Merry Christmas and a Happy New Year!

It's Christmas eve and it's time to say Merry Chirstmas and a happy new year!

All the best for 2013 - this year will be a tough act to follow!

(Could this be the year that the Gunners pick up some more silverware? - Hope so!)

Gordon

NICE Guidelines on Ectopic Pregnancy & Miscarriage + Update on SVT

Ectopic Pregnancy and Miscarriage - Summary of NICE Guidance

NICE have released new guidance on the management of ectopic pregnancy and miscarriage in women and given that my current post is in obstetrics and gynaecology I felt that this was particularly relevant! Complications in early pregnancy are common and distressing for the patient. Historically, in cases where ectopic pregnancies have led to patient deaths, a common contributing factor has been the failure of team looking after the patient to make the correct diagnosis in a case where the presentation was atypical. Clinicians should therefore have a higher index of suspicion for ectopic pregnancy as a cause of acute illness. 

Common symptoms of ectopic pregnancy include: abdominal or pelvic pain, amenorrhoea or a missed period, PV bleeding, dizziness/syncope, shoulder tip pain, urinary symptoms, breast tenderness and pain on defecation. Any patient with pain and abdominal tenderness, pelvic tenderness and cervical motion tenderness should be referred immediately to gynaecology services, ideally an early pregnancy assessment service offering serum hCG measurement and trans-vaginal / abdominal US scanning.

Management of miscarriage - expectant management should normally be the initial management strategy (7-14 days). Explore other options if late in 1st trimester and at increased risk of haemorrhage or previous traumatic experience eg. still birth.  Medical management involves vaginal misoprostol for treatment of missed or incomplete miscarriage.

Terminology used in Describing Miscarriage in the First Trimester:

• Complete miscarriage - all of the tissue has left the uterus
• Confirmed miscarriage - a non-viable intra-uterine pregnancy diagnosed on US scan
• Incomplete miscarriage - non-viable pregnancy in which the process of miscarriage has begun (eg. bleeding, pain), but pregnancy tissue remains in the uterus
• Missed miscarriage - a non-viable pregnancy identified on US scan without bleeding and pain
• Threatened miscarriage - Vaginal bleeding in the presence of a viable pregnancy

Diagnosis and Management of SVT

SVT comprises a group of conditions where atrial or AV node tissues are essential for sustaining the arrhythmia, produced either by disorders of impulse formation and/or disorders of impulse conduction. Symptoms include palpitations, chest pain, anxiety, light-headedness, shortness of breath and (uncommonly) syncope. Initial management is to slow AV node conduction either using vagal manoeuvres or adenosine. Catheter ablation is usually curative and has high long-term success rates. Every effort should be made to capture the arrhythmia on a 12-lead ECG. Giving the patient a copy of the ECG to keep can be useful. Echocardiogram is an imprortant investigation to identify underlying structural abnormalities such as left ventricular impairment.

Differential Diagnosis of a Narrow Complex Tachycardia:

• Sinus tachycardia
• AV nodal re-entrant tachycardia
• Atrioventricular re-entry tachycardia
• Atrial Tachycardia
• Atrial Flutter
• Atrial Fibrillation

Emergency Oxygen Therapy

Emergency Oxygen Therapy 

This features in an educational article in the BMJ this week. Oxygen used to be given routinely for a wide range of acute medical presentations, however increasingly it is only being recommended if the patient is hypoxaemic. Oxygen should be prescribed and given in a controlled manner. A number of publications in the medical literature have raised concerns about the risks of insufficient or excessive oxygen therapy. The main indication for oxygen therapy in an emergency setting is to protect patients from the harmful consequences of hypoxaemia.

The common acute medical presentations can be broadly categorised into those who require high concentration oxygen in all cases, those likely to require oxygen therapy, and those where patients are likely to need controlled oxygen.

1) High Flow O2 in all cases - Shock, sepsis, major trauma, anaphylaxis, cardiac arrest, carbon monoxide or cyanide poisoning.

2) O2 Therapy (Aim sats 94-98%) - Pneumonia, asthma, acute heart failure, PE

3) Controlled O2 (Aim sats 88-92%) - Exac. of COPD, acute illness in CF, acute illness in patients with obesity hypoventilation syndrome or morbid obesity, or with chronic neuromuscular / musculoskeletal conditions.

The following are common medical emergencies where oxygen was given routinely in the past but is now only advised if the patient is hypoxaemic:

MI/ACS, survivors of cardiac arrest with ROSC, sickle cell crisis, obstetric emergencies, most poisonings and metabolic/renal disorders with tachypnoea due to acidosis (Kussmaul breathing). In acute stroke, there is uncertainty in the literature as to whether routine oxygen supplementation actually improves outcomes and these patients should only be given oxygen to maintain saturations within the normal range (94-98%).

Approximately half of UK hospital patients receiving oxygen therapy do not have a prescription for this treatment or any valid written documentation. There is no evidence that oxygen therapy can relieve 'breathlessness' in non-hypoxaemic patients with acute illness. High concentration of oxygen in patients with acute exacerbations of COPD increases the risk of hypercapnic respiratory failure. High concentrations of oxygen has also been shown to increase the risk of hypercapnia in acute asthma and pneumonia.

Venturi masks are a useful way of delivering controlled oxygen to a patient. They are available in five types: 

24% O2, Blue, 2 litres

28% O2, White, 4 litres

35% O2, Yellow, 8 litres

40% O2, Red, 8 litres

60% O2, Green, 15 litres

If oxygen requirements increase, the patient requires a medical review and the underlying cause of the increased requirements should be sought. Beware that in some cases, pulse oximetry may be misleading (eg. in carbon monoxide poisoning). Clinical signs such as tachypnoea and chages in other vital signs may occur before a change in oxygen saturations.

Finally, it is very important to recognise that hypoxia is a sign of underlying illness (problem with gas transfer or regulation of respiratory activity) and not a disease in itself. Blind treatment of hypoxia may lead to a delay in identification of an underlying life threatening condition. 

Movember, Health Screening and Resistant Hypertension

Movember - Truth behind the 'Tache'

Men in the UK and around the world are raising money this month to promote men's health as part of Movember. The campaign takes place once a year in November and encourages men to grow a moustache to raise money for men's health. Initially this was focused on prostate cancer however since 2010 funds have also been used for testicular cancer research. The slogan is "knowledge is power, moustache is king". But an article in the BMJ this week written by a GP questions whether Movember is actually misleading men on some of its advice. 

The charity has obviously built a huge profile and the amounts of money raised is laudable, however some of the advice on the charity's website contradicts NHS advice, particularly with regards to screening tests. For example the website at one point suggested that all men aged 50 or above should seek a baseline PSA test. This has been recently updated but it recommends that men over age 50 should ask their doctor for a bowel cancer screening test annually (in contrast to NHS bowel screening programme recommendation of screening every two years) and that all men age 45 should undergo an HbA1c test. Aortic aneurysm screening is only relevant for men age 65-75 who have smoked and from age 20 men should have their BP checked every 2 years (or annually if high or low). The advice can be found here: http://uk.movember.com/mens-health/health-checklist/. It is unclear where Movember have sought this information. This frequency of screening tests is not based on evidence and may result in patients having conflict with their doctor. Also some of the more pressing issues on men's health receive very little if not no information, such as mental health, substance misuse, smoking, alcohol and obesity.

Periodic health checks

A recent Cochrane review looked at the benefits and harms of general health checks in terms of outcomes relevant to patients. Health checks such as these are generally assumed to be effective in reducing morbidity and mortality but these effects have not been effectively demonstrated. In fact these checks may result in overdiagnosis and overtreatment. 

While this study has looked at routine health checks in patients who are not known to have any medical condition, annual health checks are more likely to be of benefit in patients with chronic conditions. For example, in 2006 the Disability Rights Commission recommended the introduction of annual health checks for people with intellectual disabilities in an attempt to reduce health inequalities in this population. Mortality from preventable causes is three times higher in people with moderate to severe intellectual disabilities than it is in the general population, and the number of emergency admission to hospital is substantially increased. It is not yet known whether these checks will lead to fever hospital admissions but clearly it is important that attempts are made to reduce the health inequality between this group of patients and the general population and health checks may be a potential solution.

Resistant hypertension

Resistant hypertension is defined as high blood pressure which remains uncontrolled despite treatment with at least three anti-hypertensive agents at best tolerated doses. These patients are at greater risk of experiencing an adverse cardiovascular event. 5-10% of cases of resistant hypertension have a secondary underlying cause. Drug related causes include NSAIDS, oral contraceptives, adrenal steroid hormones, erythropoeitin, ciclosporin and tacrolimus. Target organ damage may occur eg. LVH, hypertensive retinopathy and renal disease - these patients should be referred to secondary care.

Examples of secondary causes of resistant hypertension (+symptoms):

• Primary hyperaldosteronism (Conn's syndrome) - hypokalaemia, fatigue, low renin, raised aldosterone levels (check plasma renin or aldosterone levels)
• Renal artery stenosis - carotid,, abdominal or femoral bruits, atherosclerotic disease, pulmonary oedema
• Renal parenchymal disease - albuminuria, micro-haematuria, nocturia and oedema (urinalysis)
• Obstructive sleep apnoea - obestiy, short neck, daytime somnolence, snoring, apnoea.
• Phaeochromocytoma - episodic palpitations, headaches and sweating (check 24hr urnary metanephrines or normetanephrines)
• Thyroid disease - hyperthyroidism increases systolic BP, hypothyroidism increases diastolic BP
• Cushing's syndrome - centripedal obesity, moon facies, abdominal striae, interscapular fat pad
• Coarctation of the aorta - radio-femoral delay, diminished femoral pulses, rib notching on CXR
• Intracranial tumours - early morning headache, positive family history