Aspirin

BMJ 2008; 337 :a1806 and
This story got coverage in the popular press and clearly indicates that aspirin is a secondary prevention drug only. We should not be using it for primary prevention, even in patients with diabetes.
We certainly need to change our practice.

Osteoporosis

I'm back after a break - with news from the BMJ.
The latest guidance from the National Osteoporosis Guideline Group is now available. This is interim guidance as we wait for NICE to release its osteoporosis appraisal. The NICE appraisal is held up by a second appeal (BMJ 2008;337:a2204).
What is in the guidance? Well the news bit for me was in two parts. Firstly - postmenopausal women with prior fragility fractures don't need to wait for a Bone Mineral Density scan before starting treatment. Secondly there is the availability of a tool to estimate risk (the FRAX tool - see the website) which is recommended for opportunistic use in:

• Men aged 50 years or more (with or without fracture) but with a WHO risk factor or a BMI <>
• All postmenopausal women without fracture but with a WHO risk factor or a BMI <>

This results in categorisation of people into low, intermediate and high risk groups.

We could be working opportunistically to identify those at high risk and starting treatment where appropriate.

Management of Infertility

BMJ 2007;335:608-11 AH Balen and AJ Rutherford

This BMJ review of fertility opens with intriguing figures that seem worth recalling for primary care fertility discussions:
"For women up to 25 the cumulative conception rate is 60% at 6 months and 85% at a year, but conception rates are more than halved by 35 or over"
Furthermore the point is made that the risk of congenital abnormalities increases with age.

These are patient education points that could usefully be included in contraceptive pill checks.

Ovarian reserve may be assessed with FSH measurement in the first 3 days of the cycle - other tests can supplement this but the validity of using these tests for making long term predictions about fertility is uncertain.

Schizophrenia

A recent BMJ article provided an update on schizophrenia. This condition seems to be slowly moving on.
More is known now about its aetiology compared to what was known when I was trained as an undergraduate. Excess dopamine activity in the mesolimbic system is acknowledged to be a key part of the neurochemical changes in schizophrenia, with one theory holding that dopamine has a role in "salience" and that the excesses can increase the salience of mundane things, turning a glance from a stranger to a glare with malevolent thoughts. Lifetime risk of the disease is 1% in the population but 6.5% in those with first degree relatives and 40% in monozygotic twins of affected individuals. Environmental factors play a role, people born following a complicated obstetric history, those of low birth weight, migrants, people who are socially isolated and city dwellers are all more likely to develop the condition. Misuse of cannabis, lsd and amphetamine are all associated with the condition.
Diagnostic criteria seem to me to be similar to what they were in the mid 1980's.

At least one present most of the time for a month:

• Thought echo, insertion or withdrawal, or thought broadcast
• Delusions of control referred to body parts, actions, or sensations
• Delusional perception
• Hallucinatory voices giving a running commentary, discussing the patient, or coming from some part of the patient's body
• Persistent bizarre or culturally inappropriate delusions
  

Or at least two present most of the time for a month

• Persistent daily hallucinations accompanied by delusions
• Incoherent or irrelevant speech
• Catatonic behaviour such as stupor or posturing
• Negative symptoms such as marked apathy, blunted or incongruous mood

Here are some suggested screening questions:

• Do you hear voices when no one is around? What do they say?
• Do you ever think that people are talking or gossiping about you, maybe even thinking about trying to get you?
• Do you ever think that somehow people can pick up on what you are thinking or can manipulate what you are thinking?

Treatments have evolved with an emphasis on early treatment and the use of atypical antipsychotic agents. Clozapine remains a useful option for resistent patients but requires monitoring because of the (<1%)>

Cervical cytology

In the last 18 months I have moved from taking a smear with an Ayelsbury spatula to the use of liquid based cytology and taking a smear with the cervical brush. This new method has clearly meant some changes at the lab, they now get a bottle of cells rather than a slide with preservative on it. beyond this the new process was a mystery to me.
The BMJ has come to my rescue and explained how automated the new process has become. Reassuringly it seems that the new technique is at least as sensitive as the old one.

Anorexia Nervosa

This clinical review (Jane Morris and Sara Twaddle BMJ 2007;334:894-8) takes a refreshing look at anorexia nervosa management. Evidence for the benefits of various treatments is poor because engaging this group in treatment is difficult and engaging them in research is harder still. As a GP the take home messages were:

• It's common (0.3% prevalence in young women) and has the highest mortality of any psychiatric disorder.
• It takes years to recover - so there are no quick fixes.
• Rapid changes in weight are dangerous, as are substance misuse, deliberate overdose and misuse of prescribed insulin.
• Medication has little benefit, side effects risk is high.
• Involving the family in the management can be helpful.

Usefully the article references several possible sources of additional educational support for patients, carers and health professionals.

Reading the Fillers

"Dreamkiller" John Frey, British Journal of General Practice, May 2007, Vol 57, No. 538, p424.

Reading the non-clinical opinion articles is probably what attracts many of us to open our journals - it's either that or the obituaries!

In "Dreamkiller", John Frey writes with US perspective on free health care. I have tended to link free access to high quality health care with poverty, believing that it is essential for low and no income families to be able to enjoy the same quality of care as their wealthier neighbours. My UK perspective has been shaped by Tudor Harts inverse care law.

Frey gives me a different point of view. The situation in the US actually prevents people from making other choices in life because if they move from an employer with health care cover to a different job without that cover, they will not be able to afford even basic health care insurance for them and their families. Moreover, it prevents people from taking early retirement because Medicare cover doesn't kick in until 64.5 years.

HRT in the news

The Guardian reports on HRT and this time it's the risks rather than the benefits that get the into the press. A timely review which appeared before the Guardian article (BMJ, Roberts, H;334 p736 to 741, Managing the Menopause) provides a good grounding on which we can develop our clinical practice.

Firstly I was reassured by the advice on use of topical oestrogens. This form of HRT is useful in reducing dyspareunia and recurrent uti and is not associated with significant systemic absorption so can be used safely as a long term treatment. Women with a uterus do not need progesterone treatment in addition to the oestrogen.

Long term HRT has no role in the prevention of chronic disease. There is a significant increase in the risk of stroke, dvt, gall bladder disease with both oestrogen and combined oestrogen-progestogen treatments. Breast cancer and dementia are also increased in women over 65. Some evidence of protection against fractures and colorectal Ca in combined therapy is noted.

The consensus advice seems to be that we should use the lowest dose of hormone for the shortest duration to give symptom relief.

Dog Bites

M Morgan in a BMJ Clinical review (BMJ 2007:334:413-417) is informative about the management of dog bites - not an uncommon problem in rural primary care.

I was surprised to learn that Pasteurella multocida infection can strike within 12 hours of a bite. I would always emphasise the need for good wound care and learnt that because of drug resistence P multocida does not respond to flucloxacillin/erythromycin - co-amoxiclav is to be preferred.

Antibiotic treatment should be preferred in immunocompromised patients and in those patients with a more than superficial wound. In established infection the duration of treatment depends on the type of infection. In primary care most establised infection will be cellulitic - 10-14 days treatment is adequate in these cases.

Sinusitis

In BMJ 2007:334:358-361 ENT specialists from the Aberdeen Royal Infirmary summarise the knowledge base on sinusitis - which they refer to as rhinosinusitis. As a simple GP, what I would like to know is how should I diagnose and treat the problem. As usual, things are not as simple as they seem. Has the patient got acute (rhino)sinusitis; <12 weeks duration and 2 or more of blockage/congestion, discharge, facial pain and loss of smell. If so then analgaesia helps, topical steroid nasal spray can help and antibiotics have a small but significant improvement in cure rate.
Chronis sinusitis is >12w duration with one of : facial pain or pressure, discoloured discharge and reduction or loss of smell. Topical steroids are the first line of treatment here and oral steroids may also be considered.
These days surgery for these problems is usually done endoscopically. In acute cases it is used to release pus and in chronic cases to restore sinus ventilation and drainage.

January - Shared Care Forum

Last night I visited our local "Substance Misuse Shared Care Forum". The meeting included 2 presentations on detoxification and abstinence and some group work.
I learnt about using AUDIT the "Alcohol Use Disorder Identification Test". This is an easy to use tool which leads to a score. Scoring <8>20 suggests alcohol dependence. Scores of 8-15 and 16-19 suggest hazardous and harmful drinking respectively.
For hazardous drinking interventions suggested were education and reduction, for harmful drinking "brief interventions" were recommended, for dependence then detoxification was recommended.
The "problem" with this is that locally, if we uncover harmful and dependent drinking there are no formal services to support treatment.

Acne - systemic treatments

Confirmation of my reluctance to use minocycline for acne appears in the BMJ - (BMJ 2007;334:154) - the drug is more expensive than its tetracycline relatives and has the adverse reaction of slate gray hyperpigmentation of the skin. It also seems more likely to lead to a lupus like syndrome.
Preferred alternatives are doxycycline 50mg daily (cost£27/6m) and lymecycline 408mg (cost £46/6m). Both of these drugs are once daily preparations and do not need to be taken on an empty stomach.

Osteoporosis

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.

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.

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.

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.

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!

Shared Care Forum - May 2006

Messages from the Calderdale and Kirklees shared care forum:

1. Tetanus status needs checking on all drug users, immunise as appropriate
2. Consider SBE with low grade fever in injecting drug users
3. 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.