Peter Stott

Preventing adverse drug reactions

treatment; but should we put great emphasis on this measure, especially when variables likely to influence IELT, such as duration and intensity of foreplay, fantasy activity and mood are not adequately controlled for? I do not think we should. Anderson Darling et al. contend that rapid ejaculation should not be considered a specific point of time but rather a dimension of the timing relationship between partners (13). Assessment of other dimensions such as feelings of ejaculatory control and satisfaction with sexual performance are more important. A new questionnaire that addresses these dimensions has been developed and validated (14). These subjective dimensions rely on the couple’s sexual expectations, communication and other behavioural factors. The first step in the management of PE should involve obtaining a comprehensive sexual and relationship history (ideally from both partners), identifying and addressing these issues; not the prescription of ejaculation-delaying medication. This is especially important in view of the comorbidity of PE with other sexual and relationship difficulties in men and their partners (15) which could be aggravated by or negate the response to pharmacotherapy in terms of overall satisfactory outcome.

Detecting peripheral arterial disease using the ankle-brachial index.

Peripheral arterial disease (PAD) is defined as ‘atherosclerosis of the distal aorta and ⁄ or lower limb arteries causing arterial narrowing and disruption of blood flow to the legs’. In this edition of International Journal of Clinical Practice, Cacoub et al. (1) remind us of the value of the ankle–brachial index (ABI) – a diagnostic test which can be used for early diagnosis of this condition. This test requires only simple equipment which is widely available in both primary and secondary care. Early diagnosis in asymptomatic patients is valuable, first because secondary prevention is effective in PAD, but also because PAD is an independent predictor for risk of cardiovascular death (2). For most patients with PAD, the disease will run a benign course. Less than one-third will require surgery or further investigation and only around 5% will require an amputation (2). However, half of all patients who present with symptoms (usually claudication) already have symptoms of coronary artery disease or ECG changes. 90% will have abnormalities on coronary arteriography. The detection of asymptomatic PAD therefore has important public health ramifications. Early detection might motivate more patients to stop smoking, change their diet to include more fish, fruit and fibre; take more exercise; and lose weight. Clinicians might take a more holistic view to the use of antihypertensives, antiplatelet therapies and hypolipidaemic agents – all of which have been shown to be useful in the secondary prevention of PAD and cardiovascular disease. Cacoub et al. (1) found that in patients considered by their GP to be at high risk of PAD, the prevalence of PAD was 27.8% overall, ranging from 10.4% in patients with cardiovascular risk factors alone, to approximately 38% in patients with signs or symptoms of PAD and those with a previous history of atherothrombotic disease. The prevalence in the asymptomatic group (i.e. one patient in 10) is of especial importance. So what does measurement of the ankle–brachial pressure index involve? This is a simple test which is relevant for all patients except those with heavily calcified vessels (3). It involves measurement of systolic blood pressure using a standard sphygmomanometer cuff and a Doppler ultrasound probe. The technique is easily mastered and frequently used by nurses in the management of venous ulcers. Measurement is first made of the brachial artery systolic pressure. During measurement the probe must be kept absolutely still. The cuff is inflated until the artery is occluded and the Doppler signal disappears. The pressure at which the artery occludes is noted then the cuff is inflated for a further 20 mmHg. Next, the cuff is deflated and the pressure at which the Doppler signal reappears is noted. This procedure is then repeated on the other arm. The higher of the two systolic pressure is used. Next, the cuff is placed around the right ankle just above but not covering the malleolus and the probe is used to identify the systolic pressure in first the posterior tibial artery and then the dorsalis pedis. Most commonly, for calculation of the ABI the highest systolic pressures are used, and for a specific leg is calculated according to the following formula:

Upper gastrointestinal cancer and economic deprivation - data from a London (UK) Cancer Network.

cola consumption has been found to be associated with CKD. A comparison of 465 patients with newly diagnosed CKD and 467 community controls in North Carolina showed a twofold increased risk of CKD in patients who drank two or more cola drinks (16 ounces) per day (9). Chronic hypokalaemia causes increased renin levels, increased sympathetic tone and altered nitric oxide metabolism. Over time, these changes can lead to vasoconstriction, salt-sensitivity, polydipsia, polyuria and tubulointerstitial injury. This hypokalaemic nephropathy is reversible if promptly treated with potassium repletion, but in long-term cases, it can lead to chronic renal insufficiency and sometimes progress to end-stage renal disease. In the North Carolina study, it was not clear what role hypokalaemia may have played; other possible causes of cola-associated CKD include diabetes, hypertension and phosphoric acid-induced kidney stone disease. Most government responses to soft drink health concerns have focused on protecting children from youth-targeted advertising and in-school vending machines. This same focus seems to hold in the medical profession, where paediatricians are generally more aware of the health risks of soft drinks, and probably more likely than internists to discuss them with their patients. In addition to the usual questions about alcohol, tobacco and illicit drug use, internists need to start asking their adult patients about soft drink consumption. Cola drinks need to be added to the physician’s checklist of drugs and substances (such as liquorice) that can cause hypokalaemia. More work is needed on the epidemiology of cola consumption, hypokalaemia and cardiovascular disease rates. Finally, the soft drink industry needs to promote safe and moderate use of its products for all age groups, reduce serving sizes and pay heed to the rising call for healthier drinks. The tale of the thirsty kangaroo-hunter reminds us of the wisdom of Aristotle: ‘In all things, moderation’.

Chronic disease--another challenge for the developing world.

1 Solomon H, Man JW, Jackson G. Erectile dysfunction and the cardiovascular patient: endothelial dysfunction is the common denominator. Heart 2003; 89: 251–3. 2 Montorsi P, Ravagnani PM, Galli S et al. Association between erectile dysfunction and coronary artery disease: matching the right target with the right test in the right patient. Eur Urol 2006; 50: 721– 31. 3 Vlachopoulos C, Aznaouridis K, Ioakeimidis N et al. Unfavourable endothelial and inflammatory state in erectile dysfunction patients with or without coronary artery disease. Eur Heart J 2006; 27: 2640–8. 4 Jackson G, Rosen RC, Kloner RA, Kostis JB. The Second Princeton Consensus on Sexual Dysfunction and Cardiac Risk: new guidelines for sexual medicine. J Sex Med 2006; 3: 28–36. 5 Bacon CG, Mittleman MA, Kawachi I et al. A prospective study of risk factors for erectile dysfunction. J Urol 2006; 176: 217–21. 6 Laurmann EO, Nicolosi A, Glasser DB et al. Sexual problems among women and men aged 40–80 years: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviour. Int J Impot Res 2005; 17: 39–57. 7 Esposito K, Giugliano F, Di Palo C et al. Effect of lifestyle changes on erectile dysfunction in men: a randomised controlled trial. JAMA 2004; 291: 2978–84.

Smoking cessation: trying hard; but could do better.

Stopping smoking is one of the most important things an individual can do to benefit health – at any stage of disease. In this issue of IJCP, Han et al. (1) demonstrate the value of clinicians continuing to encourage patients to give up smoking, even if they have relapsed several times already. Smoking cessation can extend life and it can improve the quality of life. This comes at very low cost compared with medical interventions. Economic analysis has shown that using nicotine replacement, the cost per life year saved is small – somewhere between £159 and £658 (2). However, giving up smoking is not easy. Smoking is an addictive behaviour and the habit dies hard. Around between 10% and 40% of smokers manage to quit at their first attempt, while some groups such as the elderly or pregnant mothers quit more successfully (3,4). Nevertheless, despite very best intentions, between 60% and 90% of smokers who enter first cessation programmes will relapse (4,5). At this point, it is not uncommon for physicians to lower their expectations and to be less than fulsome in their subsequent support. Yet this may not be reasonable. Smoking is an addictive behaviour and as with all addictions, to be a successful quitter, the patient must want to change. Motivation is most important and at their first attempt not all smokers may be maximally motivated. The Stages of Change model (6) postulates that when people deliberately make behavioural changes such as stopping smoking, they go through a series of changes. Each stage is associated with a different frame of mind about the behaviour concerned and each stage with a different kind of motivation. There are five stages: precontemplation in which the individual sees no problem even though others disapprove; contemplation (in which the patient is weighing up the pros and cons); active change; maintenance; and relapse. In many cases, after relapse the patient cycles back to a stage of precontemplation. This model suggests that people must be in the stage of precontemplation or contemplation if they are to engage in active change such as smoking cessation. The cyclical nature of the process also explains why almost two-thirds of relapsed smokers are interested in trying again within 30 days (7) and why smokers who have made more attempts to quit in the past continue to try to do so. Han et al. (1) demonstrate that success with relapsers can be high, even outside the confines of a strict clinical trial. In their study, between 20% and 23% of those who relapsed were abstinent at 26 weeks on each consecutive quit attempt. This is a large community study which involved some 1745 patients. Those who returned for subsequent treatments tended to be heavy smokers and more likely to have a history of treatment for mental health problems. Han et al.’s reported cessation success of 20–23% for relapsed smokers is somewhat higher than that reported in many other studies which leads one to ask how success can be made more certain. We know that trigger factors for quitting smoking include personal health, the cost of cigarettes, financial pressures and pressure from family and friends (7,8,9). We also know that at the time they are likely to relapse, patients are often aware of the danger they are in (10) – knowledge which could lead them to seek further support from outside agencies if this was available. Nevertheless, there are few studies which have identified factors which can reduce the tendency to relapse. Skills training to identify and negate tempting situations, extended treatment contact and pharmacotherapy have been cited, but a recent systematic review concluded that most studies had limited power to differentiate between interventions (11). Despite best endeavours, smoking remains one of the main challenges to public health, especially in the developing world. Most people who cease smoking will relapse at some point or other and numerically, prevention of relapse is at least as important as helping first-time quitters. At the level of the individual everyday consultation, clinicians have an important part to play, not only in helping first time quitters but also in supporting those addicts who have previously relapsed.

Psychological interventions in early psychosis. A treatment handbook

Psychological interventions in early psychosis : a treatment handbook edited by John F.M. 1 The nature of these treatments has been varied. The focus of psychological treatment research in early psychosis has tended to. The CBT and SC were manual based and supervised.Psychological Interventions in Early Psychosis provides a comprehensive overview of the emerging research and clinical evidence base for psychological.Section II: The Early Intervention Service-delivery System. Additional training in a variety of psychosocial treatments allows the case manager to offer.care for early detection and treatment of first episode psychosis without delay. Psychological, psychosocial and biological interventions tailored to the. Viii www.csipplus.org.ukRowanDocsEIupdateOct2006.pdf. Treatment Handbook.Amazon.com: Psychological Interventions in Early Psychosis: A Treatment Handbook 9780470844366: John F. McGorry: Books.Over recent years, psychosocial approaches to managing psychosis have. The early assessment modules of the treatment manual are directed towards.c the scientific literature relevant to early intervention in psychosis ducation. Psychosis by community care for early detection and treatment without delay.Early intervention in psychosis is clearly the most evidence-rich. Based interventions for treating psychosis in the early phase and. GuidelineDocument.pdf. Article Figures Data Info Metrics eLetters PDF. For people with early psychosis, early intervention services appear to have clinically important benefits over standard care. Psychological interventions improve outcomes for early psychosis. SIGN 50: A Guideline Developers Handbook. SIGN.affective and non-affective psychotic diagnoses van.