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Can be frst-line in school-aged children where the likelihood of atypical pathogens is higher buy zestoretic 17.5 mg line blood pressure keeps spiking. Only available in tablet form generic 17.5mg zestoretic with visa arrhythmia monitoring, therefore only if the child can swallow tablets generic zestoretic 17.5mg heart attack 720p movie download; whole or half tablets may be crushed generic zestoretic 17.5mg amex blood pressure medications with the least side effects. Most topical antibacterials are contraindicated in the presence of a perforated drum or grommets, however, they may need to be used if other treatment options have been unsuccessful. Flucloxacillin if there is spreading cellulitis or the patient is systemically unwell; also consider referral to hospital. Consider antibiotics for children at high risk such as those with systemic symptoms, aged less than six months, aged less than two years with severe or bilateral disease, or with perforation and/ or otorrhoea. Also consider antibiotics in children who have had more than three episodes of otitis media. Co-trimoxazole should be avoided in infants aged under six weeks, due to the risk of hyperbilirubinaemia. The major beneft of treating Streptococcus pyogenes pharyngitis is to prevent rheumatic fever, therefore antibiotic treatment is recommended for those at increased risk of rheumatic fever, i. Sinusitis acute Management Most patients with sinusitis will not have a bacterial infection. Even for those that do, antibiotics only ofer a marginal beneft and symptoms will resolve in most patients in 14 days, without antibiotics. Most bacterial conjunctivitis is self-limiting and the majority of people improve without treatment, in two to fve days. In newborn infants, consider Chlamydia trachomatis or Neisseria gonorrhoeae, in which case, do not use topical treatment. Common pathogens Viruses, Streptococcus pneumoniae, Haemophilus infuenzae, Staphylococcus aureus Less commonly: Chlamydia trachomatis or Neisseria gonorrhoeae Antibiotic treatment Conjunctivitis First choice Chloramphenicol 0. Give benzylpenicillin before transport to hospital, as long as this does not delay the transfer. Almost any parenterally administered antibiotic in an appropriate dosage will inhibit the growth of meningococci, so if benzylpenicillin or ceftriaxone are not available, give any other penicillin or cephalosporin antibiotic. Antibiotics may be considered if there is fever, surrounding cellulitis or co-morbidity, e. Adult and child >12 years: 160+800 mg (two tablets), twice daily, for fve to seven days 10 Cellulitis Management Keep afected area elevated (if applicable) for comfort and to relieve oedema. Common pathogens Streptococcus pyogenes, Staphylococcus aureus, Group C or Group G streptococci Antibiotic treatment Cellulitis First choice Flucloxacillin Child: 12. Adult and child aged over 12 years: 160+800 mg (two tablets), twice daily, for fve to seven days 11 Skin (continued) Diabetic foot infections Management Antibiotics (and culture) are not necessary unless there are signs of infection in the wound. However, in people with diabetes and other conditions where perfusion and immune response are diminished, classical clinical signs of infection are not always present, so the threshold for suspecting infection and testing a wound should be lower. Referral to hospital should be considered if it is suspected that the infection involves the bones of the feet, if there is no sign of healing after four weeks of treatment, or if other complications develop. Common pathogens Early infection is usually due to Staphylococcus aureus and/or streptococci. Later infection may be polymicrobial with a mixture of Gram-positive cocci, Gram-negative bacilli and anaerobes. Initial management involves the simple measures of clean, cut (nails) and cover. Advise moist soaks to gently remove crusts from lesions, keeping afected areas covered and excluding the child from school or preschool until 24 hours after treatment has been initiated. Current expert opinion favours the use of topical antiseptic preparations, such as hydrogen peroxide or povidone-iodine, as frst choices for topical treatment. This represents a change in management due to increasingly high rates of fusidic acid resistance in Staphylococcus aureus in New Zealand. Topical fusidic acid should only be considered as a second-line option for areas of localised impetigo (usually three or less lesions). A randomised controlled trial has been registered to establish the efectiveness of alternative topical management options for impetigo in New Zealand. Oral antibiotics are recommended if lesions are extensive, there is widespread infection, or if systemic symptoms are present. Streptococcus pyogenes has caused outbreaks of necrotising fasciitis in residential care facilities, and if this is suspected it is important to use systemic treatment to eradicate carriage, and prevent infection to others. A formal decolonisation regimen, using topical antibiotic and antiseptic techniques, is not necessary for all patients, but may be appropriate for those with recurrent staphylococcal abscesses. Decolonisation should only begin after acute infection has been treated and has resolved. As part of the decolonisation treatment, the patient should be advised to shower or bathe for one week using an antiseptic. For a diluted bleach bath, add 1 mL of plain unscented 5% bleach per 1 L of bathwater (or 2 mL of 2. A regular- sized bath flled to a depth of 10 cm contains approximately 80 L of water and a babys bath holds approximately 15 L of water. Ideally, the household should also replace toothbrushes, razors, roll- on deodorants and skin products. Hair brushes, combs, nail fles, nail clippers can be washed in hot water or a dishwasher. Bleach baths or antiseptic washing can be carried out intermittently after the initial decolonisation period, to help prevent recurrence of infection. This can also be recommended for patients with recurrent skin infections who have not undergone formal decolonisation. Antibiotic treatment Recurrent skin infections First choice Fusidic acid 2% cream or ointment (if isolate sensitive to fusidic acid) Mupirocin 2% ointment (if isolate resistant to fusidic acid and sensitive to mupirocin) Apply inside the nostrils with a cotton bud or fnger, twice daily, for fve days N. If the isolate is resistant to both fusidic acid and mupirocin, topical treatment is not indicated discuss with an infectious diseases specialist Alternatives Nil 15 Gastrointestinal Campylobacter enterocolitis Management Most people will recover with symptomatic treatment only. Antibiotics have little impact on the duration and severity of symptoms but eradicate stool carriage. Treatment is indicated for severe or prolonged infection, for pregnant women nearing term and for people who are immunocompromised. Treatment may also be appropriate for food handlers, childcare workers and those caring for immunocompromised patients. Discontinue current antibiotic treatment if/ when possible in some cases this may lead to clinical resolution of symptoms. Antibiotic treatment is recommended in adults if the patient has diarrhoea or other symptoms consistent with colitis, and a positive test for C. Common pathogens Clostridium difcile Antibiotic treatment Clostridium difcile colitis First choice Metronidazole Adult: 400 mg, three times daily, for 10 days Alternatives Vancomycin If patient has not responded to two courses of metronidazole; discuss with an infectious diseases physician or clinical microbiologist. Common pathogens Giardia lamblia Antibiotic treatment Giardiasis First choice Ornidazole Child < 35 kg: 125 mg/3 kg/dose,* once daily, for one to two days Adult and child > 35 kg: 1. Dose is per 3 kg bodyweight; ornidazole is only available in tablet form, tablets may be crushed, child dosing equates to one quarter of a tablet per 3 kg.
Lillicrap and Dr Narayanan Kandasamy for their con- It is rewarding to discover how many readers have tributions order zestoretic 17.5mg amex pulse pressure greater than 70, help and advice during the preparation of found the text useful for study purchase zestoretic 17.5mg with visa arrhythmia can occur when, for revision and for the the manuscript discount zestoretic 17.5mg fast delivery arrhythmia natural supplements. P reface to th e irst ditio This book is intended primarily for the junior hospital working knowledge in a clinical situation discount zestoretic 17.5 mg overnight delivery hypertension frequent urination. It should doctor in the period between qualication and the not be forgotten that some rare diseases are of great examination for Membership of the Royal Colleges importance in practice because they are treatable or of Physicians. Some for higher specialist qualications in surgery and conditions are important to examination candidates anaesthetics. The experienced phy- We have not attempted to cover the whole of sician has acquired some clinical perspective through medicine, but by cross-referencing between the two practice: we hope that this book imparts some of this sections of the book and giving information in sum- to the relatively inexperienced. A short account of psychiatry is given in the section The book as a whole is not suitable as a rst reader on neurology since many patients with mental illness for the undergraduate because it assumes much basic attendgeneralclinicsanditishopedthatreadersmaybe knowledge and considerable detailed information has warned of gaps in their knowledge of this important had to be omitted. The section on dermatology is incomplete but textbook of medicine and the information it contains should serve for quick revision of common skin must be supplemented by further reading. In are most commonly seen and where possible have the rst part we have considered the situation which a listed them in order of importance. The frequency candidate meets in the clinical part of an examination with which a disease is encountered by any individual or a physician in the clinic. This part of the book thus physician will depend upon its prevalence in the resembles a manual on techniques of physical exam- district from which his cases are drawn and also on ination, though it is more specically intended to help his known special interests. Nevertheless, rare condi- the candidate carry out an examiners request to tions are rarely seen; at least in the clinic. Wehave We should like to thank all those who helped included most common diseases but not all, and we us with producing this book and, in particular, have tried to emphasise points which are under- Sir Edward Wayne and Sir Graham Bull who have stressed in many textbooks. Accounts are given of kindly allowed us to benet from their extensive many conditions which are relatively rare. It is neces- experience both in medicine and in examining for sary for the clinician to know about these and to be on the Colleges of Physicians. Supplementary reading is essential to un- derstandtheirbasicpathology,buttheinformationwe David Rubenstein give is probably all that need be remembered by David Wayne the non-specialist reader and will provide adequate November 1975 1 T h e m edical in terview Good communication between doctor and patient forms the basis for excellent patient care and the clinical consultation lies at the heart of medical prac- Effective consultation tice. Good communication skills encompass more Effective consultations are patient-centred and ef- than the personality traits of individual doctors they cient, taking place within the time and other practical forman essentialcorecompetencefor medicalpracti- constraints that exist in everyday medical practice. In essence, good communication skills pro- Theuseofspeciccommunicationskillstogetherwith duce more effective consultations and, together with a structured approach to the medical interview can medical knowledge and physical examination skills, enhance this process. Important communication lead to better diagnostic reasoning and therapeutic skills can be considered in three categories: content, intervention. These skills are evidence-base shows that health outcomes for pa- closely interrelated so that, for example, effective tients and both patient and doctor satisfaction within use of process skills can improve the accuracy of the therapeutic relationship are enhanced by good information gathered from the patient, thus enhan- communication skills. Providing structure to the consultation is one of the There are a number of different models for most important features of effective consultation. They are generally similar and all em- that is responsive to the patient and exible for dif- phasise the importance of patient-centred inter- ferent consultations. Like all clinical skills, com- examination) munication skills can only be acquired by experien-. Before meeting a patient, the doctor should prepare by focusing him- or herself, Theinitialpartofaconsultationisessentialtoformthe tryingtoavoiddistractionsandreviewinganyavailable basis for relationship building and to set objectives for information such as previous notes or referral letters. Gathering information An accurate clinical history provides about 80% of the Explanation and planning information required to make a diagnosis. Tradition- ally, history-taking focused on questions related to the Explanationandplanningiscrucially importantto the biomedical aspects of the patients problems. Establishment of a manage- evidencesuggeststhatbetteroutcomesareobtainedby ment plan jointly between the doctor and the patient including the patients perspective of their illness and has important positive effects on patient recall, un- by taking this into account in subsequent parts of the derstanding of their condition, adherence to treat- consultation. Patient expectations should therefore include exploring the history from have changed and many wish to be more involved in boththebiomedicalandpatientperspectives,checking decision-making about investigation and treatment thattheinformationgatherediscompleteandensuring options. The goals of this part of the consultation are thatthepatientfeelsthatthedoctorislisteningtothem. Explanation and planning Gathering information Avoid jargon: use clear concise language; explain Ask the patient to tell their own story. Listen attentively: do not interrupt; leave the pa- Find out what the patient knows: establish prior tient time and space to think about what they are knowledge; nd out how much they wish to know saying. Encourage the patient to express their feelings: Involvethe patient:share thoughts; reveal rationale actively seek their ideas, concerns and expectations. The way in which these two are understand and which takes their perspectives into used is shown in Table 1. It encourages patient participation and collaboration and facilitates accurate information Closing the session gathering. Building a relationship with the patient in- Closing the interview allows the doctor to summarise volves a number of communication skills that enable and clarify the plans that have been made and what the doctor to establish rapport and trust between thenextstepswillbe. Itmaximisesthechances contingency plans are in place in case of unexpected of accurate information gathering, explanation and events and that the patient is clear about follow-up planning and can form part of the development of a arrangements. Itisvitaltopatient ent relationship in this way has positive effects on and doctor satisfaction with the consultation adherence to treatment and health outcomes. Closing the session Summarise:reviewtheconsultationandclarifythe Special circumstances plan of action; make a contract with the patient Certain circumstances demand a special approach to about the next steps. Sequencing Maintain a logical sequence to the Involve the Share your thoughts to interview; use exible but ordered patient encourage patient interaction; organisation by signposting and explain your rationale for doing summarising. The medical interview 5 Breaking bad news Approach to communication skills assessment Prepare: ensure you have all the clinical details and know the facts; set aside enough time; Past papers: the format of the examination should encourage the patient to bring a relative or be available for review; look at the communication friend. In some examinations spective; do not overwhelm with information in the clinical scenario is available in advance of the rst instance; check repeatedly that the pa- the examination to allow preparation of content tient understands. Make a plan: explain what will happen next; give Make a plan: before you enter the station, have a hope but be realistic; conrm your role as a clear plan as to how you will approach the partner in care. Complexsituationsrequirethedoctor present and discuss the case, listen carefully to to use basic skills to a higher level. Preparation and the examiner and present the salient features in planning, listening to the patient, delivering informa- a clear and logical manner. Closureisalsoimport- ant, ensuring the patient knows what is happening and is clear about the next steps. Communication skills are usually ments should have been through appropriate 6 The medical interview Concrete experience Consultation with a patient Interview a simulated patient Role play Reflection Active experimentation Think about the consultation Try a different approach Observe a recorded consultation in a learning environment Give and receive feedback Abstract conceptualisation What will I do differently next time? Thecycleenablesthelearnertobuildonexistingknowledgeand skills, to take responsibility for their own progress and to use real life clinical and simulated encounters to promote further learning. Dyspnoea may be observed and outstretched abnormal movements, including tremor or paucity of T resting tremor of Parkinsons disease hands facial expression, should be noted. Many patients with ischaemic heart disease have few or no physical signs and a characteristic history of peripheral vascular disease may be elicited.
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Two tubes separated by semipermeable membrane with ability to transport molecules of a substance in one-way buy zestoretic 17.5 mg low price blood pressure exercise program. If the tubes are fulfilled with a stationary fluid the activity of the membrane increases the concentration of the substance in tube A generic zestoretic 17.5mg online blood pressure medication used to treat adhd. When the fluid flows the mostly concentrated fluid will be accumulated at the beginning of the tube B generic 17.5mg zestoretic with amex blood pressure 9555. Application of the countercurrent system in kidneys + - Descending limb of the Henles loop is permeable for water and Na + - The ascending limb of the loop is relatively impermeable to water and permeable to Na order zestoretic 17.5 mg on line hypertension zinc, - Cl, urea. Interstitial hypertonicity is supported also by active resorption of Na form the duct to the interstitium. Descending vasa penetrate to the hypertonic portion there water diffuses out of the vessels and in the hypotonic portion water diffuses into the vessels. Recirculation of the water and the solutes from and into vasa recta helps to maintain hypertonicity. Concentrated and darker in early morning less water excreted at night but unchanged amounts of urinary solids. Odour: Aromatic when fresh ammoniacal on standing due to bacterial decomposition of urea to ammonia. Creatinine - from breakdown of body tissues; uninfluenced by amount of dietary protein. Ammonia - formed in kidney from glutamine brought to it by blood stream; [In the newborn, volume and specific gravity are low and composition varies. Smooth muscle coats distend as urine collects: contract periodically to expel urine to urethra. When bladder is empty and beginning to fill - inhibition of parasympathetic - activation of sympathetic Relaxation of bladder wall. In older children and adults reflex can be controlled and inhibited voluntarily. Stimulus: Distension of the receptors in smooth muscle When empty, pressure in bladder is zero. When 50 ml urine collectpressure to 10 cm H2O up to 300 or 400 ml little increase in pressure. Sensations to consciousness Micturition center: Parasympathetic S2 S4 Sympathetic efferents L1-3 - inhibits ganglia Efferent pathways: Impulses in parasympathetic nerves (pelvici)and in somatic nerves (pudendal). Differentiation of stimulus intensity: 1) by differences in action potentials firing rate 2) by differences in the number of activated receptors Intensive stimuli activation other receptors and sensory units = recruitment of sensory units. Spinothalamic tract 1) Neospinothalamic fast pain A fibres the tract passes upward to the brain in the anterolateral columns to the thalamus. Referred pain: When pain is referred it is to a structure that is developed from the same embryonic segment (dermatome) as the structure in which the pain originates = dermatomal rule. Changes in pain perception 1) Hyperalgesia 2) Hypoalgesia peripheral: stimulation of tactile and pressure receptors reduces pain perception (acupressure, acupuncture, massage) centraly: Psychogenic mechan. Physiological and pharmacological principles of the analgesia treatment of pain 49 Distracting techniques (controlled breathing, rhythmic tapping,. Afferent pathway: Sensitive fibers Centers: In spinal cord, medulla oblongata, hypothalamus. Acetylcholine - synthesis: cholin+acetylCo A (acetyltransferase) - inactivation: acetylcholinesterase: cholin+acetate Cholin the uptake for the resynthesis Ach very short effect duration Receptors for Ach - nicotinic (N) receptors - in the synapses between the pre- and postganglionic neurons, in the neuromuscular junction - muscarinic (M) receptors: postggl. Autonomic tone and excitability Tone there are discharges in autonomic nerves at rest reflex: (stimulation of baro-, chemoreceptors) central (hypothalamus) 58 sympathetic (e. Cardiovascular system the variability of cardiovascular parameters short-term, long-term Ewing battery of cardiovascular tests deep breathing orthostatic test Valsalva manoeuvre hand-grip test other cardiovascular tests oculocardiac test, diving reflex, mental and physical load. Psychosomatic relationships cerebral cortex the influence on the respiratory, cardiovascular, immune, autonomic and other systems relationships - cortex - organs organs - cortex efferent influences of the cerebral cortex: 1. Visual pathways: Collaterals of optic tract: Hypothalamus (circadian rhythm) Pretectal nuclei (accomodation, pupillary light reflex) Superior colliculus (eye movements) Field of vision: -visual area seen at given moment - monocular, binocular - blind spot (15 deg. Floaters (muscae volitantes) -slowly drifting transparent blobs of varying size and shape -particularly noticeable when lying on the ground looking up at the sky -caused by imperfections in the fluid of the eye 2. Scheerer`s phenomenon = blue field phenomenon -noticeable when viewed against a field of pure blue light - tiny bright dots moving rapidly along squiggly lines in the visual field -caused by leucocytes moving in the capillaries in front of retina 3. External ear the pinna (helps to direct sounds), the external auditory meatus, auditory Canal transmits sound waves to the tympanic membrane 2. Middle ear separated from extrenal ear by tympanic membrane (called eardrum), chain of ossicles the malleus, the incus, and the stapes. Eustachian tube connects middle ear to the pharynx and equilizes pressure differences between external and mid. Inner ear bony and membraneous labyrinth (cochlea and vestibular apparartus), receptors for two sensory functions. Cochlea spiral-shaped organ, divided by basal and Reissneri membranes to three parts scala tympani and scala vestibuli by perilymph (helicotrema), between scala media by endolymph). On basal membrane organ og Corti with receptors hair cells Adequate stimulus for auditory receptors sound - sound is produced by waves of compression and decompression transmitted in air (or other media such as water), propagation in the air 335 m/s - sound composed of many unrelated frequencies - noise - frequency (nm. The vibrations are transferred by the ossicular system through the oval window on the structures of inner ear (by the vawe movement of perilymph) - stimulation of the organ of Corti causes action potencials in nerve fibres function of mm. Axons penetrate the base of the skull through openings in the cribriform plate of the ethmoid bone as olfactory nerve filaments (fila olfactoria) to olfactory bulb. Stimulation of the olfactory cells - olfactory receptors telereceptors - they response to the odorant substance (gas) in inhaled air dissolved in the mucus 66 - chemical interaction with the membrane of the cilia + - they evoke receptor (generator) potencial by changing permeability of membrane for Na - fast adaptation - in humans ability to distinguish between 2 4000 different odors - the olfactory cells the highest degree of chemical discrimination Intensity of the stimulus depends on concentration of the odor substance (the number of stimulated receptors and the number of moleculs reaching the cell) Quality of perception depends on concentration: at low c. Function of the muscle spindle Receptors - active at rest stretching of the muscle activation of the anulospiral endings higher frequency of the impulses facilitation of the alfa motoneurons of the its own muscle. Pavlov) - originated during development = mechanisms for assurance of ability to survive and live classification: - apetitive - protective - orientation - sexual Innate mechanisms: 1. Drive: - processes which represent an immediate response to fundamental necessities of the body - they force the human to fill the needs - after filling the needs - antidrive 3. Storing of encoded information biochemical, biophysical and electrophysiological processes 3. Each receptor is highly specific for a single hormone Principal mechanisms: 1) Confirmational changes of the receptor alter the membrane permeability to ions. Properties of the hormone effects: 1) Target effect hormone acts on target cells organ (estrogen uterus, mammary gland etc. It lies in the sella turrica at the base of brain and is connected with hypothalamus by the pituitary (hypophyseal) stalk. Symptoms: Hyperglycemia (through) increased glucocorticoid activity), negative nitrogene balance, fat infiltration of the liver. Effects (three main): 1) Mammotrophic effect development of the breasts at puberty 2) Luteotrophic effect stimulation of the corpus luteum, stimulation of the progesteron secretion 3) Role in secretion of milk - producing effect. In mothers who do not nurse their baby a decrease in prolactin level to basal value in 2-3 weeks. Prolactin and estrogen synergize in producing breast growth, but estrogen antagonizes the milk-producing effect of prolactin on the breast.
B buy zestoretic 17.5 mg pulse pressure 84;a detailed anomaly scan including four chamber cardiac view and outflow tracts between 20 and 22 weeks generic zestoretic 17.5mg otc blood pressure low bottom number. Although regular fetal monitoring is common practice discount 17.5 mg zestoretic free shipping blood pressure uk, no evidence has been identified on the effectiveness of any single or multiple techniques and therefore the clinical judgement of an obstetrician experienced in diabetic pregnancy is essential zestoretic 17.5 mg with mastercard blood pressure over 160. The evidence for the accuracy of ultrasound scanning in predicting macrosomia (birth weight >4,000 g) is mixed. The accuracy of fetal weight estimation in women with diabetes is at least comparable to women who are not diabetic,353 but for prediction of macrosomia sensitivities ++ 2 have been found to vary from 36-76%, and positive predictive values from 51-85%. The trials reported either equivalent outcomes or improved outcomes (birthweight, macrosomia, large for gestational age) in women 1+ with gestational diabetes. Two randomised control trials have shown that intervention in women with gestational diabetes with dietary advice, monitoring and management of blood glucose is effective in reducing birth weight and the rate of large for gestational age infants,330, 331 as well as perinatal 330 1+ morbidity. Clinical suspicion that type 1 or type 2 diabetes is present or 4 developing in pregnancy may be raised by persistent heavy glycosuria in pregnancy (2+ on more than two occasions), random glucose >5. Strategies are likely to be simplified for women believed to be low risk based on risk factors (see Table 4). If, after nutritional advice, preprandial and postprandial glucose levels are normal and there is no evidence of excessive fetal growth, the pregnancy can be managed as for a normal pregnancy. Women who are at risk of pre-term delivery should receive antenatal corticosteroids. Women with diabetes have a higher rate of Caesarean section even after controlling for 2+ confounding factors. There is insufficient evidence on the preferred method of cotside blood glucose measurement 4 in neonates; however, whichever method is used, the glucose value should be confirmed by laboratory measurement. However, methods of glycaemic monitoring and interventions were not standardised in the study, so caution is required before extrapolating these findings to term infants. Glycaemic control at six weeks in women with type 1 diabetes, who exclusively breast fed, has 388 2++ been found to be significantly better than those who bottle fed. B Breast feeding is recommended for infants of mothers with diabetes, but mothers should be supported in the feeding method of their choice. Although most medicines are not licensed for use in lactation, specialist reference sources provide information on suitability of medicines in breast feeding. Women with gestational diabetes should be investigated postnatally to clarify the diagnosis and exclude type 1 or type 2 diabetes. The opportunity should also be taken to provide lifestyle advice to reduce the risk of subsequent type 2 diabetes. Appropriate contraception should be provided and the importance of good glycaemic control emphasised. Pre-pregnancy Discuss pregnancy planning with women with diabetes of childbearing age at their annual review. These may include: - what to do with insulin or tablets - appropriate food to maintain blood glucose levels - how often to measure blood glucose and when to check for ketones - when to contact the diabetes team and contact numbers. Explain what screening involves and what treatment to expect if retinopathy is found. This excess mortality is evident in all age groups, most pronounced in young people with type 1 diabetes, and exacerbated by socioeconomic deprivation. The life expectancy of both men and women diagnosed as having type 2 diabetes at age 40 is reduced by eight years relative to people without diabetes. In addition to its role in identifying patients at risk of diabetic nephropathy (see section 9), microalbuminuria is an independent marker associated with a doubling in cardiovascular risk. A Hypertension in people with diabetes should be treated aggressively with lifestyle modification and drug therapy. The lowering of blood pressure to 80 mm Hg diastolic is of benefit in people with diabetes. The long term follow up of these patients emphasised the need for maintenance of good blood pressure control. A Beta blockers and alpha blockers should not normally be used in the initial management of blood pressure in patients with diabetes. The reduction of events in patients with type 1 diabetes did not differ from patients with type 2 diabetes but did not reach individual statistical significance. Reduction in cardiovascular events 1+ was seen regardless of baseline cholesterol concentrations. People with diabetes experienced no more side effects from statins compared to people without diabetes. B Lipid-lowering drug therapy with simvastatin 40 mg should be considered for primary prevention in patients with type 1 diabetes aged >40 years. Unless covered specifically in the following sections, the principles of management are as for patients without diabetes. However, the case fatality from myocardial infarction is double that of the non-diabetic population. It demonstrated that long term insulin was of no additional benefit, although there was extensive use of insulin at discharge in all treatment groups making interpretation difficult. For patients with type 2 diabetes mellitus, insulin is not required beyond the first 24 hours unless clinically required for the management of their diabetes. This benefit was consistent across all patient subgroups and was independent of the thrombolytic agent used. The greatest benefit was seen in those patients treated within 12 hours of symptom onset. It should not be withheld 1+ due to concern about retinal haemorrhage in patients with retinopathy, and the indications and contraindications for thrombolysis in patients with diabetes are the same as in non-diabetic patients. Since this trial, routine clinical practice has moved to the more widespread invasive investigation of all medium-to-high risk patients to reduce the incidence of recurrent myocardial infarction. The benefits of clopidogrel therapy are likely to be overestimated in the modern era of interventional practice. There appeared to be a modest benefit in the subgroup of patients with clinically evident atherosclerotic disease that included approximately 30% of patients with a history of myocardial infarction within the previous five years. Although immediate beta blocker therapy should be avoided in patients with acute pulmonary oedema and acute left ventricular failure, subsequent cautious introduction of beta blockade is associated with major benefits. Stroke and transient ischaemic attack were reduced by 31% and 59% respectively (p<0. There is insufficient evidence to recommend fibrates, ezetimibe or nicotinic acid for the primary or secondary prevention of cardiovascular outcomes in patients with type 1 or 2 diabetes treated with statins. No evidence was identified on the effect of metformin on hospitalisation due to stroke or myocardial infarction. Sulphonylureas A meta-analysis addressing whether or not sulphonylureas increase or reduce mortality in patients with heart failure and diabetes found too little data to draw a conclusion. No studies addressing whether or not insulin increases or decreases hospitalisation due to heart failure, myocardial infarction or stroke were identified. Two formulations of metoprolol were used in clinical trials of patients with chronic heart failure. Only long-acting metoprolol succinate has been shown to perform better than placebo in reducing mortality. In the short term they can produce decompensation with worsening of heart failure and hypotension.