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.
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