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Όλες οι δημοσιεύσεις από karanti_maria

  1. Απαραίτητοι οι μετανάστες για την Ανατολική Ευρώπη! http://www.economist.com/news/europe/21665031-eastern-europe-may-not-refugees-needs-them-more-other-countries-more-vacancies
  2. Υπολογισμός ρίσκου καρκίνου μαστού, τα επόμενα 5 χρόνια: https://tools.bcsc-scc.org/BC5yearRisk/calculator.htm
  3. Progestogen Only Pill Migraine with aura is a significant and serious side effect of taking the COCP and its presence indicates that it is no longer safe for women to take it because they are at increased risk of stroke. However, they can consider changing to the POP which can be safely used by women of any age with a history of migraine or migraine with aura. With the POP, 20% of women will be amenorrhoeic, 40% will have regular periods and 40% will have irregular bleeding. There is little evidence that changing the type of progestogen will improve bleeding patterns. Remember to check for other possible causes of bleeding; if amenorrhoea occurs, the woman can be reassured to continue the POP, but only after pregnancy has been excluded.Other side effects reported while on the POP include nausea, vomiting, headache, dizziness, depression, breast discomfort and changes in libido. Many of these are temporary side effects that settle after the first few months. If started on day 1-5 of the menstrual cycle, the POP is immediately effective and no alternative contraception is required at initiation. The exception to this is if a woman has a cycle of less than 23 days, in which case she should start the POP on day 1 or 2 because she could possibly ovulate quite early in her cycle. She may also need to use additional contraception for 48 hours.In all women, if the POP is started at any other time of the cycle, pregnancy must be excluded and alternative forms of contraception must be used for 48 hours.Additionally, the POP must be taken at the same time each day with no pill-free interval. If using a traditional POP (eg levonorgestrel (Norgeston®), norethisterone (Micronor®, Noriday®) or etynodiol (Femulen®)), it must be taken within 3 hours of the same time each day. With the newer desogestrel-based POP (Cerazette®), it must be taken within 12 hours of the same time each day. With the traditional POPs, 60% of cycles will be anovulatory, but this number increases to 97% with the newer desogestrel POP.The other mode of action for POPs is to make the cervical mucus impenetrable to sperm.It also has the effect of making the lining of the uterus thin so that it is less likely to accept a fertilised egg. If changing from a COCP, the POP can be commenced immediately. Providing that no pills have been missed and you are both confident that she is not pregnant, she will be protected from pregnancy.If changing from another POP, the same rule applies.If changing from the progestogen-only implant or the progestogen-only intrauterine system (IUS; ie Mirena®), the POP can be commenced immediately with no need for additional contraception.If changing from the progestogen-only injection, the POP can be commenced when the next injection would be due and protection is immediate.If changing from a copper IUD, the POP needs to be commenced 2 days before removal of the IUD, in which case no additional contraception will be needed once the IUD is removed. However, if the POP is commenced at the same time as IUD removal, alternative forms of contraception are needed for 7 days before and 48 hours after IUD removal.By extension, if changing from barrier methods, the POP should be started on day 1-5 of the cycle or other forms of contraception will be required for 48 hours after initiation of the POP. The rules for missed pills are as follows: If it is within 3 hours (12 hours for desogestrel) since the pill should have been taken, then the pill should be taken when remembered and she should continue taking her pill at the normal time. She will be protected from pregnancy.If the pill is more than 3 hours (12 hours for desogestrel) late, a pill should be taken as soon as she remembers and she should then continue taking the pill at the usual time. This may mean that she takes two pills in the same day or close together, which is harmless. Sex occurring before a missed or late pill is protected due to the effect on cervical mucus, but she is not protected from pregnancy due to sex occurring after a missed pill unless she abstains from sex or uses other forms of contraception for 48 hours after the POP is taken. Emergency contraception should be considered if sex has occurred during the time when protection from the POP is questionable.The same rules apply if she vomits within 2 hours of taking the pill (ie she should take another pill as soon as she is able). If it is then 3 hours (12 hours) from when she should have taken the pill, or if she continues to vomit or has severe diarrhoea, she needs to use other forms of contraception throughout the illness and for 48 hours afterwards, ie until she has taken 2 pills when well. Lactational amenorrhea is only effective as a form of contraception provided that the woman is amenorrhoeic and the child is less than 6 months of age and is exclusively breastfed, with no more than 4 hours between day feeds and 6 hours between night feeds. Current breast cancer is the only absolute contraindication to commencing the POP. There has been no causal link established between use of the POP and DVT, cardiovascular disease and breast cancer, and although mood changes and weight gain have been reported on the POP, there is also no established causal association.With regard to weight, there is no direct evidence to show any reduced efficacy with increasing weight and it is not recommended to prescribe two pills to a woman over 70 kg, as some doctors have been doing. Moreover, there is no effect on the efficacy of the desogestrel pill with increasing weight. The POP can be safely taken up to the age of 55 years when it is assumed that natural loss of fertility has occurred. Alternatively, follicle-stimulating hormone levels can be measured on two occasions (at least 1 month apart), and if both readings are over 30 IU/L, this suggests likely ovarian failure. The woman should continue with the POP at that point for 1 more year (or use a barrier method) or for 2 years if she is aged under 50 years. Progestogens are not affected by non-liver-enzyme-inducing drugs.However, their metabolism is increased by liver-enzyme-inducing drugs and alternative forms of contraception should therefore be recommended for women who need to be on such drugs.If a liver-enzyme-inducing drug is stopped, it will take 4 weeks before the enzymes return to normal. Thus, if a POP is commenced, alternative contraception should be used until 4 weeks after the enzyme inducer was stopped.Enzyme-inducing drugs include carbamazepine, eslicarbazepine, nelfinavir, nevirapine, oxcarbazepine, phenytoin, phenobarbital, primidone, ritonavir, St John’s wort, topiramate, rifabutin and rifampicin. The advantages of the POP are as follows:-It can be taken by women who smoke, have cardiovascular risk factors and other conditions which exclude them from the COCP.-It is 99% effective if taken correctly.-It can be used when breastfeeding.-It is cheap.-It may help with premenstrual symptoms and painful periods. Weight change, mood change and headache may occur in some women taking the POP but there is no evidence of a causal association between the POP and these effects.
  4. Θάνατοι αμάχων στη Συρία, ανάλογα με τα όπλα που χρησιμοποιήθηκαν: http://www.bmj.com/content/351/bmj.h4736/infographic
  5. Notes from Emergency Contraception Course: Levonorgestrel 1.5 mg should be taken as soon as possible and within 72 hours of the first episode of UPSI or contraceptive failure in the cycle. Ulipristal 30 mg should also be taken as soon as possible, but is effective up to 120 hours after UPSI. A copper intrauterine device (IUD) can be inserted up to 5 days after UPSI. There is no time in the menstrual cycle when the risk of pregnancy following UPSI can be considered to be zero. However, there is no risk of conception within 21 days of childbirth; thus, emergency contraception is not required for UPSI during this time. The overall risk of pregnancy after one act of UPSI at any time in the cycle is 2-4%, but mid-cycle (days 10-17) the risk is as high as 20-30%. Levonelle® One Step prevents 95% of expected pregnancies when taken within 24 hours of UPSI. Its effectiveness declines to 85% between 24 and 48 hours and to 58% between 48 and 72 hours after UPSI. ellaOne® is a new product, a progesterone receptor modulator, and can be taken within 120 hours (5 days) after UPSI. It is as effective as Levonelle® One Step within 24 hours of UPSI, but its efficacy does not diminish significantly over 120 hours. However, it is three times as expensive as Levonelle® One Step and experience outside clinical trials is presently limited. Because it blocks the action of progestogens, it may reduce the efficacy of hormonal contraceptives (all of which contain progestogen). There are no age limits to the use of EHC and there is no evidence that the efficacy of either Levonelle® One Step or ellaOne® is affected by body mass index. There are no absolute medical contraindications to the use of Levonelle® One Step (apart from allergy to progestogens). However, it should be used with caution in women with severe liver disease or active acute porphyria. Effectiveness may be reduced by severe malabsorption. ellaOne® is contraindicated in severe hepatic impairment or poorly controlled asthma. Lactating women can take Levonelle® One Step safely, but should avoid breastfeeding for 36 hours after taking ellaOne®. There is little research evidence regarding the effect of liver enzyme-inducing drugs (including St John's Wort and many antiretroviral drugs) on the effectiveness of EHC. Advice is to take two tablets (3 mg) of Levonelle® One Step (this is outside the product licence); this advice also applies to women starting post-exposure HIV prophylaxis. The use of ellaOne® is not recommended. Insertion of an emergency IUD should always be recommended where possible. Rifampicin and rifabutin have powerful enzyme-inducing properties. An emergency IUD should be offered first line to women taking these preparations. Drugs that reduce gastric pH (antacids, histamine H2-receptor antagonists and proton pump inhibitors) may inhibit absorption of ellaOne®. Warfarin does not affect EHC, but EHC may interfere with warfarin. The anticoagulant effects may be increased or decreased. Advise repeat INR 48 hours after treatment. IUD should be offered to all women requesting emergency contraception even if they present within 72 hours of UPSI. The emergency IUD will prevent over 99% of expected pregnancies. It can be safely offered to women who have never had a full-term pregnancy. The risks are equivalent to IUD insertion in any circumstance. The risk of ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika - must be adequately addressed. An IUD containing over 380 mm2 of copper should be used if technically possible. If the IUD cannot be fitted immediately, the woman should also be given EHC (if within 120 hours of UPSI) in case she fails to re-attend. The IUD may be removed after the next period (if there has been no UPSI since menstruation) or left in situ for long-term contraception. An IUD inserted postcoitally acts principally by preventing implantation. It does not dislodge an implanted blastocyst and so does not cause abortion. There is a significantly increased risk of pelvic infection in the 21 days following insertion of an IUD. If a woman accepts an IUD she should be told how to recognise symptoms and when to seek medical advice. Women should be tested for Chlamydia trachomatis infection and given prophylactic antibiotic treatment if needed. A copper IUD can be inserted up to 5 days after the first episode of UPSI. Its principal mode of action in routine use is to disrupt sperm viability and prevent fertilisation. However, because it also prevents implantation when inserted postcoitally, it can be inserted up to 5 days after the earliest expected date of ovulation, when it will protect against all previous episodes of UPSI in that cycle. It is over 99% effective at preventing pregnancy. In a woman with a 28-day cycle, ovulation will occur around day 14 and implantation of a fertilised ovum 5 days later (day 19). There is no evidence that MIRENA is effective as emergency contraception, and it is not licensed or recommended for this purpose. Inhibition or postponement of ovulation is believed to be the primary mode of action of both Levonelle® One Step and ellaOne®. Levonelle® One Step is effective only up to the beginning of the luteinising hormone surge that triggers ovulation. Disruption of the luteal phase (causing alteration of the endometrium and thus preventing implantation) is an important secondary effect of ellaOne®. The rapid decline in efficacy of Levonelle® One Step after 24 hours suggests that it has very little effect on the endometrium. It is not effective when taken after ovulation (even within the 72-hour window). EHC does not interfere with an implanted blastocyst and therefore does not cause an abortion. 23% of women report nausea after taking Levonelle® One Step, but only 5% vomit. Taking the tablets with food will help. If a woman vomits within 2 hours of taking EHC, she should take it again as soon as possible. Some women need antiemetics (domperidone maleate is recommended). ellaOne® can cause abdominal pain. Nausea, vomiting, headache and mood disturbance may also occur. Menstrual irregularities are common during the next cycle with either drug. EHC does not provide contraceptive cover for the remainder of the cycle. Women must abstain from sex or use an effective alternative contraceptive method. ellaOne® may interact with progestogen-containing contraceptives, and women using these methods should also use condoms for 7 days plus an additional 7 days for combined hormonal contraceptives (9 days for Qlaira®) or 2 days for progestogen-only contraceptives. After taking Levonelle® One Step, 87% of women menstruate within 7 days of their expected date. If her period is more than 7 days late, or lighter than usual, Tracey should return for a pregnancy test. If EHC fails, the possibility of ectopic pregnancy should be considered. Ectopic pregnancies have been identified following administration of Levonelle® One Step in case series; however, the overall risk does not appear to be increased following EHC use. There are insufficient post-marketing data to allow accurate assessment of risk. Clinicians and women should be alert to the possibility of an ectopic pregnancy, but the risk is likely to be small. A previous history of ectopic pregnancy does not contraindicate use of EHC. There is no increased risk of fetal abnormality if pregnancy occurs following Levonelle® One Step. There is as yet only limited experience with ellaOne®, but so far no excess numbers of congenital abnormalities have been reported. All women requesting emergency contraception should be offered screening for STIs. This is best done at least 1 week after the risk event. Testing too early in the incubation period of STIs can give false-negative results. If women are found to have chlamydia it is important that their partner is also treated to prevent reinfection. The prevalence of chlamydial infection in sexually active teenage girls is over 10%. The risk of pelvic infection is increased 6-fold in the 21 days following IUD insertion. This is related to the presence of pre-existing STIs. Best practice guidance suggests that prophylactic antibiotics to treat Chlamydia trachomatis (azithromycin 1 g immediately or doxycycline 100 mg twice daily for 7 days) should be given to women at risk of STIs who are having an emergency IUD inserted. Levonelle® One Step is not licensed for use more than once in a menstrual cycle, but can be given if clinically indicated. UPSI earlier in the cycle can be regarded as "protected" in terms of pregnancy risk if EHC was used. ellaOne® should not be used more than once in a menstrual cycle as neither efficacy nor safety can be assumed. If a second risk does occur, an emergency IUD is recommended, but if this is refused then Levonelle® One Step may be given (outside the product licence). Theoretically, the efficacy of Levonelle® One Step may be reduced by prior administration of ellaOne®. Research has shown that most women use EHC correctly and that UPSI is not increased. However, it would be better to persuade her to start a regular method of contraception. Repeated use of EHC is less effective than a regular method of contraception, in particular non-intercourse-related methods like the combined oral contraceptive or injectable contraception (Depo-Provera®). If a woman is likely to continue to be at risk of unwanted pregnancy, she may "quick start" combined hormonal contraception (with the exception of co-cyprindiol), the progestogen-only pill (POP) or the implant. A pregnancy test after 3 weeks is recommended. Additional contraceptive precautions must be taken for the first 7 days of combined hormonal contraception or the implant, or for the first 2 days of the POP. If ellaOne® has been used for emergency contraception, extra precautions must be taken for an additional 7 days (ie 14 days or 9 days in total). Emergency contraception (including the IUD) can be prescribed safely and legally to women under the age of 16 years providing they are considered competent to consent. Young people are entitled to confidentiality and may need to be specifically reassured on this point. However, young persons under the age of 16 years should always be encouraged to discuss the situation with their parents or guardians if at all possible. If a pill pack is started 2 or more days late and the woman has had UPSI during the pill-free week (or in the first 7 days of the new pack), emergency contraception is indicated. All methods should be discussed. Seven consecutive pills are required to ensure that the ovaries are fully suppressed and ovulation is inhibited. A break of seven consecutive pills is then safe, and ovulation will not occur if regular pill taking resumes on the eighth day. Emergency contraception is indicated if a woman has missed two or more pills in the first seven pills of the packet and had UPSI during the pill-free interval or during the first 7 days of the pack. Women should be advised to start the new packet straight away and continue to take her pills in the normal way. She must abstain from sexual intercourse or use additional barrier contraception for the next 7 days, until their ovaries are fully suppressed. If she takes ellaOne®, she will need to use additional protection for a further 7 days, to allow for the inhibitory effect of ellaOne® on hormonal contraception. Emergency contraception is indicated if UPSI occurs within 2 days of a missed or late POP. "Late" means 3 hours late for most POPs, but 12 hours late for Cerazette®. The contraceptive efficacy of medroxyprogesterone acetate is maintained for up to 14 weeks after the last injection, and additional contraception is not required during this time. The next injection can be given up to 2 weeks late (ie 14 weeks after the last injection) without any additional precautions. After 14 weeks, emergency contraception should be given if indicated. The next injection of Depo-Provera® may be given immediately and a pregnancy test done 3 weeks later.
  6. Notes from CXR diagnosis course: Unexplained shortness of breath is a justifiable indication for a CXR, whereas for example, preoperatively as a routine examination, upper respiratory tract infection, and costochondritis are not justifiable indications. First, you should check technical factors: patient’s details date side-marker projection degree of any rotation degree of inspiration exposure (lower thoracic spine and disc spaces should be just visible) Then assess: heart mediastinum and hila lungs diaphragm skeleton soft tissues The cardiothoracic ratio is equal to the maximum cardiac diameter divided by the maximum internal diameter of the thorax. On a standard adult PA CXR, this should not be greater than 50% (two standard deviations above the mean). However, it may be increased in the elderly due to infolding of the ribs. Basal septal lines (Kerley B lines) can be seen on the CXR; these arise due to visible interlobular lymphatics and their surrounding connective tissue. These are typically 1-3 cm long, less than 1 mm thick, extend from and perpendicular to the pleural surface and are best seen in the costophrenic angles. Cardiac enlargement, prominent upper lobe blood vessels, basal septal lines, pleural effusions and alveolar pulmonary oedema “bat’s wing” shadowing are all features of heart failure. In right lower lobe consolidation, the outline of the right hemidiaphragm is lost. The right middle lobe is bounded superiorly by the horizontal fissure and inferiorly by the oblique fissure. An air bronchogram may be seen, whereby air in the bronchi is contrasted against the surrounding consolidated lung. Consolidation of the right middle lobe obscures the right heart border. This is referred to as the “silhouette sign”. The right atrium forms the right heart border. The lingula of the left lung forms part of the upper lobe and is equivalent to the middle lobe of the right lung. Consolidation of the lingula lobe obscures the left heart border. In the AP projection, the heart and mediastinum appear magnified, the scapulae are superimposed on the lungs and the clavicles may be projected above the lung apices. On a straight CXR: -distances between the spinous process of the vertebra and the medial ends of the clavicles are equal On a rotated CXR: -apparent sizes of the hemithoraces may appear different -lungs may show different densities -relative sizes of the hila may be distorted Being steeper than the left lower lobe bronchus, foreign bodies in the lung are more likely to pass into the right lower lobe. Recommend the use of pH indicator strips to measure the acidity of the aspirate. Auscultation of injected air (the “whoosh” test) is not advised as a safe testing procedure. When a satisfactory position has been confirmed, the external length of the nasogastric tube should be measured and the tube marked with permanent marker pen. During a normal inspiration, the diaphragm usually lies between the fifth and seventh ribs anteriorly. On David’s CXR, the anterior ends of the upper eight ribs are visible, the hemidiaphragms appear flat and the heart appears long and thin. These are features of hyperinflation. A pneumothorax may be classified as “simple” if there is no associated mediastinal shift or as “tension” if there is associated mediastinal shift away from the side of the pneumothorax. It is particularly important to recognise a tension pneumothorax because the mediastinal structures become distorted and compromise venous return to the heart. A tension pneumothorax is a clinical diagnosis and a medical emergency requiring immediate decompression that should not be delayed by waiting for a CXR. On a supine CXR, the pneumothorax is more difficult to identify because the air in the pneumothorax rises anteriorly to lie in the anterior costophrenic angle. This accounts for the lucency seen overlying the liver. A pneumothorax is more easily seen on a CXR in expiration, where its size relative to the underlying lung is greater than during inspiration. Chilaiditi’s sign, is a normal variant in which the colon is interposed between the liver and the diaphragm. The haustra of the colon are clearly seen. Using a careful radiographic technique, it is possible to detect small quantities of free air, even as little as 1 mL, on an erect CXR. On a PA CXR, the mediastinum is usually no wider than a vertebral body. As the carcinoma outgrows its blood supply, the centre becomes necrotic. The carcinoma is connected to the airway and the necrotic centre is expectorated. This leads to a thick-walled, irregular cavity. Other than malignancy, one of the most important groups is cavitating infections, which include pulmonary tuberculosis and staphylococcal pneumonia. Less common causes include Caplan’s syndrome, in which peripheral nodules may cavitate. This is seen in patients with pneumoconiosis and rheumatoid disease. Anterior mediastinal masses include thyroid masses, thymic tumours and germinal cell neoplasms (eg a teratoma). Posterior mediastinal masses include neural tumours and oesophageal abnormalities. Lucency in the soft tissues of the chest wall indicates the presence of gas, which is seen in surgical emphysema. Syndrome of spontaneous rupture of the oesophagus typically affects the left side of the lower oesophagus. Other radiological features include a pleural effusion and a pneumothorax.
  7. Notes from Chronic Pelvic Pain Course: Inflammatory bowel disease is a differential diagnosis in a teenager with chronic abdominal/ pelvic pain. A detailed bowel history should be taken and referral made to gastroenterology, if appropriate. If her symptoms are suggestive of Irritable bowel syndrome, she should be offered dietary advice and a trial of an antispasmodic drug. Chronic constipation can present with recurrent abdominal/ pelvic pain and can occasionally present with acute abdominal/ pelvic pain. Congenital genital tract abnormalities may present at birth, at menarche or at the beginning of sexual activity. Lower vaginal atresia results in abdominal pain as blood accumulates in the upper vagina during menses (concealed). The diagnosis is confirmed by transabdominal pelvic ultrasound scan. Psychological or social problems (abuse) at school (bullying) or at home may be relevant. A history of physical, sexual and psychological abuse is more common in women with CPP (Latthe et al, 2006). Although endometriosis may occur in teenagers, it is uncommon. Primary dysmenorrhoea (related to prostaglandin production in the uterus) is the most likely diagnosis. NSAIDs (eg mefenamic acid) are therefore likely to be effective. There is no contraindication to the use of the COCP on a continuous basis in a 15 year old by virtue of her age. As her symptoms are related to menstruation it is highly likely that use of the COCP on a continuous basis would result in symptomatic relief. Use of progestogens on a continuous basis is an alternative in women in whom the COCP/ NSAIDs are ineffective or unsuitable. Irritable bowel syndrome can be diagnosed using Rome III criteria (Longstreth et al, 2006): at least 3 months of intermittent or constant pain that is relieved by defaecation and associated with at least two of the following: -altered stool frequency -bloating -altered stool passage - straining, urgency -altered stool form - diarrhoea, "rabbit pellets" Rectal bleeding is commonly associated with haemorrhoids or an anal fissure. One-third of healthy women (with no underlying pathology) experience an alteration in bowel habit during menstruation. Deep dyspareunia may occur in women with IBS but typically occurs after rather than during intercourse due to postcoital bowel spasm. Ectopic endometrial tissue may be present in unusual sites such as the rectum and umbilicus, and associated with bleeding from these sites during menstruation. Endometriosis is found in 35-50% women with CPP. Cyclical pelvic pain (often associated with dysmenorrhoea and dyspareunia) in women of reproductive age is the most common symptom associated with the condition and merits referral to secondary care for investigation. Red flag symptoms of endometriosis (RCOG, 2006): -severe dysmenorrhoea -deep dyspareunia -CPP -ovulation pain -other cyclical or perimenstrual symptoms, eg bowel or bladder -infertility -dyschezia (pain on defaecation) The gold standard for diagnosing endometriosis is laparoscopy. There are no serum or urinary biomarkers of endometriosis. However, treatment of endometriosis, using drugs that cause ovarian suppression (eg combined oral contraceptive pill, continuous oral or intramuscular depot progestogens, GnRH agonists with "add-back" HRT for bone protection), may be started prior to laparoscopy. If these drugs successfully alleviate symptoms, a laparoscopy is not always necessary. The Mirena intrauterine system is also a recognised treatment for endometriosis-associated pain. Adenomyosis is characterised by the same symptoms as endometriosis. It is more often diagnosed histologically following a hysterectomy but can be diagnosed by pelvic magnetic resonance imaging (MRI). Adhesions due to previous surgery, pelvic infection ("chronic pelvic inflammatory disease (PID)") or endometriosis are also associated with CPP but there is little evidence that division of adhesions reduces pelvic pain symptoms. Pelvic congestion syndrome is the association of pelvic varicosities seen on MRI with pelvic pain. Ovarian suppression has been shown to be helpful. Bowel symptoms are very common in women with CPP, occurring in 50% of women with pain attending a gynaecology clinic (Latthe et al, 2006). Bladder problems, including bladder pain syndrome (interstitial cystitis) or overactive bladder, are also common in this setting, being present in 38-84% of women with pain (Latthe et al, 2006). Musculoskeletal problems cause or exacerbate pelvic pain in up to 75% of women. In endometriotic women with persistent symptoms or symptoms particularly during menstruation, oral progestogens, Depo-Provera and the COCP may be used long term. GnRH agonists, if given long term, must be prescribed with "add-back" HRT for bone protection. GnRH agonists cause menopausal-like symptoms (eg hot flushes, increased sweating, vaginal dryness, dyspareunia and loss of libido) and a decrease in bone density without HRT. GnRH agonist therapy given for 3 months may be as effective as treatment given for 6 months in relieving endometriosis-associated pain. Hysterectomy on its own is very unlikely to relieve CPP in women with endometriosis. Bilateral salpingo-oophorectomy is also required and even this is not guaranteed to cure all symptoms. She will subsequently require long-term HRT. Pain control Analgesic drugs should be used in a stepwise fashion similar to the WHO analgesic ladder. The ladder advocates a stepped approach to the use of painkillers from the following analgesia groups: -simple analgesics, ie paracetamol and NSAIDs -weak opioids, ie tramadol, codeine -strong opioids, ie morphine, fentanyl, oxycodone (in conjunction with specialist care) -adjuvants such as antidepressant or anticonvulsant drugs, eg amitriptyline, gabapentin Non-opioid analgesics form the basis of pain management at every step of the analgesic ladder (paracetamol and NSAIDs should always be prescribed with opioid analgesia). This approach is known as multi-modal analgesia first established to treat cancer pain. This introduced the concept that pain is best managed not by a single drug or therapy but by combinations, which maximise efficacy whilst keeping side effects low. The NSAID mefenamic acid is useful for the management of cyclical pelvic pain in adolescents. Tricyclic antidepressants (TCAs) and antiepileptic drugs such as the gabapentinoids are commonly used in the management of chronic pain and in particular neuropathic pain. If, as is postulated, CPP has a neuropathic component, then it is rational to try them in this setting (Engeler et al, 2012). The usual first-line drug is amitriptyline (WHO analgesic ladder). Amitriptyline should be started at a low dose, typically 10-25 mg. The drug should be slowly titrated up to effect over a period of several weeks, the aim being to use the lowest effective dose. The target dose will be in the region of 75 mg, though many patients will not tolerate the drug side effects. The substitution of nortriptyline or imipramine in similar dosage may reduce the side effects, particularly sedation. With gabapentin, patients are typically started on 300 mg daily and slowly titrated up (over a few weeks) to an initial target dose of 600 mg three times a day. Side effects of gabapentin experienced by patients can include somnolence and dizziness, but in general it tends to be well tolerated, has little interaction with other drugs and has a safe side-effect profile. The efficacy and side effects are probably similar to amitriptyline. Pregabalin has a similar side-effect profile to gabapentin but may be better suited to individual patients. The starting dose is 75 mg twice a day titrating up to a target dose of 300 mg twice a day. Addressing psychological and social issues that commonly occur in association with CPP is important. Depression, relationship breakdown and sleep disorders are common in women with chronic pain. This may be a consequence rather than a cause of their pain but specific treatment may improve the woman’s ability to function. It is important that the multifactorial nature of pain is discussed and explored from the start. The aim is to develop a partnership between clinician and patient to plan a management programme. Persistent haematuria may indicate urinary tract calculi, painful bladder syndrome (interstitial cystitis) or a bladder tumour. A UTI should be excluded and a referral made to a urologist or urogynaecologist. Diverticular disease should always be considered. Painful bladder syndrome (interstitial cystitis). CPP can be associated with gynaecological conditions such as endometriosis, and non-gynaecological conditions such as inflammatory bowel disease and irritable bowel syndrome (and diverticular disease), painful bladder syndrome (interstitial cystitis) and musculoskeletal pain (including osteoarthritis). A history of physical, sexual and psychological abuse is more common in women with CPP. In more than 50% of patients, no cause for the painful symptoms can be found.
  8. Notes from Breastfeeding class: At 6 weeks it is usual for a baby to feed often during the day, more in the evening, and to wake for some feeds during the night. Ignoring the baby's cues will lead to a reduced milk supply, and paradoxically cause him/her to feed even more. Giving formula will also decrease breast milk output. Milk is produced via a positive feedback loop: the more frequently and efficiently milk is removed, the more milk will be produced. A healthy infant, feeding comfortably and frequently, is the most effective way to ensure an adequate milk supply. Breast milk contains a protein called the feedback inhibitor of lactation (FIL). It is present in small amounts when the breast is being emptied regularly. When feeding is restricted the protein builds up in quantity and leads to a reduction in milk production by the breast. Normal babies have periodic episodes when they try to feed extremely frequently, day and night. This is an attempt to upregulate and increase the milk supply, and is particularly common at 6 weeks. It is often called a "growth spurt". Giving formula or following a schedule prolongs the episode by blocking the positive feedback loop. Following the baby's cues will usually increase supply within 1-2 days, and feed frequency will return to normal. A healthy baby will keep suckling until his hunger, thirst and need for comfort are satisfied. This ensures he gets the optimum balance of protein-rich foremilk, and lipid-rich hindmilk. He will come off the breast spontaneously when he is ready, and look content. If he needs more milk he will take the second breast when it is offered. Routinely changing breasts before the baby is ready will disrupt milk production. A baby may fall asleep at the breast. The mother can break the suction by gently inserting a clean finger in the corner of his mouth, and offer him the other side. All mothers are supposed to be taught how to express milk by hand in the immediate postnatal period. To qualify as a contraceptive method: -Breastfeeding must be full (that is, no formula, no solids, no extra fluids and no expressing by pump or hand; prolactin levels may drop if the mother is expressing) -The baby should be under 6 months old -Menstruation must be absent -There should be no long intervals between feeds -The mother should not use a pacifier to satisfy the baby's suckling needs When these criteria are fulfilled, the lactational amenorrhoea method (LAM) is over 98% effective in preventing pregnancy (Faculty of Sexual and Reproductive Healthcare (FSRH), 2009. Average duration of lactational amenorrhoea in breastfeeding mothers is up to 15 months. The copper IUD is licensed for emergency contraception up to 5 days after intercourse (FSRH, 2012). Department of Health (DH), 2011, and World Health Organization guidance (WHO, 2013) is that solids should be started around 6 months of age. This balances the infant’s need for extra nutrients (especially iron) against the risks of infection and allergy. Breastfeeding can and should be continued alongside his solids once he is 6 months old. This provides optimum nutrition, and offers continued protection from allergy and infection. She may need to express her milk to maintain supply. Most babies will take the breast when sleepy, for example at night and for pre-nap feeds. She may wish to avoid bottles and feed with a cup, to prevent teat preference developing. Suckling and breast milk both have analgesic properties, and breastfeeding reduced infant pain responses in a randomised controlled trial (Carbajal et al, 2003). Breastfeeding reduces the risk of gastrointestinal infection, respiratory illness and atopic disease (NICE, 2006) in infants. Teenagers and adults who have been breastfed are at less risk of high blood pressure, obesity and type 2 diabetes (Horta et al, 2007 Chivers et al, 2010). Mothers who have a history of breastfeeding have a decreased chance of developing postmenopausal osteoporosis (Schnatz et al, 2010). Breastfeeding also helps to protect against maternal ovarian and breast cancer. Breastfeeding may also reduce the risk of maternal type 2 diabetes (Liu et al, 2010). Mastitis begins as a sterile inflammatory reaction to milk stasis. Resting the affected breast will exacerbate this, and hasten the development of secondary bacterial infection. The key to effective mastitis treatment is frequent feeding from the affected breast. Pain relief (paracetamol, possibly supplemented by NSAIDs and/or codeine) may well be needed. Local heat, massage and milk expression should also help. As the mastitis develops, the area becomes harder, more tender and very red. Flu-like symptoms, including fever, occur. Without prompt treatment to drain the milk, there will then be secondary infection. This may progress to abscess formation, and surgical drainage or aspiration will be needed. The usual pathogens are Staphylococcus or Streptococcus, often finding entry through a cracked nipple. Recommended treatment for mastitis (WHO, 2000; NICE Clinical Knowledge Summaries (CKS), 2010) Penicillin OK Flucloxacillin 250-500 mg four times a day Amoxycillin 250-500 mg three times a day Penicillin allergy Erythromycin 250-500 mg four times a day Cefalexin 250-500 mg four times a day Alcohol ingested by a breastfed neonate has been shown to have effects on the infant even in small quantities (Mennella and Beauchamp, 1991). Breast milk has a lower level of electrolytes than formula, it is rapidly absorbed, of high nutritional value and hastens a return to normal gut flora. Unlike oral rehydration therapy, it is a familiar tasting fluid which is highly acceptable to sick infants. If the baby is given unrestricted access to the breast, supply will increase to compensate for mild to moderate GI losses. Should losses be more than this, oral rehydration fluids can be used to supplement breastfeeding until dehydration is corrected. Secondary lactose intolerance can follow a bout of gastroenteritis, but is rarely a cause of anything more than nuisance diarrhoea. It nearly always settles spontaneously within a week or two. Withholding breast milk is unnecessary and potentially dangerous. Breastfeeding offers a great deal of protection from gastrointestinal infections through a variety of mechanisms. At work the mother could send expressed milk to the child's carer. Then she could maximise breastfeeding when she is at home. Or she could allow the carer to use formula milk but continue to breastfeed as normal when at home. A study comparing breastfed with formula fed babies found that the formula fed babies developed more minor illnesses and their mothers had higher levels of absence due to their child's sickness compared with the breastfed group (Cohen et al, 1995). Less than 1% of UK babies are exclusively breastfed until 6 months (HSCIC, 2012). One of the main reasons mothers stop feeding in the early days is nipple soreness. Bottle-feeding is so dominant in the UK that most women instinctively hold the baby in the crook of their arm. For a breastfed baby, this means it is very difficult to reach the breast, and the nipple becomes stretched and distorted. It is common for the breast to be held between two fingers and offered to the baby as though it were the teat of a bottle, with similar results. If nipple injury has already occurred, the first few seconds of a feed can be sore. Pain that persists is a problem, probably because of poor positioning, causing further nipple pressure and damage. Teenager and socioeconomically disadvantaged mothers are risk factors for breastfeeding failure (Brand et al, 2011). Other reasons for women stopping breastfeeding include milk supply issues, the baby rejecting the breast, and returning to work (Brand et al, 2011). Paracetamol may safely be taken by lactating mothers. NSAIDs are sometimes found in breast milk but quantities are thought too small to be harmful. Codeine is also found in breast milk, and particularly in larger doses has been associated with infant drowsiness or sedation. Physiological jaundice starting after 24 hours of life and persisting for the first week or two is normal. When jaundice is mild, the baby is well hydrated and showing no sign of illness, there is no need for a blood test. Jaundiced babies can be sleepy, so it may be necessary to actively encourage mothers to feed frequently. This usually avoids the need for supplementary non-breast milk fluids. Principles when feeding a baby: -See that she is sitting upright, with good support for her back and baby. -Look for slow deep sucks and rounded cheeks full of milk; listen for swallowing and breathing pauses. -Mother and baby should seem serene. -Baby’s tummy should face mummy, so she is tucked in close to Leanne’s body and can reach the breast without turning his head. -The nipple should point to the baby's nose, one hand supporting the breast if needed. -Baby should be held by the shoulders and neck, so his head is partly free. -Mothers should then wait for his mouth to open really wide, in a full-size gape. Then quite quickly she needs to bring him to the breast. Nicotine and other toxins do enter breast milk. But smokers’ babies are invariably exposed to second or third-hand smoke from their parents’ clothes and skin even if smoking within the house is avoided. Stopping breastfeeding will not avoid baby’s exposure to tobacco, with the consequent risks of asthma, respiratory infection, otitis media, SIDS, etc. Many of these risks are raised further by bottle-feeding, so avoiding milk formula feeding is especially sensible when a mother smokes. Nicotine enters the milk in parallel with blood levels, and reaches a peak soon after having a cigarette. You may wish to advise mothers to delay smoking until just after a feed, in order to minimise baby's exposure. NICE guidance on NRT(nicotine replacement therapy) suggests that when a breastfeeding mother is unable to stop smoking unaided she should be offered NRT (NICE, 2008). The intermittent release methods (spray, gum, lozenges, etc) may be preferred to patches as the baby’s exposure can be lowered by careful timing of their use. She should be strongly advised that she must not smoke whilst using NRT since that would expose her baby to a very high nicotine level. Parents should never share their bed with their baby if one or both of them has had any alcohol or misused drugs. A smoker’s bed is always hazardous for an infant (WHO, 2009). The Department of Health advises that the safest place for a baby to sleep, particularly in the first weeks of life, is in a cot in the parents’ bedroom (DH, 2009). Formula feeding is advised for mothers with HIV in the UK. The Faculty of Sexual and Reproductive Healthcare has endorsed the combined oral contraceptive pill (COCP) as broadly suitable for some breastfeeding mothers. This includes mothers who are mixed feeding or those who have older babies (over 6 months) (FSRH, 2009).The available evidence suggests that the progesterone-only pill (POP) has no effect on milk supply or composition, and so is suitable for breastfeeding mothers (FSRH, 2009). Although its effectiveness when used alone is lower than the combined pill, it is very reliable when used in combination with breastfeeding. Progestogen-only injectable contraception (Depo-Provera), progestogen-only implants (Implanon), the copper IUCD and the levonorgestrel-releasing intrauterine system (IUS) (Mirena) are all suitable for use by breastfeeding women (FSRH, 2009). Nystatin drops are traditionally used to treat babies with thrush, it is the drug of choice (NICE, 2006). Treatment must be continued for several days after symptoms have resolved. Mother and baby should both be treated. Some women get severe, deep breast pain lasting for a long time after a feed. It is often attributed to thrush and anecdotally does seem to respond to fluconazole, but causation has not been proven. Breast "thrush" presents with a very different clinical picture from mastitis. The breasts usually look normal apart from a flaky nipple and the name comes from the association with oral thrush in the baby. Fluconazole is considered safe in breastfeeding as it is widely used in neonates. Diclofenac is usually considered safe in lactation. Anaesthetic gases may affect milk production, so women who have had a general anaesthetic may need extra support in the first few days. Mothers and babies can experience psychological symptoms for years after early separation. It is nearly always better that there is immediate contact after birth.Early contact with a newborn enhances bonding, and facilitates later breastfeeding. Skin-to-skin contact, is as effective as an incubator in regulating a premature baby's temperature, and preventing hypoglycaemia. It regulates the baby's heart rate and breathing pattern. It aids maternal milk production and facilitates the establishment of breastfeeding (Anderson, 1999). Necrotising enterocolitis and infection are leading causes of death for infants needing specialist neonatal care. Premature babies fed on formula have 20 times the rate of necrotising enterocolitis (Lucas and Cole, 1990) and marked increases in urinary tract and lower respiratory tract infections (Lucas, 1992). Decreases in IQ at age 7 have been documented for babies who are formula fed (Lucas et al, 1992; Quigley et al, 2009). Rates of infection are much higher in SCBU occupants who are deprived of breast milk. To express, the breast is gently squeezed proximal to the nipple, using the thumb and fingers. The colostrum or milk is collected in a sterile container. Milk may be kept at room temperature for 6 hours, or refrigerated or frozen for later use. Galactagogue metoclopramide 10mg is occasionally recommended for mothers of babies on SCBU. In general, breast milk containing a small amount of medication is preferable to formula milk. Pumping both breasts simultaneously is quicker, which is important for mothers. It helps increase milk yield because it mimics the physiological action of feeding both twins simultaneously. She will need to pump both breasts around eight times a day, so a manual pump will risk carpal tunnel syndrome, electric pumps are better. Tongue-tie as a possible cause of failure to latch. The baby’s tongue needs to be able to protrude beyond the lower lip. If present, it should be possible to have it corrected right away, usually in the paediatric surgical outpatients. It has an immediate effect on the baby’s ability to latch and breastfeed. Σωστή κι αποτελεσματική τεχνική για την εξαγωγή κι αποθήκευση μητρικού γάλακτος κατά το θηλασμό. https://www.youtube.com/watch?v=oGu9J7Yl61w https://www.youtube.com/watch?v=Y7gdfyUT6Zc https://www.youtube.com/watch?v=9gQ8119RNeI https://www.youtube.com/watch?v=6bCIU-mWIhk
  9. Notes from Urinary tract infections Course: Regarding urine dipstick tests: False-negative nitrite tests are common, but false positives are uncommon. Leukocyte esterase detects the presence of pyuria which, although highly suggestive of UTI, can be a non-specific finding. "Sterile pyuria" may result from an ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika -, renal/ bladder tumour, calculus, genitourinary tuberculosis, and antibiotic therapy prior to collecting an MSU. Physiological pyuria occurs in pregnancy. The absence of both nitrites and leukocyte esterase reliably excludes UTI (Deville et al, 2004; Public Health England (PHE), 2011. Blood and/or protein in urine are consistent with UTI, but are often non-specific findings. Visible or persistent haematuria will usually warrant urological investigation. If the clinical picture is strongly suggestive of UTI dipstick analysis is regarded as optional rather than mandatory. Dipstick testing should not be used to diagnose UTI in catheterised patients. Amoxicillin resistance among strains of Escherichia coli, the commonest urinary tract pathogen, is common (approximately 50%) in the UK (Farrell et al, 2003). Unless culture and sensitivities have been performed, and the isolate is known to be sensitive to amoxicillin, this antibiotic should not be used for the empirical treatment of UTI. Trimethoprim or nitrofurantoin are appropriate agents for empirical therapy of suspected lower UTI, although increasing trimethoprim resistance in the UK is now limiting the usefulness of this agent. Co-amoxiclav, cephalosporins or fluoroquinolones should normally be reserved as second-line agents. Empirical antibiotic therapy should be based on local guidelines which are informed by local antibiotic sensitivity data. Common urinary pathogens include: Escherichia coli- especially uropathogenic strains! Klebsiella! Proteus- sometimes seen in association with renal calculi! Enterobacter! Staphylococcus saprophyticus - especially in young sexually active females! Group B streptococci! Enterococcus! Pseudomonas aeruginosa - more common in catheterised and hospitalised patients! Staphylococcus aureus (often haematogenous rather than ascending route) - bacteraemia or endocarditis should be considered! Antibiotic resistant coliforms have become relatively common in the UK. In particular, some strains possess extended-spectrum beta-lactamases (ESBLs), and are often resistant to many antibiotics (PHE, 2011). In some cases, third-line oral agents such as pivmecillinam or fosfomycin may be useful. Alternatively, an intravenous agent such as meropenem may be required. In the past, 7 days of oral antibiotic therapy has been recommended for uncomplicated lower UTI. In most cases, however, the infection is confined to the superficial mucosa of the bladder, and such infections can be adequately treated with a short-course (3-day) regimen. Whilst dehydration may predispose a person to UTI, and adequate hydration should be encouraged to prevent recurrences, there is little benefit from increased oral hydration in the acute management of an established UTI. Appropriate oral antibiotic therapy usually relieves symptoms rapidly. Increasing oral fluids reduces the concentration of antibiotics in urine, and in patients with outflow obstruction could precipitate acute urinary retention. Tea, coffee (caffeine-containing drinks), and alcoholic and citrus drinks should be avoided until symptoms have resolved as they can cause bladder irritation. These drinks should be replaced by water. Involvement of the upper urinary tract, which may be present in the absence of symptoms such as fever and loin pain in up to 30% of women presenting with cystitis (Ramakrishnan and Scheid, 2005), is the most likely explanation for the failure of the short-course regimen. Short-course therapy will fail in about 50% of cases if occult upper urinary tract infection is present. An abnormality in the renal tract, or an antibiotic resistant organism, are alternative explanations. An ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika - should also be considered. At this point, an MSU would be helpful to confirm the sensitivity of the pathogen. If moderate or severe symptoms persist, antibiotic treatment should be reinstituted with an alternative oral antibiotic (pending culture and sensitivity results) for 7 days. In adults, formal confirmation of bacteriuria by microscopy and culture is important in the following scenarios: a "complicated" UTI history suggestive of UTI, but dipstick negative in relapsed or recurrent infections - an antibiotic resistant pathogen is more likely in pregnancy in the elderly patient with symptoms suggestive of UTI failure to respond to empirical antibiotic therapy in suspected acute pyelonephritis Short-course treatment is not appropriate for women who have recurrent UTIs caused by antibiotic-resistant organisms, or when symptoms have been present for more than 7 days, as upper urinary tract infection is more likely. In these scenarios, as for men, 7 days of antibiotic treatment is recommended. The high levels of some antibiotics in urine, together with the normal host immune system, may lead to clinical cure in some patients with lower UTI even when the organism is resistant in laboratory tests. In some women, post-coital UTIs are common - voiding urine before and immediately after intercourse may decrease their frequency. Avoiding spermicides (including spermicide-coated condoms) may also help to prevent recurrences. If these measures fail, single-dose antibiotic prophylaxis, taken before or immediately after intercourse, may be effective. Other risk factors for recurrent UTI (Minardi et al, 2011) include: diabetes mellitus impaired bladder emptying (especially postmenopause) chronic constipation (more common in children) poor fluid intake (children and elderly) atrophic vaginitis In the majority of women, however, symptomatic reinfections occur at various intervals without any detectable precipitating factor, although structural or functional abnormalities in the urinary tract should be considered. Asymptomatic bacteriuria occurs in 2-9% of pregnant women in the first trimester, and 10-30% of women with untreated bacteriuria develop acute pyelonephritis at some time during the pregnancy (Scottish Intercollegiate Guidelines Network (SIGN), 2012 [pdf]). The association between acute pyelonephritis and premature delivery is well established (Smaill, 2007; NICE, 2008). It is therefore important to screen for asymptomatic bacteriuria during early pregnancy and again in the third trimester by sending an MSU. In non-pregnant adults, asymptomatic bacteriuria (which becomes increasingly common with advanced age) is not a predictor of significant renal pathology, and it is generally accepted that antibiotic treatment is not warranted. Dipstick testing of urine from elderly patients will often be abnormal due to the presence of bacteria in the urine, and should be avoided unless infection is clinically suspected. Similarly, urine specimens for microscopy and culture should not normally be obtained from elderly patients unless there are at least two clinical features suggestive of UTI (especially dysuria, pyrexia ?38°C or new onset urinary incontinence), and empirical antibiotic therapy is deemed necessary. Acute delirium in elderly patients is a common clinical scenario with protean aetiology, including UTI (Saxena and Lawley, 2009). However, delirium should not be attributed to UTI on the basis of a positive dipstick, or MSU culture result, in the absence of other features of urinary infection. Such results may merely represent the presence of asymptomatic bacteriuria and may lead to inappropriate antibiotic therapy, and failure to address other possible causes of the delirium. Bacteriuria, if detected, should first be confirmed with a carefully taken second MSU. Therapy should be based on the sensitivities of the organism grown with the aim of eradication using a 7-day antibiotic course (Widmer et al, 2011). A urine sterility check should be performed 1-2 weeks later by sending an MSU and then regularly (monthly) throughout the remainder of the pregnancy, as recurrences are common. Nitrofurantoin is generally considered safe in the first and second trimesters, but should be avoided near term due to the risk of neonatal haemolysis (Nordeng et al, 2013). Trimethoprim should be avoided, particularly in the first trimester, as it is a folate antagonist. Beta-lactam agents (such as amoxicillin, cephalosporins and pivmecillinam) are generally considered safe in pregnancy. It is important to send a "clean catch" urine sample for microscopy and culture to confirm infection and determine the causative agent. Pyuria is not always present in childhood UTI. Vague abdominal pain, vomiting, loss of appetite, isolated fever and secondary incontinence are common symptoms of UTI in children. UTI is more common in boys during the first 3 months of infancy; thereafter the incidence is higher in girls. By the age of 6 years, 7% of girls and 2% of boys have had a culture-confirmed, symptomatic UTI (Marild and Jodal, 1998). When UTI occurs in children, it is important to consider renal tract abnormalities. Associated conditions such as chronic constipation, vulval irritation and threadworms should be excluded. Infrequent voiding and poor fluid intake may also predispose to recurrent UTIs. A cephalosporin or co-amoxiclav are recommended as empiric therapy for upper UTI in children. Specialist referral should be considered. The criteria for atypical UTI include: serious illness raised serum creatinine poor urine flow abdominal or bladder mass septicaemia failure to respond to suitable antibiotic therapy within 48 hours infection with non-E. coli organisms Recurrent UTI in childhood is defined as: one episode of pyelonephritis and one episode of cystitis; two episodes of pyelonephritis; or three episodes of cystitis. In the age group ?3 years of age the following imaging schedule is recommended: Atypical infection: US scan during the acute infection and dimercaptosuccinic acid (DMSA) scan 4-6 months following the acute infection. Recurrent UTI: US scan within 6 weeks and DMSA scan 4-6 months following the acute infection. If recurrent episodes of UTI occur there is a significant risk of renal damage. In the absence of a correctable renal tract abnormality, long-term antibiotic prophylaxis may be indicated to maintain urine sterility and protect the kidneys. Follow local guidelines on referral and management. Prophylactic antibiotics (usually trimethoprim or nitrofurantoin) may be started pending specialist assessment. If long-term prophylaxis is recommended, monitoring for side effects is necessary: Trimethoprim - monitor for folate deficiency. Nitrofurantoin - if 6 months of prophylaxis is needed, liver and lung function should be monitored. Breakthrough infections may occur and require standard treatment with an antibiotic not used for prophylaxis. If the organism causing the breakthrough infection is sensitive to the prophylactic agent, consider non-compliance. Acute pyelonephritis may present with mild symptoms, which can be managed in the community. However, bacteraemia, leading to sepsis, is a common complication. Hospital admission for intravenous antibiotic therapy is appropriate if there is evidence of sepsis (as indicated by pyrexia of 38.5°C or higher, tachycardia or hypotension) and at extremes of age. A 2-week course of ciprofloxacin is recommended for acute pyelonephritis in men. Alternatively, a 2-week course of co-amoxiclav (assuming the organism is sensitive) can be used. In women, a 1-week course of ciprofloxacin (or 2 weeks of co-amoxiclav) is recommended (SIGN, 2012). Both of these agents achieve adequate levels in serum and renal tissue, which is necessary to treat infection in the renal parenchyma effectively and any associated bacteraemia. Nitrofurantoin (which does not reach effective concentrations in the bloodstream) and trimethoprim (in which resistance is too common to rely on this agent for the treatment of a potentially life-threatening infection) are not suitable for treatment of acute pyelonephritis. A longer course of antibiotic therapy may be required if renal abnormalities are found or if relapse or complications occur. Acute prostatitis, for example, may require 4 weeks of treatment and ciprofloxacin is recommended as first-line therapy (Schiller and Parikh, 2011). At least 50% of men with recurrent UTI and over 90% of men with febrile UTI have prostate involvement which may lead to complications such as prostatic abscess or chronic bacterial prostatitis (SIGN, 2012). Refer men for urological investigation if they have symptoms of upper urinary tract infection, fail to respond to appropriate antibiotics or have recurrent UTI. Urinary catheters represent a significant risk for UTI (Nicolle, 2005). However, in the presence of a long-term urinary catheter, asymptomatic bacteriuria is common and does not require treatment. Catheter specimens of urine should only be examined if systemic symptoms of infection are present (PHE, 2011).
  10. Notes from Pelvic Cancers Course Colorectal cancer is the third most common cancer in the UK in women after breast and lung cancer, with 17,861 new cases in females registered in 2010 (Cancer Research UK: Bowel cancer incidence statistics). Colorectal cancer is the second most common cause of cancer death in the UK (National Institute for Health and Care Excellence (NICE), 2011a). Occurrence of colorectal cancer is strongly related to age, with almost three-quarters of cases occurring in people aged 65 or older. An abdominal examination and rectal examination (with consent) should be performed. The fact that patients are often not comfortable with “intimate” examinations means that they must be performed with explanation, sensitivity and consent, and as per the local agreed protocols for chaperones. Often a patient may be resistant to the examination, yet relieved that their history and symptoms are being taken seriously. The NICE recommendations for a patient with suspected cancer (NICE, 2005) state that in patients aged 40 years and older who report rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more, an urgent referral should be made. In patients aged 60 years and older who have rectal bleeding persisting for 6 weeks or more with no change in bowel habit and no anal symptoms, an urgent referral should be made (NICE, 2005). In patients aged 60 years and older who have had a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding, an urgent referral should be made (NICE, 2005). In patients presenting with a right lower abdominal mass consistent with involvement of the large bowel, an urgent referral should be made, irrespective of age (NICE, 2005). In patients presenting with a palpable rectal mass (intraluminal and not pelvic), an urgent referral should be made, irrespective of age (NICE, 2005). A pelvic mass outside the bowel would warrant an urgent 2-week wait referral for an ultrasound. Alternatively, if this is not available or if there is a high index of suspicion, this should instead be directed to a gynaecologist or a urologist. Ovarian cancer has an incidence of just over 20 per 100,000 women. Based on an assumption of an average GP list having 1,000 women, then you may expect a case every 4-5 years. Women are at higher risk if they are nulliparous; they may also have an increased risk if their body mass index (BMI) is >25 kg/m2 (Collaborative Group on Epidemiological Studies of Ovarian Cancer, 2012). Long-term use of the combined oral contraceptive pill (>10 years) increases the risk of breast cancer, but reduces the risk of ovarian cancer. In non-menstruating women with unexplained iron deficiency anaemia and a haemoglobin of 10 g/100 mL or below, an urgent referral should be made (NICE, 2005). In menstruating women with unexplained iron deficiency anaemia the situation is different. Those with dyspepsia should be referred for endoscopy under the 2-week wait rule. You should also consider endoscopy in the absence of this symptom on a case-by-case basis - see page 78 of the NICE guidance (NICE, 2005) In a study by Goff and colleagues (Goff et al, 2004), IBS was the most common misdiagnosis in women later found to have ovarian cancer. In this study, the initial diagnoses made by their GPs were: irritable bowel syndrome: 28% suspected malignancy (including ovarian): 28% urinary tract infection: 18% menstrual symptoms: 10% diverticulitis: 9% other: 7% Patients initially diagnosed with IBS were especially likely to have their diagnosis of ovarian cancer delayed for more than 6 months. This is why NICE guidelines highlight the danger of making a new diagnosis of IBS in any woman over the age of 50 years (NICE, 2011b). Around 90% of the ovarian cancers recorded in the UK are in women aged 45 and older (Cancer Research UK: Ovarian cancer incidence statistics). You may wish to check haemoglobin, kidney function and liver function while you are ordering bloods: they add weight to the possibility of a serious diagnosis if they are abnormal, but do not exclude a serious diagnosis if normal. If a pelvic/ abdominal mass (not obviously fibroids) or ascites is found, NICE advises urgent referral (NICE, 2005; NICE, 2011b). Bimanual examination is notoriously poor at picking up ovarian tumours and therefore is not recommended as part of routine screening because of the risk of false positive reassurance (Chan et al, 2008). In an older study of 800 women comparing transvaginal ultrasound with bimanual examination performed by a gynaecologist (Andolf, 1986), the ultrasound picked up 40 tumours, and the gynaecologist none. As this study was done in 1986 when ultrasound wasn’t nearly as good as it is now, the statistics must have tipped even more towards the transvaginal ultrasound. This is why NICE guidelines recommend that if a woman >50 years of age presents with new symptoms of bloating, and her CA125 is >35 IU/mL, arrange an ultrasound scan of her abdomen and pelvis (NICE, 2011b). A normal CA125 (or a normal ultrasound scan) lowers her risk of having ovarian cancer, but cannot exclude the diagnosis with certainty, although false negatives are uncommon. It could still be ovarian cancer, or an ovarian cyst. Mrs J F has abdominal symptoms and an abdominal mass and further investigation revealed that she did have an ovarian cancer, despite the normal CA125. It could also have turned out to be a caecal cancer with these symptoms. It is often difficult to decide to whom to refer. Both gynaecologists and colorectal surgeons can make cancer diagnoses in each other’s fields, and often (such as in this patient’s case) they operate together on the patient. This woman’s ovarian cancer had grown into the caecum, so she needed bowel resection at the same laparotomy, as she went into obstruction.The important issue was that a 2-week wait referral was made and she was swiftly put on the pathway to diagnosis and treatment. CA125 does not have very good sensitivity or specificity. Even if women are only referred following both a positive CA125 and ultrasound, only 1 in 26 of those referred would actually have ovarian cancer (a high rate of false positives). Conversely, 34% of women who do have ovarian cancer have a “normal” CA125 at initial presentation (a high false negative rate) (NICE, 2011b). In an attempt to improve the accuracy of the test, a "risk of malignancy" index (RMI) has been developed. Risk of malignancy index I (RMI I): RMI I is a product of the ultrasound scan score (U), menopausal status (M) and serum CA125 level RMI I = U + M + CA125 The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites, bilateral lesions. U = 0 for an ultrasound score of 0 points, U = 1 for an ultrasound score of 1 point, U = 3 for an ultrasound score of 2-5 points. Menopausal status is scored as 1 = pre-menopausal and 3 = postmenopausal. The classification of “postmenopausal” is a woman who has had no period for more than 1 year or a woman over 50 who has had a hysterectomy. Serum CA125 is measured in IU/mL (NICE, 2011b, based on work by Obeidat et al, 2004) If her CA125 had been >35 IU/mL, ovarian cancer would have been more likely. In a retrospective case note audit of 751 female patients who had a CA125 performed for suspicion of malignancy/ ovarian cancer, only 39 (20%) of the abnormal results were caused by ovarian cancer. False positive results were largely caused by another malignancy (48 cases, 26%), benign ovarian disease (26 cases, 14%), and benign gynaecological conditions, particularly leiomyomas (18 cases, 9%). The specificity of CA125 for ovarian cancer increases with concentrations >1,000 kU/L (Moss et al, 2005). The first symptoms of gynaecological cancer may be alterations in the menstrual cycle, intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding or vaginal discharge. When a patient presents with any of these symptoms, the primary healthcare professional should undertake a full pelvic examination, including speculum examination of the cervix. In patients found on examination of the cervix to have clinical features that raise the suspicion of cervical cancer, an urgent referral should be made. A cervical smear test is not required before referral, and a previous negative cervical smear result is not a reason to delay referral. Cervical cancer is a leading cause of cancer death in women worldwide, and the commonest cancer in women 5 years in the UK (Cancer Research UK: Cervical cancer key facts). Cervical screening prevents 80% of cervical cancer deaths (Peto et al, 2004). Risk factors include: never having a smear infection with the oncogenic types of human papillomavirus (HPV) smoking long-term use of oral contraceptive pills HIV/ AIDS There are about 15 oncogenic HPV types, which cause about 90% of all cervical cancers (Bosch et al, 1995). There is a 90% 5-year survival rate for women at the FIGO stage Ib-1 (clinically visible lesions limited to the cervix uteri <4.0 cm in greatest dimension). NICE guidelines recommend that if a woman who is not on hormone replacement therapy presents with postmenopausal bleeding, an urgent referral should be made (NICE, 2005). Uterine cancer is the fourth most commonly diagnosed cancer in women in the UK (Cancer Research UK: Cancer incidence for common cancers), and the most common gynaecological cancer (Cancer Research UK: Uterine cancer statistics key facts). In 2010 there were around 8,300 new cases of uterine cancer diagnosed in the UK - that is around 23 women every day. More than 9 in 10 uterine cancers diagnosed in the UK are in women aged 50 and over. Uterine cancer incidence rates have increased by around 50% since the early 1990s: this may be due to increasing obesity, and reducing parity. Postmenopausal women on sequential combined HRT are at slightly higher risk, as are women with a late menopause (Cramer, 2012). Women presenting with PMB who are taking tamoxifen have a higher probability of malignancy (substantially greater than 10%). In these cases the ultrasound image is more difficult to interpret. Therefore it is advisable to sample the endometrium initially and examine the cavity hysteroscopically (Scottish Intercollegiate Guidelines Network (SIGN), 2002).
  11. Notes from depression treatment course: In typical mild, moderate, or severe depressive episodes, the individual suffers from: lowering of mood reduction of energy decrease in activity Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called "somatic" symptoms. These can include: loss of interest and pleasurable feelings waking in the morning several hours before the usual time depression worst in the morning marked psychomotor retardation agitation loss of appetite weight loss loss of libido Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe. Antidepressants should not be offered routinely to those people with persistent subthreshold symptoms or mild depression, as the risk-benefit ratio is poor. A recent meta-analysis showed that the magnitude of benefit of antidepressant medication compared with placebo increases with the severity of depressive symptoms (Fournier et al, 2010). NICE recommends that antidepressants should be considered for: people with a past history of moderate or severe depression. people with initial presentation of subthreshold symptoms that have been present for a long period. those who have not benefited from non-pharmacological interventions, such as sleep and anxiety management, guided self-help and/or counselling. Monoamine oxidase inhibitors (MAOIs), such as moclobemide, should not be used as first-line treatment for depression. This group of drugs have potentially fatal interactions (ie hypertensive crisis) with foods containing tyramine. If prescribed, the patient should be supplied with a list of foods to avoid. Tricyclic antidepressants (TCAs) such as dosulepin are thought to enhance noradrenergic and serotonergic neurotransmission by inhibiting the reuptake of monoamine neurotransmitters into the presynaptic neurone. They have potentially serious side effects, including cardiac arrhythmia and, with the exception of lofepramine, are more dangerous in overdose than other antidepressants (NICE, 2009 [pdf]). They should not be used as first-line treatment for depression. SSRIs are the first choice antidepressants for use in moderate depression, and are the most commonly prescribed group of antidepressants in the UK (NICE, 2009 [pdf]). As the name suggests, this group of drugs inhibits the reuptake of serotonin into the presynaptic neurone thus increasing neurotransmission. They are not, however, serotonin-specific and may also inhibit the reuptake of noradrenaline and/or dopamine. Examples of drugs in this group include citalopram, sertraline, fluoxetine and paroxetine. SSRIs are as effective as tricyclics and are less likely to be discontinued because of anticholinergic or cardiotoxic side effects (NICE, 2009). There is no evidence of any clinically meaningful difference in efficacy between SSRIs, though side effect-profiles differ (Taylor et al, 2009). Side effects of SSRIs as a class include headache, gastrointestinal symptoms (ie nausea, diarrhoea), and a relatively higher propensity than other antidepressants to cause sexual dysfunction, hyponatraemia and GI bleeds (NICE, 2009). SSRIs should, therefore, not routinely be offered to patients with chronic physical conditions who are being treated with non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin (NICE, 2009). NICE recommends that CCBT should: be provided via a stand-alone computer-based or web-based programme include an explanation of the CBT model, encourage tasks between sessions, and use thought-challenging and active monitoring of behaviour, thought patterns and outcomes typically take place over 9-12 weeks, including follow up be supported by a trained practitioner (NICE, 2009) Although a patient’s history will contribute to a psychological analysis, the work of CBT involves attending to a patient’s negative thoughts and helping them correct what may be a habitual distortion of their perspective. CBT aims to help patients to view thoughts as theories or guesses. Negative automatic thoughts occur spontaneously in response to daily events. They can worsen mood and alter behaviour. Altering negative thoughts can improve the way people feel (David, 2006). CBT can be delivered using a computer-based approach (CCBT), or via group or individual therapy. CCBT is considered a low-intensity psychosocial intervention, which should be the first-line therapy for people with mild depression (NICE, 2009) Evidence suggests that the combination may be more effective than either therapy alone for some patients (Thase et al, 1997; Keller et al, 2000). While treatment with antidepressants may quickly improve mood and concentration, skills and mastery of negative thoughts are likely to be acquired through a psychological approach. For example, in focussing attention on the negative aspects and work and family life, Christopher neglects the years of positive experience. CBT could help him to adjust his thinking in this regard. The negative thinking is an example of minimisation. Minimisation is a distortion of thought found in depressed patients, where positive attributes are not given full value. CBT helps patients to recognise and correct this thinking. Patients who are not considered to be at risk of suicide should be seen 2 weeks after initiation of therapy. Those at increased risk of suicide or who are younger than 30 years of age should be seen after 1 week and on a frequent basis until the risk is not clinically relevant (NICE, 2009 [pdf]). Patients should be monitored for suicide risk throughout their management as this is a key outcome to be avoided at all costs. Patients should be asked directly about suicidal ideation and intent, and when a risk of self-harm or suicide is identified, the following should be considered: assess whether they have adequate social support and are aware of sources of help arrange help appropriate to the level of risk (see below) advise them to seek help if the situation deteriorates (NICE, 2009) It has been shown from data from clinical trials that improvement can start immediately. The greatest degree of improvement occurs in the first week and the curve begins to flatten off thereafter, with a smaller degree of improvement as time goes on (NICE, 2009 Taylor, 2009). All employers have legal responsibility under the Health and Safety at Work Act 1974 and Management of Health and Safety at Work Regulations 1999 to ensure the health safety and welfare at work of their employees. This includes minimising the risk of stress-related illness or injury to employees (Health and Safety Executive (HSE), 2009). As stress at work is often linked to specific problems (eg having too much to do in too short a time), it may be worth thinking about practical steps or adjustments that may help the employee when they return. If workload is an issue, some temporary adjustments may need to be made to reduce the amount of work they will have to deal with. This may help to reduce the pressure of work in the short term. If the person has found it difficult to cope with particular tasks involved in their job, temporary adaptations and/or changes to the job may provide valuable breathing space by reducing immediate work pressures on return. The person should be clear what their job involves and what is expected of them. If not, a review may clarify the aims of the job and the tasks they are expected to complete: “Line managers have an important role in assisting employers to proactively address work-related stress, and in doing so reduce the likelihood of employees suffering from work-related stress.” (HSE, 2009) Fitness standards, which might apply to specific careers, such as HGV drivers, pilots, divers, and food handlers, should be considered, as depression affects concentration (DVLA, 2014). Accidents are more likely to occur when concentration is reduced. If employees are required to drive during the course of their work, they may be considered unfit to perform those parts of the job that require fitness to drive. Suicidal ideation or behaviour may also be a consideration as such behaviour may put others at risk. Whilst exercise is not recommended as a routine treatment for depression, advice on sleep hygiene includes taking regular exercise as well as: establishing regular sleep and wake times avoiding excess eating, smoking or drinking alcohol before sleep creating a proper environment for sleep Agitation may be a side effect of SSRI treatment. If a depressed patient being treated with an SSRI develops increased agitation early in treatment, the prescriber should provide appropriate information, and if the patient prefers, the drug should be changed to a different antidepressant. Mirtazapine, trazodone and trimipramine are all sedative antidepressants which could be considered if cardiotoxicity or toxicity in overdose is not an issue for the patient. Alternatively, a brief period of concomitant treatment with a benzodiazepine should be considered, followed by a clinical review within 2 weeks (NICE, 2009). Remember that tolerance and dependence on benzodiazepines may develop after 2 weeks of treatment. Treatment courses should therefore be ideally restricted to 1 week. Response to antidepressant medication is typically defined as a reduction of at least 50% in symptoms (Maoz, 2007) In view of the high relapse or recurrence rate in depression, it is currently recommended that antidepressant drug treatment is continued for a minimum of 6 months after remission of major depression (12 months in older adults as there is some evidence that older people take longer to recover than younger adults). It is recommended that the same dose of antidepressant is used in this continuation phase (NICE, 2009) Dose reduction should take place gradually over a 4-week period (NICE, 2009 [pdf]). Symptoms of withdrawal from SSRIs can include: gastrointestinal disturbances, headache, anxiety, dizziness, paraesthesia, sleep disturbances, fatigue, influenza-like symptoms, and sweating, and are the most common features of abrupt withdrawal of an SSRI or marked reduction of the dose. Mild withdrawal or discontinuation symptoms may be managed by simple reassurance and monitoring. For severe symptoms, consider reintroducing the original antidepressant at the effective dose and gradually reduce while monitoring symptoms (NICE, 2009) Combining antidepressant drugs with different modes of action referred to as augmentation (Maoz, 2007), should not routinely be performed without consulting a consultant psychiatrist. While the efficacy of combinations may be additive, so may the toxicity, so monotherapy should be preferred. Both pharmacokinetic and pharmacodynamic interactions must be considered (NICE, 2009). For instance, there is an increased risk of serotonin syndrome when SSRIs are combined with MAOIs. Referral should also be sought for active suicidal behaviour and psychotic depression (NICE, 2009). Dual reuptake inhibitors are also referred to as serotonin and norepinephrine reuptake inhibitors (SNRIs); members include venlafaxine and duloxetine. Studies suggest that treatment with these drugs may be associated with an improvement in both emotional and physical symptoms of depression (Stahl et al, 2005; Karp, 2009; Kornstein et al, 2009). Duloxetine can be associated with nausea, headache and increased blood pressure (NICE, 2009). Venlafaxine has a broad range of side effects similar to those of the TCAs and SSRIs. It can increase blood pressure at higher doses, is associated with a higher incidence of discontinuation symptoms and is more toxic than the SSRIs in overdose (NICE, 2009). Mirtazapine is termed a noradrenergic and specific serotonergic antidepressant (NaSSA) and its actions result in an increase in both noradrenergic and serotonergic transmission. Like SNRIs, it is effective in treating somatic symptoms of depression (Kang et al, 2009). Side effects are similar to those of SSRIs but cardiovascular toxicity appears to be lower (Anttila and Leinonen, 2001). Before prescribing mirtazapine, practitioners should take into account its propensity to cause sedation and weight gain. Features of serotonin syndrome include confusion, delirium, shivering, sweating, changes in blood pressure and myoclonus.
  12. Clinical risk factors for osteoporosis include: Female gender - there is a 1:2 lifetime risk of sustaining a low trauma fracture in women over the age of 50 (Kanis et al, 2000) Age - age is the best predictor of fracture risk Early untreated menopause - exogenous oestrogen administration should have been considered up to around the age of 50 Previous non-vertebral fracture - a fracture at any skeletal site will increase the risk of subsequent fracture at any skeletal site by a factor of 2-5 fold Family history of osteoporosis - parental history of hip fracture or a diagnosis of osteoporosis is an important predictor of fracture risk Self-reported height loss - height loss may not necessarily be due to vertebral fractures but could be due to disc disease. However, in the context of the rest of her risk factors, the height loss may indicate vertebral fractures in this particular case Most vertebral fractures are clinically silent Only approximately 25% of vertebral fractures present with a clear clinical history The majority of vertebral fractures go undetected or are associated with relatively minor symptoms associated with the acute episode She may have experienced previous vertebral fractures, accounting for the apparent loss in height The incidence of a new vertebral fracture occurring within 12 months of an incident vertebral fracture is 20% Even clinically silent vertebral fractures are associated with increased morbidity and mortality The presence of a vertebral fracture will increase the risk of non-vertebral fractures, including hip fracture, by a factor of 2-3 fold Vertebral fractures can cause significant chronic pain, which has implications for patients’ functional abilities, mobility and mood A consequence of multiple vertebral fractures can be the development of a dowager’s hump, which can cause respiratory complications, including susceptibility to lower respiratory tract infections Vertebral fractures can be of different types, for example wedge, biconcave or crush It is possible to accurately detect vertebral fractures using a DXA scanner. This requires additional imaging of the patient lying on their side - vertebral fracture assessment (VFA). This is usually done if the patient reports height loss, kyphosis or back pain at the time of the DXA scan National Institute for Health and Care Excellence (NICE) guidance recommends performing a DXA scan (NICE, 2012). If the T-score is equal to or below -2.5, treatment with a bisphosphonate should be initiated. Co-prescription of calcium (500-600 mg/day) and vitamin D (400 IU/day) is also advised. NICE guidance (2012) recommends that women over the age of 75 years who suffer a low trauma fracture do not need a DXA scan to confirm osteoporosis. Empirical treatment with a bisphosphonate can be commenced without a DXA scan in this scenario. Age and previous fracture are powerful predictors of future fracture risk and thus NICE has determined that treating low trauma fractures in this age group does not require determination of bone mineral density (BMD) assessment by DXA scan. In all patients with a new diagnosis of osteoporosis, screening investigations should be performed to detect an underlying condition that may be predisposing to accelerated rates of bone loss. Investigations should include: full blood count (FBC) and erythrocyte sedimentation rate (ESR), eg multiple myeloma, malabsorption consideration of further investigations, including full myeloma screen if suspicious bone profile, eg primary hyper ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika -oidism, osteomalacia renal function, eg chronic renal impairment and renal osteodystrophy liver function - impaired hepatic function ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika -oid hormone/ vitamin D, eg osteomalacia, secondary hyper ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika -oidism testosterone in men - hypogonadism; if hypogonadism is established, look for its cause additional tests which may include coeliac autoantibodies, 24-hour urinary calcium measurements, and overnight dexamethasone suppression test to exclude hypercortisolism Since publication of the Women’s Health Initiative (WHI) data, oestrogen replacement therapy has lost its primary position as an effective means of reducing fracture risk in women in the postmenopausal period (Rossouw et al, 2002). The overall risks of HRT usage outweigh the benefits in postmenopausal women. Data from the WHI showed that HRT is capable of reducing the risk of vertebral and non-vertebral fractures by around 30% (Rossouw et al, 2002). The increased relative risk of breast cancer, stroke and coronary artery events has meant that the beneficial effects of HRT on the skeleton have been outweighed by other important detrimental effects. The excess risk of these events (breast cancer, stroke and coronary artery events) is probably most relevant to older postmenopausal women. In postmenopausal women who have significant flushing and sweating, the benefits of HRT may outweigh the risks. These risks and benefits need to be assessed in individual patients. If HRT is used in postmenopausal women, the duration of therapy should be reviewed frequently.Women with early menopause should be offered HRT up to the age of 50 years. There is no evidence that HRT is detrimental in this age group (Stevenson, 2011). NICE guidelines on diagnosis and management of the menopause are due for publication in July 2015. For people who have already had a low trauma fracture and who live in the community, monotherapy with calcium and vitamin D is not an effective means of reducing future fracture risk. Calcium (1-1.2 g) and vitamin D (800 IU) as monotherapy is a reasonable treatment in elderly patients living in an institutional environment and in those unable to comply with or tolerate more active treatments to reduce fracture risk. In patients receiving an active drug for osteoporosis, it is important to ensure they are vitamin D replete and have an adequate calcium intake. Co-prescription of calcium (500-600 mg/day) and vitamin D (400 IU/day) ensures this. All clinical trials demonstrating anti-fracture effects have used co-prescription of calcium and vitamin D in these doses. Vertebroplasty is an invasive procedure requiring image guidance to introduce orthopaedic cement into a crushed/ fractured vertebra to reduce pain. It is generally reserved for those patients who have persistent pain related to a vertebral fracture that does not settle spontaneously (most do) or does not respond adequately to more conventional analgesics. It is usually performed as a day case and pain relief is often rapid and effective. There is a different technique called kyphoplasty that involves re-establishing vertebral body height by inserting a balloon into the crushed vertebra before injecting cement. There is some concern that by changing the anatomy of the vertebral column using these techniques, abnormal forces may be conferred to adjacent vertebrae, increasing the risk of fracture at these sites. Vertebroplasty should only be performed at centres with specific expertise and where multidisciplinary assessments of patients are made. BMD is an important determinant of fracture risk as it largely determines the strength of the bone. BMD is a good predictor of fracture risk in patients; however, age and presence of previous fractures are also important determinants of future fracture risk. Bone density measurement at a specific site more strongly predicts fracture risk at that site than measurements at other parts of the skeleton are able to, ie spine BMD would predict vertebral fractures better than hip BMD would. normal bone density: T-score above -1.0 SD osteopenia: T-score -1.0 to -2.5 SD osteoporosis: T-score -2.5 or less severe osteoporosis: T-score -2.5 or less and fragility fracture Osteoporotic bones are brittle and break easily. However, this is not the same as the bones being soft, which occurs with vitamin D deficiency (osteomalacia). DXA cannot differentiate between osteoporosis and osteomalacia. Repeat DXA scans are not obligatory in patients with a diagnosis of osteoporosis who have been started on therapy. If a repeat DXA scan is required, the scan should not normally be repeated for 2-3 years as a minimum (Bell et al, 2009). There is no direct correlation between changes in BMD and the anti-fracture effect of bisphosphonate therapy. If secondary causes of accelerated bone loss have been excluded and patients are adherent with therapy, drugs will be effective at reducing fracture risk. It is reasonable to consider a repeat DXA scan in those patients experiencing fractures while taking appropriate antiresorptive therapy. There is no increased risk of upper gastrointestinal side effects in patients taking strontium ranelate. In the original clinical trial there was a significantly increased risk of diarrhoea in the short term after initiating strontium ranelate (Meunier et al, 2004). There are data indicating the efficacy of strontium ranelate in preventing vertebral and hip fractures. Good data also exist showing that it is effective in the prevention of vertebral and non-vertebral fractures in women aged over 80 years (Reginster et al, 2005). However, a recent European Medicines Agency (EMA) restriction on the use of strontium has limited its use to severe osteoporosis in postmenopausal women at high risk of fracture, or severe osteoporosis in men at high risk of fracture (EMA, 2013 [pdf]). This is because an increased incidence of myocardial infarction (MI) (but not in observed mortality) has been reported in strontium use. It is now contraindicated in patients with uncontrolled hypertension, current or past history of ischaemic heart disease, peripheral vascular disease, cerebrovascular disease. Other reported side effects include venous thromboembolism and a condition called DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome. It is imperative to advise patients to take oral bisphosphonates as recommended by the manufacturer. Severe oesophageal reactions have been reported with oral bisphosphonates. Alendronic acid is contraindicated in patients with abnormalities of the oesophagus and other factors which delay emptying (eg stricture or achalasia). In patients who experience mild upper gastrointestinal disturbance after commencing an oral bisphosphonate, a switch to an alternative bisphosphonate may yield a satisfactory result. Some patients with severe dowager’s hump may have swallowing difficulties that make it impracticable to take oral bisphosphonates. Both IV ibandronate and IV zoledronate have licences for the treatment of postmenopausal osteoporosis. Atypical femoral fractures have been reported in patients taking long-term bisphosphonate therapy. The characteristics of such fractures have been described by the American Society for Bone and Mineral Research (ASBMR) (Shane et al, 2010; Shane et al, 2013). It is believed that long-term bisphosphonate use suppresses bone remodelling, such that micro-cracks and stress fractures in the femoral diaphysis eventually develop into subtrochanteric fractures. Patients often report a prodrome of leg or groin pain for weeks prior to fracture, which can happen in the absence of trauma. Subtrochanteric fractures account for less than 10% of all hip and femur fractures and less than a third of these are associated with bisphosphonate use (Shane et al, 2010). It is important to remember that bisphosphonate therapy prevents far more vertebral and hip fractures than causes subtrochanteric fractures. If a patient has a suspected atypical femoral fracture associated with bisphosphonates, then the fracture requires fixation and the affected limb should be off-loaded. Partial fractures may be managed conservatively at first. Such fractures are often bilateral, so plain films of the contralateral femur should be obtained. The bisphosphonate should be stopped. In certain circumstances an anabolic agent such as PTH or strontium may be considered. Patients with such fractures should be managed with the input of an osteoporosis specialist in a tertiary referral service. The current cost of osteoporotic fractures to the UK economy is approximately £2 billion per year (Torgerson et al, 2001). Most of this is due to the cost of hip fractures and the care required for people who have lost their independence. The admission of patients with fractured neck of femur accounts for 20% of UK orthopaedic bed occupancy (Roche et al, 2005). Subtrochanteric fractures carry a similar morbidity burden to that of classic hip fractures. At 2 years post subtrochanteric fracture, 71% of patients cannot return to their previous living arrangements. Teriparatide is an anabolic drug derived from human ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika -oid hormone that is reserved for patients with high fracture risk who: have had an inadequate response to conventional therapies, or are unable to tolerate more standard therapies Teriparatide is NICE approved (NICE, 2011) for the secondary prevention of osteoporotic fractures in postmenopausal women who: are unable to take alendronate and either risedronate or etidronate, or have a contraindication to or are intolerant of alendronate and either risedronate or etidronate, or have a contraindication to or are intolerant of strontium ranelate, or have had an unsatisfactory response to treatment with alendronate, risedronate or etidronate and are 65 years or older and have a T-score of -4.0 SD or below, or a T-score of -3.5 SD or below plus more than two fractures, or are aged 55-64 years and have a T-score of -4.0 SD or below plus more than two fractures. Studies have shown that neither alendronate nor oestrogen replacement is an effective treatment for low bone density in young women with anorexia nervosa. The Royal College of Physicians (RCP) recommends that patients under the age of 65 who have been taking prednisolone (or equivalent steroid) at any dose for more than 3 months should have a bone density scan performed to help determine future management (RCP, 2002 [pdf]). If the T-score is -1.5 or lower, consideration should be given to starting an antiresorptive drug. Women taking depot medroxyprogesterone acetate are likely to experience losses in BMD while taking the drug. It is likely that BMD will be regained after withdrawal The exact contribution of depot medroxyprogesterone acetate to any increased risk of fracture is not clear at present. Amenorrhoea due to polycystic ovary syndrome is not mediated by oestrogen deficiency. Women with PCOS tend to have high circulating concentrations of oestrogens and are not at increased risk of accelerated bone loss or osteoporosis. There has been a small number of case reports of osteonecrosis of the jaw associated with oral bisphosphonate usage. The incidence of this complication is unknown but appears to be very rare. The exact cause of ONJ is unknown. Patients taking high doses of IV bisphosphonates for malignant diseases appear to be most at risk of ONJ. Patients who have suffered with ONJ tended to have dental caries and dental procedures performed while taking the drug. Therefore, it is appropriate for patients to have dental procedures performed prior to commencing an oral bisphosphonate for osteoporosis. Denosumab is a potent antiresorptive agent given by subcutaneous injection every 6 months. Its action is through the RANKL/ osteoprotegerin system, to reduce osteoclast activation. The FREEDOM trial demonstrated that denosumab had anti-fracture efficacy at vertebrae, hip and other non-vertebral sites (Papapoulos et al, 2012). Denosumab is not associated with change in renal function, but caution must be taken to ensure patients are vitamin D replete before its use (Miller, 2011). It is associated with symptomatic hypocalcaemia. As with bisphosphonates, denosumab is associated with atypical femoral fractures and osteonecrosis of the jaw. if patients are over the age of 65, they should be treated with an appropriate therapy to prevent steroid-induced bone loss without the necessity for a DXA scan. any dose of prednisolone (or equivalent steroid) has a detrimental effect on bone if used for longer than 3 months. Doses as low as prednisolone 2.5 mg per day have been shown to increase fracture risk. Higher doses of steroids are associated with a greater increased risk of fracture. Patients can lose up to 15% of their BMD within the first 6 months of treatment with steroids If a patient is predicted to take steroids for longer than 3 months, treatment with an appropriate bone-sparing agent should be commenced at initiation of steroid therapy. The risk of fracture increases rapidly after initiation of glucocorticoid therapy; the risk diminishes rapidly after withdrawal of treatment. Steroid-induced osteoporosis is a severe form of osteoporosis that is associated with a greatly increased risk of fracture. Alendronate, etidronate and risedronate are licensed for the prevention and treatment of glucocorticoid-induced osteoporosis. patients with steroid-induced osteoporosis fracture at higher levels of BMD than do patients with postmenopausal osteoporosis! Adherence and persistence with therapies for osteoporosis is low. Approximately 50% of patients will stop taking a bisphosphonate after 12 months. This figure falls to 30% after 24 months (Seeman et al, 2007). Reasons for discontinuation of bisphosphonates include: side effects need to be fasting remembering to take them not feeling that the drug works inconvenience frequency of taking dislike of long-term medications necessity to stay upright
  13. The menopause and hormone replacement therapy training module A diagnosis of menopause can generally be determined from the clinical presentation, depending on the woman’s age and presenting history. A history of irregular periods or amenorrhea at or around the age of the natural menopause (52 years), and the absence of other co-morbidities or red flag conditions may be considered indicative of the menopause. Hot flushes are a unique symptom of the menopause. The level of FSH is only helpful if the diagnosis is in doubt or if premature ovarian failure is suspected. The levels of FSH fluctuate rapidly during the menopause transition and therefore its diagnostic use is limited. A minimum of two tests at least 2 months apart may be required to confirm the diagnosis. Several lifestyle adaptations may help to reduce the severity of menopausal symptoms and these should be encouraged. Reducing caffeine and alcohol may improve the severity and frequency of vasomotor symptoms (Greendale and Gold, 2005). Regular aerobic exercise such as swimming or running is thought to be beneficial for vasomotor symptoms. Smoking and elevated BMI are associated with increased reporting of menopausal symptoms. Many of these lifestyle changes will have additional benefits beyond reducing menopausal symptoms, for example, reducing the risk of cardiovascular disease, osteoporosis and breast cancer. The menopause transition should therefore be seen as a window of opportunity to identify women at risk and encourage health prevention strategies to help reduce future morbidity. "Evidence from randomised controlled trials that alternative and complementary therapies improve menopausal symptoms or have the same benefits as HRT is poor" (British Menopause Society (BMS), 2008a). Many women perceive complementary therapies to be a safe alternative to HRT, however they should be advised that their use is not evidence based and safety concerns do exist. Some contain oestrogenic properties and therefore the risk of breast cancer is unclear; furthermore many have the potential for interaction with other medications. Although many complementary therapies have been studied, evidence for their efficacy and safety is lacking. Most carry a placebo effect of up to 50-60% improvement in menopausal symptoms, compared with 80-90% improvement with HRT (Royal College of Obstetricians and Gynaecologists (RCOG), 2010). However, due to the popularity of complementary therapies, clinicians should be able to discuss the risks and benefits of their use. Complementary therapies may have a role in women in whom oestrogen is contraindicated or in those who wish to avoid HRT. In women with mild symptoms, alternative therapies may provide adequate relief in combination with lifestyle measures. For women who choose to use alternative therapies, the preparations recommended should be as quality controlled and evidence based as possible (eg red clover isoflavones, which have strict quality control in the UK). Common groups include: -phytoestrogens: these are plant derivatives with oestrogenic properties. The most common group is the isoflavones, which can be found in and red clover. They appear to show some benefit in RCTs and meta-analyses, however efficacy for vasomotor symptom relief is lower with traditional HRT and more research needs to be done on major outcome measures (Panay et al, 2013) -herbal remedies: popular preparations include black cohosh, evening primrose oil, dong quai, ginko biloba and agnus castus. Little evidence exists to support their use in menopause Patients could be directed to the following article (Borelli and Ernst, 2010), which is a review of the use of complementary therapies for menopausal symptoms. Several non-hormonal options exist for the management of menopausal symptoms. Women should be adequately counselled regarding the risks and benefits of non-hormonal options and HRT, and an informed decision made. Non-hormonal medications can be of use in women who wish to avoid HRT or in whom it is contraindicated. Several alternatives to oestrogen-based therapy exist, however in general they only affect hot flushes and furthermore there is no evidence to suggest any benefits in terms of bone density: Progestogens, eg 5 mg/day norethisterone: these may improve hot flushes and night sweats and can be tried in women with severe vasomotor symptoms but with a contraindication to oestrogen. The long-term safety of progestogens is unclear and concerns exist regarding the risk of breast cancer associated with combined HRT compared with oestrogen-only HRT SSRI/ SNRIs: evidence suggests that the SSRIs such as fluoxetine, and SNRIs such as venlafaxine 37.5 mg BD, may reduce hot flushes (Panay et al, 2013). SNRIs can be very useful in women with breast cancer who are experiencing hot flushes and cannot have hormonal treatments. Not all SSRIs/ SNRIs are the same. There are concerns that paroxetine reduces the effectiveness of tamoxifen by inhibiting its bioactivation by cytochrome P450 2D6 (CYP2D6), resulting in an increased risk of death from breast cancer in women on tamoxifen (Kelly et al, 2010) Gabapentin: this anticonvulsant may improve hot flushes compared with placebo (Panay et al, 2013) Clonidine: this is an alpha adrenoreceptor agonist, originally developed as an antihypertensive. It is often used in doses of 50-75 mg daily. A recent meta-analysis suggests it may have modest benefit over placebo (Panay et al, 2013) A thorough assessment should be made to assess a woman who is considering starting HRT. The British Menopause Society recommends that the following information is considered: Patient history Periods, symptoms and contraception: Date of last menstrual period (could she be pregnant?) Frequency, heaviness and duration of periods Hot flushes and night sweats? Vaginal dryness? Other symptoms? Contraception: does she require it? If your patient needs contraception: Advise her to continue to use contraception for 1 year after the last menstrual period if she is older than 50, or for 2 years if she is younger than 50 Note that HRT is not contraceptive unless the levonorgestrel-releasing intrauterine system is being used as the progestogenic part of HRT (Faculty of Sexual & Reproductive Healthcare (FSRH), 2010 [pdf]) Personal or family medical problems: a) Breast/ ovarian/ bowel cancer in close family members: In parents, sisters or brothers or the patient themselves? At what age did they develop it? Deep vein thrombosis or pulmonary embolism in parents, brothers or sisters or the patient themselves: When and why: was it after a hip or knee replacement? Was the person on the pill or pregnant? Did they have any tests to confirm the clot? Were they treated with warfarin? c) Risk factors for heart disease and strokes: Has the patient had a heart attack or stroke already? Have her parents, brothers or sisters had a heart attack or stroke and if so at what age? Smoking, and if so how many? Hypertension or diabetes? High cholesterol level? d) Risk factors for osteoporosis: Was the menopause before the age of 45? Systemic corticosteroids for 6 months or more? Anorexia or significant weight loss? Family history (especially mother or sister) Low calcium or vitamin D intake or deficiency, or malabsorption disorders Has the patient had a fracture already, and if so how did it happen and where was it? e) Other: Migraines (not just headaches) What medicines they are taking, including herbal remedies and vitamin supplements Risk of pregnancy? What does the patient want? Does she want to take HRT or not? If yes, what preparation would she prefer? If not, what are her most important treatment endpoints? The menopause is a natural event and most women do not require HRT for symptom relief. Some women experience moderate to severe symptoms that affect their quality of life and ask for active intervention. For mild symptoms this may just involve simple dietary and lifestyle advice. For more severe symptoms HRT may be indicated. It is essential to determine the risks and benefits of HRT, based upon individual menopausal status and health status. Women should be adequately counselled before commencing HRT to discuss risks, benefits and possible side effects. Each woman’s individual risk will depend on age, personal and family history, duration of HRT usage and regimen: Women should be reassured that the risk of breast cancer associated with HRT is small (0.1% per annum) (Sturdee and Pines, 2011) Women who are about to start taking combined HRT should be advised of the small potential increased risk of breast cancer after 5 years of use (Hickey et al, 2005) The addition of progestogen increases the risk of breast cancer compared with oestrogen alone (BMS, 2008c) For clarity, risk should be presented in terms of absolute risk: Absolute risks: Breast cancer: for women aged 50-59 using combined HRT for 5 years there are an extra 6 cases of breast cancer per 1,000 women. This risk increases with age. There does not appear to be a significantly increased risk of breast cancer for women using combined HRT for up to 3 years and oestrogen-only therapy for 5 years Venous thromboembolism (VTE): in women aged 50-59 using oestrogen-only HRT, there are 2 extra cases of VTE per 1,000 women and for combined HRT there will be 7 additional cases of VTE per 1,000 women Stroke: in randomised controlled trials, both oestrogen-only and combined HRT increased the risk of stroke compared with placebo. In younger women the overall risk is very low, and therefore the absolute risk with HRT remains low Benefits: Symptoms: HRT is effective in treating symptoms associated with oestrogen deficiency Colorectal cancer: HRT has been shown to reduce the incidence of colorectal cancer Cardiovascular disease: in the 50-59 age group, HRT use does not result in an increased cardiovascular risk. There is increasing evidence to support a "window of opportunity" where HRT may be cardioprotective (Sturdee and Pines, 2011; MHRA, 2007 [pdf]; Marsden and Sturdee, 2009) Osteoporosis: HRT is effective in preventing and treating osteoporosis, and prevents both vertebral and hip fractures, however NICE does not recommend its use because of the long-term breast cancer risk (NICE, 2011a; NICE, 2011b). Although HRT has several health benefits beyond improving menopausal symptoms, current regulatory guidance (Committee on Safety of Medicines, 2003 [pdf]) states that HRT should not be prescribed as a first-line treatment for osteoporosis prevention in asymptomatic women. However, HRT is recommended first line for the prevention of osteoporosis in women with premature ovarian failure (POI) (Panay et al, 2013). It should be documented clearly in the patient's notes that a full discussion of the risks and benefits of HRT has taken place, along with alternative management options, and whether the patient has decided to take HRT or not. Hypertension is not a contraindication to HRT but may be considered a co-morbidity factor in stroke risk, if not controlled or with a known history of stroke or thrombophilia disorders. Referral to a specialist clinic would be advised in complex cases. All women should be advised to stop smoking, and the menopause is one of the few times in a woman’s life when they pause to reconsider their overall health, and might actually listen to your advice, and help to quit, if offered. In women with an intact uterus a progestogen should be given in addition to oestrogen to reduce the risk of endometrial hyperplasia. There are generally two different ways in which combined (oestrogen and progesterone) therapy is given: (i) Sequential therapy The progesterone is given for 10-14 days per cycle and therefore a monthly bleed occurs. This regimen is generally most appropriate for perimenopausal women to reduce the risk of irregular bleeding (ii) Continuous combined therapy The progesterone is given daily throughout the cycle and therefore no withdrawal bleed occurs. Continuous combined regimens are generally better for postmenopausal women such as those whose last menstrual period was longer than 12 months previously, those who have been on sequential regimens for at least 2 years, or those over 54 years Best practice guidelines state that HRT should be prescribed using the lowest effective dose to treat the symptoms, based on health benefits vs risk assessment. 1 mg oral estradiol is a standard starting dose. This should be titrated against symptom relief and risks (Sturdee and Pines, 2011). Sequential combined HRT is only required in the perimenopausal woman when menstrual bleeding has not stopped. It should be prescribed for 2 years if started under the age of 50 or 1 year after the age of 50. Continuous combined HRT is indicated for women who are 12 months past their last menstrual period (LMP). Some clinicians may start at 6 months from the LMP although there is an increased risk of breakthrough bleeding (BTB) and higher rate of non-compliance and discontinuation of treatment. Oral HRT is often the first choice when starting HRT. Transdermal HRT avoids liver first pass effects and therefore may be indicated in the event of many side effects, contraindications or patient preference. There is no evidence from placebo-controlled studies that HRT leads to weight gain. Many women will experience weight gain due to the reduction in basal metabolic rate and altered distribution of body fat that occurs postmenopausally. Women should therefore be educated regarding diet and lifestyle and considered for referral to a dietician. Several options exist if progestogenic side effects are a problem: decrease duration of progesterone to 10 or 7 days (but be aware of increased risk of endometrial hyperplasia of 2% and 4% respectively) reduce dose try an alternative progestogen (progesterone and dydrogesterone generally have fewer side effects) (Panay et al, 2013) use bioidentical progesterone, eg utrogestan, cyclogest, crinone use local route, eg levonorgestrel intrauterine system (Mirena®), crinone vaginal gel (unlicensed and expensive, but has role in women with severe progestogen intolerance) The levonorgesterel intrauterine system has the added advantages of inducing amenorrhoea, or lighter bleeds, at a time when women may be experiencing erratic heavy bleeding, and it is also contraceptive. The levonorgesterel intrauterine system has a 4-year license as the progestogenic element of combined HRT (Panay et al, 2013) try continuous combined therapy if postmenopausal Bilateral breast tenderness is a common side effect of initiating treatment and is caused by the progestogenic effect of fluid retention and the oestrogenic effect of stimulating breast tissue. HRT may exacerbate benign breast disease and development of breast cysts. Generalised mastalgia is readily managed with simple analgesics. There is some evidence that evening primrose oil is beneficial in relieving mastalgia (Blommers et al, 2002). A mammogram would only be indicated if abnormal pathology is suspected. Bilateral mastalgia is not a typical red flag for breast cancer which is generally unilateral. The WHI study concluded that oestrogen-only HRT is not associated with an increased risk of breast cancer in women between 50 and 60 years of age (WHI, 2002). All women should be encouraged to attend for routine national mammogram screening appointments. Initiating HRT may be straightforward. In some instances women may experience a number of side effects or problems. This will require a review of each problem to determine if there is an issue with compliance or aspects of the prescription. It is not unusual to have to try a number of preparations or consider changing the route and dose of HRT. Treatment should be used for 3 months where possible to fully assess the effects.
  14. Notes from EFT (Emotional Freedom Technique) Course Negative emotions create disruptions in the body's chi energy system. By tapping on certain Meridians, we clear the disruptions in energy flow. Gary Craig founded and evolved EFT. Patients tell their story, relive their trauma, explore their emotions, while tapping, to rebalance the pattern. The same recipe taps all Meridians and is called the 100% overhaul system. Prepare the patient, before the sequence, doing the setup, which consists of massaging the tender points underneath the collar bone, in circular motion, while repeating for three times: "Even though I have this fear of flying, I deeply and completely love and accept myself." The sequence of gentle tapping is: eyebrow medially-eyebrow laterally-underneath the eye-underneath the nose-underneath the lower lip-collar bone-arm pit-diaphragm-three points in our internal wrists-tips of fingers-top of the head. We test emotional scale decrement to zero. We alternate positive and negative statements during the sequence. After that, we proceed to the nine gamut procedure, with humming-eye movements-drinking water-counting, all while tapping on the dorsal part of patient's little finger depression: "Look forward, close eyes, open eyes, look hard down to the right, look hard down to the left, circle eyes clockwise, circle eyes anticlockwise, hum a song, count 5 to 1, drink some water, clear emotions to zero." Test effectiveness by ordering to try to bring out that negative feeling. In repeated sessions, the phrase transforms into: "Even though I still have a little bit of fear of flying, I deeply and completely love and accept myself" or "...the remainder of this fear for flying..." We tap together the karate chops/edges of our palms, on one another, during the reversal technique, for secondary benefit psychological syndromes, repeating the phrase: "Even though I cannot get rid of/don't want to get rid of/feel safe with/it is comfortable/has become part of my identity/I like my fear of flying, I still deeply and completely love and accept myself", in order to trick our subconscious. We break down to small independent pieces to tap on, the problem our patient reports. https://www.youtube.com/watch?v=kbBNaqsKatM https://www.youtube.com/watch?v=M5j-Wudv1to&feature=player_embedded
  15. Παροχές σε εκατοντάδες κενές θέσεις Ειδικών Ιατρών στη Σαουδική Αραβία, Ηνωμένα Αραβικά Εμιράτα, Κατάρ, κτλ. The benefits: Attractive Tax free Salary Relocation Package Fully Furnished Family Accommodation Free Malpractice Insurance Coverage Continuous Medical Education Family Medical Health Care Insurance Child Education Coverage Annually Air Tickets (Including Family Travel Packages) http://www.grecruitment.com/
  16. Γρήγορες κι αποτελεσματικές ψυχολογικές θεραπείες, με EFT!
  17. Παρακεταμόλη: προκαλεί εμφράγματα, εγκεφαλικά, υπέρταση, γαστρίτιδες, άσθμα, πρόωρους θανάτους από διάφορες αιτίες, και δεν είναι αποτελεσματικό παυσίπονο σε σύγκριση με το placebo! http://www.dailymail.co.uk/health/article-2976701/Paracetamol-linked-heart-attack-risk-Fears-high-doses-taken-long-time.html http://www.dailymail.co.uk/wires/pa/article-2976623/Careful-use-paracetamol-urged.html http://www.dailymail.co.uk/health/article-2703469/Paracetamol-no-effect-pain-Research-casts-doubt-popular-GP-remedy.html http://www.dailymail.co.uk/news/article-2703439/Paracetamol-no-better-placebo-treatment-pain-despite-recommended-doctors-years.html http://www.dailymail.co.uk/health/article-2058841/Paracetemol-linked-making-asthma-symptoms-worse-claims-new-report.html http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60805-9/abstract
  18. Notes from the Course of Rapid Hypnotic inductions: Relevance of the word "now". Perform sensory overload, using continuous instructions like "pull, push, οpen eyes, close eyes, relax leg, relax hand, raise leg, raise arm, etc Control hypnotizzability, with little stories, looking for sonnambulists. Shock induction or rapid redirection. "I shall always take care of you, watch you closely, keep you safe, make sure you succeed in what we are planning." "Follow my simple instructions without giving them much thought." "Hold my hand, press it, harder, harder, close your eyes, sleep!" Immediately after, we must use appropriate deepeners like stairs going down, stairs narrowing, stairs colored, stairs getting darker, massaging the "third eye", numbers decreasing, deep breaths with laser light coming in, fractionation, etc. We also move gently the patient's body back and forth, like a baby. When patients leave their dead weight on our shoulder, and are completely off balance, it is safe to say they entered hypnotic trance. Pattern interrupt using a handshake. We rapidly change hands, bring their hand close to their face, touch their forehead, ask το close eyes, cause confusion, say sleep, proceed with deepeners. We can repeat many times for fractionation. When patients lie on a chair, after the shock induction, we push their head backwards, and start moving it back and forth, like a baby. We should improvise new stimuli that lead to shock, confusion, redirection and trance, so as patients never expect them. I control hypnotic state by raising her relaxed hand holding it by the thumb. I also watch for catalepsy-stiff arm, slowing respiration rate, eyes watering, lips fattening, dry mouth, shoulders relaxing, REM, frequent swallowing. Fractionation repeats trance inductions over and over, each time going much deeper in trance, we guide patients in and out of trance. Fractionation is frequently used by religious evangelists, politicians, etc. These shock inductions work best with intelligent, controlling, educated patients, having a powerful personality that doubts everything. We must never hesitate, feel uncomfortable, but instead be decisive, sure, calm, even in our voice, to induce trust safety and efficiency. I must fix my gaze between their eyes, just above their nose, they must look at a spot under my eye. When patients follow my commands efficiently in trance, I reward them by saying "good" "perfect" "that's it". Elman induction is about overcoming the critical faculty, or suspension of disbelief. Firstly, we teach how to relax the body, part by part, one part at a time, and afterwards we teach how to relax the mind. "Η cannot relax for you, you have to do it yourself." Counting numbers backwards from 100 till they all vanish is a secure indication of trance. With our calm voice we repeat that "it is harder to see the numbers, they try but numbers fade away, they confuse the numbers, numbers fly away from them, numbers become very distant", etc. Betty-Erickson induction has patients focus on a spot on a wall, we tell 4 truisms about objects in their peripheral vision, we guide patients to relax muscles, we control their breathing. Alternatively, 4 kinesthetic stimuli could be used. Cerbone butterfly technique induces trance by rapidly moving fingers in front of patients' faces.
  19. 5πλάσιοι καρκίνοι ωοθηκών και μήτρας σε γυναίκες που έκαναν εξωσωματικές! Μελέτη εκατοντάδων χιλιάδων ασθενών, μέχρι 25 χρόνια μετά. http://link.springer.com/article/10.1007%2Fs00432-015-2035-x#
  20. Πως αντιμετωπίζεται η ασθένεια του φανατικού fan, επίμονου θαυμαστή που παρακολουθεί θύματα: http://www.jaapl.org/content/34/4/439.full.pdf
  21. Δεκάδες χιλιάδες προσωπικό, δεκάδες δις ευρώ κόστος, στρατιωτικοί δορυφόροι, αεροπλανοφόρα, βόμβες laser, jet stealth αεροπλάνα, πλαστικά εκρηκτικά τρίτης γενιάς, κάμερες ανίχνευσης θερμότητας, predator drones, υποβρύχια πυραυλικά συστήματα, συνεχείς επιθέσεις για ένα χρόνο-μέρα και νύχτα, και ο Βρετανικός Στρατός κατάφερε να σκοτώνει πόσους τζιχαντιστές τρομοκράτες του ISIS/Daesh τη μέρα; 1! http://www.telegraph.co.uk/news/uknews/defence/11870763/British-air-strikes-have-killed-330-Isil-terrorists-in-year.html
  22. Σε αυτό τη δημόσιο νοσοκομείο, είχαν τους ασθενείς δεμένους στα κρεβάτια τους, κλειδωμένους, παρατημένους. Καήκαν ζωντανοί βασανιστικά, ανήμποροι να διαφύγουν. Πουθενά στην Ευρώπη και στον Κόσμο δεν επιτρέπονται τέτοιες απαράδεκτες συνθήκες νοσηλείας, που για τον ΟΗΕ αποτελούν βασανιστήρια. Οι εργαζόμενοι και ολόκληρη η Διοίκηση του Τριτοβάθμιου Ψυχιατρικού Ιδρύματος πρέπει να συλληφθούν και να φυλακιστούν για έκθεση ασθενών σε κίνδυνο, κατάχρηση εξουσίας, βασανισμό κατά συρροή, καταπάτηση όλων των Δικαιωμάτων του Ανθρώπου της Χάρτας του ΟΗΕ, εγκληματική αμέλεια, ανθρωποκτονία εκ προθέσεως και κατά συρροή. http://www.zougla.gr/greece/article/fotia- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --nosokomio-dafni http://news247.gr/ ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika -seis/koinonia/katepeigoysa-ede- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --th-fwtia- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --dafni-demenoi- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --treis-trofimoi-poy-vrethhkan-nekroi.3647183.html http://www.iefimerida.gr/news/224478/tragodia- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --dafni-tesseris-telika- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --nekroi-apo-ti-fotia-eikones http://www.newsbomb.gr/ellada/news/story/621416/dafni-demenoi-apo-tis-ennea-to-vrady-mexri-tis-ennea-to-proi http://www.skai.gr/news/greece/article/291503/fotia- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --psuhiatriko-nosokomeio-dafniou-/ http://www.thetoc.gr/koinwnia/article/purkagia- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --dafni-apomakrunoun-astheneis http://www.news.gr/ellada/koinonia/article/235196/demenos- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --14-mhnes-me-imantes- ## no greeklish please&#33; ## - oxi fragolevantika grapste kalytera sta agglika --dafni.html
  23. Τζιχαντιστές πουλούν μπουκαλάκια με αίμα σφαγιασμένων Χριστιανών προς $100,000 το ένα!
  24. Λόγω τεράστιας έλλειψης Ιατρών στην Αγγλία, προσλαμβάνουν πλέον εξειδικευμένους νοσηλευτές για να αναλάβουν τα ιατρικά καθήκοντα! Οι μισθοί τους, όπως βλέπετε, θα είναι τριπλάσιοι των Ειδικών Ιατρών του ΕΣΥ, στα δημόσια μας νοσοκομεία! Όσοι εξειδικευμένοι νοσηλευτές και Ειδικοί Ιατροί μπάφιασαν με το ρημαγμένο κι απαξιωτικό μας ΕΣΥ, μπορούν να πάνε να βρουν εργασιακή ηρεμία, οικονομική ευμάρεια, οικογενειακή ευτυχία, στο NHS. Job Reference: 394-334X15 Employer: The Hillingdon Hospitals NHS Foundation Trust Department: Physician Associate (NPAEP) Location: Various Salary: £50,000 per annum The Trust only accepts applications made through this site, please register when you click APPLY at the end of this advertisement. The Trust is able to offer hospital accommodation, pension scheme, on-site nursery (through third party provider), together with salary sacrifice schemes (including child care vouchers, ride to work) and a range of national and local staff discounts (subject to availability). HSJ Best Places to Work 2015 Top 100 Physician Associates x 200 (NPAEP) Ref: 394-334X15 The National Physician Associate Expansion Programme (NPAEP) in England is seeking 200 Physician Assistants/Associates (PAs) to work in the English National Health Service (NHS) for a period of one to two years. Positions are available in a range of clinical specialties in over 40 host organisations across North West England, East Midlands, Yorkshire, Humber and Newcastle, and North West London. The Hillingdon Hospitals NHS Foundation Trust (THHFT) is formally hosting the NPAEP Programme and will be the employing organisation for participating PAs. If you are a PA with significant clinical experience, this is an exciting opportunity to live and work in the UK and to use and develop your skills in clinical excellence and leadership in an internationally acclaimed healthcare system. PAs are seen as a crucial part of England’s future healthcare workforce and the NHS will benefit from the input of experienced PAs to help embed the profession. NPAEP PAs will provide expert assistance to the lead clinician in their host organisation and the wider multidisciplinary team, and will participate in all aspects of the team’s activities as appropriate. They will be expected to perform delegated duties with a high degree of clinical skill and knowledge and to assist in clinical teaching and supervision of colleagues and students. In this way, NPAEP PAs will demonstrate the benefits associated with utilising PAs in the NHS. There will be a focus on acquiring further skills and expert knowledge in the relevant specialty field. NPAEP PAs will be supervised by a designated physician and will also have individual mentors to support their career development. Furthermore, NPAEP PAs will be supported in their interests to expand clinical proficiency, build upon leadership skills and improve performance of didactic and clinical teaching through a unique continuing professional development (CPD) program and the provision of scheduled, protected non-clinical time. Candidates must have: Significant clinical experience as a PA and/or completion of a post-graduate residency or fellowship program Current and valid certification with the National Commission on Certification for Physician Assistants (NCCPA) or Registration with the UK Physician Associate Managed Voluntary Registration Committee (PAMVRC) Evidence of continuing professional development/continuing medical education Experience in PA education, quality assurance, process improvement and clinical audit strongly preferred. PAs placed with the Programme will receive: £50,000 annual salary 33 days paid vacation, plus 8 additional public holidays Generous protected non-clinical time, for the NPAEP Continuing Professional Development program which will include networking opportunities and educational opportunities on topics relevant for PA clinical practice, PA education, as well as leadership training modules developed with the NHS Leadership Academy Residential on-boarding/induction in the UK Financial contribution towards relocation Reimbursement for costs of registration with the Physician Associate Managed Voluntary Registration Commission (PAMVRC) and membership of Faculty of Physician Associates at the Royal College of Physicians (formerly known as the UK Association of Physician Associates) Advice to obtain the relevant visa, find accommodation and about life and work in the UK. For more information including links and application instructions, please see the FULL ADVERT in the 'additional information' link below the job description and person specification. Closing date: Thursday, October, 22, 2015, in the first instance. Invites to interview will be sent out to candidates from Monday, September, 14, 2015 onwards. Interviews for candidates will be held at the following locations in the UK and the US: Thursday, September, 24-25, 2015 – Hillingdon Hospital, Hillingdon, London, UK Monday, October, 12, 2015 – Saturday, October, 17, 2015 Boston, Mass Tuesday, November, 17, 2015 – Saturday, November, 21, 2015 Seattle, WA Interviews will be offered in person at the locations above. Technology-assisted/remote interviews may be offered where there are available slots that cannot be filled by candidates attending in person. For further details contact: Rachel Stanfield, NPAEP Programme Director, rachel.stanfield@nhs.net We welcome applications from overseas. Applicants who require Tier 2 sponsorship to work in the UK are welcome and will be considered alongside all other applications. However, non-EEA candidates may not be appointed to a post if a suitably qualified, experienced and skilled EU/EEA candidate is available to take up the post as the employing body is unlikely, in these circumstances, to satisfy the Resident Labour Market Test. The UK Border Agency requires employers to complete this test to show that no suitably qualified EEA or EU worker can fill the post. For further information please visit the UK Border Agency website. Once a sufficient number of applications have been received the vacancy may be closed prior to the published closing down date. All contracts are issued under Agenda for Change Terms & Conditions of employment and all posts are subject to appropriate job matching or evaluation process, where indicated. Applications are welcome from all sections of the community to ensure our workforce is representative of the population. Please note that all candidates at risk in London and going through the NHS London Redeployment scheme are to be given priority as part of the recruitment process where their application meets the essential criteria for the role. https://www.jobs.nhs.uk/xi/vacancy/12e14530f711d850b8b414e47e8f02c2/?vac_ref=913883690
  25. Μάθετε μια ξένη γλώσσα γρήγορα, ακούραστα κι αποτελεσματικά! http://www.pimsleur.com/learn-spanish-latin-american/pimsleur-spanish-levels-1-4-unlimited-software/9781442348714 http://www.pimsleur.com/learn-italian/pimsleur-italian-levels-1-4-unlimited-software/9781442367869 http://www.pimsleur.com/learn-arabic-modern-standard/pimsleur-arabic-(modern-standard)-levels-1-2-mp3/9781442376595 http://www.linguaphone.co.uk/levels/beginner-to-intermediate/spanish-all-talk-download-course.html http://www.linguaphone.co.uk/levels/beginner-to-intermediate/italian-all-talk-mp3-download-language-course.html http://www.collins.co.uk/product/9780007363971/Learn+Spanish+with+Paul+Noble http://www.collins.co.uk/product/9780007486267/Learn+German+with+Paul+Noble http://www.collins.co.uk/product/9780007363957/Learn+French+with+Paul+Noble
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