A BMJ Leader (BMJ 2006;333:982-983 (11 November)) brought the apparent link between osteonecrosis of the jaw (ONJ) and bisphosphonate treatment to my attention. Bisphosphonates are widely used in the treatment and prevention of osteoporosis and increasingly are used in patients with metastatic cancer in the bone. I could not recall ever recognising osteonecrosis of the jaw in a patient on bisphosphonate treatment and didn't discuss the potential for this complication with patients initiating onto bisphosphonate treatment - in my practice this is largely with patients known to have or be prone to osteoporosis. What should I do? Fortunately a follow on letter (BMJ 2006;333:1122-1123 (25 November)) came to my rescue. The dose of bisphosphonate used in osteoporosis prevention and treatment is 1/12th that used in oncology. The authors of the letter quote Merck as having received 170 reports of ONJ in alendronate therapy but estimate 20 million patient years of treatment with the drug by 2004 for patients with Pagets disease of the bone and osteoporosis. This puts my concerns into perspective as the majority of patients developing ONJ seem to be those receiving it in high dose and intravenously. Although I need to be aware of this serious side effect, at present I don't think it merits the sort of attention proposed in the original article.
Finally for an up to date clinical review of osteoporosis see BMJ 2006;333:1251-1256 (16 December). One in two women and one in five men over the age of 50 years are affected by fragility fractures. Oral bisphosphonates (alendronate and risedronate) are first line treatments, with strontium ranelate an alternative, especially where bisphosphonates are not well tolerated. Poor compliance and persistence with treatment are common.
Wednesday, December 27, 2006
Friday, June 30, 2006
Bile is green
More peering at the journals resulted in me finding this simple and effective study by Walker et al (BMJ 2006;332:1363-5). Bile is green, preferably dark green by the look of the picture. Vomiting bile in infants is an indicator of gi obstruction until proven otherwise. Yellow coloured vomit might be indicative of obstruction, but might not, other clinical factors need to be taken into account.
Back Pain
BMJ Clinical Reviews either hit the spot or leave me cold. Koes et al on "Diagnosis and Treatment of Low Back Pain" hit the spot. Whilst the tenor of the article was emphasising the GP things that I already do - encourage exercise and early mobilisation - it was the proportion of people with serious underlying disease (in an American study) that caught my eye:
- 4% have a compression fracture
- 3% spondolisthesis
- 0.7% a tumour or metastasis
- 0.3% ankylosing spondylitis
- 0.01% and infection
this really caught my eye. In the last 3 months I have seen a dozen or so people with back pain, surely I am missing something in 1 of them. The article reminded me that I should watch for red flags:
- age at onset <20>55 yrs
- non mechanical pain
- thoracic pain
- pmh of cancer, steroids or HIV
- feeling unwell
- weight loss
- widespread neurological symptoms
- structural spinal deformity
but it didn't help with what to do if there was a red flag flying. Imaging should be carried out where there are red flag signs, perhaps some other advice on investigations could have been included.
Cholesterol, statins and CHD prevention
The BNF back pages cover the Joint British Societies guidance on CHd risk assessment in a way that is easy for me to understand and easy for me to use when I talk to my patients about their CHD risk. So what's the problem?
A recent spate of BMJ articles have given me cause to wobble. Ravnskov in BMJ 2006;332;1330-1332 opens up the debate. The controversy is that if docs were to follow the American National Cholesterol Education Program guidance then 85% of Norwegian men and 20% of the women would be classified at high risk and therefore to be treated with statins. Ravnskov points out that stain safety at the very high doses required to achieve the new targets is uncertain. It is stated that very high dose atorvastatin (80mg daily) doesn't necessarily achieve target lipid levels and is not associated with reduced mortality, moreover more than half of patients suffered some side effects.
Responding letters in subsequent issues of the BMJ make the point that there is some evidence that more aggressive treatment of high risk patients reduces risk of chd at the expense of myopathy and liver disorder.
I conclude that we need to balance our enthusiasm for aggressive treatment of lower risk patients against the potential costs, to the patient and the NHS finances.
A recent spate of BMJ articles have given me cause to wobble. Ravnskov in BMJ 2006;332;1330-1332 opens up the debate. The controversy is that if docs were to follow the American National Cholesterol Education Program guidance then 85% of Norwegian men and 20% of the women would be classified at high risk and therefore to be treated with statins. Ravnskov points out that stain safety at the very high doses required to achieve the new targets is uncertain. It is stated that very high dose atorvastatin (80mg daily) doesn't necessarily achieve target lipid levels and is not associated with reduced mortality, moreover more than half of patients suffered some side effects.
Responding letters in subsequent issues of the BMJ make the point that there is some evidence that more aggressive treatment of high risk patients reduces risk of chd at the expense of myopathy and liver disorder.
I conclude that we need to balance our enthusiasm for aggressive treatment of lower risk patients against the potential costs, to the patient and the NHS finances.
Thursday, June 08, 2006
The Anomalous Left Coronary Artery
(BMJ 2006;332:1139-41) I do wish I could keep all those rarities that I ought to be aware of "just in case" firmly stuck in my head, ready to recall in the appropriate consultations. You know, those things that if we missed them might be life threating, those things that the regional specialist sees once or twice a year, that I might never see, or might see once and be for ever worried about missing it (again).
Kumpf et al report on the anomalous left coronary artery in (2) young athletes with syncope. 3 Coronary arteries arise from the 3 aortic sinuses in the normal young athlete, but in some people, the left coronary can arise from the right aortic sinus. This can lead to syncope. If recognised it can be treated by re-siting the anomalous artery. If not recognised it can lead to fatal arrhythmia. Even a normal exercise test is not of value in excluding the diagnosis - apparently it requires an echocardiogram, done by someone who has the condition in mind and is looking for it.
What is required here is a website of rare medical conditions that if missed might prove fatal - access might need to be restricted.
Kumpf et al report on the anomalous left coronary artery in (2) young athletes with syncope. 3 Coronary arteries arise from the 3 aortic sinuses in the normal young athlete, but in some people, the left coronary can arise from the right aortic sinus. This can lead to syncope. If recognised it can be treated by re-siting the anomalous artery. If not recognised it can lead to fatal arrhythmia. Even a normal exercise test is not of value in excluding the diagnosis - apparently it requires an echocardiogram, done by someone who has the condition in mind and is looking for it.
What is required here is a website of rare medical conditions that if missed might prove fatal - access might need to be restricted.
Diabetes and Lipid Lowering
A leader by this title appeared in the BMJ (BMJ 2006; 332:1103-4). It states what we already thought we did anyway - we need to lower lipids in all of our type 2 diabetic patients. Targets are now to reduce LDL cholesterol to <2mmol/l. It seems that for every 1mmol/l reduction in LDL-C there is a 21% reduction in cardiovascular events.
Statins would appear to be the lipid lowering drug group of choice, fibrates are second line. Even with statin therapy, 70% of cardiovascular events still occur.
So - we should be auditing our type 2 diabetics, checking that they are on statins and working out whether we are hitting the target for LDL-C reduction. Now there's a job for someone.
Statins would appear to be the lipid lowering drug group of choice, fibrates are second line. Even with statin therapy, 70% of cardiovascular events still occur.
So - we should be auditing our type 2 diabetics, checking that they are on statins and working out whether we are hitting the target for LDL-C reduction. Now there's a job for someone.
Friday, May 19, 2006
Hypertension
Last night our local cardiologist reviewed the aetiology, diagnosis and management of hypertension, touching on the role of ambulatory monitoring. What did I learn?
- Whilst beta blockers have a role in people with heart disease, they should be avoid as first line antihypertensives because of their potential for causing diabetes. They are quite good at reducing the risk of heart disease but less effective at reducing the risk of stroke.
- Bisoprolol is probably a better choice beta blocker compared to atenolol because it gives better 24 hour cover.
- ACEI's and ARB's can be combined in resistent hypertension - sometimes to good effect.
- Ambulatory monitoring remains a useful adjunct in diagnosis of white coat hypertension and in monitoring those people who are resistent to treatment. Rule of thumb at 10mmHg to 24 hr mean systolic and 5mmHg to 24 hr mean diastolic. In people with BP's of 130-139/85-90 consider annual repeat.
- Statins have significant effect on reducing risk of CVD in people with hypertension - perhaps they should all have treatment? ASCOT trial seems to be best evidence to date on this.
- Diuretics remain a good first choice agent in over 55 yr olds and people of Afro-Carribean origin.
- NICE and BHS are going to issue a consensus statement in July 06 - must watch out for that!
Friday, May 05, 2006
Shared Care Forum - May 2006
Messages from the Calderdale and Kirklees shared care forum:
- Tetanus status needs checking on all drug users, immunise as appropriate
- Consider SBE with low grade fever in injecting drug users
- Pain relief in substitute treatment - more difficult with buprenorphine, consider split doses, consider raised doses, consider switch to methadone. In methadone patients consider split doses with increased total dose and consider additional analgaesic.
Monday, April 17, 2006
COX1 vs COX2
Well, I didn't really have a grip on why COX 2 inhibitors could increase the risk of cardiovascular events. This article (BMJ 2006;Vol 332 :895-8) really explains it well. I can now think of it as a balance between prostacyclin mediated repair effects at a site of damaged vascular endothelium (inhibited by COX2) and platelet aggregation (inhibited by COX1). The COX2 specific NSAID's diminish the repair and do nothing to the platelets, the non specific NSAID's have an effect on both, reducing the risk of an event. I think....
Thursday, April 13, 2006
Moderate Drinking - cardioprotection myth
the BMJ news section this week reports on an article (Addiction Research and Theory, doi:10.1080/16983) which seems to confirm what I had heard rumoured recently.
This metanalysis shows a flaw in the methodology of papers purporting support the notion that there is a reduction in mortality in moderate drinkers. Most papers report non-drinkers as including people who had stopped drinking, which people often do as they get older or become unwell. So for now at least the "J-shaped curve" suggesting a cardioprotective effect from moderate alcohol intakes seems to be something that needs more research.
This metanalysis shows a flaw in the methodology of papers purporting support the notion that there is a reduction in mortality in moderate drinkers. Most papers report non-drinkers as including people who had stopped drinking, which people often do as they get older or become unwell. So for now at least the "J-shaped curve" suggesting a cardioprotective effect from moderate alcohol intakes seems to be something that needs more research.
Tuesday, March 28, 2006
BMJ catch up reading
Review of Recent Issues of the British Medical Journal
Sorry but most of the links are only open to those with an Athens account – or to those with access to the particular journal.
Gastro-oesophageal reflux disease
This BMA review summarised information on GORD, reminding me:
Treatment should be with a full dose of a PPI for 1 month along with H. pylori eradication therapy if needed. If symptoms recur after treatment then a step down policy may help. If symptoms do not respond to treatment then endoscopy is appropriate, although it may not show any abnormality. The gold standard for a diagnosis of GORD is 24 hour ambulatory oesophageal pH measurement. Recently it has been recognised that there are some people who have non- acid GORD and medical management of these patients is currently unsatisfactory. In some cases anti-reflux surgery may be appropriate.
Finally, it is worth looking at the NICE dyspepsia management guideline.
Management of Depression in the Elderly
This research article is the end product of a prospective randomised study of the management of depression in the elderly. The conclusion was that “collaborative care” for elderly people with depression resulted in more enduring health benefits than the control group. Collaborative care seems to mean care managed by a primary care nurse, with involvement of a primary care physician and consultant psychiatrist, offering education, behavioural activation, antidepressants, some behaviour based psychotherapy (problem solving treatment) and relapse prevention, geared to the needs and preferences of the patient. The researchers suggest that the engagement in primary care is essential and that the relapse prevention element of the treatment was important in preventing relapse!
Proteinuria
This “10 minute consultation” reviews the management of a patient referred to a GP following the finding of Proteinuria on an insurance medical.
Key points – think of transient causes
Think of persistent causes:
In practice – recheck the dip test and test for sugar and blood. Examine the patient – including the heart and BP. Check the U+E and spot urine protein:creatinine ratio. Refer if significant Proteinuria. Review if you don’t refer – to recheck degree of Proteinuria.
Smoking Cessation and Catastrophe Theory
This BMJ research paper examines the evidence about successful smoking cessation. Surprisingly it concludes that deciding to stop on the spur of the moment is really a quite successful approach. The authors propose that commissioners should be commissioning services (a “3 T’s” approach) that create motivational tension to trigger the decision to quit smoking; they should ensure that treatment is available immediately.
As a provider I should be spending less time on motivating people to plan to change and more time on tipping the motivational balance towards change. When the patient bursts through the door demanding nicotine replacement treatment I should be better disposed to supplying it, rather than asking them to make an appointment to see the nurse in a week or so!
Eczema Therapy
This BMJ article outlines eczema therapy and reassuringly for me things seem to be much the same as they were 10 yrs ago for mild to moderate eczema – emollients and topical steroids being the mainstays of treatment.
For more resistant disease there are some developments. Topical calcineurin inhibitors – tacrolimus and piecrolimus – have been introduced into the market, however evidence that they are effective in patients who have failed with topical steroids is lacking. These agents are restricted in their prescription to doctors “with a special interest” in skin disease.
UVB is another option and seems to produce improvement even at 3 months post treatment. The caveat here is the need for advising the patient regarding the risk of skin cancer and then monitoring them for this.
More serious disease, at a level that would trigger referral to a specialist, might be managed by a systemic immunosuppressant – ciclosporin and azathioprine are the most frequently used agents here.
Sorry but most of the links are only open to those with an Athens account – or to those with access to the particular journal.
Gastro-oesophageal reflux disease
This BMA review summarised information on GORD, reminding me:
- To remember its association with asthma
- To remember the association with oesophageal adenocarcinoma
- Smoking, obesity and diet are related
- Routine endoscopy is not required unless there are features that cause alarm
- PPI treatment is effective for people with typical symptoms
Treatment should be with a full dose of a PPI for 1 month along with H. pylori eradication therapy if needed. If symptoms recur after treatment then a step down policy may help. If symptoms do not respond to treatment then endoscopy is appropriate, although it may not show any abnormality. The gold standard for a diagnosis of GORD is 24 hour ambulatory oesophageal pH measurement. Recently it has been recognised that there are some people who have non- acid GORD and medical management of these patients is currently unsatisfactory. In some cases anti-reflux surgery may be appropriate.
Finally, it is worth looking at the NICE dyspepsia management guideline.
Management of Depression in the Elderly
This research article is the end product of a prospective randomised study of the management of depression in the elderly. The conclusion was that “collaborative care” for elderly people with depression resulted in more enduring health benefits than the control group. Collaborative care seems to mean care managed by a primary care nurse, with involvement of a primary care physician and consultant psychiatrist, offering education, behavioural activation, antidepressants, some behaviour based psychotherapy (problem solving treatment) and relapse prevention, geared to the needs and preferences of the patient. The researchers suggest that the engagement in primary care is essential and that the relapse prevention element of the treatment was important in preventing relapse!
Proteinuria
This “10 minute consultation” reviews the management of a patient referred to a GP following the finding of Proteinuria on an insurance medical.
Key points – think of transient causes
- UTI
- Pregnancy
- Orthostatic Proteinuria
- Fever
- Heavy exercise
- Vaginal mucus
Think of persistent causes:
- Primary renal disease (glomerulonephritis, renal tubular disease)
- Secondary renal disease (diabetes, hypertension, heart failure, vasculitis, amyloidosis, myeloma.
In practice – recheck the dip test and test for sugar and blood. Examine the patient – including the heart and BP. Check the U+E and spot urine protein:creatinine ratio. Refer if significant Proteinuria. Review if you don’t refer – to recheck degree of Proteinuria.
Smoking Cessation and Catastrophe Theory
This BMJ research paper examines the evidence about successful smoking cessation. Surprisingly it concludes that deciding to stop on the spur of the moment is really a quite successful approach. The authors propose that commissioners should be commissioning services (a “3 T’s” approach) that create motivational tension to trigger the decision to quit smoking; they should ensure that treatment is available immediately.
As a provider I should be spending less time on motivating people to plan to change and more time on tipping the motivational balance towards change. When the patient bursts through the door demanding nicotine replacement treatment I should be better disposed to supplying it, rather than asking them to make an appointment to see the nurse in a week or so!
Eczema Therapy
This BMJ article outlines eczema therapy and reassuringly for me things seem to be much the same as they were 10 yrs ago for mild to moderate eczema – emollients and topical steroids being the mainstays of treatment.
For more resistant disease there are some developments. Topical calcineurin inhibitors – tacrolimus and piecrolimus – have been introduced into the market, however evidence that they are effective in patients who have failed with topical steroids is lacking. These agents are restricted in their prescription to doctors “with a special interest” in skin disease.
UVB is another option and seems to produce improvement even at 3 months post treatment. The caveat here is the need for advising the patient regarding the risk of skin cancer and then monitoring them for this.
More serious disease, at a level that would trigger referral to a specialist, might be managed by a systemic immunosuppressant – ciclosporin and azathioprine are the most frequently used agents here.
Tuesday, January 31, 2006
Headache
Peter Goadsby recently reviewed headache in the BMJ, see "Recent advances in the diagnosis and management of migraine BMJ, Jan 2006; 332: 25 - 29".
There was lots of information in their for the GP and as it's a review and summary I took away some messages.
Migraine - worth diagnosing because there are some effective treatments. Diagnosis relies on:
Repeated headache lasting 4-72 hours, normal physical examination, no other reasonable cause for the headache, at least two of
There was lots of information in their for the GP and as it's a review and summary I took away some messages.
Migraine - worth diagnosing because there are some effective treatments. Diagnosis relies on:
Repeated headache lasting 4-72 hours, normal physical examination, no other reasonable cause for the headache, at least two of
- Unilateral pain
- Throbbing pain
- Aggravation of pain by movement
- Moderate or severe intensity of pain with at least one of
- Nausea or vomiting
- Photophobia and phonophobia
Secondary Headache is the one that worries us GP's. Are we missing a sinister cause? Warning signs for secondary headache include:
- Pain of sudden onset
- Fever
- Marked change in pain character or timing
- Neck stiffness
- Pain associated with higher centre complaints
- Pain associatedwith neurological disturbance, such as clumsiness or weakness
- Pain associated with local tenderness, such as of the temporal artery
The article also considers the pathophysiology of migraine, treatments and differentiating different sorts of headache.
Resuscitation training
Last week saw me access my annual cardio-pulmonary resuscitation training. At the start of the session one member of the group expressed anxiety that the guidance is continually changing. "For the better" said our trainer - reminding us that the guidance is based on evidence. Studies of survival after CPR have influenced the guidance.
As of April this year, but not before, he is allowed to teach the latest methods! This was odd to say the least, but I was pleased to learn that he was happy to fill us in on what the new guidance entailed. In essence, it's all the same BUT instead of 15 chest compressions to 2 breaths we need to do a ratio of 30:2. If we are concerned that as resuscitators we are at high risk of HIV/Hepatitis from resuscitating, then it is acceptable to just do chest compressions (100 per minute) providing the airway can be maintained! Apparently this has been done in the US and survival is as good or better than chest compressions + respirations. Providing the airway is open, chest compressions allow some air in and out of the chest.
See BMJ 2005;331:1281-1282 for "A new international consensus on cardiopulmonary resuscitation"
As of April this year, but not before, he is allowed to teach the latest methods! This was odd to say the least, but I was pleased to learn that he was happy to fill us in on what the new guidance entailed. In essence, it's all the same BUT instead of 15 chest compressions to 2 breaths we need to do a ratio of 30:2. If we are concerned that as resuscitators we are at high risk of HIV/Hepatitis from resuscitating, then it is acceptable to just do chest compressions (100 per minute) providing the airway can be maintained! Apparently this has been done in the US and survival is as good or better than chest compressions + respirations. Providing the airway is open, chest compressions allow some air in and out of the chest.
See BMJ 2005;331:1281-1282 for "A new international consensus on cardiopulmonary resuscitation"
Tuesday, January 10, 2006
A New Year
Well, we are 10 days into January and I am yet to make a post. I confess that not much learning went on over Christmas and the early New Year has been blighted by my handing my notice in at work - I am returning to mainstream general medical practice in April.
Perhaps it's time to reflect on the blog so far. Why am I bothering to do it?
Well - I have access to the internet at all the places where I work and at home. It's easy to use the blog to collect my thoughts and learning experiences all in one place. I can access it from anywhere. I could use paper but by now a notebook would be either very tatty or lost (or more likely - both). Additionally, a paper based system would be less easily searchable. I could just keep a big text file on one PC at home and this would certainly be more personal but would lack the "write it up anywhere" feature that makes the blog so appealing. So at least for now I aim to continue with 1-3 posts per month concentrating on learning experiences.
Perhaps it's time to reflect on the blog so far. Why am I bothering to do it?
Well - I have access to the internet at all the places where I work and at home. It's easy to use the blog to collect my thoughts and learning experiences all in one place. I can access it from anywhere. I could use paper but by now a notebook would be either very tatty or lost (or more likely - both). Additionally, a paper based system would be less easily searchable. I could just keep a big text file on one PC at home and this would certainly be more personal but would lack the "write it up anywhere" feature that makes the blog so appealing. So at least for now I aim to continue with 1-3 posts per month concentrating on learning experiences.
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