Meetings 2005

June 7
Blood tests are not very useful except to check compliance
Make an accurate diagnosis , in syncope there are prodromal symptoms
Nausea Witnessed tonic , clonic convulsion is very important. Post ictal confusion . In syncope there is weakness . 
Collaborative May 12 05

Aim is to treat in community copd and diabetes . 
1. Identify from notes and make register
2. make templates and fill them in
3. red flags eg hba1c
4. give self care management plans
5. group care 
6. websites patients can access
7. website practice manager can fill in
8. plan red flag 
9. do a study of what benefit can come from it , what risk
10. do the action eg take hbaic
11. act on it eg give metformin 
12. identify lead clinician eg nurse , health care assistant , gp
13. for copd its fev1<80% of predicted , do spirometry and reversibility
14. stop smoking , home oxygen eg ltot , pulse oximeter
15. carer patient 
16. keep instructions at age 7
April 20, 2005
Harts BPH Dr cole

BPH may present as lower urinary tract symptoms -luts , eg nocturia , frequency every hour , recurrent uti , on digital rectal examination etc. 
BPH is related to prostate volume over 30cc(30gms) , psa >1.4 , an age . psa is proportional to prostate volume 
Do PSA , but 12% with prostate cancer will have normal psa as the cancer is so advanced tha the cells don't produce psa.. Digital rectal exam which does not reliably measure prostatic volume does not raise psa

Normal values are under3 for age less than 40s, 3.5 for 50s , 4 for 60s and 6.5 for 70s but refer is suspicious . Do PSA in those who ask , family history , over age 50 , afro carribeans , dre , luts Psa of higher than 4-10 gives 225 risk of cancer and over 10 , 675. Screening reduces death rate from prostate cancer but not overall mortality. Early treatment with hormones may even be able to deal with early metastasis. PSA is very high in prostate cancer , not so high in bph , prostatitis , they will need flow studies , bone scan , transrectal ultrasound , biopsy to confirm diagnosis. Alpha blockers give immediate relief bur are short term. 5 alpha reductase inhibitors like finestride and duestride -avodart- act over months and upto 4 years and reduce prostate volume which should be less than 30cc . This shrinkage relieves prostatic symptoms, reduces risk of acute urinary retention and cancer and are well tolerated .They halve death rate They act by stopping the conversion of testosterone to dihydrotestosterone (dht) which normally liquefies seminal fluid. Complications of prostatectomy eg turp are are erectile dysfunction in 70% for which pd inhibitors can be given and which improves with time and incontinence in 10%. Selenium , tomatoes and finestride linked to lower incidence of prostate cancer

April 9 Obesity David Llyod A fast growing problem. Obesity causes increase in total cholestrol , glucose , diabetes , systolic hypertension, sleep apnea and orthopaedic problems. and even a 10kg wt loss reverses these significantly. 17% of children are obese and 33% overweight 26% of adults in inner city , 17 in urban due mainly to eating about 100 extra calories a day and reduced exercise due to tv watching and computer games. In children use bmi ie wt in kg/(htxht in m) and in adults a waist size of 34inches or 88cm in women or 102cm (40 inches) in men is defined as obese to account for muscular people. 1 kg weight loss leads to 1cm loss at the waist. Bmi less than 18 is underweight , and over 25 is overweight . Weight management programs lead to wt loss of about 5% of body wt over a year in half the patients . Women lost 12kg , men 6kg , some lost 50kg. Ask them to fill in a checklist form before and those who are not motivated should not be accepted.. Do baseline blood tests including thyroid before and also cholestrol and sugar levels and afterwards. Introduce xenical after 3 months but give with fat soluble vitamins. Ban grazing in between meals and eating while watching . Encourage walking , playing , low calorie drinks , wholemeal bread , fruits , stop coke , pizzas . In children can try no wt gain for less than age 7, 0.5kg.m till teen and .5kg/w for teens , involve the parents Wt management clinic Those with bmi over 40 are referred to hospital , accept those 30-40 , monthly appt for 12m , 10-20mon appts , Form filled first meeting - motivation , past history of dieting eg yoyo wt changes , lot of wt loss over a short time or if same size since childhood , readiness to change , barriers to change , current diet , levels of activity. Mark ht , wt , bmi , waist size 88 for females 102cm males Check from notes bp , urinanalysis , tft ,lft glucose, lipids , sex hormones Set goals , mention and reinforce at each meeting benefit of wt loss , aim is 2.5kg first month , 5% of body in 3m A one week food diet is a must to be written immediately the patient eats any food. Ambivalence grid -four squares benefits of wt loss , benefits of staying the same , causes of wt loss , causes of staying the same . Encourage fruits , complex carbohydrates , walking , playing , trampoline . Discourage alcohol , reduce fat to 30%, smoking . Recognize trigger factors eg anger etc. -encourage walking the dog or reading a book instead of eating. Outcomes in one clinic was bmi fell from 37 to 33 in ie 106cm to 95cm , also check belt comfort gets better, glucose , cholestrol improves Rarer causes of overweight are hypothyroidism , cushing or steroid use ,, chromosomal prader willi , spina bifida or where they cant exercise. March 31 Dr Ryan Asthma Best to give self management plans to patients , ie inc symbicort to 3 puffs bd and cut down to min 1 puff bd when better . Aim should be total control ie no more than 1 puff blue a day or 1 inhaler a year .. Ask 3 qs 1. cough constantly 2 awake at night needing inhaler 3 difficult speaking or interferes with daily activity eg houseword etc. Average reading age in Britain is 9 and 15% are functionally illiterate In asthma there is excess mucus in lower resp tract and twitchy smooth -ring muscle Max steroid dose is 800u gram of becotide or 400 of fluticasone per day Mdi or breath actuated to start , ask patient to demonstrate use Monitoring is by peak flow , becotide starts working within 3 days Self management plans based on personal best peak flow , written action plan , control with inhaled corticosteroids and oral ones , reduce days off work by two thirds , steroid compliance doubles , lung function improves , gp visits halved Check taking meds and not forgets , refer to Ask about rhinitis and treat it . Step up if blue use >3 puffs per day. Ventolin and symbicort work immediately , seretide within 15mins , oxis builds up best. Good control is less than two days of blue use per week , morning peak flow more than 80% of predicted . If fails consider monteluekaast , theophylline , oral steroids, step down after ten days Monitor the proportion of patients with active disease or taking asthma treatment: o having no or few current symptoms o able to use their prescribed inhalers effectively o using inhaled steroids o with normal lung function (PEF or FEV1 >80% predicted) o with actual/best PEF or FEV1 >85% o with an asthma action plan (patients who should have an action plan include those on step 3 or above, plus any not on this level of treatment who have had an emergency nebulisation, a course of oral steroids or A&E attendance or hospital admission with asthma within the past 12 months). Identify groups of patients at risk: o children with frequent consultations with respiratory infection o children over 5 years with persistent symptoms of asthma o patients with asthma and psychiatric disease or learning disability o patients using large quantities of beta2 agonists Monitor the provision of asthma action plans, particularly to patients: o with moderate or severe asthma, based on step 3 or above o with regular symptoms o having frequent steroid courses or exacerbations o having emergency nebulisation or A&E attendances/hospitalisations o seeing different doctors. Specialist input has a role in the management of patients with persistent symptoms, although the evidence for this comes from a before and after analysis in ambulatory care in secondary care, supported by extrapolation from studies in hospital inpatients.498, 499, 500, 501 No evidence was found on which to base a recommendation regarding the value of specialist primary care physicians, neither is there a robust definition of this group. Evidence level 2+ Specialist review in adults with continuing symptoms is recommended to confirm or refute a diagnosis of asthma and to identify and manage the causes of persistent symptoms. March Cholestrol Current targets are tc 5 , ldl 3 or reduced by 30% whichever is greater eg if chd or crf more than 30% , do after 14hr fast Treat with diet , exercise , . tg is packaged in vldl and gives rise of 0.5 , it is high in non fsting All diabetics should go to secondary prevention , south Asians should have risk x 1.5 Aim for tc 4.5 ldl 2.5 or even lower , check cholestrol after 6m and then yearly if stable , also lft , check 4m if not stable , ask for muscle pains and do ck , it can be high in body builders Statins Decrease cholestrol by 20% , tg by 10 and inc hdl by 10 . In diabetics even if tg high , start first on statin and increase exercise Fibrates Lower tg and ldl , raise hdl and have few side effects Niaspan Cuts ldl by 5-25 % loers tg by 20-50% , raises hdl by 15-35. Side effects are hot flushes and burning soles Ezetrol on its own cuts tg by 10-15% , ldl by 15-25% , raises hdl by 1-3% Live can store just 200g of glycogen , has to put rest out in cholestrol packages. If tg is 10 and ch is 8 in alcoholics it can come down to normal after stopping drinking . Females before menopaue have hdl 1.3-1.6 which comes down to 1-1.3 after. Ezeterol 10mg and atorvastatin 10mg can lower cholestrol by 50% , use if patients get muscle aches with statins , then reduce statin dose and add ezetrol or if alt is high , reduce statin and add ezetrol Omega 3 Dec tc by 5-20% tg by 25-45 and inc hdl by 5-10, help to prevent thrombosis Resins Cholestyramine if nothing else works Examples Male age 42 Tc 7.6, tg 2.1 hdl 1.3 ldl 5, fh of mi , treat with statin 83 year old mi age 81 tc 5.8 hdl 1.5 ldl 3.4 tg 1.9 high alt , already on simvastatin 40 Since tc and ldl are high and already of high simvastatin , reduce it to 20 and add exetrol Male 67 , obese , previous mi , fatty live tc 7.2 tg 8.9 hba1c 8 on atorvastatin Treat with fibrate . Can add omcor eg supralip Mal 35 smoker , father mi , 70 units per week alcohol Tc 17.8 tg 37 fbs 5.3 alt 867 ggt 356 Must reduce alcohol , start on fat free diet for 6w , fenofibrate , check tg after 2w abstaining from alcohol , high risk of pancreatitis , efer to lipid clinic Male 49 fh of mi , tc 6.7 hdl 1.2 , ask to buy own statin Studies 4S Aim to reduce chd by 30% using statins age 40-80 , tc more than 3.5 , mi chd or diabetes or coronary disease , if hypertensive Note vitamins even vit c didn't help Simvastatin benefits started after 6m , elderly benefit by reducing srokes March 23 Headaches Dr Evangelou If less than 30mins its not a migraine , episodic hemicrania mostly in young females responds to 25-50mg tds indomethacin, same for cluster headaches in males . Cluster headaches also respond to 40mg/day of steroids , stop after day 2 if not effective. moh is medication overdose headache when taking 8 or 10 paracetamol a day and is a kind of withdrawl headache. For headaches use a step ladder approach . Migraine Only 50% are unilateral , can last 4hrs to 3 days , happen on day of rest , moh can happen with otc or triptans Diff diagnosis Cervicoglenohumeral , sinus , refractory erros , tmj , teeth Check anxiety , emotions , cravings , food allergies , sleep , hormonal changes Medication Paracetamol but not more than 2xw or risk of moh -asprin 600-900 /day -ibuprofen 400-600 -prchloroperazine -buccastem 3mg -domperidone?20 -metoclopropamide 20 -migramax -paramax sachets -pain and antisickness Step 2 -diclofenac 100 suppository -domperidone 30mg supp Step 3 Triptan -ineffective in aura ? -80% relapse within 48hr -sumatriptan 50, radis 50, nasala spray 20, ?, nasal 10 -zolmitriptan 2.5?, nasal 5 almotriptan12.5 Emergency T Do NOT use pethidine I/m diclofenac 75(3ml), i/m chlorpromazine 25-5-mg ie 3 injections In pregnancy use paracetamol , not aspirin , can use prochlorpromazine Metchlopramide , domeperidone not used in 1st trimester Prophylaxis can cut migraine by 70% Inderal LA 80 od to 160bd or atenolol 25-100bd or metoprolol 50-100bd Amitryptiline 10-150 daily , amitryptiline is good for tension headaches Nortryptline ; desimprimane 2nd line valporate 300-1gbd very good is topramate 25od-50bd gabapentin , pizotifen , methylsergide Failed treatment Check not a tumour- papiloedema etc., moh , caffeine overuse , hormone , inadequate dose eg propranolol . refer to headache clinic at qmc. In children paracetamol works well , nasal spray from age 16 Paediatric asthma Dr Vyas Under use of antibiotics can cause bronchiectasis and empyema and damage the airways permanently .. Premature babies always seem to have airway damage and obstruction probably due to oxygen . During inflammation more steroids are needed and absorbed locally , so cut down after the asthma crisis is over . Cromoglycate , atrovent of no use in children . Long acting b2 agonists licensed after age 4. Only 1cm height difference after five years of inhaled steroid use in children but none after 13 years. Fluticasone better at this than becotide. 4 children died of asthma at qmc in the last six months. 40% can achieve optimal control Camp trial - inhaled steroids very useful in decreasing need for prednisolone Lung function If asthma not controlled but adding beta agonist gives a huge improvement suspect not compliant or cant use inhaler properly Recurrent wheezing may be due to reflux and respond to ppi even if gaviscon does not help Rarer causes are chronic infections , bronchomalacia , vesicular rings , immune deficiency, vocal cord dysfunction -lower volume of speech during stress Broncholitis - no t or salbutamol for recurrent wheeze , oxygen Emergency Oxygen , i/v hydrocortisone , pulse oximeter , ? March 22 High risk CV patients Trials show that statins can reduce the risk of stroke and mi by 25-40% in both primary prevention and secondary prevention after mi or stroke. High risk Ps are dm , ht , dyslipaedimia , smokers , sedentary , obese All studies have 1.Purpose 2. Inclusion criteria 3 Randomisation 4 End points eg 1 . Lower ldl to 1.6 2. all diabetics 4 end points - death , further mi or stroke , worsening angina Summaries over 5 years Trial Inclusion primary or secondary drug result reduction Cardsldl<4,tg< Diabetes P Ator10mg 37stroke or mi Ascot tc>6.5,red ldl by 1.2 HT S A10 36 4S all S S30 30 Lipid all S P40 24 Care all S Prava40 24 HeartPorS tc>3.5, mean5.9 all 20000 Both S40 cv 17 all 13 ...... A80 reduces ldl by 50% , inc hdl by5 16% relative reduction over and above Pravastatin Only 1% adverse effects -muscle pain or very rarely myositis ... A 80mg daily gives another 20% risk reduction over 20mg ...... Niaspin regresses plaque over 6m March 18thu mr man Nasal -SPA Average child between the ages of 2-5 gets 8 upper resp tract infections a year , after age 7 that immune system matures and infections disappear, green snotty nose grows only commensals , if cellular orbital infection suspected must do emergency referral as can get pressure on optic nerve and blindness, put pillow and soft toys in freezer for one hour - kills mites for months. Antibiotics in first 6 weeks of life may reduce tolerance to eradicated gut bacteria and give rise to atopy. Naseptin or better Bactroban can eliminate nasal staph. If continuous cough or snorting and throat clearing ask to swallow very cold water each time for three months. Green mucus in morning is usually commensals. Sinus infection give augmentin or flagyl/cefuroxime for 2 w. Cough at 2am may be reflux , give ppi Surgery is indicated for periorbiatal abscess , csf leak (repair from nose side) , polyps , cystic fibrosis , aspergillosis Viral infection can last 10-15 days , often fever , malaise , cough , later purulent discharge, ask which nose is clear . If there are periods when nose is clear then rassure. Glue ear , resp infections go down after age 7 when adenoids get smaller and respiratory tract enlarges Rhinosinusitis if sinus infection with fever or pain , nasal obstruction and rhinorrhea , give amoxil Xrays and ct scans not indicated for sinus infections Allergic rhinitis Epidemic , four fold increase in twenty years , 20% is seasonal and 6% of pop is perennial. Late March is spring pollen, hdm mostly winter time Treat is sneezing , itchy and runny eyes -give desloratidine or levocertizine antihistamine after age ? If nasal obstruction give nasonex a nasal steroid but compliance is poor till age 6.Do not give otrivine which damages lining , ephedrine is for very short term use, can use saline sprays, explain avoidance , encourage nasal blowing after age 3 Skin tests Just touch the epidermis , do not draw blood . If hdm give advice on allergen avoidance , mattress and pillow covers from zip bag at John Lewis , hot wash every 2w , pu teddy bar and pillow in freezer in the morning good for 6weeks. Avoidance doesn't work if more than 1 allergen on skin test Pets if itchy eyes Nose symptoms - Lakeside -March 9 Mr Sama Nasal polyps , before referring treat as follows from the start with triple therapy 1. Steroid nasal drops for 4 weeks 2. Augmentin or Erythromycin for 2 weeks 3. Prednisolone 20-40mg daily for 1 week 4. Maximum twice a year Main symptoms are Rhinorrhea , Rhinosinusitis , Nasal polyps , structural Note facial pain is NOT sinus if there is no nasal blockage Rhinorrhea - fluctuating nasal blockage , episodic discharge , sneezing , smell + -, taste ok, no facial pain , fh or pmh of atopy , bilateral ,seasonal , exposure to allergen , ie a total of blockage , rhinorrhea , sneezing. Diagnosis by skin testing . must use steroid drops or inhaler regularly for 4 weeks before effect happens, next use second generation steroid sprays , next steroid drops , next referral Cromoglycate - helps sneezing , not used much Antihsitamines topically eg Rhinolast for 6 weeks Depot do not use as can get viral illness , use oral steroids instead for a week Oral antihistamines Oral steroids to start and steroid spray at the same time Nasal drops eg Flixonase nasules or Betnesol are used in the head down position , 1 ampule used for both nostrils twice a day , ie total of two ampules daily Steroids help blockage , sneezing , smell , itchy eyes , rhinorrhea Turbinate surgery helps blockage Rhinosinusitis - nasal blockage , postnasal discharge , reduced smell , episodic facial pain Nasal polyps - Profuse blockage , profuse rhinorrhea , anosmia , NOT painful (inferior turbinate is ) , fh , patient comes in boxes of tissues Structural eg deviated septum No rhinorrhea , blockage is present , no sneezing , trauma history Unliateral symptoms are more sinister and need referral early Summary If mucosal symptoms -rhinorrhea , sneezing = nasal steroids If smell and taste involved , think of sinusitis , polyp Facial pain without symptoms of rhinorrhea or blockage , think of non sinusitis Nasal cycle Daily we breathe through alternate nostril for hours . When lying dependent on one side , if there is some pending breathing obstruction the dependend part of the nose becomes blocked quickly. No treatment . ? Weight loss External 2cm of nose is the narrowest part and gets blocked with polyp etc. If not blocked unlikely to be another blockage further up Allergies and Asthma Primary prevention Mother may transfer Ig E to fetus Breast feeding protects against infant wheezing One study showed Cetrizine taken for 18m if there is fh of sensitivity to hdm (human dust mite) or pollen Early exposure to cats and dogs may induce tolerance to inhaled antigen Tobbacco smoking linked to infant wheezing , not asthma TH1 cells inhibit TH2 in early exposure TH2 cells promote allergy Secondary prevention 1Avoid allergen -cats and dogs hdm avoidance -barrier bed covers -remove carpets -remove soft toys from bed -high temp washing of bed linen -ascaracides to soft furnishings -dehumidification -bad homes are damp . hot and unventilated -freezing pillow for 1hr a week Skin testing useful North Notts -Dr Alan Spencer or ?smith Asthma Aim is to get peak PEFV1 to greater than 80% of predicted or best If symptoms less than 3 days a week use Step 1 short beta prn Next Step 2 if >1 dose per day or >4 days a week Steroid inhaler 200-400mcg per day or use Montelukast if cant use steroid inhaler If still not then lower steroid dose and Step 3 Children 2-5 add moneleukast Step 4 refer Children 5-12 Ventolin prn , Steroid 200-400 Step 3 long acting beta agonist helps to reduce steroid dose to 100mcg per day Step 4 Montelukast Step 5 steroids upto 800mcg per day Step 6 oral steroids Refer . . . Basic Life support - March 3 Make sure patient and yourself are safe from traffic Shake p and shout are you all right in each ear If no answer shout for help Watch breathing , chest action and air on cheeks , if none shout to person to go for ambulance , tell them p is not breathing and to come back and tell you Check pulse , if present , give five deep mouth to mouth breaths over 1 min, tilt head back with back of hand , open mouth slightly , remove loose dentures or obstruction , do not finger sweep , keep other hand on floor while checking for chest movements If not present shout for assistant , give two breaths , make sure chest moves , seal lips over lips , can use handkerchief till it gets damp or one way mouth mask or ambu bag 15 sternal compressions , locate rib , slide finger till meets sternal notch , use two finger breadths above it , lock fingers , use heels to push with locked elbows directly above p - aim for 2-3cm , have to be firm without breaking ribs 15 compressions to 2 breaths - inward then lift mouth and watch for exhalation , then second breath . In adults need to seal lips and pinch soft part of nose , put other hand on floor , ti , In children need to just put cheek to close nose . head back only till sniffing position , do not blow hard as can cause lung leaks, for compression use flat of one hand . In babies hold in one arm , use two fingers of other hand . Can use mouth to nose if mouth blocked Dada meeting Alvesco - steroid inhaler work on receptors only in lung , so no oral thrush Ezetrol -add to statin if triglycerides high Niaspin - raises HDL if too low Glucophage SR - once a day Metformin Priory -City Hospital Alcohol or Drug abuse , work on abstinence , total 18 beds , 7 for Broxtowe Age 18 or over. Cure 60% for alcohol and drug abuse over 2 years Private patients -3,000 pounds per week , can be assessed and admitted same day 10 week for NHS after GP referral. Day care as well Detox Heroin - 40mg per day methadone (withdrawl from methadone causes muscle pains), along with clonidine and buscopan for cramps for 14 days Alcohol -95% employed , chlordiazepoxide upto 40mg qds . Alcoholics may get withdrawl fits even at blood levels of 1.5 and need valporate to cover 500mg bd for 2 weeks or rectal diazepam ?4w, ?6w Diazepam - 2mg per day reducing Treatment Group therapy , 1:1 counselling for some , 2 lectures per week , patient presentation-effect on family - cost etc. , relaxation techniques , family programmes , after care Lectures Co dependency , the family , building self esteem , from denial to acceptance, Anger management , meeting and support groups , ? addiction , relapse pattern Family prog on wed 2pm lecture , 3.30 counselling group 7.30 family support group Open to family members 12m after discharge of 'graduates' Waiting times nhs 24hr emergency , 2w op, 10-12w for admission by assessment group which meetds every 2w Staff- 3 psychiatris , 24hr nursing cover , plus other ooh, 3k per week private Patient presentation COPD March 1 In obstructive lung disease fev1 falls , fvc in restrictive Spirograms Check that lung age is consistent eg if person is age 20 , it should not look like 100 year old, check pre and post brnchodilator , 200ml variability is compatible with diagnosis of copd If fev1 1.76l -60% of predicted , fvc 3.74 104% so fev1% =47%. Fvc is reduced in copd , obesity , restrictive type diseases , poor effort. If fev1% is severe it less than 40% , moderate less than60, mild less than 80%. In reversible cases post broncholdialtor fev1% is the best predictor of survival . Ask p to keep peak flow charts to assess variability eg mornings etc. In copd there is loss of elasticity in the lungs due to damage and the muscles have to be used to force the air out . this force shuts off the small airways early and so there is a restrictive type of deficit on the flow volume curves ie reduced fev1 and fvc . Lung resection can help. The abrupt shut off causes a scalloping type of curve at the end of expiration ie concave to right .Flow along y axis and volume along x axis . The fvc is the end of the curve on the x axis , the peak flow is the top of the curve . In copd both are reduced Cases Fev1 60 , fvc 104 , fev% 47 , give long acting b2 to improve fev1 or combination steroid plus long acting b2 ED - February 26th Belfry Hotel ED is eight times more common in obesity , ie waist circumference over 100cm or 40 inches . ED is a strong marker for heart disease later on. Sildenafil (viagra) and Valderanfil are short acting over two hours , while Tadalafil (Cialis ) is long acting and can last 36 hrs . Sildenafil has visual se at high doses since retina has same receptors . Cialis has no se. Tmax for sil is 1hr , for val 30mins and for tada 2hrs , Thalf life is 3hrs for short ones and 17hrs for tada ie since effect is at quarter thalf it can last 34 hrs . Tadafil has 70% success in non diab , 50% in diabetics . Note quartet of dm, insulinr, obesity , ht is deadly. Does not increase risk of heart disease in fact improves it , ?ci with nitrates. Give eight tablets to try at maximum dose before switching after 3m .Offer patients the choice of what drug he wants. Can give sls or to diabetics , but severe distress only by hospital. Do shim , ie 1-5 marks for each question on 1. how confident do you feel about erection and sustaining it etc. , less than 9/25 is severe Nitric oxide released at nerve endings stimulates camp which activates pde phospho diesterase and these drugs inhibit this enzyme and so inhibit the smooth muscles which end erection. Premature ejaculation helped by ssris eg paroxetine , fluoxetine . Tadafil two tablets a week should be enough. Side effects in about 15% are headache , flushing . Prescription costs are about pounds 9 a tablet , cheapest from internet site Central obesity is an indicator of insulin resistance and gets better with wt loss. Psychotherapy non genital sensate focus , genital sensate focus , vaginal containment , CHECK TESTOSTERONE LEVELS and give patches if less than 14 explain sexual arousal response , position of clitoris , set goals , focussed and short term - 6 sessions , cognitive therapy. Counsellor should be empathic , welcome , listen , get details of history , language use , , give information , partner issues deal with issues of fear , loss , anxiety , social advice , sadnes , loneliness , send to relate if marital conflict, web sites, motivation on scale of 1-10 web , In daibetics the white and red cells start sticking to endothelium of penis , these drugs improve the blood flow and urinary symptoms of dribbling , nocturia , frequency can try daily dosing with cialis 5-10mg , build up improves sexual promotion , ED treatment is better than antidepressant Low glycaemic foods slow insulin releaser , no excercise for two weeks after MI as scar is weak Obesity 10 Kg wt loss leads to 20% reduction mortality , 30% fall dm related deaths -40% fall in obesity related deaths reduction in bp . lipids . 50% in fasting blood sugar 15% fall in LDL , 30% in TG , 8% rise in HDL obesity increases uterus, pancreas , colon, breast cancers