Iron Deficiency Anaemia

As we improve our preventative health screening practices in Remote Indigenous Health we inevitably encounter incidental abnormalities in routine pathology. Given our limited resources and developing recall systems, what do we do about them?

The ABS report that remote indigenous populations are 2-3 times as likely to suffer from anaemia compared to their urban counterparts. A prevalence of greater than 5% is considered by the World Health Organization to be of public health significance. Childhood iron deficiency anaemia has been reported as high as 90% in some remote communities and has been associated with cognitive and psychomotor delay.

Incidental Eosinophilia

As we improve our preventative health screening practices in Remote Indigenous Health we inevitably encounter incidental abnormalities in routine pathology.  Given our limited resources and developing recall systems, what do we do about them?  Over the next few weeks we will address a handful of common queries and a sensible approach to management.

Eosinophilia is a common finding in this region. Continue reading “Incidental Eosinophilia”

Professional Burn Out – Am I Enough?

Behind every committed professional is the quietly disconcerting question “Am I enough?”

Our profession is full of them; harm avoidant, reward dependent, goal orientated individuals.  However in remote practice, these effective traits can lead to frustration and burn out.  Supporting systems are still in development, recruitment and retention is difficult and workforce shortages restrict ideal models of care.  Shifting roles and responsibilities with unclear expectations and excessive workload are risk factors and common challenges in remote medicine.  The usual response is to try harder.  We work longer hours, take on more responsibility, fill the gaps, often at great personal cost.

https://www.racgp.org.au/Education/Curriculum/Doctors’-health

We work in challenging environments with multiple risk factors for professional burn out.  Acceptance of our limitations within such environments is an important protective exercise, and yes colleagues: You are enough.

Q. Is bed rest an effective treatment for anything?

  • Meta-analysis on 39 randomised control trials for 15 different conditions (5777 patients)

Following a medical procedure: Out 24 RCTs-No outcomes improved significantly

  • 8 worsened significantly in some procedures
  • Lumbar puncture – vertigo, nausea and vomiting (no significant improvement in headache)
  • Spinal anaesthesia – headache, back pain
  • Radiculography – headache, nausea,vomiting, dizziness
  • Cardiac catheterisation – haematoma,pain, bleeding

As a treatment Out of 19 RCTs-No outcomes improved significantly

  • 9 worsened significantly for some conditions
  • Acute low back pain – disability (day 1, day 7 and day 28), normal activity, pain
  • Labour – length of stay, contraction frequency, assisted delivery, anaglesia required, APGAR score
  • Proteiunuric hypertension during pregnancy – plasma urea and urate, premonitory symptoms of eclampsia
  • Myocardial infarction – VTE, mortality, non-fatal reinfarction, ischaemia or congestive cardiac failure
  • Acute infection hepatitis – time to recovery

A. There is no evidence that bed rest has any significant beneficial effect when used as a treatment or following a procedure. In some disorders, it seems to be harmful.

What is the appropriate mode of delivery after a previous shoulder dystocia?

 

  • The rate of SD in women who have had a previous SD has been reported to be 10 times higher than the rate in the general population.There is a reported recurrence rate of SD of between 1% and 25%.May be an underestimate due to selection bias,as CS may have been advocated for pregnancies after severe SD esp with a poor neonatal outcome.(Level 3 evid).
  • Either CS or vaginal delivery can be appropriate.(Recommendation Level D).There is no requirement to recommend elective CS routinely,but factors such as severity of any previous neonatal or maternal injury,predicted fetal size and maternal choice should all be considered and discussed with the woman and her family,in planning the next delivery.(Level 4 evid)

Does induction of labour prevent shoulder dystocia?

  •  Early IOL for women with suspected fetal macrosomia,who do not have gestational diabetes,does not improve either maternal or fetal outcome.(Evid level 4)
  • In women with gestational diabetes, the incidence of SD is reduced with early IOL.(Evid level 2+)
  • The NICE diabetes guideline recommends that pregnant women with diabetes who have a normally grown fetus should be offered elective birth through IOL,or by elective CS if indicated, after 38 completed weeks
  • Infants of diabetic mothers have a 2-4 fold increased risk of SD compared with infants of the same birth weight born to non diabetic mothers.
  • IOL does not prevent SD in non-diabetic women with a suspected macrosomic fetus.(Recommendation Level D)
  • IOL at term can reduce the incidence of SD in women with GDM.(Recommendation Level B)

References

  • Baskott TF,AllenAC.Perinatal implications of SD.Obstet Gynecol 1995;86:14-7
  • SmithRB,LaneC,PearsonJF.SD:what happens at the next delivery?Br J Obs Gynae 1994;101:713-15
  • AskerDB,SachsBP,FriedmanEA.Risk Factors for SD.Obs Gynae 1985;66:762-8
  • NesbittTS,GilbertWM,HerrchenB.SD and assoc RFs with macrosomic infants born in California.Am J O&G 1998:179:476-80
  • BaherAM.RFs and fetal outcome in cases of SD compared with normal deliveries of a similar birthweight.Br J Obst Gynae 1996:103:868-72
  • Centre for Reviews and Dissemination,NHS National Institute for Health Research.Expectant Mx vs IOL for suspected fetal macrosomia:a systematic review.Database of Abstracts of reviews of effectiveness 2004:2:2
  • IrionO,BoulvainM.IOL for suspected fetal macrosomia.Cochrane Database Systematic Rev 2002:2:CD 000938
  • UstaIM,HayekS,YahyaF,Abu-MusaA.SD:what is the risk of recurrence?Acta Obst Gynae Scand 2008:87:992-7

What dose Ketorolac?

Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial Motov, Sergey et al. Annals of Emergency Medicine 2016 Dec.

Study Design:

  • N = 240, 18-65 years
  • Randomised to receive 10mg, 15mg, 30mg IV ketorolac as single dose (double blinded)
  • Acute flank, abdominal, MSK or headache pain with intensity > 5/10
  • Pain scores, vital signs, adverse effects recorded at baseline, 15, 30, 60, 90, 120 minutes
  • Subjects still desiring pain medication 30mins after study drug administration were offered IV morphine 0.1mg/kg as a rescue

Excluded

  • Age > 65
  • Pregnancy or breastfeeding
  • Active peptic ulcer disease
  • Acute GI haemorrhage
  • Known renal or hepatic insufficiency
  • Allergy to NSAIDs
  • Unstable vital signs
  • Patients that had already received an analgesic

Results

  • There was no difference in reduction of pain scores between the groups

–10 mg – 7.7 to 5.2

–15 mg – 7.5 to 5.1

–30 mg – 7.8 to 4.8

  • No different in the use of rescue morphine
  • No clinically concerning change in vital signs and no clinically significant adverse effects related to the study medication at any dose
  • No placebo group

Conclusions

  • Ketorolac has similar analgesic efficacy at IV doses of 10, 15 and 30mg
  • The ceiling dose of 10mg provides effective pain relief to ED patients with moderate to severe pain without increased adverse effects

Even Short-term Oral Steroids Carry Serious Risk

Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1415 (Published 12 April 2017)Cite this as: BMJ 2017;357:j1415

Cohort study of more than 1.5 million adults 30 days of initiating these drugs, even at relatively low doses, users had:

  • a nearly 2x increased risk for fracture
  • 3x risk for VTE and
  • 5xrisk for sepsis
  • > one in five adults included in the Clinformatics DataMart, a large national database of commercial insurance claims, received prescriptions for short-term oral corticosteroids during the 3-year study, which ran from January 1, 2012, to December 31, 2014.
  • Of 1,548,945 adults aged 18 to 64 years included in the database, 327,452 (21.1%) received at least one outpatient prescription for short-term oral corticosteroids (30 or fewer days). The mean age of users was 45.5 years (standard deviation [SD], 11.6 years) compared with 44.1 years (SD, 12.2 years) for nonusers (P < .001). The median duration of use was 6 days (interquartile range, 6 – 12 days).
  • The six most common indications for the drugs were upper respiratory tract infections, spinal conditions, intervertebral disc disorders, allergies, bronchitis, and nonbronchitic lower respiratory tract disorders.
  • Within 30 days of drug initiation, there was an increase in incidence rate of the following: sepsis, with a rate ratio of 5.30 (95% CI, 3.80 – 7.41); venous thromboembolism, with a rate ratio of 3.33 (95% CI, 2.78 – 3.99); and fracture, with a rate ratio of 1.87 (95% CI, 1.69 – 2.07).
  • Rate ratios decreased during the following subsequent 31 to 90 days, however.
  • Recommendation: prescribing the smallest possible amount of corticosteroids for treating the condition in question. “If there are alternatives to steroids, we should be use those when possible,”

Should we be giving our women steroids prior to elective caesarean section?

Image result for pregnancyDelivery by elective caesarean section at less than 39+0 weeks of gestation can lead to respiratory morbidity in neonates, requiring admission to the neonatal intensive care unit

A recent retrospective cohort study showed that, compared with elective caesarean section births at 39+0 weeks of gestation, births at 37+0 weeks of gestation and at 38+0 weeks of gestation were associated with an increased risk of a composite outcome of neonatal death and/or respiratory complications, treated hypoglycaemia, newborn sepsis and admission to the NICU (adjusted OR for births at 37 weeks of gestation 2.1, 95% CI 1.7–2.5; adjusted OR for births at 38 weeks of gestation 1.5; 95% CI 1.3–1.7; P for trend <0.001).

The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycaemia, admission to the NICU and hospitalisation for 5 days or more were increased by a factor of 1.8–4.2 for births at 37 weeks of gestation and 1.3–2.1 for births at 38 weeks of gestation.A further study in Denmark23 showed the risk of respiratory morbidity for infants delivered by elective caesarean section decreased by gestation compared with vaginal birth (37 weeks of gestation OR 3.9, 95% CI 2.4–6.5; 38 weeks of gestation OR 3.0, 95% CI 2.1–4.3; and 39 weeks of gestation OR 1.9, 95% CI 1.2–3.0).

Treatment with antenatal corticosteroids prior to delivery by elective caesarean section has been shown to reduce the need for admission to the NICU up to 38+6 weeks of gestation compared with controls.

A. Corticosteroids should be given to reduce the risk of respiratory morbidity in all babies delivered by elective caesarean section prior to 38+6 weeks of gestation.

  • 1. Tita AT, Landon MB, Spong CY, Lai Y, Leveno KJ,Varner MW, et al.; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network.Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009;360:111–20.
  • 2. Yee W,Amin H,Wood S. Elective cesarean delivery, neonatal intensive care unit admission, and neonatal respiratory distress. Obstet Gynecol 2008;111:823–8.
  • 3. Hansen AK,Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008;336:85–7.
  • 4. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbid- ity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynecol 1995;102:101–6.