Sept 05
Lipids
Cholestrol is a compound which if it gets into the arterial vessel wall causes it to narrow and eventually block completely if a clot forms on top leading to death of muscle eg the heart area supplied by that artery.
It is made in the liver 50% , then secreted into bile and absorbed via the gut 30% together with that eaten in the diet eg egg yellows . It is attached to ldl - a protein in the liver and in this form can get into the vessel walls . Another protein hdl takes it up from the vessels and takes it to the liver . So it follows that too much cholestrol , too much ldl or too little hdl are all bad
QOF targets are tc 5 or below in those with chd or cardiac risk factor > 20%, however other guidelines suggest that its better to have tc below 4 ,  ldl below 2 and hdl above 1.03 in men and 1.4 in women 
Triglycerides should also be kept below 1.7 

Before starting therapy encourage diet and exercise and check lfts and ck levels. Get men to waist below 94cm . women below 80cm  
Drugs which help to do this are 
LDL reducers
Statins - these act on the enzyme Acetyl co-a in the liver , Simvastatin 10-40mg or Atorvastatin 10-20mg can cut ldl by 20-60 % and also cut tg a little and raise hdl a bit
However after 10mg , every doubling of the dose cuts ldl by only 6% and because acetyl coa is also made in the muscle , it affects the cell membrane and leads to muscle aches , so its better to cut dose back to 10mg and add ezetrol 10mg 
Ezetrol
   Reduces intestinal absorption and in the drug ezetemibe combined with simvastatin

TG reducers
 Alcohol increases TG markedly and also increases risk of pancreatitis . Fish oil such as omacor 1-2g per day helps cut it . Also useful are fibrates 

HDL increasers
	Alocohol does a little hence the protective effect of  moderate drinking (21 units per week for men , 14 for women) . Nicotinamide helps but can cause hot flushes . Exercise raises hdl levels 

TC reducers
  Resins like cholestyramine are very rarely used as they cause flatulence 
Metabolic syndrome
Diabetes +waist >94cm and any two of tg 1.7 , hdl 1.04 , bp 130/85 fbs 5.6 

Dr Pinsloo
Aim seems to be getting to tc 4 and ldl 2 but currently tc 5 ldl3 or by 30% whichever  is greater in patients with established chd or if without chd but cardiac risk factor >20%
Bhs guidelines are tc 4 and ldl 2 if high risk >20% , treat earlier if ethnic minorities or fh of ihd
Start with diet and exercise 
Statins - measure ck first and lfts , absolute contraindication is liver disease , relative with ? drugs , ?do not drink grapefruit juice if on statins
They cut tg by upto 30% , raise hdl by max 15%, simvastatin 10mg is the best , doubling dose gives only another 6% cut in ldl
Statins act on acetyl co-a in liver and also muscle esp the hydrophobic outer membrane and can cause muscle aches and in extreme cases even rhabdomyolisis -check urine for ?

Fibrates
 Cut tg and raise hdl by increasing apo a , good for prim and sec prevention, not to be used in patients with severe renal or hepatic disease , se are ?dyspepsia , myopathy , ? interaction with statin 
Nicotinamide 
Raise hdl but main side effect is hot flushes , cuts ffa release from cells,soreducing liver ldl , not to be used in liver disease or peptic ulcer ,start with 500 mg dose 

Ezetemibe
Cuts tg by 15% , ldl by 15% hdl by 5% ; occasional ge side effects 
10mg sim   +10mg eze cuts tc by 50% and eze10+atorva 10 cuts ldl by 50%
so useful in those who get muscle aches with statins
  We get 50% cholestrol from bile 30% from diet and  rest from sloughing of epithelial cells 

Omega 3- Omecor or Maxepa cut tg esp if its 10 or over , can be combined with statin , reduces sudden death , cut tcby 5 tg by 25-45 and raise hdl by 50%
Omecor 1-2g per day and maxepa upto 9g/day but latter  gives fish oil breath
Cholestyramine tastes like gritty sand and flatulence  cuts tc by 5% 

Cetp in future if hdl below 0.6
Cases 
1.	Raised TC- Statin (or eze if intolerant ) after ck ,lft ,titrate dose , add eze if resistant 
2.	Raised TG -fish oil or fibrate , monitor ck lft 
3.	Combined statin+fish oil fibrate 
 
Metabolic syndrome
 Diabetes , male waist ?>94cm, female 80 ?
Plus any two of 
Tg >1.7 , hdl<1.04 , bp >130/85 , fbs >5.6 
Ck of 500 or more may be acceptable if on statin and no symptoms , check hb or protein in urine , check not raising ?
Alcohol raises tg markedly so ask about alcohol 

Lipids
DM and chd 42% less deaths from mi if on statin , also stroke
High risk if >20% probability of death during next ten years 
One third of mi die within a day of first attack
Metabolic sybdrome -waist >102 men , 88cm women 
Hdl <1.0 men , 1.3 women , fasting tg>1.7 , fbs >6.9 bp>130/85
High risk if any 3 of 5 above 
Ldl target <2.6
If gets to target ALLIANCE
Tg normal 1.7 , borderline 2.25 , high till 5.6 then very high and there is risk of pancreatitis and vascular disease -manage the tg and not the hdl, 14% risk cut if even 1mmol tg decrease
Dual inhibition 
Cholestrol made in liver ,g ets to gut and is reabsorbed . Liver makes 2g daily , we eat 0.4g daily
Dietary goal for tg , dm
Ezetemibe reduces gut reabsorption, get another 20% reduction if added to statin
Statin 10+eze = statin 80
Eze raiss hdl as well and is well tolerated
Targets ldl 1.8 , take 6w , can get 70% to targets
Max is atrovastatin 80 , check crp as well marker of nflamm
Eze cuts crp levels , doubling statin eg from 20-40-80 gets only 6% reduction in ldl each time , eze gives 25%, can use it as monotherapy and gives 25% cut in ldl 
Inegy statin+eze  well tolerated , take at night , statins raise alt , less so with inegy 
45% less mortality , 47% less chd , 59% less non fatal mi , 50% hf , 47% stroke 
Hypertension
There seems to be no J curve ie lower limit , current thinking is that 110/70 is Ok 
Even a 10/5 decrease cuts risk of stroke by 40% chd by 16%and pvd
Hot study 20,000 people target 140/85 , prevents 5 events per 1000 per year
Diabetics get 51% reduction in cv events by reducing diastolic from 90 to 80
British guidelines
Target 140/85 , diabetics 130/80 , renal 130/80, proteinuria 125/75
ASCOT
Acei + Cachb (A,C) is better than Betablocker + thiazide (B, D) - better for cvs risk , better tolerated , better bp control 
LIFE
Losarten - a angiotensin 2 inhibitor in vessel walls , angiotensin constricts walls , main side effect is cough 
Cuts dm mortality by 40, new onset dm by 25% , new onset afib 33%, subsequent stroke bt 15%Even at the same bp level losarten cuts ht by 25, ish 40,afib 48., by reducing left atrial size , also cuts heart attacks 
Roosevelet died of systolic 380
Strokes 
8% of NHS costs 2x that of chd . Replacing atenolol with losartan will prevent 1`7,500 strokes and save 700m
HOT 
Using upto 4 drugs can get 80% to 90 dbp and 50% to 80 
A=acei or angio2 , b=bb c=cachb d=diuretic
Younger and non black
Step 1 A or B
Step 2 add cachb
Step 3 a+c+d
Older or black
Step 1 start with c or d 
ASCOT a+c better than b+d
LIFE 
A+d better than b+d
Ie do not use bb

July 05
Cardiological examination
Feel pulse regular , volume , check jvp via internal jugular pulse 
Check carotid pulse at angle of jaw and bruits
Lie patient down and palpate apex beat , then tricuspid area , then pulmonary and finally aortic 
Listen to first heart sounds at apex , left lateral decubitus to amplify
Sit patient up and repeat

Neuro exam
Ask about time- date , year place-, calculation 100-7
Cranials 
2- corneal reflex , light , accommodation
3,4,6 eye movements
5 sensory - touch and pain on frontal , max, mand
motor -masseter
7-motor eye power , smile , teeth , blow cheeks
9- gag reflex
11- turn neck against resistance
12- protrude tongue and twist it side to side

Reflexes -biceps , triceps , supinator legs - knee , ankle , plantar 
Power arms , shoulder , 
Co-ord
Cerebellar - nose to finger , don't place fingers in one place only , P to close eyes as well , heel shin , heel to toe walk , stand with eyes closed and hands stretched
Sensory-finger tip pain , vibration and joint position and same on toe



Premenopausal bleeding - Prof at Village
  Teenage - check fbc , exclude pregnancy , treat with cont pill
Older woman -as above plus inspect cervix , treat without investigations such as tft , endometrial biopsy, give mefenemic acid or tranxemic acid , offer mirena for menorrhagia 

Liquid Cytology- Sept 8
    This is a new technique where the brush has two parts. The center part goes into the endocervix and the whole brush is rotated clockwise only five times . The gloved hand then breaks off the brush into the 10ml liquid , the gloves taken off and the cap closed and the name put on. If the squamo columnar junction is outside the brush range , another brush has its external bristles rotated twice clockwise (which stiffens the bristles and allows cells to be taken) and the brush is broken off into the same bottle and the writing done on the form. Look at the cervix for deformities suggesting adenocarcinoma .
	In the lab the fluid is centrifuged and the cell rich culture seen under the microcope. The field of view is only 1.3 inches but cells are better . Large irregular nuclei suggest dyskariosis.

Renal tests
New test is the gfr