Wednesday, August 27, 2003
childcare services
try website
Establishment of a nationally coordinated childcare advice service throughout the NHS. All staff in the NHS now have access to a childcare coordinator, who can provide advice and support concerning the provision of nursery places for preschool children and appropriate childcare for school aged children. Details of local childcare coordinators can be found at www.doh.gov.uk/iwl.
try website
Establishment of a nationally coordinated childcare advice service throughout the NHS. All staff in the NHS now have access to a childcare coordinator, who can provide advice and support concerning the provision of nursery places for preschool children and appropriate childcare for school aged children. Details of local childcare coordinators can be found at www.doh.gov.uk/iwl.
BMJ 2003;327:434-436 (23 August) infertilityABC of subfertility
One in six couples have an unwanted delay in conception
Most couples presenting with a fertility problem do not have absolute infertility (that is, no chance of conception), but rather relative subfertility with a reduced chance of conception because of one or more factors in either or both partners. Most couples with subfertility will conceive spontaneously or will be amenable to treatment, so that only 4% remain involuntarily childless. Conception is most likely to occur in the first month of trying (about a 30% conception rate). The chance then falls steadily to about 5% by the end of the first year. Cumulative conception rates are around 75% after six months, 90% after a year, and 95% at two years. Subfertility is defined as a failure to conceive after one year of unprotected regular sexual intercourse.
A strong association exists between subfertility and increasing female age. The reduction in fertility is greatest in women in their late 30s and early 40s. For women aged 35-39 years the chance of conceiving spontaneously is about half that of women aged 19-26 years. The natural cumulative conception rate in the 35-39 age group is around 60% at one year and 85% at two years.
The age related decline in female fecundity is caused by a steadily reducing pool of competent oocytes in the ovaries.
The chance of conception in an ovulatory cycle is related to the day in the cycle on which intercourse takes place. The window of opportunity lasts six days, ending on the day of ovulation. A study by Dunson et al (2002) showed that the probability of conception rose from six days before ovulation, peaked two days before ovulation, then fell markedly by the day of ovulation. This shows that sperm need to be deposited in the female genital tract before ovulation to maximise chances of conception. This is consistent with the progesterone induced changes in cervical mucus that occur immediately after ovulation and impede the penetration of sperm.
Preconception advice
--------------------------------------------------------------------------------
Pre-existing medical problems*
• Stabilise medical conditions and ensure that medical control is optimal
• Check that drugs needed are safe for use in pregnancy and do not affect sperm function
• Where appropriate, refer woman to an obstetric physician for advice on implications of the condition in pregnancy
Weight
• Check BMI
• Advise on weight gain or loss where BMI is < 20 or > 30
Smoking
• Advise both partners to stop smoking
Recreational drugs
• Advise both partners to stop using recreational drugs
Folic acid
• Women who are trying to conceive should take folic acid supplements (0.4 mg) daily to reduce the risk of neural tube defects. Women with a history of neural tube defect or epilepsy should take 5 mg daily
Virology screening
• Screen for rubella immunity and offer immunisation to those not immune
• Consider screening for HIV and hepatitis B and C in groups at risk
Prenatal diagnosis
• Tell older women about options for prenatal diagnosis
Timing of intercourse
• Check couple's understanding of ovulatory cycle and relate most fertile days to the length of woman's cycle
• Advise that intercourse occurs regularly. Two to three times a week should cover the most fertile time
Factors affecting fertility
• Discuss any factors in either partner's history that might warrant early referral for specialist infertility advice
* For example, hypertension, diabetes, epilepsy, thyroid disorder, cardiac problems, and drug history
•Management of infertility in primary care: The initial investigation and management of the infertile couple. Evidence based clinical guidelines, 1998 www.rcog.org.uk/guidelines.asp?pageID = 108&GuidelineID = 25
One in six couples have an unwanted delay in conception
Most couples presenting with a fertility problem do not have absolute infertility (that is, no chance of conception), but rather relative subfertility with a reduced chance of conception because of one or more factors in either or both partners. Most couples with subfertility will conceive spontaneously or will be amenable to treatment, so that only 4% remain involuntarily childless. Conception is most likely to occur in the first month of trying (about a 30% conception rate). The chance then falls steadily to about 5% by the end of the first year. Cumulative conception rates are around 75% after six months, 90% after a year, and 95% at two years. Subfertility is defined as a failure to conceive after one year of unprotected regular sexual intercourse.
A strong association exists between subfertility and increasing female age. The reduction in fertility is greatest in women in their late 30s and early 40s. For women aged 35-39 years the chance of conceiving spontaneously is about half that of women aged 19-26 years. The natural cumulative conception rate in the 35-39 age group is around 60% at one year and 85% at two years.
The age related decline in female fecundity is caused by a steadily reducing pool of competent oocytes in the ovaries.
The chance of conception in an ovulatory cycle is related to the day in the cycle on which intercourse takes place. The window of opportunity lasts six days, ending on the day of ovulation. A study by Dunson et al (2002) showed that the probability of conception rose from six days before ovulation, peaked two days before ovulation, then fell markedly by the day of ovulation. This shows that sperm need to be deposited in the female genital tract before ovulation to maximise chances of conception. This is consistent with the progesterone induced changes in cervical mucus that occur immediately after ovulation and impede the penetration of sperm.
Preconception advice
--------------------------------------------------------------------------------
Pre-existing medical problems*
• Stabilise medical conditions and ensure that medical control is optimal
• Check that drugs needed are safe for use in pregnancy and do not affect sperm function
• Where appropriate, refer woman to an obstetric physician for advice on implications of the condition in pregnancy
Weight
• Check BMI
• Advise on weight gain or loss where BMI is < 20 or > 30
Smoking
• Advise both partners to stop smoking
Recreational drugs
• Advise both partners to stop using recreational drugs
Folic acid
• Women who are trying to conceive should take folic acid supplements (0.4 mg) daily to reduce the risk of neural tube defects. Women with a history of neural tube defect or epilepsy should take 5 mg daily
Virology screening
• Screen for rubella immunity and offer immunisation to those not immune
• Consider screening for HIV and hepatitis B and C in groups at risk
Prenatal diagnosis
• Tell older women about options for prenatal diagnosis
Timing of intercourse
• Check couple's understanding of ovulatory cycle and relate most fertile days to the length of woman's cycle
• Advise that intercourse occurs regularly. Two to three times a week should cover the most fertile time
Factors affecting fertility
• Discuss any factors in either partner's history that might warrant early referral for specialist infertility advice
* For example, hypertension, diabetes, epilepsy, thyroid disorder, cardiac problems, and drug history
•Management of infertility in primary care: The initial investigation and management of the infertile couple. Evidence based clinical guidelines, 1998 www.rcog.org.uk/guidelines.asp?pageID = 108&GuidelineID = 25
BMJ 2003;327:393 (16 August)
Diagnosing pulmonary embolism in primary care
use pulse oximetry after exercise can help diagnose PE in fit low risk pts with no physical signs
Diagnosing pulmonary embolism in primary care
use pulse oximetry after exercise can help diagnose PE in fit low risk pts with no physical signs
BMJ 2003;327:389-391 (16 August)
Appraisal: the catalyst of personal development
Maurice Conlon, director of GP appraiser training programme
good article
Appraisal: the catalyst of personal development
Maurice Conlon, director of GP appraiser training programme
good article
Monday, August 11, 2003
British heart foundation factfile 8/2003
what are cardiac troponins
good article as troponins are more sensitive than creatine kinase
but does our lab do them?
what are cardiac troponins
good article as troponins are more sensitive than creatine kinase
but does our lab do them?
Friday, August 08, 2003
Volume 327, Number 7410, Issue of 9 Aug 2003
Short interpregnancy interval is associated with adverse outcome
Conceiving shortly after giving birth is independently associated with preterm birth and neonatal death. In an analysis of almost 90 000 women having second births after an uncomplicated first birth at term, Smith and colleagues (p 313) found that, after demographic factors were adjusted for, women with an interpregnancy interval of less than six months had a 60% excess of moderately preterm birth, double the risk of extremely preterm birth, and almost four times the risk of neonatal death. The authors state that strategies to reduce the number of women who have very short intervals between pregnancies may reduce the numbers of preterm births.
pregnancy
Short interpregnancy interval is associated with adverse outcome
Conceiving shortly after giving birth is independently associated with preterm birth and neonatal death. In an analysis of almost 90 000 women having second births after an uncomplicated first birth at term, Smith and colleagues (p 313) found that, after demographic factors were adjusted for, women with an interpregnancy interval of less than six months had a 60% excess of moderately preterm birth, double the risk of extremely preterm birth, and almost four times the risk of neonatal death. The authors state that strategies to reduce the number of women who have very short intervals between pregnancies may reduce the numbers of preterm births.
pregnancy
Volume 327, Number 7410, Issue of 9 Aug 2003
Acute low back pain usually improves within a month, then recurs
People with low back pain show rapid improvements in pain and disability within one month but typically have a recurrence within a year. Pengel and colleagues (p 323) systematically reviewed 15 studies on the course of acute low back pain and sciatica. They found that most people who were initially off work returned to work within a month, but low levels of pain and disability persisted after three months. These findings contradict clinical practice guidelines, which imply that recovery from acute low back pain is rapid and complete.
Acute low back pain usually improves within a month, then recurs
People with low back pain show rapid improvements in pain and disability within one month but typically have a recurrence within a year. Pengel and colleagues (p 323) systematically reviewed 15 studies on the course of acute low back pain and sciatica. They found that most people who were initially off work returned to work within a month, but low levels of pain and disability persisted after three months. These findings contradict clinical practice guidelines, which imply that recovery from acute low back pain is rapid and complete.
Volume 327, Number 7410, Issue of 9 Aug 2003
Tennis elbow is helped by NSAIDs in the short term
In an excerpt from Concise Clinical Evidence (p 329), Assendelft and colleagues review the evidence for treatments for tennis elbow (also known as lateral epicondylitis). Topical non-steroidal anti-inflammatory drugs (NSAIDs) are safe and effective for pain relief in the short term, and there is some evidence of benefit from oral NSAIDs. The treatments for which effectiveness is still unknown include acupuncture, exercise, extracorporeal shock wave therapy, surgery, braces, and NSAIDs in the long term. In an accompanying commentary, Mellor (p 330) cautions against seeing this review as definitive: many trials have been short term, during which tennis elbow often spontaneously resolves; more research is needed on treating chronic tennis elbow.
Tennis elbow is helped by NSAIDs in the short term
In an excerpt from Concise Clinical Evidence (p 329), Assendelft and colleagues review the evidence for treatments for tennis elbow (also known as lateral epicondylitis). Topical non-steroidal anti-inflammatory drugs (NSAIDs) are safe and effective for pain relief in the short term, and there is some evidence of benefit from oral NSAIDs. The treatments for which effectiveness is still unknown include acupuncture, exercise, extracorporeal shock wave therapy, surgery, braces, and NSAIDs in the long term. In an accompanying commentary, Mellor (p 330) cautions against seeing this review as definitive: many trials have been short term, during which tennis elbow often spontaneously resolves; more research is needed on treating chronic tennis elbow.
BMJ 2003;327:249 (2 August)
The authors used the PSA concentration from the initial enrolment visit to determine the sensitivity and specificity of the test at various cut-off values.
The authors used a receiver operating characteristics curve to plot the diagnostic accuracy of the various cut-off values. They found that, 82% of the time, men aged under 60 who had prostate cancer nonetheless had a PSA concentration that was considered normal. Currently, a PSA concentration of 4 ng/ml is considered normal.
According to those criteria, only 2% of the men had a false positive result—they had an abnormal PSA concentration (>4 ng/ml), but subsequent biopsy showed that they did not have prostate cancer.
The authors found that lowering the threshold from 4.0 to 2.6 ng/ml would double the rate of detection of cancer to 36%, although it would also increase the number of false positives.
In an accompanying editorial Dr Fritz Schroder and Dr Ries Kranse of the Erasmus Medical Center in Rotterdam said there was no conclusive evidence that the PSA screening test actually reduces the risk of death from prostate cancer without reducing men's quality of life.
The American Cancer Society's current recommendations say that a PSA concentration above 4.0 but less than 10 ng/ml means a 25% chance of having prostate cancer.
The risk is more than 67% for concentrations above 10 ng/ml, the recommendations say.
The authors used the PSA concentration from the initial enrolment visit to determine the sensitivity and specificity of the test at various cut-off values.
The authors used a receiver operating characteristics curve to plot the diagnostic accuracy of the various cut-off values. They found that, 82% of the time, men aged under 60 who had prostate cancer nonetheless had a PSA concentration that was considered normal. Currently, a PSA concentration of 4 ng/ml is considered normal.
According to those criteria, only 2% of the men had a false positive result—they had an abnormal PSA concentration (>4 ng/ml), but subsequent biopsy showed that they did not have prostate cancer.
The authors found that lowering the threshold from 4.0 to 2.6 ng/ml would double the rate of detection of cancer to 36%, although it would also increase the number of false positives.
In an accompanying editorial Dr Fritz Schroder and Dr Ries Kranse of the Erasmus Medical Center in Rotterdam said there was no conclusive evidence that the PSA screening test actually reduces the risk of death from prostate cancer without reducing men's quality of life.
The American Cancer Society's current recommendations say that a PSA concentration above 4.0 but less than 10 ng/ml means a 25% chance of having prostate cancer.
The risk is more than 67% for concentrations above 10 ng/ml, the recommendations say.
Volume 327, Number 7409, Issue of 2 Aug 2003
Participants who ate fish at least once a week had a 60% lower risk of developing Alzheimer’s disease than people who rarely or never ate fish (relative risk 0.4 (95% confidence interval 0.2 to 0.9)). Total intake of omega 3 polyunsaturated fatty acids was also inversely associated with the development of the disease, with people whose consumption was in the top 20% having a risk that was 70% lower than the risk among people in the lowest 20%.
While it is not known exactly why fish is protective, the secret may lie in the high content of omega 3 fatty acids in fish. These fish oils may stabilise phospholipid concentrations in the brain membrane and may influence neurotransmitter function. Several epidemiological and animal studies have supported a protective role for omega 3 polyunsaturated fatty acids and suggested that they have a positive effect on learning and memory.
Participants who ate fish at least once a week had a 60% lower risk of developing Alzheimer’s disease than people who rarely or never ate fish (relative risk 0.4 (95% confidence interval 0.2 to 0.9)). Total intake of omega 3 polyunsaturated fatty acids was also inversely associated with the development of the disease, with people whose consumption was in the top 20% having a risk that was 70% lower than the risk among people in the lowest 20%.
While it is not known exactly why fish is protective, the secret may lie in the high content of omega 3 fatty acids in fish. These fish oils may stabilise phospholipid concentrations in the brain membrane and may influence neurotransmitter function. Several epidemiological and animal studies have supported a protective role for omega 3 polyunsaturated fatty acids and suggested that they have a positive effect on learning and memory.
Friday, August 01, 2003
Volume 327, Number 7409, Issue of 2 Aug 2003
The best way to protect infants is to ban smoking in the home
Banning smoking in the home had a small but significant effect in reducing infants' exposure to environmental tobacco smoke, and less strict strategies have no effect. In a cross sectional survey in two British cities, Blackburn and colleagues (p 257) examined the measures used by parents who smoked to protect their infants from exposure to tobacco smoke in the home. Though most parents used harm reduction strategies such as keeping windows open and avoiding smoking near the baby, the authors found—by testing urinary cotinine to creatinine ratios in the infants—that only banning smoking made a difference.
The best way to protect infants is to ban smoking in the home
Banning smoking in the home had a small but significant effect in reducing infants' exposure to environmental tobacco smoke, and less strict strategies have no effect. In a cross sectional survey in two British cities, Blackburn and colleagues (p 257) examined the measures used by parents who smoked to protect their infants from exposure to tobacco smoke in the home. Though most parents used harm reduction strategies such as keeping windows open and avoiding smoking near the baby, the authors found—by testing urinary cotinine to creatinine ratios in the infants—that only banning smoking made a difference.
