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Impetigo Scabies Fungal Nail Infections ANTIPLATELET DRUGS BEST PRACTICE 19 FEBRUARY 2009 SKIN Impetigo Scabies Fungal Nail Infections bpac nz ANTIPLATELET DRUGS better medicine Editorial Team We would like to acknowledge the following people for Tony Fraser their guidance and expertise in developing this edition: Professor Murray Tilyard Dr Michael Crooke, Wellington Clinical Advisory Group Dr Rebecca Grainger, Wellington Michele Cray Dr Hayden McRobbie, Auckland Dr Rosemary Ikram Dr Amanda Oakley, Hamilton Dr Cam Kyle Assoc. Prof. CK Wong, Dunedin Dr Chris Leathart Dr Edward Wong, Auckland Natasha Maraku Dr Neil Whittaker, GP Reviewer, Nelson Dr Lynn McBain Adam McRae Dr Peter Moodie Best Practice Journal (BPJ) Associate Professor Jim Reid Associate Professor David Reith ISSN 1177-5645 Professor Murray Tilyard BPJ, Issue 19, February 2009 Programme Development Team Noni Allison BPJ is published and owned by bpacnz Rachael Clarke Level 8, 10 George Street, Dunedin, New Zealand. Rebecca Didham Terry Ehau Bpacnz is an independent organisation that promotes health Peter Ellison care interventions which meet patients’ needs and are evidence based, cost effective and suitable for the New Zealand context. Dr Malcolm Kendall-Smith Julie Knight We develop and distribute evidence based resources which describe, facilitate and help overcome the barriers to best Dr Tom Swire practice. Dr Anne-Marie Tangney Bpacnz is currently funded through contracts with PHARMAC and Dr Trevor Walker DHBNZ. Dr Sharyn Willis Dave Woods Bpacnz has four shareholders: Procare Health, South Link Health, Report Development Team IPAC and the University of Otago. Justine Broadley Todd Gillies Lana Johnson Web SOUTH LINK HEALTH Gordon Smith Design Contact us: Michael Crawford Mail: P.O. Box 6032, Dunedin Management and Administration Email: [email protected] Kaye Baldwin Free-fax: 0800 27 22 69 Tony Fraser Kyla Letman www.bpac.org.nz Professor Murray Tilyard Distribution Lyn Thomlinson This magazine is printed on an environmentally responsible paper managed under the environmental management system ISO 14001, Colleen Witchall produced using Certified ECF pulp sourced from Certified Sustainable & Legally Harvested Forests. CONTENTS Management of impetigo 8 Impetigo is a highly contagious, bacterial infection of the skin, most commonly seen in children. It is typically diagnosed clinically and the aim of treatment is to clear the eruption and prevent the spread of infection to others. Topical treatment is usually adequate although oral antibiotics can be used for extensive infection. Scabies – diagnosis and management 12 Scabies manifests as an itchy skin rash, as a result of an allergic reaction to the female scabies mite. Infection is easily spread from person to person with direct skin contact. Clinical diagnosis can be made if burrows are observed on the skin. Permethrin and malathion are effective treatments for the rash. 18 Management of fungal nail infections Fungal nail infection (onychomycosis) accounts for around 50% of all nail disease. Laboratory diagnosis is recommended before considering oral or topical treatment. However, treatment may not always be necessary, especially for elderly people or for those who do not have troublesome symptoms. BPJ | Issue 19 | 1 CONTENTS 24 Transient ischaemic attack – a medical emergency For one in four people, transient ischaemic attack (TIA) is a forerunner for stroke. If TIA is suspected, aspirin should be immediately commenced, followed by stroke risk assessment. Patients at high risk of stroke should be referred urgently for specialist assessment. 32 The role of antiplatelet agents Antiplatelet drugs including aspirin, clopidogrel and dipyrimadole, reduce the incidence of cardiovascular events by about 20–25% in people with established cardiovascular disease or at high risk of cardiovascular disease. This article provides an overview of each drugs current place in therapy. 38 Warfarin versus aspirin for the prevention of atrial fibrillation related stroke The decision whether to choose aspirin or warfarin for stroke prevention is often not clear cut. There is evidence that treatment with warfarin is more effective for stroke prevention than aspirin. However warfarin is underutilised, particularly in elderly people, despite the fact with effective communication and monitoring it can be used safely 44 Sexually transmitted infections in New Zealand Chlamydia remains the most commonly diagnosed STI in New Zealand, according to the annual STI Surveillance Report. Although not yet as prevalent as chlamydia, cases of gonorrhoea are increasing at a greater rate. Genital warts are the most frequently reported viral STI and the number of cases of syphilis continues to increase. 2 | BPJ | Issue 19 CONTENTS 48 PHO performance indicator programme: Why people smoke There are many reasons why people begin smoking, continue to smoke and find it hard to quit. Clinicians who want to discourage people from smoking are more likely to be successful if they have some understanding and empathy of these reasons and barriers. Essentials 4 Upfront New hope for genetic disorders: pre-implantation genetic diagnosis 17 Quick Reads Removal of isotretinoin prescriber restrictions Quiz Feedback Feedback and expert commentary from the BPJ 17 quiz: Bones and Joints/CVD 56 risk assessment Evidence that Counts Statins and the JUPITER study, CRP and atherosclerosis, aspirin and cognitive 62 function, diverticulitis, PPIs and C. difficile, nicotine gum and pregnancy All web links in this journal can be accessed via the online version. www.bpac.org.nz BPJ | Issue 19 | 3 UPFRONT www.bpac.org.nz keyword: genetics New hope for genetic disorders Pre-implantation genetic diagnosis Pre-implantation genetic diagnosis (PGD) represents the are transferred to the uterus. This enables parents to latest technology in genetic testing. However it also opens make a choice about the future of an affected embryo up an ethical minefield between the balance of scientific rather than an affected foetus. advances and “playing God”. The purpose of this article is to provide information about the issues, preparing GPs and Currently PGD can be used for three different primary care professionals for questions from patients. abnormalities: ▪ Single gene defects e.g. cystic fibrosis, Huntington’s It is vital that GPs and other health professionals disease, haemophilia “know more about genetic testing and genetic services ▪ Numerical chromosomal abnormalities (aneuploidy) in New Zealand so they can better facilitate informed e.g. Down syndrome, Turner syndrome consent, know when to refer patients for testing and be able to offer some degree of genetic counselling ▪ Structural chromosomal abnormalities e.g. if required. Professor Mark Henaghan, Human translocations Genome Research” Project. PGD can be used for couples who are carriers of a familial What is pre-implantation genetic diagnosis? genetic disorder that would cause serious impairment for the child and for which there is a 25% or greater risk of an Until recently the only testing option available for parents affected pregnancy. at risk of conceiving a child with a genetic disorder was prenatal diagnosis. This involves sampling foetal It may also be used for couples who are having trouble cells through the placenta (chorionic villus sampling) conceiving due to advanced reproductive age or who or the amniotic fluid (amniocentesis). Couples then have experienced recurrent implantation failure or decide whether to abort the foetus or continue with the miscarriage. pregnancy. PGD involves: PGD is a procedure used in conjunction with in vitro 1. Creation of an embryo via IVF fertilisation to test embryos for serious inherited genetic conditions and chromosomal abnormalities before they 2. Removal of one or two cells from the embryo 4 | BPJ | Issue 19 3. Genetic testing of these cells for specific genetic the new PGD technology available for sex selection, conditions or chromosomal abnormalities which is freely available in the US, and we are currently considering using this technology to weigh 4. Transfer of unaffected embryos to the uterus New hope for genetic disorders the chances of our next (and final) pregnancy being a girl. I believe I should have the right to decide The Ministry of Health currently funds 40 cycles of IVF/ whether or not to take advantage of such wonderful Pre-implantation genetic diagnosis PGD a year to detect serious inherited genetic diseases. advancements in medical technology as PGD for sex There is limited availability of PGD in New Zealand (see selection. I don’t believe it is up to the Government page 7). PGD is most commonly used in New Zealand to or policymakers to be able to make such personal test for Huntington’s disease, cystic fibrosis and spinal choices on my behalf. We are a loving, hard-working muscular atrophy. family and have the resources to take care of another child; if there is a technology that allows us to increase Patients considering PGD should be given relevant our chances of it being a girl then we plan to take information, advice on alternatives and referral for genetic advantage of it. Forum, Who Gets Born. and psychosocial counselling from a trained genetic ” counsellor. Saviour siblings Saviour siblings are children who are created in order to Gender selection donate mast cells to an existing sick child in the family. PGD can be used in New Zealand to select the gender of PGD along with human leukocyte antigen (HLA) tissue a child, if it prevents transmission of a sex-linked genetic typing can be used to select genetically matched sibling condition such as haemophilia or Duchenne’s muscular embryos. In New Zealand, saviour siblings are permitted dystrophy, when a specific test is not available. for inherited disorders e.g. beta thalassemia, under the oversight of Ethics Committee on Assisted Reproductive Gender selection for social reasons (e.g. family balancing) Technology. Approval from the Minister of Health must be is not legal in New Zealand, although it is allowed in some sought to use cord blood on a sibling. No saviour siblings other countries such as the United States. The use of PGD have been born in New Zealand to date. for any other social reasons e.g.
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