karanti maria's topic

[karanti_maria]

Η τεράστια έλλειψη Γενικών Ιατρών στην Αγγλία αναγκάζει τους Αξιωματούχους του Υπουργείου Υγείας και τους Διοικητές Νοσοκομείων να γεμίσουν τα κενά κλινικής εξέτασης και συνταγογράφησης με νοσηλευτές!

Οι Γενικοί Ιατροί στην Αγγλία έχουν τουλάχιστον 11 χρόνια εκπαίδευσης πριν θεωρηθούν ικανοί να βλέπουν ασθενείς.

Οι νοσηλευτές θα αποκτούν τα ίδια καθήκοντα μετά από εκπαίδευση 4 μηνών!

Έχει να πεθάνει κόσμος και κοσμάκης...

http://www.telegraph.co.uk/news/nhs/11804730/Paramedics-to-be-trained-as-GPs.html

http://www.dailymail.co.uk/news/article-3198761/Paramedics-16-weeks-training-stand-GPs.html

[karanti_maria]

Thousands of breast cancer patients have debilitating surgery 'needlessly' for early form of tumours which won't harm them!

http://www.dailymail.co.uk/health/article-3205431/Thousands-breast-cancer-patients-debilitating-surgery-needlessly-early-form-tumours-won-t-harm-them.html

[karanti_maria]

ΖΗΤΟΥΝΤΑΙ ΕΛΛΗΝΕΣ ΕΙΔΙΚΟΙ ΚΑΙ ΕΙΔΙΚΕΥΟΜΕΝΟΙ ΓΙΑΤΡΟΙ ΟΛΩΝ ΤΩΝ ΕΙΔΙΚΟΤΗΤΩΝ

ΣΤΗ ΓΕΡΜΑΝΙΑ

ΠΡΟΣΦΕΡΟΝΤΑΙ ΤΜΗΜΑΤΑ ΕΚΜΑΘΗΣΗΣ ΓΕΡΜΑΝΙΚΩΝ ΣΤΗ ΓΕΡΜΑΝΙΑ ΚΑΘΩΣ ΚΑΙ ON LINE ΑΤΟΜΙΚΑ ΜΑΘΗΜΑΤΑ

Παρουσίαση των υπηρεσιών μας στην εκδήλωση που θα γίνει

στις 2 Σεπτεμβρίου 2015 και ώρα 8 μμ. στη Θεσσαλονίκη

Ξενοδοχείο Mediterranean Palace

Σαλαμίνος 3 – Θεσσαλονίκη, Αίθουσα «Nafsika»

Δυνατότητα προσωπικών συνεντεύξεων από το πρωί της 2ας Σεπτεμβρίου κατόπιν ραντεβού

Πληροφορίες στο 6972132914 και στο Email: softhom@otenet.gr

[karanti_maria]

Όλα τα φαρμακευτικά σκευάσματα που κυκλοφορούν στην Αγγλία και τα χαρακτηριστικά τους!

https://www.medicines.org.uk/emc/search

[karanti_maria]

Ενδιαφέρον ιατρικό blog γεμάτο χρήσιμες πληροφορίες!

http://www.kevinmd.com/blog/

[karanti_maria]

Τα χαρίζω, σας τα στέλνω.

Rapid German (Musical Brain Trainer) (v. 1+2) (Audiobook) By Earworms Learning

German, English | 2007 | ISBN: 190544303X | MP3 + PDF |

Earworms is a revolutionary accelerated learning technique that takes the hard work out of learning.

By listening to these specially composed melodies with their rhythmic repetitions of German and English a few times, you pick up over 200 essential words and phrases that will not just be on the tip of your tongue, but will be burned deeply into your long-term memory in next to no time.

If you like music, and want to make rapid progress without any formal knowledge of language learning, earworms mbt© Rapid German is the course for you.

Volume 1 is your survival kit of essential words and phrases to get you by on your trip abroad. Volume 2 will have you talking about yourself, past, present, and future, expressing your opinions, chatting, and flirting (who knows?).

Volume 2 will have you talking about yourself (past, present, and future), chatting, and even flirting!

This audiobook also comes with a free booklet to accompany the course which you can download by clicking on this link. Free booklets.

You will feel you are learning within minutes and might just be amazed by how easy acquiring a language can be!

http://earwormslearning.com/store/index.php?route=product/product&path=100&product_id=74

[karanti_maria]

Our client is an NHS Trust based in the Home Counties. They require Gastroenterology Consultant cover ASAP, for at least 3 Months. We can offer a regular locum booking at this Trust. Please contact us even if you are not available for this specific position, as we have ongoing requirements all over the UK.

You will need recent Gastroenterology experience, full GMC registration and the right to work in the UK.

• 3-6 Month bookings
• Shifts are mainly 8am to 5pm, plus 1:5 on call
• Pay is £120 per hour

Why choose Merco?

As a government approved framework agency, Merco Medical receive new bookings daily from Trusts all over England, Scotland and Wales. Whether you are recently qualified or a seasoned locum, we will work with you on a personal and consultative basis to secure locum work that meets your preferences – we are not a call centre! Register with Merco and you will receive:

• Suitable locum job opportunities
• Excellent hourly pay rates
• Personal attention from your own dedicated Account Manager
• Prompt weekly payments
• Revalidation support

We can fast track your registration to get you working quickly. For more details about this locum job, or something similar, click apply below or contact Andrew Brooks in our Doctor Registrations Team on 0208 947 3077 or info@merco.co.uk – evening and weekend enquiries welcome.

[karanti_maria]

Το πιο χρήσιμο χειρουργικό εργαλείο!

BIPOLAR NON STICK SEALER SPECIAL COATED REUSABLE FORCEPS PIN 4MM 9.5" ELECTRO SURGICAL INSTRUMENTS CE.

All Products Are Excellent Quality With 100% Satisfaction Guaranteed.

• High quality Medical Standard Stainless Steel.
• Autoclaveable and Sterilizable.
• ISO 9001- 2000, FDA and CE Mark registered Manufacturer.
• Quality can’t be compared with cheap alternatives.
• Actual pictures, so you can see what you are going to buy.

• Note: If you are not satisfied with your purchase for any reason, please contact us before leaving negative or neutral feedback.

• Guarantee:

  30 days money back guarantee if product is found faulty.

  Postage:

• P & P includes packing, postage and handling costs
• Combined postage: As all the items are of different sizes and carry different weights, therefore postage will be combined depending on weight for multiple products in one transaction. Please wait for invoice before you pay or ask for an estimate before you buy.
• Item will be posted next working day after receiving cleared funds.

http://www.ebay.com/itm/BIPOLAR-NON-STICK-SEALER-REUSABLE-FORCEPS-PIN-4MM-9-5-SURGICAL-INSTRUMENTS-CE-/151215209494?hash=item233520fc16

[karanti_maria]

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

[karanti_maria]

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

[karanti_maria]

Τζιχαντιστές πουλούν μπουκαλάκια με αίμα σφαγιασμένων Χριστιανών προς $100,000 το ένα!

[karanti_maria]

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! ## - oxi fragolevantika grapste kalytera sta agglika --nosokomio-dafni

http://news247.gr/ ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika -seis/koinonia/katepeigoysa-ede- ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika --th-fwtia- ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika --dafni-demenoi- ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika --treis-trofimoi-poy-vrethhkan-nekroi.3647183.html

http://www.iefimerida.gr/news/224478/tragodia- ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika --dafni-tesseris-telika- ## no greeklish please! ## - 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! ## - oxi fragolevantika grapste kalytera sta agglika --psuhiatriko-nosokomeio-dafniou-/

http://www.thetoc.gr/koinwnia/article/purkagia- ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika --dafni-apomakrunoun-astheneis

http://www.news.gr/ellada/koinonia/article/235196/demenos- ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika --14-mhnes-me-imantes- ## no greeklish please! ## - oxi fragolevantika grapste kalytera sta agglika --dafni.html

[karanti_maria]

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

[karanti_maria]

Πως αντιμετωπίζεται η ασθένεια του φανατικού fan, επίμονου θαυμαστή που παρακολουθεί θύματα:

http://www.jaapl.org/content/34/4/439.full.pdf

[karanti_maria]

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#

[karanti_maria]

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. 

[karanti_maria]

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

[karanti_maria]

Γρήγορες κι αποτελεσματικές ψυχολογικές θεραπείες, με EFT! 

 

[karanti_maria]

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/

[karanti_maria]

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

 

 

 

[karanti_maria]

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.

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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! ## - 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! ## - oxi fragolevantika grapste kalytera sta agglika -oid hormone/ vitamin D, eg osteomalacia, secondary hyper ## no greeklish please! ## - 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! ## - 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

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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.

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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).

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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&#33; ## - 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&#33; ## - 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).