What is the incidence of gallstone disease in potentially pregnant ladies?

Bismillah, alhamdulillah:

The sort of question that can send a family doctor into a slightly dizzy spell. But it wasn’t too long before UpToDate gave me a stab at the answer, the table (below) is taken from UpToDate and shows an interesting variation with low incidence in Chinese and Japanese women aged between 20-40 (around 2-3 %) to 6-12% in UK/US and a very high percentage in Pima Indians (touching ~70%) ! My patient’s question was should she have the gallstones removed removed prophylactically before her pregnancy or not? Eye balling the figures I went for an prevalence of 10% in potentially fertile ladies having gallstones, which should imply 10% of pregnant women also have gallstones. I asked her, ‘When was the last time you heard that 10% of pregnant ladies needed to have their gallbladders removed?’ This brought the message home to my patient and she could visualise the statistics and felt comfortable leaving the stones as they were totally asymptomatic and she had no risk factors for gallbladder cancer.

Fantastic UpToDate!

Prevalence of Gallstones

MERS update and interesting camel info

Bismillah, alhamdulillah.

Just finished a presentation of MERS for the public. Interesting information that I came across regarding camels and their role in the disease. Some highlights were:

  • Camel’s have had antibodies against the corona virus since at least 1992.
  • The camel virus genome sequences vary by less than 1% compared to the human MERC Coronavirus
  • The prevalence of corona virus in camel’s by PCR is highest prior to the age of 2.
  • Seropositivity in camels was quite variable ranging from 5->90%.
  • Taif was mentioned as having a high seropositive rate amongst its camels.
  • for more see the short power point:

MERS Update 21 May 2014

 

When is the peak of infantile reflux?

Bismillah, alhamdulillah:

Got asked this question today. I guessed 3 – 6 months based on my own clinical experience and then I had a quick look at UpToDate:

  • 50% at 0-3 months
    5% at 10-12 months
    Peak at 4 months (61%)

In one study of healthy infants younger than 13 months of age, regurgitation of at least one episode per day was reported in approximately one-half of 0- to 3-month-old infants, compared with only 5 percent of 10- to 12-month-old infants [5]. Regurgitation was most common around four months (61 percent), decreasing to 21 percent between six and seven months. The description of regurgitation as being a “problem” was given by 23 percent of parents of children aged six months, and decreased thereafter. A change in formula, thickening of feedings, termination of breast-feeding, and use of medication to treat regurgitation were reported by parents to be beneficial in some children. In most children with regurgitation that is considered to be a problem by their parents, the condition improves and usually resolves by the end of the first year of life [6] (UptoDate)

What percentage of children with haematogenous osteomyelitis will have abnormal lab studies?

We had an interesting case in our practice which led to the following two questions. The answers are from UpToDate :

What percentage of children with haematogenous osteomyelitis will have abnormal lab studies?

LABORATORY FINDINGS — Elevations in peripheral white blood cell count (WBC) are variable and nonspecific, while elevations in the erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are more consistently observed in children with hematogenous osteomyelitis [4,30]. This was illustrated in a review of 44 children with acute hematogenous osteomyelitis in whom serial tests were obtained during therapy [30].

The white blood cell count was elevated in only 35 percent.

The erythrocyte sedimentation rate (ESR) was initially elevated (≥20 mm/h) in 92 percent of patients (mean 45 mm/h).

The serum C-reactive protein (CRP) concentration was elevated in 98 percent on admission.

How quickly does CRP and the ESR return back to normal in such cases?
ESR and/or CRP levels – The ESR and CRP levels are generally reliable laboratory markers of inflammation and response to therapy. The ESR usually increases during the first several days after diagnosis and then declines in the weeks that follow [30]. CRP also increases early in the infection but returns to normal sooner than ESR. In addition, the rate at which CRP returns to normal may be a sensitive indicator of a complicated clinical course. These observations were demonstrated in the following reports:

In a prospective series of 50 children treated for acute S. aureus hematogenous osteomyelitis, CRP returned to normal in an average of nine days, compared with 29 days for ESR [31].

In a report of 63 consecutive children with hematogenous osteomyelitis, those with a higher CRP from the fourth day of treatment on were more likely to have a complicated clinical course, as defined by requirement for repeated drainage, duration of symptoms, and extent of radiographic findings [32].

Either ESR or CRP may be used to monitor initial response to therapy, depending on which test is more readily available. Although we prefer monitoring both levels, CRP begins to decline sooner.

 

Have you tried SLIT?

Bismillah, alhamdulillah.

Sounds like an unusual name but I have a few patients on SLITs! So what exactly is SLIT? The acronym stands for Sub Lingual Immuno Therapy! Over the last few years it seems that this has come into the main stream and is being widely prescribed where I practice. I did some quick reading via UpToDate and here were a few highlights that I saw:

  • Source article http://www.uptodate.com/contents/sublingual-immunotherapy-for-allergic-rhinitis
  • It works – but it is not clear by how much
  • Oral therapy should be stopped if there is mucosal ulceration
  • Don’t start in pregnant ladies but may continue if already started.
  • Duration can be limited i.e. 16w before allergy season or up to 4 years.
  • In Jeddah I am aware that Dr Soliman Fakeeh hospital offer a French product called: Staloral® : sublingual solution containing allergen extracts.
  • As I am writing this article I came across a European patient who had tried the oral therapy over 20 years ago! He ran into problems with mucosal ulceration when the potency was increased.
  • The italicised extracts below are from the UpToDate article on the subject:
  • In a 2011 systematic review of 60 randomized trials (published through 2009), which included approximately 2300 adults and children receiving active SLIT treatment, treatment resulted in a statistically significant reduction in symptoms (standardized mean difference of -0.42 [95% CI -0.69 to -0.15]) and in medication requirements (standardized mean difference of -0.43 [95% CI -0.63 to -0.23]) [35].
  • No trial reported anaphylaxis or the need to administer epinephrine.
  • Effects on quality of life could not be assessed because a variety of different measurements were used.
  • Many study designs have now chosen the clinical outcome of “total combined score” (TCS) as the accepted evaluation tool to measure primary efficacy. However, no standardized scoring methodology has been adopted across the industry for quantification of symptoms and medication use.
  • In an attempt to define clinically meaningful improvement, the World Allergy Organization (WAO) has proposed that a 20 percent mean reduction in TCS compared with placebo be demonstrated [38].
  • There are two forms of SLIT with inhalant allergens that have been widely studied: dissolvable sublingual tablets (SLIT-tablet) and sublingual allergen extracts (SLIT-drops).

  • The most consistent results have been obtained with SLIT-tablet formulations.

  • SLIT has been shown in randomized trials to be effective for allergic rhinitis (with or without conjunctivitis) and safe for patients with concomitant milder asthma. However, efficacy in reducing the symptoms of persistent, not well-controlled allergic asthma has not been conclusively demonstrated.

  • SLIT has been used in Europe and some other countries for decades for the treatment of allergic rhinoconjunctivitis. The first sublingual products, a five-grass pollen tablet, a single grass pollen tablet, and a short ragweed pollen tablet, became available in the United States in 2014.

  • SLIT is self administered by patients (or their caregivers) at home, although the initial dose is usually given under medical supervision. A significant percentage of patient experience local application site reactions (eg, oral pruritus, throat irritation, tongue swelling), but systemic allergic reactions are markedly fewer as compared with subcutaneous immunotherapy (SCIT).

  • SLIT appears to be somewhat less effective than SCIT

24/7 primary care – panacea or problem?

Bismillah, Alhamdulillah:

I was asked to comment on the following article in the BJGP  (Family medicine in the emergency department, Jordan by Wafa Halasa) which looked at offering 24/7 primary care services in Jordan.

In between patients I had a quick look at the abstract, quickly reading through I realised that the approach of providing 24/7 primary care with Family Medicine consultants (as they are known in the Middle East and the ?US – aka GPs in the UK) is a regressive step in the care of patients. The paper showed a 40% increase in demand once primary care was provided around the clock. The only way they were able to curtail this was by putting a fee. Increased access to [primary care] physicians is not always a panacea as the paper itself shows.

The strengths of family medicine are found in the ability to integrate data from many sources and provide patients a reasoned approach to dealing with the modern medical system. The ability to provide a balanced and well reasoned advice to our patients is enhanced by practitioners who feel happy and who are working sensible hours. Further, patients who come in the middle of the night to see a family doctor are not best placed to understand the complex positives and negatives of various modes of treatment that the family doctor can offer.

Family medicine is a profession that may share the case load of low acuity urgent medicine with their Emergency Room colleagues but we are now progressing into a world of medicine where chronic disease management and prevention is becoming a major and more complicated role than people had envisioned even a decade ago. Family doctors are ideally placed through their training to approach the challenge of chronic disease and health promotion. Family doctors and their practices have evolved to take up this challenge with better electronic health records, disease registries, recall systems, empowered nursing staff, collaborative health team work and so on. They have taken a lot of the role that has been handed down to them from secondary care and hospital based out patient clinics. Family medicine is slowly evolving into a new speciality and the days of Family Doctors covering gaps in service provision for ER departments should pass.

The Emergency Room has to respond and provide the increase level of second tier ER physicians who are needed to deal with the many low acuity urgent cases which ER physicians feel do not belong in the ER room. This is a challenge to the ER profession as a whole and they need to rise to the challenge and offer better career development with increased training of their staff to deal with low acuity urgent problems using the learned wisdom of family doctors.

On the other side of the demand and supply equation of medical services, society has to ask itself why are we seeing such a huge demand for health care provision from our populations. The benefits of a modern industrial society was the better living conditions and better quality of life and health. It would be reasonable to conclude that demand should decrease and not increase as a result. Yet we see increase demand for health care provision, so what is fuelling demand?

With most complicated issues there are many complicated answers but one thing that I have noticed over the decades that I have been around is that the practice of medicine has increased the dependency of our populations on doctors. If medicine was a business then we would be very happy that we are increasing demand by this increased medical dependency. Medicine is a profession and cannot be a profit-driven-business. Its main drive is to do benefit and not do harm. Its practitioners thus have a duty to uphold the best interests of patient care, which at times runs counter to patient satisfaction.

Urgent care, being a case in point, should be ‘urgent’. Rather than telling people your care is not urgent our leadership in the medical field is redefining the concept of urgency in terms of patients’ understanding of their problems. This is a disservice to patients. The medical profession should not induce dependence on its services. Rather they should encourage independence. If we are to win the effort to convince the public in general that they are in general well and do not need to be nannied by the medical profession (perhaps we should call it industry) then we should not be giving misleading signals by providing non-acute 24/7 care. If we change the meaning of ‘urgent’ and lower the threshold to consider problems as urgent, we will have ethically and morally failed as a medical profession in doing our best to the populations we serve.