Diabetic network

I recently received an invite to attend a meeting organised by our local diabetes network. A local biochemist was discussing "Metabolic Syndrome". Well I have to say that I really did not know what to expect and was intrigued by what I heard. As a medical student I was well aware of the association between abdominal obesity and heart disease. What I hadn't kept up to date with was how biochemists and in particular North American biochemists seem to have significantly developed this idea.
Abdominal obesity associated with insulin resistance, raised BP (130/85 or more) and raised triglycerides is linked with an increased risk of type 2 diabetes and atheromatous vascular disease. The American criteria -

• Central obesity as measured by waist circumference:
  Men — Greater than 40 inches
  Women — Greater than 35 inches
• Fasting blood triglycerides greater than or equal to 150 mg/dL
• Blood HDL cholesterol:
  Men — Less than 40 mg/dL
  Women — Less than 50 mg/dL
• Blood pressure greater than or equal to 130/85 mmHg
• Fasting glucose greater than or equal to 110 mg/dL

are about to be replaced by European criteria which are even more stringent.

Why make the diagnosis? Well one good reason seems to be that it is possible to reduce adverse outcomes by increasing exercise (1 hour of moderate exercise daily) and dieting. Our local biochemist recommended starches with a low glycaemic index.

For more information the American Heart Association has a useful resource.

The most striking thing from the talk I attended was the prevalence data - it was suggested that 20% of adult males are affected! Now where is that exercise bike?

Heart Failure

Local guidelines now available and have been read.
Key points -
Consider doing Brain Natriuretic Peptide test when it is available, normal levels are negatively predictive for heart failure.
Everyone should have an ECG (normal is >90% predictive of not having Heart Failure) and if diagnosed with HF an echo.
Control arrhythmias.
Everyone should have a max tolerable dose of ACEI or A2RA (monitor creatine).
Diuretics do not improve exercise tolerance but can clear peripheral and pulmonary oedema, use at lowest dose to get improvement and monitor U+E's.

Establish aetiology and treat underlying causes - IHD and hypertension are commonest causes. Consider valvular heart disease, alcohol excess and familial causes.

Use the New York Heart Association classification of symptoms and consider referral to Class III and IV

General stuff - those on frusemide >80mg daily should be on a twice weekly weight chart and fluctuations of 2kg in 3 days should prompt review of diuretic Rx. Some patients can be taught to adjust this themselves. Aim for a healthy, low salt diet. Long haul flights are contraindicated in those who are so breathless that they need to stop after climbing a flight of stairs or who cannot hold a conversation without symptoms. Travel - hot climates might need adjustment of diuretic. Encourage aerobic exercise. Avoid soluble forms of tablets because of sodium content. Avoid NSAIDs.

Haemoglobinopathy

Whilst I am busy reflecting on my learning needs this morning I might as well recall that I don't really know much about haemoglobinopathy and it's time to review this as well.

New practices and a different population

Having previously practiced in an area with a static population I am now seeing many patients who are seeking asylum from African countries and the Middle East. TB is much more common in this population. Time to do some research I think.
In addition to the asylum seeking population, the indigenous population seen in this practice are usually homeless. This brings with it a higher proportion of people with mental health problems and in particular I have been struck by the high rates of depression and schizophrenia, so definitely these are areas to brush up on.

Sick notes

Last week I got asked for the usual sick notes, but then I had a request that filled me with uncertainty. Time to check out the rules - if I can find them.