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Emma Henshall

Even the young and lean will benefit from disrupting the insulin-androgen cycle...

Prof Bruce Campbell

Neurologist answers GPs questions about BP & lipid targets, medications and more….

Sophia Auld

Practical tips from the updated Handbook...

Antonia Shand

New Australian research suggests a communication gap between dermatologists and GPs could be creating risk...

Sophia Auld

Early detection, medication advice, atypical red flags and more...

Sophia Auld

‘Exercise snacks’ could help patients achieve health benefits in just a few minutes per day...

Danielle O'Neal

Binge eating disorder often goes undiagnosed for more than a decade. Here's how to spot the signs and manage it...

Dr Linda Calabresi

Endometriosis, or more particularly diagnosis of endometriosis is often a challenge in general practice. When should you start investigating a young girl with painful periods? Is it worth investigating or should we just put them on the Pill? At what point should these young women be referred? Consequently, the most recent NICE guidelines on the diagnosis and management of endometriosis, published in the BMJ will be of interest to any GP who manages young women. According to the UK guidelines, there is commonly a delay of up to 10 years between the development of symptoms and the diagnosis of endometriosis, despite the condition affecting an estimated 10% of women in the reproductive age group. Endometriosis should be suspected in women who have one or more of the following symptoms:
  • chronic pelvic pain
  • period pain that is severe enough to affect their activities
  • deep pain associated with or just after sex
  • period-related bowel symptoms such as painful bowel movements
  • period-related urinary symptoms such as dysuria or even haematuria
Sometimes it can be worthwhile to get the patient to keep a symptom diary especially if they are unsure if their symptoms are indeed cyclical. Women who present with infertility and a history of one or more of these symptoms should also be suspected as having endometriosis.

Investigations

With regard investigations, the guidelines importantly state that endometriosis cannot be ruled out by a normal examination and pelvic ultrasound. Nonetheless after abdominal and pelvic examination, transvaginal ultrasound should be the first investigation to identify endometriomas and deep endometriosis that has affected other organs such as the bowel or bladder. Transabdominal ultrasounds are a worthwhile alternative in women for whom a transvaginal ultrasound is not appropriate. MRI might be appropriate as a second line investigation but only to determine the extent of the disease. It should not be used for initial diagnosis. Similarly, the serum CA-125 is an inappropriate and unreliable diagnostic test. Diagnostic laparoscopy is reserved for women with suspected endometriosis who have a normal ultrasound.

Treatment

If the symptoms of endometriosis can’t be adequately controlled with analgesia, the guidelines recommend hormonal treatment with either the combined oral contraceptive pill or progestogen. Women need to be aware that this will reduce pain and will have no permanent negative effect on fertility. Surgical options to treat endometriosis need to be considered in women whose symptoms remain intolerable despite hormonal treatment, if the endometriosis is extensive involving other organs or if fertility is a priority and it is suspected that the endometriosis might be affecting the woman’s ability to fall pregnant. All in all, these guidelines from the Royal College of Obstetricians and Gynaecologists don’t offer much in the way of new treatments but they do provide a framework to help GPs manage suspected cases of endometriosis and hopefully reduce that time delay between symptom-onset and diagnosis. BMJ 2017; 358: j3935 doi: 10.1136/bmj.j3935
Prof Clare Collins

There are many reasons people go vegan, from wanting to be healthier, to reducing their environmental footprint, to concerns about animal welfare. No matter what the reason, many people find it difficult to meet the nutrient intake targets for specific vitamins and minerals while on a vegan diet. These include vitamin B12, iron, calcium, and iodine. Here’s how to make sure you’re getting enough of these vitamins and minerals while following a vegan diet.

1. Vitamin B12

Vitamin B12, or cobalamin, is essential for making red blood cells, DNA (your genetic code), fatty acids located in myelin (which insulate nerves), and some neurotransmitters needed for brain function. Vitamin B12 is stored in the liver, so a deficiency probably won’t happen in adults in the short term.
Symptoms of B12 deficiency
Symptoms of vitamin B12 deficiency include tiredness, lethargy, low exercise tolerance, light-headedness, rapid heart rate or palpitations, bruising and bleeding easily, weight loss, impotence, bowel or bladder changes, a sore tongue, and bleeding gums. Other symptoms related to the nervous system include a loss of sensation in the hands or feet, problems related to movement, brain changes ranging from memory loss to mood changes or dementia, visual disturbances, and impaired bowel and bladder control.
Testing for B12 deficiency
Your doctor may request a blood test to check your vitamin B12 status and determine whether indicators are in the healthy range.
Vegan food sources of B12
Vitamin B12 is abundant in animal foods including meat, milk and dairy products. For vegans, plant sources of vitamin B12 include some algae and plants exposed to bacterial action or contaminated by soil or insects. While traces of vitamin B12 analogues can be found in some mushrooms, nori or fermented soy beans, more reliable sources include vitamin B12-supplemented soy or nut “milks”, or meat substitutes. Check the nutrition information panel on the label for the the B12 content. Crystalline vitamin B12 added to these products can boost the B12’s absorption rate to a level similar to that from animal products.

2. Calcium

Calcium is needed to develop and maintain the skeleton bones, and is stored in the teeth and bones. It is also essential for heart, muscle and nerve function.
Testing for calcium deficiency
Low calcium intakes are associated with osteoporosis or “brittle bones” and a higher risk of bone fractures. A bone scan is used to measure bone density, with osteoporosis diagnosed when bone density is low. Both low calcium intakes and low vitamin D levels increase the risk of osteoporosis. Check your bone health using the Know Your Bones online quiz.
Vegan food sources of calcium
Although the richest sources of calcium are milk and milk-based foods, vegans can get calcium from tofu or bean curd, some fortified soy or nut beverages, nuts, seeds, legumes, and breakfast cereals. Calcium needs can be higher for vegans and vegetarians due to the relatively high oxalic acid content of foods such as spinach, rhubarb, beans, and the high phytic acid content of seeds, nuts, grains, some raw beans, and soy products. These specific acids can lower the calcium absorption from these foods by 10-50%. In a study of calcium intakes of 1,475 adults , vegans were below national recommendations and had lower calcium intakes compared with vegetarians, semi-vegetarians, pesco-vegetarians, and omnivores.

3. Iodine

Iodine is needed to make thyroxine, a thyroid hormone used in normal growth, regulation of metabolic rate, and development of the central nervous system. Iodine is concentrated in the thyroid gland.
Symptoms of iodine deficiency
Iodine deficiency can lead to the enlargement of the thyroid gland, a goitre, or hypothyroidism. Symptoms of hypothyroidism include lethargy, tiredness, muscular weakness, feeling cold, difficulty concentrating, poor memory, weight gain, depression, facial puffiness, hair loss, dry skin, constipation, and slower heartbeat. In women, iodine deficiency can increase risk of miscarriage and stillbirth, and congenital anomalies, including mental retardation and cretinism.
Testing for iodine deficiency
Your iodine status can be assessed by a range of tests, including thyroid hormones in your blood, the size of your thyroid gland, or the presence of a goitre. Talk to your doctor about these tests.
Vegan food sources of iodine
The iodine content of food depends on the iodine content of plants, which in turn depends on soil iodine content. When soil content is low, iodine may need to be supplemented. Major sources of iodine are seafood, dairy products, and eggs. For vegans, iodised salt, commercial bread made using iodised salt, fortified soy or nut milks (check the product label) and seaweed are important. Substances called goitrogens, which are found in brassica vegetables – including cabbage, broccoli and Brussels sprouts, sweet potato and maize – can interfere with the production of thyroid hormones.

4. Iron

Iron is needed to make haemoglobin in red blood cells, which carries oxygen around your body. Iron is also needed for the production of energy in your muscles, and for concentration and a healthy immune system.
Symptoms and testing for iron deficiency and anaemia
Not having enough iron leads to iron deficiency, and is associated with reduced work capacity, impaired brain function, lower immunity, and delayed development in infants. The first stage of iron deficiency is referred to as low iron stores and your doctor may refer you for a blood test to check your iron status.
Vegan food sources of iron
In Australia and New Zealand, the biggest contributors to iron intake are wholegrain cereals, meats, chicken, and fish. The amount of iron absorbed from food depends on a person’s iron status (with those who are iron-deficient absorbing more), as well as the iron content of the entire meal, and whether iron is haem (from animal foods) or non-haem iron from plant sources such as grains and vegetables. Although iron from plant sources is less able to enter the body, you can boost your absorption by adding lemon or lime juice (citric acid) or other vitamin C-rich vegetables and fruits, which convert non-haem iron to a form than is better absorbed. Take care with food components that inhibit absorption of both haem and non-haem iron, including calcium, zinc and phytates in legumes, rice and other grains, and polyphenols and vegetable proteins that can inhibit absorption of non-haem iron. Long-term vegans will also need to keep an eye on levels of vitamin D, omega-3 fat and protein. A good strategy is to check in with your GP periodically to review your health and well-being, and an accredited practising dietitian can check whether you’re getting all the nutrients you need.The Conversation This article is republished from The Conversation under a Creative Commons license. Read the original article.
Dr Linda Calabresi

We all know that the previous avoidance strategy to prevent young children developing food allergies has been turned on its head. But out there in the real world, many new parents remain very nervous about feeding their six-month-old cooked egg or letting them taste peanut butter. As much as we would like to think a word of reassurance from their trusted GP is all that is needed, such reassurance is likely to carry much more weight if it is accompanied by a written resource from a reputable source. Enter the Prevent Allergies website. Among many other resources available on the site, there is a very succinct, definitive, printable brochure - entitled ‘Nip Allergies in the Bub’ - that clearly outlines the latest evidence-based information about what parents should be feeding their child and when with regard to lowering their risk of food allergies.

Ohio University

Low-density lipoproteins (LDL), the kind of cholesterol found in fast food, processed meats and desserts, has come to be known as 'bad' cholesterol due to it's association with heart attacks and coronary disease. Despite this, 75% of heart attacks occur in patients whose cholesterol levels don't indicate they're at high risk, leading many to suspect the link isn't as simple as initially thought. Researchers at Ohio University may have just figured out why.

Dr Linda Calabresi

Prospective fathers might consider taking fish-oil supplements to improve their fertility, new research suggests. Danish researchers conducted the study into the reproductive function among over 1500 young men (aged 18-19 years) from the general population. They compared parameters such as total sperm count and motility, as well as serum hormone levels including testosterone and FSH among those men who had reportedly taken fish oil supplements regularly over the past three months with those who didn’t.