Forum Πρωτοβάθμιας Φροντίδας Υγείας
ΠΦΥ -Εκπαίδευση => Αποσπάσματα από τον έντυπο & ηλεκτρονικό τύπο => Μήνυμα ξεκίνησε από: Argirios Argiriou στις 26 Φεβρουαρίου 2008, 00:02:54
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Κλινικές ανασκοπήσεις.
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Summary points:
Wound management is as important as use of antimicrobials in preventing infection.
Primary closure should be avoided in limb injuries where possible because of increased risk of infection.
For patients considered to be at higher risk of infection, the prophylaxis of choice is co-amoxiclav.
Erythromycin or flucloxacillin should never be used alone prophylactically as Pasteurella infection is usually resistant.
Infected wounds presenting within 12 hours of injury are usually due to Pasteurella multocida.
Patients at particularly high risk of infection are immunosuppressed patients, particularly those with asplenia or cirrhosis or those who have had a mastectomy.
http://www.bmj.com/cgi/content/full/334/7590/413
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Summary points:
Trigeminal neuralgia is a rare but characteristic pain syndrome.
Most cases are still referred to as idiopathic, although many are associated with vascular compression of the trigeminal nerve.
A minority of cases are symptomatic of multiple sclerosis or nerve compression by tumour.
The condition is variable and patients may have just one episode.
Most patients respond well to drugs; carbamazepine is usually the first line treatment.
If drug treatment fails or is not tolerated, surgical treatments are available.
Ablative surgical treatments are associated with facial sensory loss, almost no risk of severe complications or death, and a high rate of pain recurrence; microvascular decompression has a risk of severe complications or death, albeit very low, and a lower relapse rate.
http://www.bmj.com/cgi/content/full/334/7586/201
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Summary points:
Intermittent claudication is a common condition and in most cases is easily diagnosed.
It is associated with a significantly increased risk of death from cardiovascular disease.
Only a small proportion of patients with claudication require revascularisation.
The main treatment aim is to reduce the risk of mortality from cardiovascular events.
Smoking cessation, control of hypertension and diabetes, and prescription of statins and antiplatelet drugs are key elements for treating the condition.
Exercise, angioplasty, and bypass surgery can improve symptoms of claudication.
http://www.bmj.com/cgi/content/full/333/7576/1002
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Summary points:
Atopic eczema is an itchy inflammatory skin condition with associated epidermal barrier dysfunction.
The prevalence of atopic eczema seems to be rising, but the factors responsible for this rise are not fully understood.
The pathophysiology of eczema involves systemic as well as cutaneous immune and epidermal dysfunction.
Eczema is a complex trait with significant genetic and environmental influences.
Emollients and topical steroids are the mainstay of treatment for mild to moderate eczema; moderate to severe eczema may require the addition of second line agents such as topical or systemic calcineurin inhibitors, ultraviolet phototherapy, or systemic azathioprine.
A clearer understanding of the genetic basis and pathophysiology of eczema is expected to lead to new improved treatments.
http://www.bmj.com/cgi/content/full/332/7541/584
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Summary points:
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Emollients and topical steroids are the mainstay of treatment for mild to moderate eczema
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Τί σκευάσματα για να μαλακώνουν και να λιπαίνουν το δέρμα (emollients) προτείνετε στους ασθενείς σας που έχουν έκζεμα;
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Συνήθως κάποια κρέμα με βιταμίνη Α όπως ακουαζολ ή βεπανθόλ ή τις παιδικές κρέμες που χρησιμοποιούν για τον ποπούλη ( :)) οι μαμάδες ( ως γνωστό αυτές τα ξέρουν όλα !)
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http://www.frezyderm.gr/products/skinProduct08.asp
http://www.frezyderm.gr/products/skin.asp
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Summary points:
Acute organophosphorus poisoning may induce multisystem toxicity leading to severe toxicity and death.
Poisoning is diagnosed on the basis of history and clinical examination; biochemical investigations can have a role for confirming the diagnosis.
Management consists of prompt resuscitation, antidotes as required (particularly atropine, oximes, benzodiazepines), and selective decontamination.
Ongoing monitoring and high quality supportive care are essential.
Healthcare staff treating exposed patients should exercise standard precautions.
http://www.bmj.com/cgi/content/full/334/7594/629
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"It is more important to know what sort of person has a disease
than to know what sort of disease a person has."
Hippocrates
Summary points:
Irritable bowel syndrome is believed to result from a variety of biological and psychosocial factors.
Irritable bowel syndrome is not a diagnosis of exclusion; a positive diagnosis can usually be made.
The usual medical treatment is often highly unsatisfactory; if psychological factors seem important, these should be dealt with.
Tricyclic antidepressants and some selective serotonin reuptake inhibitors are of value in improving symptoms.
Cognitive behaviour therapy has a strong evidence base for its effectiveness.
Gut directed hypnotherapy is an effective treatment and is especially suitable for more severely affected patients who might be prepared to travel to specialist centres.
http://www.bmj.com/cgi/content/full/334/7603/1105
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Summary points:
Rape and sexual assault are common, particularly among young women although men and children may also be assaulted.
Perpetrators are usually known to those they assault.
People who have been sexually assaulted often seek medical help but may not disclose the assault.
Management includes treatment of injuries; emergency contraception; prevention of infections, including HIV; and psychosocial support.
Although many people experience psychological symptoms after rape, most recover.
A minority of people after assault have significant and disabling persistent symptoms that require specialist intervention and active treatment.
Collection of evidence may be crucial in identifying and prosecuting perpetrators.
Optimal acute management is the provision of all necessary services in one place and in a sensitive, safe, and forensically secure environment.
http://www.bmj.com/cgi/content/full/334/7604/1154
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Summary points:
Herpes zoster and postherpetic neuralgia are common causes of debilitating neuropathic pain.
Systemic antiviral agents reduce both the acute pain of herpes zoster and the incidence of postherpetic neuralgia.
Corticosteroids, tricyclic antidepressants, gabapentin, and opioids reduce acute pain and may have additional effects on the reduction of postherpetic neuralgia.
Tricyclic antidepressants, gabapentin, opioids, and lidocaine patches are effective in established postherpetic neuralgia.
Large scale vaccination of children and older adults may have an important impact on the incidence of herpes zoster and postherpetic neuralgia.
http://www.bmj.com/cgi/content/full/334/7605/1211
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Summary points:
Most patients with acute sciatica have a favourable prognosis but about 20%-30% have persisting problems after one or two years.
The diagnosis is based on history taking and physical examination.
Imaging is indicated only in patients with "red flag" conditions or in whom disc surgery is considered.
Passive (bed rest) treatments have been replaced with more active treatments.
Consensus is that initial treatment is conservative for about 6-8 weeks.
Disc surgery may provide quicker relief of leg pain than conservative care but no clear differences have been found after one or two years.
http://www.bmj.com/cgi/content/full/334/7607/1313
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1. Imaging is indicated only in patients with "red flag" conditions or in whom disc surgery is considered.
2. Passive (bed rest) treatments have been replaced with more active treatments.
3. Disc surgery may provide quicker relief of leg pain than conservative care but no clear differences have been found after one or two years.
Άκρως ενδιαφέρουσες οι επισημάνσεις, αλλά η εφαρμογή τους σκοντάφτει σε διαχρονικές, ακλόνητες αντιλήψεις της Ελ υπαίθρου:
1. Τί; Δεν θα μου βγάλεις ακτινογραφία; Έλα δώσ'μου το χαρτί, δεν κουβαλήθηκα μέχρι εδώ για να δώ τα μούτρα σου. (Και πάλι καλά που στο ΚΥ δεν υπάρχει αξονικός τομογράφος)
2. Αστειεύεσαι γιατρέ; Και πώς θα μου περάσει η μέση περπατώντας; Θα μου γράψεις μια σειρά ενέσεις να μου τις χτυπήσει η Τασούλα. Ορέ, δεν ξέρει τίποτα ετούτος εδώ!
3. Τί λες τώρα, γιατρέ; Εγώ έκανα εγχείρηση στη μέση στο Διαβαλκανικό πριν από 5 χρόνια και από τότε δεν με ξανάπιασε, χαλάλι τα λεφτά που έδωσα!
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1. Τί; Δεν θα μου βγάλεις ακτινογραφία; Έλα δώσ'μου το χαρτί, δεν κουβαλήθηκα μέχρι εδώ για να δώ τα μούτρα σου. (Και πάλι καλά που στο ΚΥ δεν υπάρχει αξονικός τομογράφος)
2. Αστειεύεσαι γιατρέ; Και πώς θα μου περάσει η μέση περπατώντας; Θα μου γράψεις μια σειρά ενέσεις να μου τις χτυπήσει η Τασούλα. Ορέ, δεν ξέρει τίποτα ετούτος εδώ!
1. "Τι; Δεν έχετε αξονικό; Ήθελα να ήξερα τι ρόλο παίζει αυτό το Κ.Υ. και δεν το κλείνετε!" Το σχόλιο αυτό άκουσα από Αθηναίο του οποίου ο συγγενής είχε διακομιστεί στο Κ.Υ. μετά από τραυματισμό στο κεφάλι συνεπεία τροχαίου ατυχήματος, όταν τον ενημέρωσα ότι θα διακομιστεί στο νοσοκομείο για αξονική! (Μεταξύ μας: Που να του έλεγα ότι ούτε καν ακτινολογικό δεν διαθέτει το Κ.Υ.! Που δεν διαθέτει! Χε.χε.χε..)
2. Μου αρέσει που πολλοί διανύουν 20 χιλιόμετρα σε καρόδρομο (ντάκα ντούκα με την ανάρτηση του αυτοκινήτου) για να ρθουν στο Κ.Υ. (αν στο χωριό τους δεν υπάρχει Τασούλα) για να κάνουν την περίφημη ενδομυϊκή αντιφλεγμονώδη ένεση που τους συνέστησε ο καλός (όπου καλός=πληρωτός) γιατρός, γιατί όπως τους είπε στην ακτινογραφία που έκαναν στη μέση "ένας σπόνδυλας έχει φύγει από τη θέση του" (η λογική απορία που γεννάται, όμως μέχρι τώρα δεν έχω βρει το κουράγιο να τη διατυπώσω, είναι "και που πήγε ο σπόνδυλας που έφυγε;"*). Προφανώς οι ενδομυϊκές ενέσεις θα βοηθήσουν στην επανάκαμψη του αγνοούμενου - άσωτου σπόνδυλα.
*Μήπως να τους έλεγα να ψάξουν στο δρόμο - καρόδρομο μήπως κάπου παράπεσε ο σπόνδυλας;
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Summary points:
Stopping smoking before the age of 40 is crucial to improve health—beyond 40, people lose three months of life expectancy for every further year smoking.
The most important factor leading to failure of attempts to stop is nicotine dependence.
Nicotine dependence is most effectively treated with a combination of drugs and specialist behavioural support, such as provided by the NHS Stop Smoking Service.
Varenicline, bupropion, nortriptyline, and nicotine replacement are all effective.
Relapse during or after treatment is common, and treatment is usually needed several times.
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Prescribing smoking cessation drugs:
Bupropion (Zyban)
Start bupropion while smoking and quit smoking in the second week. Use 150 mg per day for six days, then 150 mg twice a day for eight weeks. Take the evening dose early to avoid wakefulness. Causes 1 in 1000 to have a seizure, which needs discussion with patient.
Nortriptyline (Nortrilen)
Start nortriptyline while smoking, increasing the dose from 25 mg to 75 mg. Quit while taking the maximum dose and continue for 8-12 weeks, tapering down at the end. Reassure patients that side effects abate in time and fewer than 1 in 10 patients stop because of side effects.
Varenicline (Champix)
Start varenicline while smoking. Comes in a starter pack escalating the dose from 0.5 mg daily to 1 mg twice a day by the second week. Quit in the second week. Continue for 12 weeks. Most people experience mild to moderate nausea, which can be reduced by taking varenicline after food and with water. Take the evening dose early to avoid wakefulness. Side effects abate with time and fewer than 1 in 10 patients stop the drug.
Nicotine replacement patches (Nicorette, Niquitin, Nicopas, Nicotinel)
Put the patch on smooth, hairless skin. Avoid using the same site for all patches. Put the 24 hour patches on the night of the last cigarette. If it slides off, tape it on with micropore. Skin reactions are common: check site rotation, use an emollient or hydrocortisone cream, consider changing the make of patch or switching to another form of nicotine replacement.
http://www.bmj.com/cgi/content/full/335/7609/37
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Summary points:
Schizophrenia usually starts in late adolescence or early adulthood.
Genetic risk and environmental factors interact to cause the disorder.
The most common symptoms are lack of insight, auditory hallucinations, and delusions.
Clinicians should suspect the disorder in a young adult presenting with unusual symptoms and altered behaviour.
Treatments can alleviate symptoms, reduce distress, and improve functioning.
Delayed treatment worsens the prognosis.
Suggested screening questions for patient presenting with possible psychosis:
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?
http://www.bmj.com/cgi/content/full/335/7610/91
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Summary points:
• Appropriate use of prophylaxis against deep vein thrombosis (DVT) in hospital inpatients is important for reducing the risk of fatal and non-fatal pulmonary embolism and post-thrombotic complications.
• For patients at low risk of DVT, ambulation is important, and mechanical methods of prophylaxis (such as graduated compression stockings and intermittent pneumatic compression devices) can provide added protection.
• Patients at higher risk of DVT should be considered for guideline based anticoagulation with low molecular weight heparin, unfractionated heparin, or vitamin K antagonists unless clearly contraindicated.
• Fondaparinux may provide additional prophylactic options.
• The place of aspirin in DVT prophylaxis remains controversial.
• To ensure adequate prophylaxis against DVT, doctors should be encouraged to follow appropriate guidelines.
http://www.bmj.com/cgi/content/full/335/7611/147
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Summary points:
Benign positional vertigo is one of the commonest causes of dizziness.
It is characterised by short attacks of rotational vertigo that are precipiated by head move-ments such as looking up, lying down, or turning over in bed.
The diagnosis is confirmed by Hallpike positional testing which shows a characteristic torsional nystagmus when the head is reclined and turned to the affected side.
Benign positional vertigo is probably caused by otoconial debris that is trapped in the posterior semicircular canal and starts to move when head position is changed quickly with respect to gravity. The concurrent flow of endolymph stimulates the hair cells of the affected canal, causing vertigo.
The condition can be treated successfully in most patients by a simple manoeuvre of the head that clears the canal from debris.
Repeated manoeuvres and self guided positional exercises will increase the success rate in those whose condition does not improve after one treatment session.
http://www.bmj.com/cgi/content/full/311/7003/489
and three videos with Dix-Hallpike and Epley Maneuvers, from youtube:
http://www.tidsskriftet.no/index.php?seks_id=1816273
http://www.youtube.com/watch?feature=endscreen&NR=1&v=YK2Zj_TrBhE (εδώ προτείνουν μετά τον χειρισμό του Epley να έχειι ο ασθενής τον αυχένα του ίσιο για 48 ώρες και για αυτό συνιστούν μάλιστα στην χρονική αυτή περίοδο να βάζουμε στον ασθενή αυχενικό κολλάρο).
(εδώ προτείνουν να εκτελέσει κανείς τον χειρισμό Epley τρεις συναπτές φορές)
feature=endscreen&NR=1 (με μοντέλο που δείχνει πώς μετακινούνται οι ωτόλιθοι κατά τον χειρισμό Epley).
Ear Model:
feature=channel
Bony Labyrinth Model - Semicircular Canals:
Δείτε και γραπτές οδηγίες στα Αγγλικά και στα Ελληνικά εδώ: http://www.pfy.gr/forum/index.php/topic,1900.msg13671.html#msg13671 και εδώ http://www.pfy.gr/forum/index.php/topic,1900.msg13760.html#msg13760 αντίστοιχα.
Και μία χρήσιμη συμβουλή φίλου μου ΩΡΛ στον τοίχο του στο facebook:
Ασθενής που αποστέλλεται από τον Παθολόγο του στον ΩΡΛ για έλεγχο ζάλης-ιλίγγου, πρέπει να έχει σταματήσει το όποιο φάρμακο για τον ίλιγγο παίρνει 3-4 ημέρες πριν, προκειμένου να αποφευχθούν τα όποια ψευδώς "αρνητικά" αποτελέσματα
Καλή σας ημέρα!!
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Summary points:
• Parkinson's disease should be suspected in someone with tremor, stiffness, slowness, balance problems, or gait disorders.
• All patients with suspected Parkinson's disease should be referred untreated to a specialist in differential diagnosis and be reviewed regularly by the specialist for accurate diagnosis and treatment.
• Much debate surrounds which drug class should be used as initial treatment for Parkinson's disease and which adjuvant therapy should be added when patients taking levodopa develop motor
complications.
• Patients should have access to a Parkinson's disease nurse specialist and allied health professionals throughout the course of the disease.
http://www.bmj.com/cgi/content/full/335/7617/441
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Summary points:
Perennial allergic rhinitis is a common condition in general practice.
The most common allergen is the house dust mite, followed by cats and dogs.
Diagnosis is through history and skin prick testing.
Patients with unilateral symptoms, especially if they have pain or bleeding, should be referred to an ear, nose, and throat specialist.
Avoidance measures should be taken where appropriate.
Medical treatment, mainly with antihistamines, topical corticosteroids, or both, is usually highly effective.
Immunotherapy is reserved for severe cases in which avoidance measures and medical treatment are either not effective or not tolerated.
Surgery is reserved for certain patients who have structural abnormalities.
http://www.bmj.com/cgi/content/full/335/7618/502
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Summary points:
• The prevalence of coeliac disease is 0.5-1% in international population studies.
• A combination of tissue transglutaminase antibody, endomysial antibody, and immunoglobulin A should be used for initial testing.
• Antibody negative coeliac disease with villous atrophy is now recognised.
• Treatment should involve a gluten-free diet, with support from a dietitian and a gastroenterologist.
http://www.bmj.com/cgi/content/full/335/7619/558
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Summary points:
The lifetime risk of developing colorectal cancer is about 5%.
Increasing age and a family history of colorectal cancer are the greatest risk factors for the disease.
Patients presenting with suspicious symptoms and signs should be referred and investigated urgently in a specialised unit.
Colonoscopy and computed tomographic colonography are of equal sensitivity for detection of colorectal cancer.
Colonoscopy allows biopsy of suspicious lesions and removal of polyps.
Population screening by testing for faecal occult blood has begun in the United Kingdom.
http://www.bmj.com/cgi/content/full/335/7622/715
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Summary points:
Cervical cancer disproportionately affects women in developing countries, which have no effective screening systems.
Cervical biopsy is the most important investigation in diagnosing cervical cancer.
Cervical cancer is a clinically staged disease.
Fertility sparing surgery (conisation or radical trachelectomy (excision of the cervix)) is an option for women with early stage disease.
Chemoradiotherapy is the standard of care for locally advanced and early stage cancers with poor prognostic factors.
Chemotherapy is palliative only in patients with recurrent or metastatic disease.
http://www.bmj.com/cgi/content/full/335/7623/765
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Summary points:
Venous thromboembolism, comprising deep vein thrombosis and pulmonary embolism, are common and treatable in hospital and the community.
Major risk factors include age, recent surgery (especially orthopaedic), cancer, and thrombophilia.
Established treatments are unfractionated heparin, low molecular weight heparin, fondaparinux, and warfarin.
Treatment agents and duration depend on the cause.
http://www.bmj.com/cgi/content/full/332/7535/215
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Summary points:
Cataract is not always due to ageing.
Cataract symptoms vary depending on type of cataract and the patient's lifestyle and visual requirements.
Cataract surgery in the developed world is undertaken when the benefit from removal of symptoms outweighs the small risks attached to modern surgery.
After surgery, 85-90% of patients should obtain vision sufficient to meet the requirements for driving in most countries.
New implant technology promises to improve the image quality and conquer the problems of presbyopia (the need for spectacles to read).
Posterior capsule opacification 2-5 years after surgery is still a problem in many cases.
http://www.bmj.com/cgi/content/full/333/7559/128
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BMJ 2003;326:1180-1184 (31 May).
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Summary points:
Deep vein thrombosis is an important cause of morbidity and mortality.
Clinical diagnosis is unreliable.
Screening investigations include D-dimer tests and plethysmographic techniques.
Definitive diagnosis is usually by venography or ultrasonography.
Initial treatment is with heparin—unfractionated or low molecular weight—followed by oral anticoagulation.
Outpatient treatment of deep vein thrombosis is safe.
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Treatment of deep vein thrombosis:
The standard initial management of deep vein thrombosis has traditionally meant admission to hospital for continuous treatment with intravenous unfractionated heparin. Treatment then continued with a transition to long term use of oral anticoagulants (vitamin K antagonists).
Recently a change has taken place, and low molecular weight heparins are being used.
Guidelines prepared by the haemostasis and thrombosis task force recommend that patients receive heparin for at least four days and treatment should not be discontinued until the international normalised ratio has been in the therapeutic range for two consecutive days. According to these guidelines, a patient with a first episode of a proximal vein thrombosis should receive anticoagulants for six months, with a target international normalised ratio of 2.5. The issue of length of anticoagulation is still under debate.
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Elastic compression stockings:
Patients with a deep vein thrombosis should wear compression stockings as the rate of post-thombotic syndrome may be reduced. In one study of 194 patients (with a first episode of proximal deep vein thrombosis) the rate of post thrombotic syndrome was reduced by 50% if graded compression stockings were used.
( http://www.pfy.gr/forum/index.php/topic,881.msg5574.html#msg5574 ).
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http://www.bmj.com/cgi/content/full/326/7400/1180
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BMJ 2007;334:674 (31 March).
Anticoagulation for three versus six months in patients with deep vein thrombosis or pulmonary embolism, or both: randomised trial.
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Conclusion: For patients in the UK with deep vein thrombosis or pulmonary embolism and no known risk factors for recurrence, there seems to be little, if any, advantage in increasing the duration of anticoagulation from three to six months. Any possible advantage would be small and would need to be judged against the increased risk of haemorrhage associated with the longer duration of treatment with warfarin.
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http://www.bmj.com/cgi/content/full/326/7400/1180