In recent decades, the worldwide burden of infectious disease has fallen, thanks to sanitation, hygiene, and prevention and control efforts. But the covid-19 pandemic shows how great a threat to global health remains – particularly as the climate crisis continues to affect disease spread and our response in myriad ways. Increasing temperatures are expanding the areas where diseases such as malaria and dengue thrive. More flooding and drought increases disease risk. Hygiene requires access to clean water. Further urbanization and migration related to climate change will also complicate prevention and control. The BMJ has published “The time is now” collection, calling for the strengthening of the global response to climate change and communicable disease. https://www.bmj.com/communicable-dise…
Exercise training is a safe, effective and low-cost intervention for improving walking ability in patients with IC. Additional benefits may include improvements in QoL, muscle strength and cardiorespiratory fitness. Clinical guidelines advocate supervised exercise training as a primary therapy for IC, with walking as the primary modality.
However, evidence is emerging for the role of various other modes of exercise including cycling and progressive resistance training to supplement walking training. In addition, there is emerging evidence for home-based exercise programmes. Revascularisation or drug treatment options should only be considered in patients if exercise training provides insufficient symptomatic relief.
Peripheral artery disease (PAD) is caused by atherosclerotic narrowing of the arteries supplying the lower limbs often resulting in intermittent claudication, evident as pain or cramping while walking. Supervised exercise training elicits clinically meaningful benefits in walking ability and quality of life. Walking is the modality of exercise with the strongest evidence and is recommended in several national and international guidelines. Alternate forms of exercise such as upper- or lower-body cycling may be used, if required by certain patients, although there is less evidence for these types of programmes. The evidence for progressive resistance training is growing and patients can also engage in strength-based training alongside a walking programme. For those unable to attend a supervised class (strongest evidence), home-based or ‘self-facilitated’ exercise programmes are known to improve walking distance when compared to simple advice. All exercise programmes, independent of the mode of delivery, should be progressive and individually prescribed where possible, considering disease severity, comorbidities and initial exercise capacity. All patients should aim to accumulate at least 30 min of aerobic activity, at least three times a week, for at least 3 months, ideally in the form of walking exercise to near-maximal claudication pain.
What you need to know
- Functional neurological disorder (FND) is associated with considerable distress and disability. The symptoms are not faked
- Diagnose FND positively on the basis of typical clinical features. It is not a diagnosis of exclusion
- FND can be diagnosed and treated in presence of comorbid, pathophysiologically defined disease
- Psychological stressors are important risk factors but are neither necessary nor sufficient for the diagnosis
Functional disorders are conditions whose origin arises primarily from a disorder of nervous system functioning rather than clearly identifiable pathophysiological disease—such as irritable bowel syndrome, fibromyalgia, and functional neurological disorder (FND)—they are the second commonest reason for new neurology consultations.1 FND is common in emergency settings,2 stroke,3 and rehabilitation services.4 It causes considerable physical disability and distress, and often places an economic burden both on patients and health services.5 Many clinicians have had little formal clinical education on the assessment and management of these disorders, and patients are often not offered potentially effective treatments.
With the annual flu season looming, GPs are anticipating a frenzy of vaccinations, perhaps more so than ever this year. As so many ‘flu and respiratory viruses circulate every year, and as the ‘flu vaccine is for one strain of influenza only, is the vaccine worth getting, and what are the risks associated with vaccinating vs. not vaccinating?
In this week’s episode, we discuss the high vaccine uptake in New Zealand, and the role that social distancing for COVID-19 may have played in their low numbers of seasonal flu. We also talk about whether or not the message we give to patients about the benefits and risks of vaccination is transparent enough, and how we might communicate better with them to allow them to make an informed decision. We feel pressure to increase vaccination rates, because we believe we are protecting people, but does the evidence support that?
Our guests: Nikki Turner is the director of the Immunisation Advisory Centre (IMAC) at the university of Auckland. She is an academic general practitioner, and a professor at the university. Jeff Kwong is a professor at the University of Toronto, and the interim director of the Centre for Vaccine Preventable Diseases at the university’s Dalla Lana School of Public Health. Newest Oldest Longest Shortest Random
Chest pain is a common chief complaint. It may be caused by either benign or life-threatening aetiologies and is usually divided into cardiac and non-cardiac causes. James E. Brown, Professor and Chair, Wright State University Boonshoft School of Medicine, Kettering, Ohio, gives us an overview of assessing chest pain in the emergency setting.
From a BMJ Study article (April, 2020):
Compared with usual diet, moderate certainty evidence supports modest weight loss and substantial reductions in systolic and diastolic blood pressure for low carbohydrate (eg, Atkins, Zone), low fat (eg, Ornish), and moderate macronutrient (eg, DASH, Mediterranean) diets at six but not 12 months. Differences between diets are, however, generally trivial to small, implying that people can choose the diet they prefer from among many of the available diets (fig 6) without concern about the magnitude of benefits.
The worldwide prevalence of obesity nearly tripled between 1975 and 2018.1 In response, authorities have made dietary recommendations for weight management and cardiovascular risk reduction.23 Diet programmes—some focusing on carbohydrate reduction and others on fat reduction—have been promoted widely by the media and have generated intense debates about their relative merit. Millions of people are trying to lose weight by changing their diet. Thus establishing the effect of dietary macronutrient patterns (carbohydrate reduction v fat reduction v moderate macronutrients) and popular named dietary programmes is important.
Biological and physiological mechanisms have been proposed to explain why some dietary macronutrient patterns and popular dietary programmes should be better than others. A previous network meta-analysis, however, suggested that differences in weight loss between dietary patterns and individual popular named dietary programmes are small and unlikely to be important.4 No systematic review and network meta-analysis has examined the comparative effectiveness of popular dietary programmes for reducing risk factors for cardiovascular disease, an area of continuing controversy.
From a BMJ online release (March 17, 2020):
“The finding in two randomised trials that advice to use ibuprofen results in more severe illness or complications helps confirm that the association seen in observational studies is indeed likely to be causal. Advice to use paracetamol (acetaminophen) is also less likely to result in complications.”
Scientists and senior doctors have backed claims by France’s health minister that people showing symptoms of covid-19 should use paracetamol (acetaminophen) rather than ibuprofen, a drug they said might exacerbate the condition.
Ian Jones, a professor of virology at the University of Reading, said that ibuprofen’s anti-inflammatory properties could “dampen down” the immune system, which could slow the recovery process. He added that it was likely, based on similarities between the new virus (SARS-CoV-2) and SARS I, that covid-19 reduces a key enzyme that part regulates the water and salt concentration in the blood and could contribute to the pneumonia seen in extreme cases. “Ibuprofen aggravates this, while paracetamol does not,” he said.