Wednesday Meeting Evaluation - Pennine GP Training



BMJ reading

Jan 11th

Medical abortion

Used up to 63 days gestation (9/40)

Mifepristone 200mg orally follwed 24 hours later by Misoprostol SL 800mcg.

Most women abort 2 to 6 hours after taking the Misoprostol

Women should seek medical help id:vaginal bleeding more than two sanitary towels for two consecutive hours, temp persistently > 38 C, severe abdo pain unrelieved by analgesia, or D&V lasting > 24 hours after taking misoprostol

Causes of polydipsia

Common (>1in 10)

Diuretics, caffeine & alcohol

DM

Lithium

Heart Failure

Infrequent (1 in 100)

Hypercalcaemia

Hyperthyroidism

Rare

Psychogenic polydipsia

Hypokaleamia

Jan 4th

Cardio-selective beta-blockers for patients with COPD who have an MI provide substantial survival benefits – so use them!

Interesting paper on IGR and the risk of progression to diabetes when using statins, diuretics or betablockers. Surprisingly beta-blockers did not increase that risk whereas statins and diuretics did.

Oral rehydration in diarrhoea (if no signs of dehydration)

2 years = 100-200mls after each loose stool

But if signs of dehydration use 75mls/kg over four hours then revert to the regime above.

Dec 14th

Duration of common childhood illness

90% will be better within:

Cough = 3 weeks

Brochiolitis = 3 weeks

Cold 2 = 1 week

Otitis media = 1 week

Dec 7th

Age over 50 (usually > 70) with ESR usually > 40 proximal mylagia and stiffness (struggles to get off toilet or bath and/or raise arms over shoulder height). They may struggle to turn over on bed. Morning stiffness usually lasts about an hour.

Screen for TA symptoms = admit

PMR base line invx – FBC, ESR/CRP, Cr&Es, LFTs, adj calcium, plasma electrophoresis and Rh factor.

Rx Oral pred 15 a day – should have symptom resolution within 3 to 5 days

Reduce by 1mg per week until at 10mg and then 1mg a month

If symptoms recur, revert Back to prior dose.

Consider periodic screening for DM and osteoporosis prophylaxis

Nov 30th

Idiopathic Hyperhidrosis

Life style advice – avoid alcohol, spicy food, stress/emotional triggers. Use loose fitting clothes made wit natural fibres, use antiperspirant spray rather than deodorant.

If that fails try topical aluminium chloride (axillae or hands only)

Other options ionyophoresis.

Oral anticholinergics e.g. oxybutinin (unlicensed) or second line glycopyrrolate

Botox injections (last 6 to 9 months)

Sympathectomy

Nov 23rd

Erythrocytosis = HB >185 and PCV >0.52 in a man and 165 & 0.48 in a woman.

Secondary causes – alcohol, smoking, and obesity but does remedying the PCV & HB make any difference to morbidity & mortality??

Chronic hypoxia of any cause will cause erythrocytosis e.g. attitude, respiratory disease e.g. sleep apnoea, copd etc, heart failure etc

Drugs – diuretics, anabolic steroids and erythropoietin.

Cancer – renal cell carcinoma, hepatocellular carcinoma

Renal stage renal disease

Primary causes – Polycythaemia Rubra Vera due to the JAK2 mutation

Risks of erythrocytosis = VTE due to increased viscosity

Hyperviscosity symptoms – myalgia, weakness, paraesthesia, blurred vision, fatigue and headache

Invx in primary care = rpt FBC after 2 weeks, Cr&Es and LFTs re ? renal or hepatic disease, serum ferritin, Pox re ? hypoxia, TTU for haematuria

Correct secondary causes if possible and re-check FBC

Refer!

PCR Rx = aspirin, venesection and cytoreductive drugs e.g. hydroxyurea, busulfan and JAK inhibitors.

Nov 16th

Secondary Prevention of MI – NICE summary

All patients should be offered cardiac re-hab – benefits = reduced hospital admissions, reduced rate of second MI, reduced death rate and better quality of life. It should commence within 10 days of discharge.

Do not recommend routinely eating oily fish. Do recommend, smoking cessation, Mediterranean diet, weight management, moderate alcohol and regular physical activity.

Low dose aspirin should be offered to all patients. If allergic use clopidogrel.

Clopidogrel and aspirin for 12 month in: NSTEMI or ST elevation MI & stent / medical (no Rx or fibrinolytic Rx) treatment.

Ticagrelor and aspirin for 12 months is an alternative in: NSTEMI or patients with ST elevation in whom the cardiologist is going angio.

Offer clopidogrel instead of aspirin to patients 12 months post MI who have TIA, CVA, PVD etc.

If patients are on an anticoagulant prior to MI then aspirin or clopidogrel is added for 12 months.

Ace inhibitor uptitrated to max dose within four weeks of discharge. If intolerant use an ARB.

Start spironlactone or eplerenone within 3 to14 days if evidence of LV dysfunction/HF.

Start betablocker as soon as possible after MI and titrate to the maximum tolerated dose and continue for at least 12 months. If LVD/HF continue long term.

Oct 26th

Invx of suspected SLE

If SLE suspected GP tests should be – FBC, ESR, CRP, LFTs, Cr&Es, urine dip test (?nephritis), antinuclear antibody, antinuclear antigen antibodies

Most patients with positive antinuclear antibodies do not have SLE.

Antinuclear antibodies may be positive in: Crohn’s, autoimmune hepatitis, PBC and lympho proliferative disorders.

Specificity is also low at 57%.

Clinical features (joint pain/swelling, Raynauld’s, malar rash, Sicca syndrome, lymphadenopathy, splenomegaly, anaemia etc) + a positive rest increase the positive predictive value.

Normochromic, normocytice anemia with lymphopaenia and neutropaenia are common.

A disproportionate rise in ESR to CRP is common

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Oct 21st

New generation antianginals

The antianginal drugs recommended for initial treatment are β blockers and calcium channel blockers, which reduce myocardial ischaemia by heart rate reduction and vasodilatory mechanisms, respectively. Either or both of these drug classes should be prescribed, together with a short acting nitrate for prompt alleviation of angina attacks. However, if these drugs are not tolerated, are contraindicated, or fail to correct symptoms, alternative antianginals are available.

Alternative antianginal drugs include older less familiar ones such as nicorandil, which has been available for the past 20 years, and newer antianginal drugs such as ivabradine and ranolazine. Antianginal drugs reduce myocardial ischaemia by augmentation of oxygen delivery, reduction of oxygen demand, or a combination of both. Nicorandil augments oxygen delivery through coronary vasodilatation. Ivabradine reduces myocardial oxygen demand by reducing heart rate, whereas both ranolazine and trimetazidine are thought to do so through metabolic modulation, increasing the efficiency of myocardial energy production.

 

Side effects

Ivabradine

Adverse effects include visual “flashing lights” known as phosphenes in up to 16% of patients, which are usually only mild to moderate in intensity and transient.

Nicorandil

Common adverse effects include headache (>10% of cases) (especially on initiation of treatment), flushing, dizziness, decreased blood pressure and/or increase in heart rate, and gastrointestinal side effects.

Ranolazine

Undesirable effects with ranolazine tend to be mild to moderate in severity and often develop within the first two weeks of treatment. The most common are constipation, nausea, and weakness.

Oct 5th

Gout review – interesting points

Effects 1-2% of population (men >40 and women > 65)

But only 10% of patients with hyperuricaemia develop gout

There is progressive urate crystal deposition in the cartilage, periarticular tissues and the acute attack occurs when crystals are shed from the cartilage into the joint space

It usually resolves within 2 weeks if untreated

Uricacid is derived for degredation of purines (70% endogenous and 30% dietary origin) and levels increase with decreased renal excretion or increased production.

Metabolic syndrome is strongly associated with gout

Beer and spirits >> risks than wine

Meat, seafood and fructose containing drunks increase risk

Gout co-morbidity – HT 74%, Obesity 53%, DM 26%,CKD 20%, IHD 14%

During an acute attack serum urate levels may be normal

Blood invx FBC (myeloproliferative??), HBa1c, fasting lipids, Cr&Es

Ask re smoking (CVD risk) and alcohol (causation)

Rx options

Naproxen 500mg for 5 days

Oral pred 30mg a day for 5 days

Colchicine 1.2mg stat and 600mcg after one hour (low dose regime)

Prophylaxis – commence if pt has 2 or more attacks over 12 months

Start 2 to 4 weeks afte acute attack

Start allopurinol at 100mg and uptitrate monthly with colchicine cover 600mcg bd

Measure FBC, Cr&Es lfts and uric acid monthly during uptitration

Allopurinol hypersensitivity syndrome (liver & kidney damage with skin rash) is more common with CKD, diuretic use and higher dose allopurinol at initiation – hence low start with uptitration.

Once target uric acid level achieved it should be checked 6 to 12 monthly to ensure in the lower half of the normal range but after 2 years this can be relaxed to upper half of normal range with bi-annual uric acid level checks

Sept 28th

Rational testing - acute cardiac? Chest pain

ECG still 1st line test

CK testing is no longer recommended

Tropinin assays are the test of choice

The new Highly Sensitive Troponin tests have much greater sensitivity

Levels are measures on admission and 3 hours after admission irrespective of timing of onset of pain

Beware heart failure, septicaemia and renal failure can increase troponins

September 21st

Cow’s Milk allergy

Effects 2 to 7.5% of children under 12 months

Whereas lactose intolerance is very rare

Symptoms- prurtius, erythema, eczema, reflux, colic, diarrhoea etc after cows milk ingestion

NB Breast fed babadies can get cows milk allergy from cow milk proteins transferred from mother to chils in breast milk !

Rx- exclusion of cows milk protein from diet – note soya based formulas are not the answer you have to recommend an extensively hydrolysed formula e.g. Aptamil Pepti

Most children out grow it by 3 years of age

Urinary incontinence in women NICE

Hx

Define whether they have stress, urgency (Overactive Bladder) or mixed urinary incontinence

A bladder diary over 3 days is helpful

Ex

Abdominal exam and pelvic exam - confirm pelvic muscle contractions before progressing to pelvic floor training

Absorbent products or handheld urinals should not be considered primary Rx option just a coping strategy adjunct pending definitive therapies.

SI or Mixed – 1st line = 3 months pelvic floor training (which should involve at least 8 contractions 3x a day)

SI – do not use duloxetine 1st line!

SI –refer to urogyneacologist or specialist incontinence service if pelvic floor training fails

OB – 1st line = bladder training before oral Rx (e.g. Oxybutinin or tolterodine immediate release preps or Darifenacin) which should be a trial for 4 weeks prior to dose increase or medication change.

Newer Rx

OB – Botulinus toxin and percutaneous nerve stimulation

August 24th

DKA in type 2 can occur = type 2 ketosis prone diabetes

Can be the 1st presentation of the patients diabetes

More common on non Caucasians e.g. Afro-Caribbeans, Africans, Hispanics etc

Often an older and may be obese

Due to intercurrent illness reducing pancreatic insulin output in a patient with insulin resistance

August 3rd

1 in 8 adults will have CKD as per the eGFR based CKD classification system.but only 1 in 3000 to 5000 develop end stage renal failure per year. The value of early detection and Rx of generic CKD remains to be proven.

Useful review re CKD – Patients > 65 without HT or DM, in the absence of macro albuminuria, and a stable eGFR between 45 and 59 are very unlikely to have significant progression in their CKD and the value of coding it and treating it is very debateable.

July 27th

NICE guidance on VVs

Compression hosiery as a sole Rx options is no longer indicated unless the patient is not suitable for any other intervention

Symptomatic or VVS with complications = refer to vascular service

E.g. Patients recommended for referral include

• Patient with pain, swelling or heaviness of the legs.

• Associated skin changes

• Bleeding from VVs

• Venous ulcer – i.e. a break in the skin below the knee which has nit healed after 2 weeks

1st line invx in hospital is duplex uss to confirm the diagnosis of VVS and truncal reflux

1st line Rx = radio frequency or laser ablation

2nd line Rx = USS guided foam scherotherapy

NB – compression hosiery post Rx is only worn for a maximum of 7 days

July 20th – NSAIDS review

NSAIDS are second line agents on the Rx of arthritis

Naproxen has no excess risk for CVD

Diclofenac has the highest risk

NSAIDs negate the effect of aspirin so use COX2 inhibitors in patients on aspirin

Use PPI cover when using SSRIs or Corticosteroids with nsaids

Use PPI cover with nsaids in the > 65s

If you have to use nsaids in > 65 consider eGFR 1 to 2 weeks after start and then ‘periodically’

Avoid nsaids in CCF and CKD

NSAIDS increase BP in hypertensives, especially for patients on ACE inhibitors, ARBs, diuretics and betablockers

July 13th – AF 10 minute consultation

Although still part of QOF and NICE guidelines, the use of aspirin has been dropped from the European Society of Cardiology guidelines for AF in 2012.

CHADS2 score 0 = no Rx , 1 = no Rx or anticoagulation, >1 = anticoagulation

These rate controlling drugs are combined warfarin (target INR = 2.5 ) or one of the newer generation anticoagulants, such as Dabigatran 150mg bd (but reduced to 110mg bd in patients > 80 years).

NB There are now alternatives to Dabigatran e.g. Rivaroxaban 20mg with evening meal (reduced to 15mg if eGFR < 50) or Apixaban 5mg a day (changed to 2.5mg bd if eGFR < 30 or patient > 80 years or patient < 60kg).

Start bisoprolol 2.5mg (1.25mg in elderly) and uptitrate in increments of 1.25mg every one to two weeks until target pulse rate is achieved or the maximum dose of 10mg has been reached.

If unable to tolerate betablockers then use diltiazem slow release starting at 90mg bd increasing to 120mg bd if pulse rate uncontrolled.

Verapamil is an alternative starting at 40mg tds and uptitrating in increments of 40mg every 1 to 2 weeks.

June 29th - Myeloma review

Newly diagnosed patients are projected to live for five years wit with newer Rx regimes

Median age of diagnosis is 70 BUT 2% of cases occur < 40 years

More common in men and Afro-Caribbean’s

Usual IGA or IGN monoclonal antibody

IGM is more likely Waldenstroms macroglubulinaemia

Polyclonal antibodies suggests inflammation

At presentation

75% have anaemia

70% have bone pain/disease e.g. pathological fracture

30% hypercalcaemia

25% renal impairment (due to light chains blocking renal tubules)

Invx of suspected myeloma in GP – FBC, ESR, Calcium, Cr&Es, Plasma electrophoresis and urinary BJP

MGUS – 1% per year chance of converting to myeloma

Patients with myeloma have reduced renal reserve sp nephrotoxic drugs should be used with caution

June 22nd

Post Circulation stroke

Account for 20% of strokes

Diagnosis often delayed or missed

Symptoms

Diplopia or homonymous hemianopia

Unilateral or bilateral sensory loss

Vertigo

Ataxia

Dysarthria

Dyspahagia

Diagnosis

MRI better thav CT

June 8th

Managing unscheduled vaginal bleeding in non pregnant pre-menopausal women

Under the age of 30 malignant causes are rare and under 24 very, very rare!

The peak incidence for Cx cancer is 30 to 34 years.

The peak incidence of endometrial cancer is 55 and is very rare < 40 years.

Uterine fibroids occur in ¼ of women and half of these will causes symptoms (heavy or irregular bleeding)

Endometrial polyps are also associated with heavy and irregular bleeding but the incidence of cancer in polyps is low ( 30% fall with treatment correlates with an improvement in prognosis.

Normal ECG abd BNP in a non acute setting means heart failure is very unlikely

Causes of non cardiac moderately raised BNP: COPD, DM, CKD, liver failure and sepsis.

Levels > 400pg/ml = to be seen by a cardiologist in 2 weeks

Invx of choice = ECG and BNO, echo if abnornmal. Base line bloods include FBC, Cr&Es, LFTs, Hba1c, Lipids and TSH.

May 4th BMJ

Repeat CVD risk calculation before 8 to 10 years is not warranted if their initial risk assessment is 15%

If 15% to 20% rpt in 1 year

➢ 20% = Rx

April 27th BMJ

Move towards prophylactic use of tamoxifenor or raloxifene in women deemed to be high risk of breast cancer.

Diabetes in the elderly – American Diabetes Association guidelines

Elderly with little co-morbidity Hba1c target ................
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