Fibromyalgia- first line med
Amitriptyline
Avoid opioid analgesia
Rreassurance and regular aerobic exercise
Does the lancet think in acute back pain there is difference between panadol and placebo?
No
Compare terms hyperaesthesia, dysaesthesia, paraesthesia, hyperalgesia, allodynia, hyperpathia
hyperaesthesia is increased sensation to stimulus (subgroups hyperalgesia, allodynia, hyperpathia)
parasthesia not unpleasant abnormal
dysaesthesia unpleasant abnormal
hyperalgesia- painful stimulus but extra pain
allodynia- pain from non painful stimulus
hyperpathia - pain from reped stimulus
Describe codeine metabolism
Codeine is metabolised to morpine via CYP 2D6
May be absent in 10% caucasians
Can be uptrarapid metaboliser with +++ effect
What is the effect of tramadol?
serotonin and noradrenaline reuptake inhibitor and mu opioid agonist
How does tapentadol work/compare?
Mu opioid but weaker than morphine
NA reuptake inhibition
Better GI tolerability than oxxy
Cannot give with MAOi
What is NNT for targin and constipation
NNT if already opiod const = 4
NNT otherwise = 14
What is a 25 mcg/hr fent patch in morphine per day
90mg/day morphine
Gabapentin target and pregabalin target?
alpha-2-delta subunit of calcium channels in brain and dorsal horn
trigeminal neuralgia first line
carbamazepine
painful diabetic neuropathy first line
duloxetine
Post herpetic neuralgia first line
pregab or gabapentin or TCA
Secondary causes of increased LDL
hypothyroidism
nephrotic syndrome
cholestasis
anorexia
Causes of increase TAG AND HDLs
Oestrogen use
Alcohol
Causes of increase TAG and HDL decrease
type 2 DM
obesity
renal imp
smoking
Effect of fish oil on lipid profile
reduce TAG
no change LDL
First line in LDL predominant
statin
ezetimibe second line
Effect bile acid binding resin on TAG
increase
What is the risk of statin plus nicotinic acid?
Increase risk rhabdo
Which fibrate should you not combine with a statin?
Gemfibrozil
TAG increase- first lineq
Fenofibrate or gemfibrozil
Or fish oil
NOT ok to use statin monotherapy
What do you use first line if both LDL and TAG are up?
If TAG under 4 total then use statin
If over 4 then use fibrate first line
What should your CK cutoff be?
tolerate up to 5 times ULN, mild muscle sx
Tolerate up to 3 x ALT LN
Also if asympt and up, should repeat after 7 exercise free days.
If CK stays up after stop a statin, what should you do?
Consider hypothyroidism or NM disease
Does statin cause diabetes
can impair glucose metabolism
sort of 1 in 1000
Fibrate effect on kidney
increase creatinine but no kidney effect; ok up to 30mmol or 30%
What is the MOA of oxybutynin?
Inhibits M2 and M3 receptors in bladder to stop muscarinic ACh action –>antispasmodic
No antinicotinic effects
Avoid in GI obst, narrow angle glaucoma, GORD
Which type of incontinence can you use oxybutynin?
Urge incontinence
What are the other types of antispasmodics, and how are they classified
There are nonselective antimuscarinics which act on M2 and M3 receptors eg oxybutynin and tolterodine. Can cross BBB to lead to less dizziness and cog symptoms
There are M3 selective eg solifenacin. Cannot easily cross BBB- M3 selective, increase risk dry mouth at higher dose. Safer if over 65
If person who is 30 has spleen out, how to pneumovax 23 them?
Give 30, 35 and then at 65
If person who is 66 has spleen out, how to pneumovax?
Give at 66, then 71
If completely healthy caucasian 65 year old, how to pneumovaz?
Single dose at 65
How do ATSI rules differ for pneumovax?
The same except age 50 cutoff and revaccinate everyone twice
Are obesity, down sydrome and alcoholism considered Flu refundable?
No
EEG in delirium?
Background slowing
What is thought to be the brain imbalance in delirium?
Cholinergic deficiency and dopaminergic excess
Leading RF for delirium?
Dementia
what is tricky about DLB and dlirium
Both have fluctuating cognition and visual hallucinations
What is the drug of choice in delirium short term?
Haloperidol
-be aware of extrapyramidal effects, long QT
Quetiapine associated with increased death rates among dementia
Benzos- worsen delirium
What stroke can present as a delirium?
Right parietal and medial dorsal thalamus
paget’s most common location
pelvis >femur>lumabr>skull>tibia
What is the mutation in 5-10% sporadic paget’s?
SQSTM1 mutation- encodes p62 which regulates osteoclass
What is the biochemical finding in paget’s?
Increase ALP
hypercalcaemia if immobilised
Skull pagets can lead to…
deafness
Radiograph of pagets
focal osteolysis with coarse trabecular pattern, bone expansion, cortical thickening
cotton wool appearance of skull
RADIONUCLEOTIDE BONE SCAN MOST USEFUL
Do you treat pagets?
If pain–>antiresorptive
If no pain–>no indication to treat
If pain at pseudofracture site–> surgery
If you cannot use bisphosphonates in pagets due to renal impairment, what could you use?
Calcitonin
Aboriginal with paget’s?
No! They don’t get it!
Complications of paget’s?
Sarcoma rare
pain and deformity
spinal cord stenosis
patholgical fracture
nerve root compression
CN- ophthalmoplegia, facial and bulbar palsy, trigeminal neuralgia
hearing loss from temporal bone involvement
Increase Ca and increase ALP
vs
Decrease Ca and increase ALP
mets, HPT
osteomalacia, renal failure
Which is worse for falls risk? Psychoactive or antihypertensive?
Psychoactive
Also 4 or more medications
How many times a year to fall to prevent one warfarin serious bleed?
300
What effect does delay to theatre have on hip fracture?
Double mortality with operative delay over 2 days
Hip fracture patients - how many never get home?
20% never get home
30% dead at one year
Most common form of incontinence in the elderly?
Urge and mixed urge/stress
Effect of anticholinergics on voiding
Reduced flow rate and increased residual colume
Cholinergics effect on incontinence
Cholinergics may precipitate or worsen urge symptoms and incontinence
What do calcium channel blockers do to your gut?
constipating (smooth muscle)
First line for stress incontinence?
Pelvic floor exervises
Topical oestrogens can help with urethral atrophy
NOT HRT
Mid urethral sling last line- may make it worse so need urodynamics to rule out detrusor instability
Treatment for urge incontinence in cognitively intact?
Antimuscarinic (oxybutynin, solifenacin, tolteridone, darifenacin) - but peripheral anticholinergic effects
What is material risk?
Telling the patient about a risk that would change the PATIENT’s mind about an intervention
Can you refuse palliative treatment as next of kin?
No
Can refuse medical care but not palliative care
Palliative treatment includes reasonable provision of food and water but PEG feeding is medical treatment