Download 2013 summary of BMJ key points (click)

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 = 50 to 100mls after each loose stool
>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
1
Brochiolitis
Cold 2
Otitis media
= 3 weeks
= 1 week
= 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
2
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%.
3
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
.
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.
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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 !
5
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
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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
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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
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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 (<2%).
PCB about 1/2 have no identifiable cause, 1/3 Cx ectropion, 1/5 CIN or rarely Cx
cancer, only 2% have chlamydia
BTB on cocp – most common cause is missed pills. If you want to change increase
the oestrogen to 35 mcg in preference to changing the progesterone
June 1st
Management of recurrent UTI in non-pregnant healthy women
Definition – 2 or more UTIs in 6 months or 3 or more in 1 year.
1/3 to ½ of women who has a UTI will have a recurrence in 3 months
Risk factors:
Prior recent UTI
Sexual intercourse
Postmenopausal
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When to refer
Hx of urinary tract surgery
Known anatomical abnormality
Calculi
Asymptomatic haematuria after successful antibiotic Rx
Persistent gross haematuria
Things that might help
? regular use of cranberry products – debated
Post coital voiding – debated
Lactobacilli vaginal pessaries
Things that do help
Prophylactic use of antbx (daily, 3x a week or postcoital) for 6 month trial
Use of hone supply of 3 days courses of antbx e.g. Trimethoprim
Vaginal oestrogen in post menopausal women
Things that don’t help
Direction of wiping
Loose or cotton underwear
May25th
Rx of sinusitis
1. Increasing symptoms (but systemically well) after 5 days or persistent
symptoms after 10 days = 7 to 14 days of inhaled nasal steroids.
If improvement after 48 hours fails to materialise consider a 5 day course of
antbx with added nasal decongestants.
2. Increasing symptoms (and systemically unwell) after 5 days or persistent
symptoms after 10 days 5 days = 5 day trial of antbx, nasal decongestant and
possible inhaled nasal steroids BUT if no improvement after 48 hours refer
ENT.
May 11th
Acne review surprises!
Topical retinoids are now a mainstay of treatment
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Avoid prolonged antibiotic courses and antibiotic monotherapy because of the risk of
bacterial resistance
Use topical retinoids, topical retinoids + benzoylperoxidase (different times of the
day), topical retinoids and topical antbx rather than benzoylperoxidase or topical
antbx in isolation
General treatment algorithm according to acne severity
Severity
Topical
Benzoyl
Topical
Oral
Hormonal
Azelaic
Oral
retinoid
peroxide
antibiotic
antibiotic
agent*
acid
retinoid†
Maintenance Recommended
Mild
Mildmoderate
Moderate
No
treatment
treatment
Recommended
Possible
treatment
treatment
Recommended
Possible
Recommended
treatment
treatment
treatment
Recommended Recommended
treatment
Moderate-
Possible
No
severe
treatment
treatment
Severe
No
No
No
No
Alternative
No
treatment
No
No
No
treatment
No
Recommended treatment‡
No
No
No
Alternative
No
treatment
Possible
Alternative Monotherapy†
treatment
treatment
Recommended
Possible
Alternative Monotherapy†
treatment
treatment
treatment
No
No
No
treatment
Recommended Recommended
Possible
Monotherapy†
*Female patients only.
Heart failure invx (May 11th BMJ)
A normal ECG has 90% negative predictive value for excluding systolic heart failure.
BNP is raised in heart failure and has 90% sensitivity for diagnosing heart failure
(also 93% negative predictive value if level normal) it inhibits aldosterone and rennin
production and sympathetic drive. The higher the level the worse the prognosis. A >
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
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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 <58.5mmol/l
Elderly with multiple co morbidity or memory impairment Hba1c target <64mmol/l
Elderly with end stage chronic disease or significant cognitive impairment Hba1c
target < 69mmol/l
Management of Hidradenitis suppurativa
Smoking and obesity important risk factors
Make sure you use adequate analgesia in flare not just antbx
Rx aggressively with antbx early and use for 3 months to limit scarring –
erythromycin, lymecycline, , doxycycline or oxytet 1st line but topical clindamycin is
an option – you can also use both early on in the disease.
Refer to dermatology if flare ups becoming frequent or evidence of scarring starting
etc – dermatology often use clindamycin with rifampicin and may use dapsone.
March 2nd 2013 BMJ
Topic: incidental thrombocytopaenia
What things have you learnt which may change your practice?
Other than the obvious causes such as ITP, hypersplenism, chronic liver disease and
myelodysplasia there are a wealth of possible common causes.
Drugs which cause thrombocytopaenia: alcohol, heparin, quinine, trimethoprim,
thiazides, phenytoin and carbamazepine
B12 deficiency, folate deficiency
HIV and Hep C
Pregnancy
Recommended invx of incidental isolated thrombocytpopaenia – 1st just rpt the
FBC, if platelets < 20 admit, <30 urgent referral and discuss with haematologist, 30 –
100 and stable routine referral. Invx = Blood film, Cr&Es, B12, folate, LFTs,
gamma GT, LDH, CRP, plasmaphoresis
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NB if platelets < 50 stop aspirin and clopidogrel and nsaids
If platelets 100 to 150 recheck and do invx, if all normal rpt FBC at 6 weeks and then
periodically
BMJ review on bed bugs Jan 2013
What did I learn?
They are 2 to 5mm long and brown in colour.
They can survive up to 1 year between feeds.
They exist in other places other than beds – dark places such as behind curtains and in
crevices.
The rash does not necessarily appear in the morning but can take up to 11 days – it is
due to allergy to the mite’s saliva.
The rash is a 2mm to 5mm maculopapular often with a central haemorrhagic punctum
usually on covered areas of the body.
Rx = wash clothes and bed clothes > 60C
Throw away highly infested items
Vacuuming infested areas
Get the pest controllers in to treat the house
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