

Further reading :
'A negative pregnancy test result does not exclude tubal pregnancy, because the placenta in tubal location can be either compromised or nonviable and therefore not able to produce enough human chorionic gonadotropin for a positive pregnancy test result.'

http://www.thedoctors.com/knowledgecenter/patientsafety/articles/con_id_000309

Do serum b-hcg if neg.

(30min + email to pass on above info to colleagues)

Theobromine (not caffeine) in chocolate

2012-01-19T13:32:00.000-08:00

http://en.wikipedia.org/wiki/Theobromine
Theobromine is the primary alkaloid found in cocoa and chocolate
similar, but lesser effect to caffeine in the human nervous system, making it a lesser homologue.
is also an isomer of theophylline.
half life 6-10hr
vasodilator (a blood vessel widener), a diuretic (urination aid), and heart stimulant
Theobromine can also be found in small amounts in the kola nut (1.0-2.5%), the guarana berry, ilex guayusa, ilex paraguariensis (yerba mate), and the tea plant
may occur in the body as it is a product of the human metabolism of caffeine, which is metabolised in the liver into 10% theobromine, 4% theophylline, and 80% paraxanthine
theobromine poisoning may result from the chronic or acute consumption of large quantities, especially in the elderly
Animals that metabolize theobromine more slowly, such as dogs, can succumb to theobromine poisoning from as little as 50 grams of chocolate for a smaller dog and 400 grams for an average-sized dog.

20min

Dronedarone (NICE 2010) under SVT section of BNF

2012-01-15T23:59:00.000-08:00

option for non - permanent AF for those
- not controlled on first line therapy + no HF 3-4 + 1 CVS risk factor

multi-channel blocking arrythmic - lowers ventricular rate + prevents recurrence

(20min - shared with colleague who also hadn't heard of this drug)

Cyanotic heart disease

2012-01-11T04:54:00.000-08:00

http://www.hawaii.edu/medicine/pediatrics/pedtext/s07c03.html
cyanosis from reduced hemoglobin in blood of at least 3-5 gm/dL

Respiratory problems with alveolar hypoventilation usually improve with paO2 measurements well above 100-150 mmHg, whereas in right-to-left shunt cardiac lesions, the improvement in arterial pO2 is very minimal.

Classifying cyanotic congenital heart defects into those with increased vascularity with an accentuated second heart sound and those with decreased blood flow with a diminished second heart sound

> vascularity + S2 - transposition of the great vessels, truncus arteriosis, total anomalous pulmonary venous return, single ventricle, single atrium, and hypoplastic left heart. Eisenmenger syndrome also falls into this category, but this is an acquired condition in which a patient with a left-to-right shunt and chronic CHF develops pulmonary hypertension and a subsequent right-to-left shunt

< vascularity + S2 - tetralogy of Fallot(-like lesions), pulmonary atresia, tricuspid atresia, and Ebstein's malformation

Transposition represents 4%-5% of all congenital heart defects .A heart murmur may not be present

Tetralogy : Older infants and children may assume a squatting position during playtime or long walks which increases systemic vascular resistance and decreases right to left shunting, increasing their oxygenation.loud systolic ejection murmur

Truncus arteriosus consists of a single arterial vessel arising from the heart, positioned over a ventricular septal defect. may be a systolic murmur at the left sternal border

Total anomalous pulmonary venous return (TAPVR) occurs in about 1%-2% of patients with congential heart disease.total or partial. An atrial septal defect is necessary for survival

Tricuspid atresia consists of an absence or atretic tricuspid valve and a hypoplastic right ventricle. Blood from the right atrium enters the left atrium through an atrial septal defect or foramen ovale.

Even short term NSAIDS can increase CV risk in patients with previous MI

2012-01-04T13:31:00.000-08:00

http://www.npc.nhs.uk/merec/resp/copd/resources/merec_monthly_42.pdf
Danish Cohort Study
Diclofenac highest risk
Naproxen lowest risk
Ibuprofen also low risk and appropriate in view of low GIT side effects

risk independent of duration, and apparent in first few weeks

National prescribing centre email alerts

2012-01-04T13:13:00.000-08:00

http://www.npc.nhs.uk/email_alerts.php

subscribed to :
MeRec
weekly awareness bulletins
New Meds
General News
Events and Conferences

Hypertension new guidance

2012-01-04T13:10:00.000-08:00

7/11/11 local suggestions :
- no need to change patients stable on bendroflumethiazide

- when diuretics are recommended by the new algorithm indapamide 2.5mg tablets 1od is the most cost effective first line choice

Ototoxic drugs

2012-01-03T23:46:00.000-08:00

http://en.wikipedia.org/wiki/Ototoxicity
Macrolides can cause reversible tinnitus (renal or hepatic impairment increase risk)
Bumetanide is less ototoxic than frusemide

Post traumatic stress disorder

2012-01-03T23:29:00.000-08:00

Trauma focussed CBT or watchful waiting for less than 4w(for mild cases) preferred to drug treatement

http://en.wikipedia.org/wiki/Posttraumatic_stress_disorder
SSRIs (first line drug treatement) for which there are data to support use include: citalopram, escitalopram,[133] fluoxetine,[134] fluvoxamine,[135] paroxetine,[136] and sertraline.[134][137]

bupropion and venlafaxine lowest drop-out rates.
Sertraline, fluoxetine, and nefazodone ~15%)
heterocyclics and paroxetine ~20%+

paroxetine or mitazepine advised on passmedicine

Hyperarousal, avoidance stimuli, flashbacks, emotional numbing for >1 month (otherwise acute stress disorder)

UKMEC guidelines for COC

2012-01-03T23:14:00.000-08:00

1 no restriction
2 advantages outweigh dis
3 disadvantages outweight ad
4 absolute CI (unacceptable risks)

eg.
3 : breast feeding 6w-6m,>35yr smoking <15/d, immobility, migraine without, BMI >35, FH VTE 1st deg <45yr
4 : major surgery, migraine with aura , breast cancer, CVA, IHD, uncontrolled HTN, VTE, Thrombophilia

DM diagnosed >20yr ago is 3or 4 depending on severity

Prevention peri-natal HIV transmission

2012-01-03T22:35:00.000-08:00

Advanced prevention reduces transmission from 25%

to less than 2% if anti-retrovirals given during pregnancy (from 28-32/40 RCOG guidelines), labour (AZT infusion 4hr before elective Caesarian), and newborn for 4-6w,

less than 10% if started during labour

http://www.cdc.gov/hiv/topics/perinatal/resources/factsheets/perinatal.htm

15-25% of children born to HIV-infected mothers get infected with HIV during pregnancy or delivery, and 15% through breastfeeding

http://www.unicef.org/programme/breastfeeding/hiv.htm

2008 BHIVA guidelines suggest vaginal delivery may be acceptable for women on HAART with undetectable viral loads

NICE CKD guidelines

2012-01-03T22:20:00.000-08:00

Rise in creatinine of up to 30% allowable after starting an ACEI

Glandular fever

2012-01-02T19:41:00.000-08:00

99% rash with amp or amox
remember to advise no contact sports for 8w to reduce risk of splenic rupture

Adenosine for SVT

2012-01-02T18:24:00.000-08:00

CI in asthmatics (use Verapamil instead)

Glitazones

2012-01-02T18:20:00.000-08:00

Monitor LFT pre-treatment and 'regularly' during treatment

Amiodarone monitoring

2012-01-02T18:16:00.000-08:00

TFT, LFT, U+E, CXR prior then TFT/LFT every 6m
http://www.pbm.va.gov/monitoring/amiodaron.htm

Pyoderma gangrenosum

2012-01-02T18:05:00.000-08:00

potential for rapid spread high so PO steroids 1st line usually

Gestational Diabetes NICE guidelines

2012-01-02T17:40:00.000-08:00

meds if diet and exercise fail to maintain blood glucose targets during a period of 1-2 weeks
no signif maternal/neonatal outcome diff with glyburide (glibenclamide used in UK) or metformin compared to insulin
aim to keep fasting blood glu 3.5- 5.9 and 1hr postprandial <7.8 (advise test before/after every meal)
type1 patients should test for ketonuria if high glucose or unwell
at delivery stop hypoglycaemics, repeat fasting glucose at 6w postpartum
http://www.gpnotebook.co.uk/simplepage.cfm?ID=1845886994&linkID=67273&cook=yes

screening
1in40
if risk factors BMI >30, 1st degree FH, previous macrosomia, South Asian/ Black Caribbean/ Middle Eastern
OGTT 24-28/40 (if previous gestational DM then 16-18/40 + 28/40 )

2011 BTS Asthma guidelines

2012-01-02T17:18:00.000-08:00

Trial of treatment if high probability of asthma even if spirometry normal (rather than waiting for peak flow diary results) eg.atopy, nocturnal/ early morning symptoms, audible wheeze

Spirometry if intermediate probability : FEV1/FVC <0.7

>400ml improvement in FEV1 with 400mcg inhal salbutamol suggestive

variability has poor sensitivity - although diurnal variation over 2w >20% is significant [highest PF-lowest/highest *100]

Animal bite

2012-01-02T17:14:00.001-08:00

1 Coamox (metro + doxycycline if pen allergic)

2010 NICE diagnosis + management constipation in children

2012-01-02T15:27:00.000-08:00

Faecal impaction - Consider with overflow, faecal mass palpable in abdomen, PR is for specialists - Movicol escalating rather than glycerol supp first line

Infantile constipation - extra water/ cycling legs/ massage abdo/ fruit juice/ fruit before considering lactulose (unusual if purely breast fed - look for organic causes)

http://publications.nice.org.uk/constipation-in-children-and-young-people-cg99

BPH with LUTS

2012-01-02T13:00:00.000-08:00

http://www.gpnotebook.co.uk/simplepage.cfm?ID=1932853271&linkID=27818&cook=no

>30g prostate consider finasteride. Can combine with alpha blocker

Anaphylaxis meds

2012-01-02T12:46:00.000-08:00

Adrenaline mcg, HC mg, chlorpheniramine mg

<6m 150/25/250mcg per kg
<6yr 150/50/2.5
<12 300/100/5
>12 500/200/10

Adrenaline can be repeated after 5min
IM antlat mid third thigh =best site

Optic neuritis and MS

2012-01-02T12:22:00.000-08:00

Uhthoff's phenomenon - worsening of vision following rise in body temperature

Optic neuritis - commonest presentatin
suspect when sudden loss/reduction of vision or blurred/foggy and pain on movement (absent in 60% of paeds cases)
Red densentization
Often only 1 eye affected
Disc often normal in appearance

IV steroids (PO steroids may increase relapse rate) but acuity= to placebo at 1yr, reduces progression of MS in first 2yr for those with MRI lesions
http://en.wikipedia.org/wiki/Optic_neuritis

Dysmenorrheoa

2012-01-02T12:15:00.000-08:00

Primary
onset usually starts within 2yr of menarche
usually within few hrs of period
ibuprofen or mefenamic acid 1st line
OCP 2nd line

Secondary
usual pathology
usually starts 3-4d before period
Clinical knowledge summaries suggest refer all for ix
Unlike IUD, Mirena may help

MI secondary prevention

2012-01-02T11:56:00.000-08:00

NICE 2007
Aspirin, Statin, B blocker, ACEI

Clopidogrel
ST segment elevation 4w
NSTEMI 12m if 6m mortality risk more than 1.5% (NICE 2010 Unstable angina/ NSTEMI guidelines)

Aldosterone antag
if HF or systolic dysfunction with 3-14d, preferably after ACEI

Intussusception rather than constipation

2012-01-02T11:47:00.000-08:00

Suspect if :
blood stained stool
drawing knees up and turning pale during paroxysms
vomiting
sausage mass

Usually infants 6-18m, Boys x2 risk, usually ileocaecal
USS = ix of choice
Barium enema usually reduces
Otherwise surgery partic if peritonism

Asthma guidelines

2012-01-02T11:34:00.000-08:00

Step 2 Inhal steroid 200-800mcg/d beclomethasone (or equiv)
Step 3 Long acting B2 agonist (LABA). If poor response consider LRA or SR theophylline
Step 4 Trial steroid up to 2g/d, or 4th drug from above
Step 5 lowest dose po steroids to control symptoms (maintaining 2g/d inhaled) / refer

LRA partic useful in aspirin induced aspirin. Increased risk Churg Strauss

Fluticasone lipophilic, longer duration than beclo
Hydrofluoroalkane propellent gives smaller particles than chlorofluorocarbon so half dose needed.

LABA may inhibit mast cell release of mediators !

Vitiligo

2012-01-02T11:30:00.000-08:00

Peripheries most affected. May exhibit Koebner phenomenon.

European Soc Cardiology Chronic AF guidelines

2012-01-02T11:11:00.000-08:00

CHA(2)DS-VAS(2) score (supercedes CHADS2)to decide on anticoag

CHF, HTN, Age>75, Diabetes, Stroke or TIA, Vascular disease, Age>65, Sex (female)

0=no treatment preferred to aspirin
1=oral anti-coag preferred to aspirin or dabigatran
2 or more = oral anti-coag or dabigatran

but 2006 NICE guidelines give age <65 lone AF as having 1% annual risk of stroke and advise aspirin.

Makes it difficult to counsel young patients with lone AF (NB.cardioversion first choice)

So all >75yr olds for oral anti-coag

SIGN guidelines - opiates in palliative care

2012-01-02T08:25:00.000-08:00

Thought -
although fentanyl/alfentanyl/buprenorphine preferred in renal impairment, if a patient becomes unwell and stops drinking, they may stop oral meds but analgesic patch will continue to accumulate if not removed, or reduced.

SIGN 2008 control of pain in adults with cancer guidelines

2012-01-02T08:19:00.000-08:00

Metastatic bone pain - consider NSAIDS, bisphosphonates, XRT
Increase opiates by 30-50% when increasing

2010 CHF NICE guidance

2012-01-02T08:02:00.000-08:00

>survival:
1st line ACEI (SAVE, SOLVD, CONSENSUS) + B blockers (CIBIS)
2nd line Spironolactone(RALES)or ARB or Hydralazine with nitrates (VHEFT-1)
Consider cardiac re-synchronisation or digoxin (partic if AF)
Give diuretics if fluid overloaded

Annual influenza vacc + one off pneum vacc

Urinary incontinence

2012-01-02T07:52:00.000-08:00

Bladder diary min 3d + MC+S

Stress predominant - Pelvic floor exercises, surgical eg.sacral nerve stim
Urge predominant - Bladder re-training min 6w, oxybutynin immediate release (first line), surgical eg.retropubic mid urethral tape
Overflow - treat cause

CURB-65 criteria for severe pneumonia

2012-01-02T07:40:00.000-08:00

3 or more = severe

Confusion (AMT <8/10)
Urea >7.0
RR>30
BP systolic <90 or diastolic <60
>65yr

nb.hypoxaemia, coexisting disease also assoc poor prognosis

HOCM

2012-01-02T07:22:00.000-08:00

1 in 500
autosomal dominant
nb.exercise induced syncope, FH sudden death
ESM increases with valsalva, decreases with squatting
ECG LVH, T wave inversion, deep Q waves, occ AF

2011 Hypertension NICE guidance

2012-01-02T06:42:00.000-08:00

ABPM better predictor of CVS risk than clinic results
Need to avoid overtreatment of white coat hypertension - NICE advocate ABPM and HBPM (Home)

Stages of HTN :
Stage 1 >140/90 and ABPM daytime or HBPM >135/85
Stage 2 >160/100 >150/95
Severe systolic >180 or diastolic >110 (consider immediate treatment)

ABPM average >=14 measurements, *2/hr
HBPM 2 readings each time at least 1min apart, bd 7d , discard day1, average others

Stage 2 offer treatment
Stage 1 if <80yr and target damage, CVS disease, DM, CVS risk 10yr >20%, renal disease

<40yr consider referral to exclude secondary causes

Step1 <55 (A), >55 or Afro (C)
Step2 A+C
Step3 A+C+D (Chlorthalidone 12.5-25mg od, or Indapamide 1.5mg MR od or 2.5mg od)

Step4 if BP still >140/90 in clinic, potassium less than 4.5mg add spironolactone, potassium more than 4.5mg increase thiazide if possible otherwise alpha or B Blocker

Advice if still not controlled

Consider direct renin inhibitor blocks conversion angiotensinogen to angiotensin 1eg.Aliskiren(Rasilez) if intolerant to other drugs as effects similar to ACEI or ARBs

Hypocalcaemia

2012-01-02T06:36:00.000-08:00

Alk Phos raised - CRF, hypoparathyroidism, pseudoparathyroidism
Alk Phos low/normal - osteomalacia, overhydration, pancreatitis

2011 Who guidance for Diabetes Mellitus

2012-01-02T06:13:00.000-08:00

Diagnosis:
1 random glucose >11.1
2 fasting glucose >7
3 HbA1C > 6.5% although less than 6.5% does not exclude

If asymptomatic 1 or 2 must be demonstrated on at least 2 occasions

HbA1C test assumes a normal red blood cell aging process and mix of hemoglobin subtypes (predominantly HbA in normal adults).

- recent blood loss, hemolytic anemia (consider fructosamine test) , haemoglobinopathy, blood donation unsuitable for test
http://en.wikipedia.org/wiki/Glycated_hemoglobin

IFG 6.1- less than 7.0
IGT 7.8-<11.1 and fasting glucose <7.0

Transdermal opiate intoxication in the elderly

2012-01-01T22:05:00.000-08:00

More common than we realize - a likely cause of drowsiness in a patient with limited intake of fluids (accumulation due to renal impairment)

(2 cases in the past week eg.the normally aggressive demented patient who now sleeps all the time, eg.the stroke patient more drowsy than usual)

Diagnosis of 'dying' often made too late ?

2012-01-01T21:58:00.000-08:00

http://www.bmj.com/content/343/bmj.d8008
Would you like to die the way your patients do, doctor?
Be aware of denial of death / false promises of immortality / need for dignity.

Some pyschological areas to focus on in mild depression

2012-01-01T18:08:00.000-08:00

Identify lifestyle changes / opportunities eg.hobbies/ interests and set achievable goals

Replace -ve inputs with more +ve ones (similar to replacing -ve thoughts in CBT) eg.listen to cheerful instead of depressing music

Recognize depression in those around them to understand why they might not be helping.

If a patient is able to make changes to their lifestyle it might sometimes be best to delay forcing them to talk/ think about lots of negative ideas eg.hold off advising formal CBT/ NLP in favour of brief interventions with follow up.

Potential empiric treatmentf for 40F with uncomplicated cystitis.

2012-01-01T11:57:00.000-08:00

Uptodate letter (American Publication) suggests several treatments which apart from the first I haven't seen in any UK publications -
Nitrofurantoin 100mg bd 5d
Fosfomycin 3g single dose !
Trimethoprim-sulfamethoxazole 160mg/800mg bd 3d !
Pivmecillinam 400mg bd 3-7d !
Thought:
Perhaps UK guidelines might consider these treatments in the future if local sensitivities suggest they are useful.

HER2 monoclonal ABs for breast cancer

2011-12-20T22:31:00.000-08:00

20% and 30% of breast cancers overexpress receptors for human epidermal growth factor 2 (HER2) and are amenable to targeted treatments, such as monoclonal antibodies.

Trastuzumab + pertuzumab (which binds to a different part of the HER2 protein) v trastuzumab alone : extra 6m progression-free survival (18.5 v 12.4m)
but more diarrhoea/ febrile neutropenia/ skin and mucosal symptoms

http://www.bmj.com/content/343/bmj.d8077

Avoiding litigation

2011-12-20T22:28:00.000-08:00

know your medicine;
be alert to early signs of deterioration;
act promptly if a problem arises;
warn patients of risks;
write thorough, legible medical notes;
be aware of your limits and seek help if unsure
http://www.bmj.com/content/343/bmj.d7827

Post anaphylaxis

2011-12-20T22:23:00.000-08:00

>16yr Observe 6-12 hours from the onset of symptoms to detect potential biphasic reactions.
<16yr admit
http://www.bmj.com/content/343/bmj.d7595
(no mention of role of urinary N-methylhistamine in Ix )

Excessive infant crying

2011-12-20T22:14:00.000-08:00

assoc :
strain on the family / higher rates of physical abuse and postnatal depression / behavioural problems in childhood
http://www.bmj.com/content/343/bmj.d8159

1-2hr/day is average in first few months

Pre-signing of scripts to allow another person who is not appropriately trained to prescribe eg.nurse

2011-12-07T02:25:00.000-08:00

Passmedicine scenario -
If a senior partner, and no other senior partner available, contacting PCT takes precedence over informing the nurse of your concerns.

Child Protection

2011-12-06T18:38:00.000-08:00

13% of 11-17 year olds report severe maltreatment at the hands of carers and family
12% of under 11s witness violence or abuse in the home
Radford’s study (2011) concludes that there has been a gradual decline in reported child maltreatment between 1998 and 2009
verbal and physical aggression (reported rates reduced from 14.5% to 6% and 13% to 9.8% respectively). Reported neglect has remained about the same
CAF Common assessment framework - referral/ inter-disciplinary assessment
Child Protection Plan Registrar
duty officer for the Children’s Social Care team
section 47 investigation (risk - emergency protection may be needed) is more comprehensive than a section 17 ix (need).
"the hidden man", if known - that is, any known male living in the household
doctor should challenge decisions by social care if the child seems insufficiently protected

Must anonymize data before sending to an external body, 7% children subject to physical abuse, CAF doesn't collect info on ability of health professionals to respond to needs

93% DrsNet module

Medicine unboxed

2011-12-04T21:42:00.001-08:00

Adding morality, philosophy, empathy and imagination to care :
http://www.projeqt.com/medicineunboxed#lsi87150ci0q

Tips to help loneliness

2011-12-04T21:26:00.000-08:00

After reading the Wakley 2010 Lancet prize essay about a lonely elderly patient in hospital - moving , but lacking in any constructive longterm advice for the patient such as below :

http://www.personal-development.com/chuck/cure-loneliness.htm
learn to like self
volunteer
positive attitude

http://psychcentral.com/lib/2007/coping-with-loneliness-tips-for-seniors/
Hobby
Pet
Reminisce
Home visitation services

Dabigatran

2011-12-04T21:05:00.000-08:00

NICE guidelines :
Treatment for the prevention of stroke and systemic embolism in adult patients with nonvalvular atrial fibrillation with one or more of the following risk factors:
o previous stroke, transient ischaemic attack, or systemic embolism
o left ventricular ejection fraction below 40%
o symptomatic heart failure of New York Heart Association (NYHA) class 2 or above
o age 75 years or over
o age 65 years or over with one of the following: diabetes mellitus, coronary artery disease, or hypertension.

increased incidence of GI bleeds compared to warfarin

Placebo effect

2011-12-04T20:55:00.001-08:00

difference in treatment effect between the placebo group and a conceptual natural history control group
http://www.bmj.com/content/343/bmj.d7665?etoc=&ga=w_ga_mpopular

Causes of bias in statin studies

2011-12-04T20:44:00.000-08:00

http://www.bmj.com/content/343/bmj.d7134 concludes statins do not prevent infections

healthy tolerator bias - healthy subjects able to tolerate side effects
adherent phenotype - patients willing to keep taking - conscientiousness, mood, and cognitive function
?patients with high cholesterol have a lower risk of infection
publication bias - publishing favourable outcomes as most research drug company funded

Salt intake and cardiovascular mortality

2011-12-04T20:33:00.000-08:00

http://www.bmj.com/content/343/bmj.d7549
J shape curve, but lower end of curve patients may be avoiding salt because they are already ill.

Exemestane

2011-12-04T18:36:00.000-08:00

BNF Indications
Adjuvant in early Oestrogen receptor +ve post menopausal following 2-3yr tamoxifen,
or
in advanced post menopausal cancer in whom anti-oestrogen therapy failed

Steroidal aromatase inhibitor

Self Harm : NICE guidance

2011-11-30T23:45:00.000-08:00

Do not offer drug treatment as a specific intervention to reduce self harm
NB.needs of any dependent children
Coping strategies that the person has used
Care plans should be multidisciplinary and developed collaboratively with the person who self harms and his or her family, carers, or significant others
http://www.bmj.com/content/343/bmj.d7073

PE risk and Autoimmune disease

2011-11-30T23:35:00.000-08:00

Standardised incidence ratios highest year after admission for :
ITP (10.79, 95% CI 7.98 to 14.28),
polyarteritis nodosa (13.26, 9.33 to 18.29),
polymyositis or dermatomyositis (16.44, 11.57 to 22.69),
SLE (10.23, 8.31 to 12.45),
UC (10.26, 9.03 to 11.62).
RA / DM1 not far behind
http://www.bmj.com/content/343/bmj.d7693

Probable pro-coagulable state from inflammation.
Absolute numbers still small, and many confounding variables not explored.

Chronic vulvovaginitis differential

2011-11-29T17:57:00.000-08:00

http://www.bmj.com/content/343/bmj.d7314

Any vaginitis may trigger genital psoriasis as a result of the Koebner phenomenon in predisposed individuals.
negative swab result should not preclude a trial of antifungal medication

Common
•candidiasis (worsens pre-menstrually, cheesy discharge, erythema is accentuated in the sulcus between labia minora and majora, fissures )
•bacterial vaginosis
•Contact dermatitis (allergic and irritant contact): caused by intravaginal pessaries and creams

Uncommon
•Desquamative inflammatory vaginitis: unknown cause, shiny erythematous patches and/or petechiae, green discharge. Can be triggered by vaginal surgery . 2-4w trial of intravaginal clindamycin 2% cream with 1% hydrocortisone used externally usually helps.

•Intravaginal foreign body (eg, retained tampon): heavy discharge

•Chronic fixed drug eruption: erosive, assoc with NSAIDS, statins

•Type 1 hypersensitivity reactions: latex condoms and seminal fluid (Should be within few min of exposure, assoc swellings/ urticaria)

Rare
•Mucosal lichen planus: check mouth for reticulate white eruption on the buccal mucosa, loss labia minora, introital fusion, heavy purulent discharge
•Oestrogen hypersensitivity vulvovaginitis: cyclical

Very rare
•Crohn’s disease:
•Pemphigoid without generalised skin disease (rare to see intact blisters)
•GvHD: indistinguishable from lichen planus (if indistinguishable from Graft verses host disease could maternal cells be involved in the aetiology of lichen planus ? - just a thought)

Steroid conversion on line

2011-10-18T19:04:00.000-07:00

http://www.medcalc.com/steroid.html
Methylpred *5 as potent as hydrocortisone so 1000mg MP= 5000mg HC

Metformin and renal function

2011-10-16T18:20:00.000-07:00

eGFR
<30 stop
30-50 --------- max 1000mg/d
50+ ------------ max 2000mg/d

PN41

Modified release metformin trial

2011-10-16T18:18:00.000-07:00

'If patients have persistent GI side effects in spite of slow
introduction (500mg once a day (with breakfast),
increasing by 500mg at intervals of 1–2 weeks) of the standard formulation, a short
trial of modified release metformin should be
considered before using alternative treatments'

PN41

Ella one

2011-10-15T15:06:00.000-07:00

cannot be used with enzyme inducers, PPI antacids or H2 antagonists and can only be used once each cycle.

FFPRHC EC booklet

2011-10-15T15:04:00.000-07:00

Quick start contraception after EC..need to do PT at 3 weeks.

PCOS RCOG guideline

2011-10-15T15:00:00.000-07:00

if amenorrhoeic at risk of endometrial hyperplasia rx norethisterone 5mg tds 12d.
Scan if no bleed after and refer if lining >10cm

Superficial Thrombophlebitis (SIGN Dec 2010)

2011-10-15T14:53:00.000-07:00

scan if within 3cm of sapheno-femoral jtn
all should use anti thrombotic stockings for a month and ? 1 month LMWH.

up to 1/4 have underlying DVT
http://www.gpnotebook.co.uk/simplepage.cfm?ID=221577240&linkID=32211&cook=no
support bandage , elevation, ibuprofen

End of life care cardiac failure

2011-10-15T14:45:00.000-07:00

Implanted Cardiac Defibrillators need to be switched off in Terminal care
- contact technician or should have a magnet in A&E.

Breathlessness: 2/3 benefit from 10-30 mg morphine daily without risk of respiratory depression.

Anxiety..Lorazepam.

If e GFR <30 should not use morphine or diamorphine unless terminal.

Defibrillation course notes (West Midlands Ambulance service 34page handout)

2011-10-10T20:34:00.000-07:00

Changes to BLS minimise pauses in chest compression -

Supposed to diagnose cardiac arrest if unresponsive and not breathing normally (can argue against this for health professionals ie. resp arrest often precedes cardiac arrest and knowing whether a pulse is present allows focus on airway /breathing)

Rescue breath over 1sec rather than 2sec

30:2 ratio for adults (+ children if lay rescuer), 100/min, 4-5cm sternum depression

omit 2 rescue breaths for an adult and give 30 compressions immediately after cardiac arrest

Guidelines 2000 encourage chest compression alone if rescuer unable/ reluctant to perform mouth-mouth ventilation

Remember mouth to nose alternative (or mouth to tracheostomy if tracheostomy present)

Recovery position - legs straight, nearest arm out at 90deg elbow bent/palm uppermost, far arm across chest holding back of hand against victim's nearest cheek, pull on far leg, adjust so hip/knee at right angles. TURN to opposite side after 30min to relieve pressure on arm !

Q Are you choking ?
Up to 5 back blows then up to 5 abdo thrusts

Adjustments : Paed (+ drowning eg.if lifeguard) resus : 5 initial rescue breaths, 1min CPR before going for help if alone, compress chest by 1/3 of its depth (use 2 fingers <1yr)

Agonal gasps can be misdiagnosed as breathing (present in 40% of cardiac arrest victims)

Change rescuer delivering chest compressions every 2min if possible

Turn patient on back if no response + open airway with head tilt and chin lift

AED Automated external defib
Remove 02, jewellery, check for pacemaker/GTN, hormone, nicotine patches

Chance of successful defib declines by 7-10% with each min delay. However when time for ambulance arrival exceeds 5min a period of chest compression prior to defib may improve survival (In these studies paramedics performed the CPR + delivered 100% 02 so lay people may not achieve the same results). CPR achieves at best 15% normal cardiac output and 30% cerebral perfusion.

Standard AED suitable >8yr old. If 1-8yr use paed pads or paed mode if available, otherwise use as it is. Insuffic evidence for/against AEDs <1yr.

PAD Public access defibrillation

How early can MRI detect abnormalities in Disciitis

2011-10-06T02:47:00.000-07:00

Sheep model - injecting discs with bacteria - takes >7days to reliably detect changes
http://cds.ismrm.org/ismrm-2001/PDF1/0249.pdf

http://www.ncbi.nlm.nih.gov/pubmed/21070900
case - highly suggestive clinically with staph skin infection but normal MRI - cases below suggest a repeat MRI is needed.

http://linkinghub.elsevier.com/retrieve/pii/S0009926010002187
The MRI appearances of early vertebral osteomyelitis and discitis
Clinical Radiology, Volume 65, Issue 12, Pages 974-981
J.A.T. Dunbar, J.A.T. Sandoe, A.S. Rao, D.W. Crimmins, W. Baig, J.J. Rankine

In four cases the features typical of spinal infection were not evident at the initial MRI. In three cases there was very subtle endplate oedema associated with disc degeneration, which was interpreted as Modic type I degenerative endplate change. Intravenous antibiotic therapy was continued prior to repeat MRI examinations. The mean time to the repeat examination was 17 days with a range of 8–22 days. The second examinations clearly demonstrated vertebral osteomyelitis and discitis.

Conclusion
Although MRI is the imaging method of choice for vertebral osteomyelitis and discitis in the early stages, it may show subtle, non-specific endplate subchondral changes; a repeat examination may be required to show the typical features.

and

Acute MRI changes in infectious discitis: report on two cases
http://www.springerlink.com/content/q7t176u07k638755/
Previous reports suggest that MRI changes should be seen within 48h of symptoms arising. We report on two patients with proven discitis at the L5/S1 disc. MRI performed within 60h of the onset of symptoms did not demonstrate evidence of infection and therefore did not confirm the diagnosis of discitis. The reliability of early MRI to confirm infective discitis is questionable. The cases we report on did not display any of the typical changes of discitis on MRI within the first 48h after the onset of symptoms. Absence of typical infective changes on MRI does not necessarily exclude an infection within the disc space.

Infection Control Presentation + Assessment Q's Summary

2011-10-05T17:47:00.000-07:00

Infec Control def : techniques/ procedures to prevent healthcare assoc infec
'Transient' microorganism can be transferred
4 most popular sources of infec : people, surfaces, equipment, animals
Elderly most at risk of infection
Use protective equip + precautions to reduce risk when in contact with bodily fluids
Report all needle stick injuries + first aid
Spillage : Clean immediately, protec equip, discard material in waste bag

Bioparox

2011-10-04T18:17:00.000-07:00

Inhal antibiotic with anti-inflam properties - claims not to cause antibiotic resistance. Used PRN inhal by child during breathing exac. Prescribed in Poland.
Advised stop - Q. Why is this used in Poland.

Be sure to delete 'ghost patients' from practice lists

2011-09-30T00:58:00.000-07:00

Prevents being seen to commit fraud by claiming to treat non existent patients
http://webapp.doctors.org.uk/Redirect/www.dailymail.co.uk/news/article-2035714/Phantom-patients-net-GPs-millions-How-dishonest-doctors-claim-NHS-cash-dead-patients-non-existent-treatments.html

BASH Guidelines for migraine

2011-09-29T00:12:00.000-07:00

1 simple analgesic + antiemetic eg.paramax (paracetamol/metoclopramide)
2 parenteral
3 specific treatment eg.triptan or ergotamine

Disciits

2011-09-20T18:53:00.000-07:00

http://en.wikipedia.org/wiki/Discitis
lack of mobility = main symptom (doesn't mention tenderness)
throbbing sensation ?suggestive
usual cause staph aureus so skin infection with pustules occurring at the same time would seem suggestive.

Hiccups Triage

2011-09-20T16:49:00.000-07:00

http://www.patient.co.uk/health/Hiccups-(Hiccoughs).htm

lasting >48hr causes include

•Certain medicines - examples are steroids, tranquillisers, painkillers containing opiates (such as morphine) and methyldopa (for blood pressure).
•Changes in blood chemistry such as from alcohol, high blood sugar, or lack of calcium or potassium in the blood.
•Gut problems such as acid reflux, distention (stretching) of the stomach, infection of the gallbladder or infection under the diaphragm.
•A general anaesthetic.
•Conditions affecting the neck, chest or abdomen (tummy). For example, surgery, infections (such as sore throat or pneumonia), swellings or tumours in these parts of the body.
•Some heart conditions - a heart attack or inflammation around the heart.
•Brain conditions such as stroke, head injury or brain infection.
•Hiccups sometimes occur in the late stages of a terminal illness such as when a person is very ill with advanced cancer.

Haemolysis or hyperkalaemia

2011-09-20T13:26:00.000-07:00

The biochem analysers look for haemolysis and give a score.
>50 consistent with haemolysis.
Rang regarding a patient with K of 8, who was know to have had high k 3d ago, with worsening renal func, and wasn't drinking so probably genuine. Sample delayed by 6hr but value on machine only 2. Technician informed was confident of no haemolysis.

Action - advised lab to pass on this info to clinicians + explain in words
eg. value of 30 could say 20-50% chance of haemolysis
eg. value <10 could say <5% chance of haemolysis

Like any test the likelihood of a +ve result is dependent on the 'pre-test probability' ie. clinical likelihood from hx/examination

Volumatic or Aerochamber

2011-09-15T15:27:00.000-07:00

large volume spacer (volumatic) for any age child; they should be used for routine use of both preventer and reliever medication.

Aerochambers are smaller spacer device’s that can be very handy to carry in a handbag or baby change bag for occasional use

Purple urine bag syndrome

2011-09-07T21:56:00.001-07:00

80yr presents with purple urine in catheter bag -
reassure
ask about systemic features of infection
indoxyl sulfate from tryptophan is converted to indirubin and indigo
by bacteria in the catheter or bag
http://en.wikipedia.org/wiki/Purple_urine_bag_syndrome

Prognosis in Palliative care Study (PiPS) predictor model

2011-09-06T23:49:00.000-07:00

http://www.bmj.com/content/343/bmj.d5171.full
23 parameters that are independently associated with a poor prognosis
'communicating the prediction to the patient is as important as forecasting it'

http://www.bmj.com/content/343/bmj.d4920.full
Clinicians’ predictions of survival are inaccurate and over-optimistic

11 variables (pulse rate, general health status, mental test score, performance status, presence of anorexia, presence of any site of metastatic disease, presence of liver metastases, C reactive protein, white blood count, platelet count, and urea) independently predicted 2w + 2m survival.

4 variables had prognostic significance only for 2w survival (dyspnoea, dysphagia, bone metastases, and alanine transaminase)

8 variables had prognostic significance only for 2m survival (primary breast cancer, male genital cancer, tiredness, loss of weight, lymphocyte count, neutrophil count, alkaline phosphatase, and albumin).

Cyclosporin should be prescribed by brand

2011-08-30T22:29:00.000-07:00

Makes monitoring levels easier.
Capimmune brand popular

Methadone brand choice

2011-08-30T22:25:00.000-07:00

Physeptone 1mg/ml sugar free
Tablets only if travelling abroad

Not recommended for AF by NICE

2011-08-30T22:19:00.000-07:00

given bd, fewer interactions.
RE-LY patient group differs from typical UK patients
evidence warfarin still has superior outcomes
cannot be reversed unlike warfarin, and can only be removed with dialysis
AugPN

Pioglitazone risk of bladder cancer (and heart failure)

2011-08-30T22:03:00.000-07:00

relative risk 1.12- 1.33
6m rv - only patients who are deriving benefit continue
hx bladder cancer/ uninvestigated haematuria should not receive
assess risk factors for bladder ca before starting - age; current or past history of smoking; exposure to some occupational or chemotherapy agents such as cyclophosphamide; or previous irradiation
http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON125962

Lei Gong Teng

2011-08-30T22:01:00.000-07:00

(Tripterygium wilfordii, also known as Thunder God Vine or Seven-step vine) concerns about serious side effects on fertility and on the liver, kidneys, immune system, blood, and heart.
http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON125972

Memory and Sleep

2011-08-14T23:53:00.001-07:00

A minimum number of hours of uninterrupted sleep may be needed to help consolidate memories
http://www.bmj.com/content/343/bmj.d5016.full

consider effect of sleep apnoea

Patients who self discharge

2011-08-14T23:48:00.000-07:00

Empathy
Regret
Follow up
Hospital - GP communication
http://www.bmj.com/content/343/bmj.d5054.full

Bariatric surgery for those with BMI > 50

2011-08-14T23:35:00.000-07:00

healthcare within a context of limited financial resources
intentionally non-discriminatory - independent of social factors
http://www.bmj.com/content/343/bmj.d4944.full

TEMPI syndrome (6 patients so far) - ?cause

2011-08-14T23:33:00.000-07:00

telangiectasias, elevated erythropoietin value and erythrocytosis, monoclonal gammopathy, perinephric fluid collections, and intrapulmonary shunting.
http://www.bmj.com/content/343/bmj.d5061.full

Behavioural interventions in elderly depression

2011-08-14T23:11:00.000-07:00

SSRIs for depression in elderly -
large primary care based cohort
inc risk of falls RR 1.6
citalopram, escitalopram, and fluoxetine assoc with hyponatraemia RR 1.52
trazodone, mirtazapine, and venlafaxine assoc higher risk all cause mortality
Unexpectedly, low dose tricyclic antidepressants did not have the highest hazard ratio for any of the adverse outcomes reported
venlafaxine typically used in more severe or treatment resistant depression (may be indicative of extensive medical comorbidity ie.confounding variable perhaps like most of these associations).
all patients should be provided with psychological support and behavioural interventions—particularly those aimed at increasing their daily activity and improving their sleeping patterns

SNP genotyping now rapid and cost effective

2011-08-14T23:05:00.000-07:00

Personalised stratefied medicine from single nucleotide polymorphisms (SNPs)help guide disease risk and response to drugs.
http://www.bmj.com/content/343/bmj.d4953.full

Betanin causes the red colour in urine or stool after eating beetroot.

2011-08-07T15:54:00.000-07:00

Betanin degrades faster if the urine is alkaline. Presumably this might account for beetroot not always causing noticeable discolouration (as in patient just seen - who was surprised to notice for the first time despite often having had before).
http://en.wikipedia.org/wiki/Betanin

Tranexamic acid in trauma

2011-07-24T23:59:00.000-07:00

CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage 2) study
TXA reduced all cause mortality (RR 0.91, 95% CI 0.85 to 0.97) and the risk of death as a result of bleeding (0.85, 0.76 to 0.96).
http://www.bmj.com/content/343/bmj.d3958.full

Non alcoholic fatty liver disease (NAFLD)

2011-07-24T23:54:00.000-07:00

NAFLD is now recognised as a common condition (or spectrum of disease) affecting both adults and children, especially those with obesity, type 2 diabetes, insulin resistance, and dyslipidaemia. Most obese adults and many obese children have it.

Minority progress to liver fibrosis, cirrhosis, or liver cancer.
Prognosis uncertain, no specific treatment, ?worth identifying patients to advise weight loss and exercise.
http://www.bmj.com/content/343/bmj.d4652.full

Drugs in water

2011-07-24T18:30:00.000-07:00

Pharmaceuticals routinely taken by people are not fully absorbed by our bodies, and are excreted and passed first into wastewater and then into surface water. Similarly, medical waste and disposal of unused pharmaceuticals down the drain

Caffeine pollution of rivers and streams

http://www.ewg.org/BottledWater/Bottled-Water-Quality-Investigation/Bottled-Water-Quality-Investigation-Test-Results

bottled water is exposed to a wide variety of plastic chemicals that leach from packaging. The main type of packaging for bottled water is polyethylene terephthalate or PET,

Acetaldehyde is one of the most common contaminants released from PET bottles during overheating

Toluene was detected in four brands. Toluene is a petroleum-derived industrial chemical and a solvent

Gross beta particle radioactivity was detected in seven brands with average level of 3.7 pCi/L (picoCuries/liter).

Future : protection of source water quality and better tap water treatment strategies