OLM : Aspirin in or out, Orthorexia & Obesity Madness, CT Angio, Heart failure & BNP

27-03-2010 CT ANGIO – Not yet please (Areas of agreement and controversy: There is broad consensus that coronary CT angiography is indicated in patients with an intermediate pre-test probability of coronary artery disease (CAD) when other non-invasive tests have been equivocal. In this context, CT can reliably exclude significant CAD. Cardiac CT also has an established role in the evaluation of bypass grafts and suspected coronary anomalies. Radiation exposure from CT procedures remains a concern, although techniques are now available to reduce the X-ray dosage without significantly compromising the image quality. However, with the current level of knowledge, the cardiac CT examinations are not justified to screen for CAD in asymptomatic individuals. Neither is it considered appropriate in patients with a high pre-test probability of CAD, for whom invasive catheter coronary angiography is usually of more benefit.)
27-03-2010 CLOPIDOGREL & PPI – Maybe not that bad (Results showed no difference in event rates between those prescribed a PPI and those not given a PPI.)
26-03-2010 COX2 v COX1 Metanalysis – As safe as COX1s according to pharma funded studies (A pinch of salt?)
27-03-2010 MIGRAINE & YOUR HEART – How did they approve this negative study in the first place? (Migraine Intervention with Starflex Trial (MIST) results, showing no difference in headache cure between patients who underwent patent foramen ovale (PFO) closure and sham-treated migraineurs.)
26-03-2010 Obesity a psychological disorder – proposal by Prof Volkow for DSM V bec it resembles addiction to drugs: ‘Obesity is characterized by compulsive consumption of food and the inability to restrain from eating despite the desire to do so. These symptoms are remarkably parallel to those described in DSM-IV for substance abuse and drug dependence (Table 1), which has led some to suggest that obesity may be considered a “food addiction” (Cota 2006).’
27-03-2010 NPH to Lantus conversion: Same units if NPH once daily. If bd its 80% of the DAILY (i.e. Total) NPH dose (work out the amount of NPH if 70/30 mix)
26-03-2010 Orthorexia – Coined 1997 not in DSM IV or V (due 2013) – a focus on healthy foods – when extreme can lead morbidity or mortality.
27-03-2010 Aspirin Primary Prevention in DM (More CVAs ?less CVDs) – Diabetes Care study (Patients receiving aspirin lowered their cumulative incidence of coronary heart disease events by 3.91%, reducing the rate of deaths from coronary heart disease by 4.65%. However, subjects’ cumulative incidence of stroke increased by 0.51%, elevating the stroke mortality rate by 0.28%.) BUT (The use of aspirin to ward off CVD is still controversial and merits further study, according to the investigators. In 2 large, randomized trials recently published in the Journal of the American Medical Association and the British Medical Journal, respectively — namely, the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes trial and the Prevention of Progression of Arterial Disease and Diabetes trial — low-dose aspirin use in this population did not prevent cardiovascular events.)
27-03-2010 ASPIRIN/CLOPIDOGREL & BREASTFEEDING – Not proven to be unsafe. Minimise exposure, don’t give if infant has fever because of Reye’s. (There have been no adverse reports described in infants exposed to low dose aspirin, clopidogrel or dipyridamole via breast milk, however, they should be used with caution in breastfeeding mothers. Infant monitoring of adverse effects described with therapeutic doses should be undertaken especially signs of bruising and bleeding, which may be prolonged in the case of aspirin and clopidogrel. Due to the short half-life of clopidogrel and once daily dosing, the risk of adverse effects in infants may be minimized by timing the dose in relation to the feed immediately before the infant’s longest sleep period and expressing and discarding the milk before the next feed is due.)
27-03-2010 DIET – Reducing saturated fats not enough need to replace with polyunsaturated fats (“This is pretty important on a policy level,” said Mozaffarian. “It’s naturally assumed that lowering saturated fat is good for the heart, but that’s not what the evidence shows.” Simply reducing saturated fat without regard to what is substituted for it might not derive any benefit, he said.  The results of the study are published online March 23, 2010 in PLoS Medicine.)
26-03-2010 Xray can give fNEG, if pain persists consider MRI (UK Dr v US Dr :  Use clinical accumen before MRI v Use MRI if ANY doubt)
27-03-2010 HEART FAILURE & BNP – Treat to keep the BNP low gives beter results (Outpatients with chronic, primarily systolic heart failure lived longer if their medical management was guided by natriuretic-peptide-assay results, compared with med adjustments based on “usual clinical care,” in a meta-analysis that had to rely on a limited number of randomized, controlled trials [1])
27-03-2010 TKR Satisfaction – 95% at one year in the US
27-03-2010 VACCINE ROTARIX – Porcine DNA in vaccine FDA warning
27-03-2010 CT ANGIO – Not yet please (Areas of agreement and controversy: There is broad consensus that coronary CT angiography is indicated in patients with an intermediate pre-test probability of coronary artery disease (CAD) when other non-invasive tests have been equivocal. In this context, CT can reliably exclude significant CAD. Cardiac CT also has an established role in the evaluation of bypass grafts and suspected coronary anomalies. Radiation exposure from CT procedures remains a concern, although techniques are now available to reduce the X-ray dosage without significantly compromising the image quality. However, with the current level of knowledge, the cardiac CT examinations are not justified to screen for CAD in asymptomatic individuals. Neither is it considered appropriate in patients with a high pre-test probability of CAD, for whom invasive catheter coronary angiography is usually of more benefit.)
27-03-2010 CLOPIDOGREL & PPI – Maybe not that bad (Results showed no difference in event rates between those prescribed a PPI and those not given a PPI.)
26-03-2010 COX2 v COX1 Metanalysis – As safe as COX1s according to pharma funded studies (A pinch of salt?)
27-03-2010 MIGRAINE & YOUR HEART – How did they approve this negative study in the first place? (Migraine Intervention with Starflex Trial (MIST) results, showing no difference in headache cure between patients who underwent patent foramen ovale (PFO) closure and sham-treated migraineurs.)
26-03-2010 Obesity a psychological disorder – proposal by Prof Volkow for DSM V bec it resembles addiction to drugs: ‘Obesity is characterized by compulsive consumption of food and the inability to restrain from eating despite the desire to do so. These symptoms are remarkably parallel to those described in DSM-IV for substance abuse and drug dependence (Table 1), which has led some to suggest that obesity may be considered a “food addiction” (Cota 2006).’
27-03-2010 NPH to Lantus conversion: Same units if NPH once daily. If bd its 80% of the DAILY (i.e. Total) NPH dose (work out the amount of NPH if 70/30 mix)
26-03-2010 Orthorexia – Coined 1997 not in DSM IV or V (due 2013) – a focus on healthy foods – when extreme can lead morbidity or mortality.
27-03-2010 Aspirin Primary Prevention in DM (More CVAs ?less CVDs) – Diabetes Care study (Patients receiving aspirin lowered their cumulative incidence of coronary heart disease events by 3.91%, reducing the rate of deaths from coronary heart disease by 4.65%. However, subjects’ cumulative incidence of stroke increased by 0.51%, elevating the stroke mortality rate by 0.28%.) BUT (The use of aspirin to ward off CVD is still controversial and merits further study, according to the investigators. In 2 large, randomized trials recently published in the Journal of the American Medical Association and the British Medical Journal, respectively — namely, the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes trial and the Prevention of Progression of Arterial Disease and Diabetes trial — low-dose aspirin use in this population did not prevent cardiovascular events.)
27-03-2010 ASPIRIN/CLOPIDOGREL & BREASTFEEDING – Not proven to be unsafe. Minimise exposure, don’t give if infant has fever because of Reye’s. (There have been no adverse reports described in infants exposed to low dose aspirin, clopidogrel or dipyridamole via breast milk, however, they should be used with caution in breastfeeding mothers. Infant monitoring of adverse effects described with therapeutic doses should be undertaken especially signs of bruising and bleeding, which may be prolonged in the case of aspirin and clopidogrel. Due to the short half-life of clopidogrel and once daily dosing, the risk of adverse effects in infants may be minimized by timing the dose in relation to the feed immediately before the infant’s longest sleep period and expressing and discarding the milk before the next feed is due.)
27-03-2010 DIET – Reducing saturated fats not enough need to replace with polyunsaturated fats (“This is pretty important on a policy level,” said Mozaffarian. “It’s naturally assumed that lowering saturated fat is good for the heart, but that’s not what the evidence shows.” Simply reducing saturated fat without regard to what is substituted for it might not derive any benefit, he said.  The results of the study are published online March 23, 2010 in PLoS Medicine.)
26-03-2010 Xray can give fNEG, if pain persists consider MRI (UK Dr v US Dr :  Use clinical accumen before MRI v Use MRI if ANY doubt)
27-03-2010 HEART FAILURE & BNP – Treat to keep the BNP low gives beter results (Outpatients with chronic, primarily systolic heart failure lived longer if their medical management was guided by natriuretic-peptide-assay results, compared with med adjustments based on “usual clinical care,” in a meta-analysis that had to rely on a limited number of randomized, controlled trials [1])
27-03-2010 TKR Satisfaction – 95% at one year in the US
27-03-2010 VACCINE ROTARIX – Porcine DNA in vaccine FDA warning

MRCGP Book Review – Cases and Concepts for the new MRCGP

بسم الله

This is a book written by 3 Family Doctors (GPs) working in the UK giving a structured approach to a touch over 40 cases for te MRCGP exam. The structured approach is useful for both the UK new MRCGP exam and the structured OSCES in the international MRCGP.

You can buy the book via Amazon or perhaps a friend has a second hand copy once the have successfully done the MRCGP.

To give you an idea I have attached an extract of the book under the ‘Fair Dealing‘ section of the UK copyright law. You can download the extracts from below.

Extract of MRCGP cases book

Moxonidine (physiotens)

Moxonidine (physiotens)

Centrally acting. Not unpopular in KSA.  Works. Dose: Start 0.2 mg qd (Max 0.4 mg qd). Don’t combine with HTZ, arrythmias, eGFR <60.  MOXCON trial : inc mortality in Heart failure given Moxonidine. Does improve insulin resistance but not by much (-0.2 mmol/l).

Package insert. Agonist of  imidazoline receptor subtype 1 (I1) found in medulla oblangata. Compared to the older central-acting antihypertensives, moxonidine binds with much greater affinity to the imidazoline I1-receptor than to the α2-receptor. In contrast, clonidine binds to both receptors with equal affinity.

Disclaimer
Do not use the above information to self treat! These are meant as a place for me to jot my obervations and notes down rather than on scraps of paper all over the place.  If you feel ou may benefit seek the help of a doctor and discuss any ideas you have with him/her.

HbA1c and all that!

يسم الله

Just when I thought life was simple, I am starting to understand that HbA1c is not quite what it is meant to be.

First of all it is a dying breed and will be replaced by a new number which is no longer a percentage (Ref):

HbA1c-DCCT                              HbA1c-IFCC
(%)                                                (mmol/mol)
4.0 20
5.0 31
6.0 42
7.0 53
8.0 64
9.0 75
10.0 86

And why are they doing this?

Because now we are using a more accurate measure of glycosylation of Hb by looking at a single Valine on of the Hb chains rather than using a biological assay which included glycosylation of other things as well as Hb (but UKPDS used this ‘biological’ test! – So is validity true?)

And then I started spotting HbA1c and FG & 2HPP discrepancies:

So I needed to add a bit more to my HbA1c rudimentary knowledge: turns out the 120 day is not quite an accurate picture. The previous 30 days has a 50% impact on the HbA1c while the days 90-120 (before the test) only have a 10-20% effect on it. (http://www.endocrinetoday.com/view.aspx?rid=61106) . So the fresher your RBCs are and the worse your recent sugars are the higher your HbA1c will be even though the MPG (Mean Plasma Glucose) may be unchanged. (MPGs can be worked out by 7 measurements per day – super snazzy glucose meters that sample your glucose automatically).

So does the average life cycle of a red blood cell differ by ethnicity / genetic profile? From the anecdotal lack of complications in my diabetics with HbA1cs off the Richter scale (10-15%) the answer sees to be yes – at least in Saudi Arabia.

Does BTS (Beta Thallasemia Trait) have an effect?  Potentially depending on the assay it seems is a possibility. (Ref)

Vitamin B12: Yes – no – yes again? Should we be checking Vitamin B12 once a year? Read this case report which argues for a yes: Report of Metformin induced B12 deficiency and neuropathy.

And then finally to cap it all off – statins can increase your risk of diabetes by 9%! This is the result of a meta-analysis published in the Lancet in Feb 2010. (Read more here). In short if you are low risk then it may not be a good idea, for moderate to high risk and if your old it works out as follows:

Results further revealed that treatment of 255 patients with statins for four years would result in one extra case of diabetes. But, for 1 mmol/L reduction in LDL concentration, the same 255 patients could expect to experience five fewer major coronary events, such as coronary heart disease death or nonfatal myocardial infarction.

Hope you are good at statistics and risk analysis and perhaps a bit of Bayes theorem.

//

Tayside Diabetes Handbook – Change in Reporting of HbA1c

What is HbA1c?
Glucose in the blood binds irreversibly to a specific part of haemoglobin in red blood cells, forming HbA1c. The higher the glucose, the higher the HbA1c. HbA1c circulates for the lifespan of the red blood cell, so reflects the prevailing blood glucose levels over the preceding 2-3 months
What does it tell us?
The DCCT in Type 1 diabetes and the UKPDS in Type 2 diabetes both showed that the risk of microvascular and macrovascular complications of diabetes increases as HbA1c increases. HbA1c thus gives a measure of an individual’s risk of the long-term complications of diabetes.
Why measure it?
HbA1c measured 3-6 monthly shows how an individual’s glucose control, and thus risk of complications, changes in response to alterations in management. Target HbA1c levels can be set for individual patients and therapy adjusted to reach them.
Current HbA1c Numbers
Current HbA1c assays are aligned to the assay used in the DCCT, so that an individual’s risk of complications can be inferred from the result. The non-diabetic reference range is HbA1c-DCCT 4.0- 6.0 %
Current Targets
The general target currently is HbA1c-DCCT <7.0 %. However, this should be individualised, considering the person’s risk of severe hypoglycaemia, cardiovascular status and co-morbidities.
Why Change?
The new IFCC reference method is more specific for HbA1c than the assay used for standardisation in the DCCT and UKPDS. Comparing results from different labs throughout the world and interpreting clinical trial results will now be easier. In future, HbA1c-IFCC results will be reported in mmol/mol after standardisation using the IFCC reference method
New Units and Numbers
The non-diabetic reference range for HbA1c-IFCC using the IFCC reference method will be 20- 42 mmol/mol, rather than the HbA1c-DCCT-aligned range of 4.0 – 6.0 %.
How Old and New Relate
A guide to the new values expressed as mmol/mol is:
HbA1c-DCCT                              HbA1c-IFCC
(%)                                                (mmol/mol)
4.0 20
5.0 31
6.0 42
7.0 53
8.0 64
9.0 75
10.0 86

Presentation – Buy.ology

يسم الله

Came across an interesting book while passing through Dubai duty free called Buyology by a Martin Lindstorm. I thought it had some interesting messages for us as Family Physicians when dealing with our patients who are also customers and recipients of very powerful advertising messages that are not always in their best health interests. I had a chance to present the material to our team of doctors at the Family Medicine Department in King Faisal Hospital,  Jeddah.

One of the most interesting and alarming findings was that health advice on cigarette adverts actually increase the desire of smokers to have a cigarette!

You can download the presentation here: Buy.ology.

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Disclaimer

All copyrighted images belong to the orignal sources (via Google Images)