Common Clinical Conditions in General Practice - I Dr. Brendan O’ Shea Department of Public Health and Primary Care Conditions Covered • Session 1 – – – – Hypertension Ischaemic heart disease / Angina / MI Diabetes mellitus URTI / LRTI • Session 2 – – – – – Asthma COPD Low back pain Arthritis / Joint pain Thyroid disorders General Approach to CCCs • Each condition needs to be considered in terms of: • Your Diagnosis and how to make it – Definition and Prevalence – Actions at diagnosis – Follow up / management – Prevention & screening Terminology • Chronic Disease - CDM • Long Term Condition – ‘LTCs’ • Common Clinical Conditions Your Diagnosis…….. • • • • • • How to make it Understanding the natural history Understanding the implications of Dx. Steps and Interventions at diagnosis Good follow up Effective continuing care Common LTCs – 80 patients Hypertension 42 Renal Failure 5 (Malignancies 8) ICHD 26 Anxiety 4 Breast 3 Cholesterol 26 Asthma 3 Gastric 1 Thyroid 17 Dementia 3 Prostate 1 Depression 12 TIA 3 Bladder 1 Osteoporosis 12 Alcohol 2 Myeloma 1 Diabetes 11 Cardiomyopathy 2 Myeloprolif 1 A fib 9 Epilepsy 2 COPD 7 Haemochromatosis 2 PVD 7 Uterine prolapse 2 CCF 7 CVA 6 Gout 5 Comment: data garnered from POMR + Drugs Common Clinical Conditions • Large Volume of Data • System of learning..... Clinical Approach – Talk to / Examine Patients Programme of Active Reading Texts Web Based Resources Hypertension • Moderate Incidence / High Prevalence 25% Adults (50% of > 60 yrs) NICE Hypertension • Case Study – 49 y.o. Caucasian Irish male with a LRTI; 1st visit in 3 years – Opportunistic screening shows BP 167/98 • • • • • What is the next step? What are the important things to cover in the Hx What investigations should he have? What treatment would you advise? What if he was 65 y.o? Hypertension • Case Study – 49 y.o. Caucasian Irish male with a LRTI; 1st visit in 3 years – He returns 3 months later for f/up: – BP 152/92. He still smokes 30/day, alcohol 28 upw • What now? Hypertension • Case Study – 49 y.o. Caucasian Irish male with a LRTI; 1st visit in 3 years – He returns 3 months later for f/up: – BP 152/92. He is still smoking 30/day • What now? • He is reluctant to take further medication or give up smoking. How would you approach this problem? Hypertension • Definition – Level of blood pressure above which there is a benefit from investigation and treatment • Prevalence – Dramatically underestimated – >30% undiagnosed (conservative) – Approx 50% in 60 + yr age-group Hypertension  Why Treat?  Major risk factor for cardiovascular disease (not just MI and stroke – retinal, renal, PVD)  Clear evidence that controlling BP reduces that risk  HOPE study (ramipril), ALLHAT, Blood Pressure Lowering Treatment Trialists’ Collaboration  Screening  ‘Opportunistic’ or Organised Screening  All adults: check routinely every 5 yrs to age 80 y.o.  Annual checks if “high normal,” or hx of abnormal BP Hypertension • Classification – Essential HTN (95%) – cause unknown • Isolated systolic HTN – elderly patients (5% at 60 y.o.) – Secondary HTN (5%) – responds less easily to Rx • Renal disease – 75% intrinsic renal disease (GN, PAN, polycystic kidney disease, chronic pyelonephritis) – 25% renovascular disease • Endocrine disease – Cushing’s / Conn’s syndrome, phaeochromocytoma, acromegaly, hyperPTH • Others – coarctation, pregnancy, steroids, COCP, alcohol Hypertension  Classification of BP Levels (BHSoc)  Category  Blood Pressure  Optimal  Normal  High Normal  Hypertension  Grade 1 (mild)  Grade 2 (moderate)  Grade 3 (severe)  Isolated Systolic Hypertension  Grade 1  Grade 2 Systolic BP (mmHg) Diastolic BP (mmHg) < 120 < 130 130 – 139 < 80 < 85 85 – 89 140 – 159 160 – 179 ≥ 180 90 – 99 100 – 109 ≥ 110 140 – 159 ≥ 160 < 90 < 90 Hypertension • Diagnosis – Proper procedure and equipment (BHSoc) – If > 140/90 proceed to 24 Hr ABPM – Assess absolute 10 yr risk of cardiovascular disease • Ambulatory BP Monitoring – Suspect white coat HTN (10%) – Wide variations in BP measurements – HBPM – seated, BD, 4-7 days, calculate average. Hypertension • History / Symptoms and Signs – Usually asymptomatic, maybe headache / visual disturbance – Symptoms of end-organ damage – e.g. LVH, TIA, CVA, MI, angina, PVD, renal impairment – Contributory factors • Obesity, excess alcohol intake, excess salt, lack of exercise, environmental stress, medications, illicit drugs – Cardiovascular risk factors • Smoking, DM, hypercholesterolaemia (esp total chol:HDL ratio), FHx • Examination – – – – – General: BMI, abdominal circumference, CVS: BP, pulse, heart size, heart sounds, heart failure Renal: bruits, palpable kidneys, dipstick urine Fundoscopy (hypertensive retinopathy) 24 Hr ABPM Hypertension Investigations 24 hr ABPM – Dipstick urine and send for microalbuminuria • 30% pts with HTN have microalbuminuria, one of the strongest markers for complications in untreated HT – U+E (consider LFT’s if likely to start a statin) – Fasting blood glucose – Fasting lipid profile – ECG – Sokolow Lyon ; LVH – predictor of complications – CXR (if suspect cardiomegaly) Management of Hypertension • • • • Entry on Disease Register Communicate on care Ascertain expectations Educate re the long haul- Planned Management • Explain system of care • Recalls – 2-3 per annum initially • Specialist referral if high risk Score > 20% End Organ Management of Hypertension • Web based knowledge resource www.patient.co.uk ‘RAPRIORS’ – – – – – – – – Reassure Advise Prescribe Recall Investigate Other opinion Refer Second opinion Management of Hypertension • Lifestyle Interventions – All patients with HTN / high normal BP – Grade 1 HTN and no complications – 6 month trial – Reduce BP and pre-empt rise of BP with age (DASH diet) • • • • • Maintain a normal BMI Reduce salt intake to <100 mmol/day (<6g NaCl) Limit daily alcohol consumption to 15/ 21 upw (F: M) Regular aerobic exercise ≥30 mins most days Eat five portions fresh fruit and vegetables per day – Reduce risk of CVD • Smoking cessation** • Reducing intake of total / saturated fats, replacing saturated fats with Management of Hypertension • Thresholds for Drug Treatment – Grade 1 HTN if • • • • • Any complications of HTN Any end-organ damage Diabetic Estimated 10 year risk of CVD ≥20% despite lifestyle advice If not treated, monitor BP annually as 10-15% will reach threshold for tx within 5 years, and CVD risk also increases with age – Sustained Grade 2 HTN or higher Choice of Antihypertensive Under 55 ACE/ARB II CCB Over 55 CCB D (Chlorthalidone/Ind) ARB II CCB D (Chlorthalidone/Ind) + Spironolactone Management of Hypertension  Increasing Efficacy of Drug Treatment  All drug classes produce BP reductions of usually 4 to 8% for systolic and diastolic  70% of patients require tx with a combination of drugs  Initiate therapy with a low dose and add small dose of a second drug, rather than increasing the original dose  Give an interval of 4 weeks to observe full response, if possible  Long acting single dose 24 hr formulations preferred The drugs you choose...  Know 4-6 anti hypertensives in detail  They are part of your 30-40 drug formulary... 4-6 Anti hypertensives 3-4 stepped Analgesics 2-4 first line Antibiotics Inhaled beta 2 agonist, anticholinergic, steroid Short / LA Benzodiazepine, SSRI Ads X 2. OHGs X 3, Statins X 2, Steroid creams / PO Ongoing Management • BP Target (Monitor 6 monthly when stable) – Aim 140/85 (but <150/90 gives a major reduction in CV events) – Diabetic patients / Chronic renal disease / established CVD aim <130/80 • Cholesterol / Alcohol / Tobacco / Ex / Wt Targets – Total cholesterol • Lower by 25% / aim <4.0 mmol/L, whichever is greater – LDL cholesterol • Lower by 30% / aim <2.0 mmol/L, whichever is greater Management of Hypertension • Additional Drug Therapy – Aspirin 75mg OD • Primary Prevention – ≥50 y.o. with controlled BP <150/90 AND target organ damage / 10 year CVD risk ≥20% – Diabetic patients • Secondary Prevention – all patients unless CI – Statins • Primary Prevention – If 10 year CVD risk ≥20% - titrate dose to reach targets • Secondary Prevention – Use sufficient doses to reach targets if total chol >3.5 mmol/L Malignant Hypertension • Definition – Severe HTN (>200/130 mmHg) in conjunction with bilateral retinal haemorrhages / exudates / papilloedema • Presentation – Headache, visual disturbance – May ppt fits, encephalopathy, renal failure, heart failure • Management – Untreated 90% die within 1 year NICE  Related NICE guidance           Chronic heart failure. NICE clinical guideline 108 (2010). Available from www.nice.org.uk/guidance/CG108 Hypertension in pregnancy. NICE clinical guideline 107 (2010). Available from www.nice.org.uk/guidance/CG107 Prevention of cardiovascular disease at population level. NICE public health guidance 25 (2010). Available from www.nice.org.uk/guidance/PH25 Type 2 diabetes. NICE clinical guideline 87 (2009). Available from www.nice.org.uk/guidance/CG87 Medicines adherence. NICE clinical guideline 76 (2009). Available from www.nice.org.uk/guidance/CG76 Ischaemic Heart Disease • Case Study – Our previous patient is now 58 y.o. He never managed to give up the cigarettes. His 60 y.o. brother recently had a CABG. – Medications: • Coversyl Plus (perindopril+indapamide) • Pravastatin 20mg nocte • Nu-Seals Aspirin 75mg OD – He presents complaining of recurrent chest pain Ischaemic Heart Disease • Case Study – What questions will you ask him in the history? – If you can only do one investigation, what should it be? – What medication(s) can you offer him for symptom relief? Ischaemic Heart Disease • Case Study – His stress test his positive and angiography confirms significant atherosclerosis. He is placed on the waiting list for a CABG. – 5 months later (while languishing on a waiting list, and having had his admission for surgery cancelled twice) he has an MI. – He returns to you after his discharge from hospital. • What medication would you expect him to be on? • When can he return to his job as a taxi-driver? Ischaemic Heart Disease • Prevalence – Cardiovascular disease is the commonest cause of death in Ireland – 32% (CSO 2011) Malignancy - 30% Respiratory – 12.6% www.cso.ie Angina • Definition – Central chest tightness / heaviness brought on by exertion and relieved by rest (+/- radiation) – Caused by myocardial ischaemia • Atheroma (usually) / anaemia / aortic stenosis / tachyarrhythmias / HOCM, thyrotoxicosis • Prevalence – Affects 2% of population (UK) • Unstable Angina – Angina that occurs with increasing frequency / severity, especially if on minimal exertion or at rest How are you getting on today ? Those pills you put me on are making me feel really lousy Gosh, I’m really sorry to hear that... Really ? Angina • Diagnosis – Typical history – Relieved with GTN • Investigations – Bloods • FBC, ESR (exclude arteritis), fasting lipids and glucose, TFT’s – Resting ECG (usually normal)(?) • Evidence of old MI, ST depression, flat / inverted T waves – Stress ECG • CI: Symps uncontrolled by max medical tx, MSSK, physically unfit – refer Cardiology for dx +/- angiography Angina  Management  Cardiovascular risk factor modification  Secondary prevention – aspirin 75mg OD (↓ mortality by 34%)  Occupational advice – may need to change to less physical job; inform driving insurer  Symptom control (see next slide)  Cardiology referral – anyone who’s fit enough for angiography +/- stenting (i.e. most patients); elderly pts with AS  PTCA gives symptom improvement in 70%, ?↓ mortality?  Stenting improves symptom control and relapse rate  Drug-eluting stents reduce restenosis  CABG ↓ mortality over 10 yrs and ↓ symps in 80-90% Angina  Drug Treatment  GTN spray – 1-2 puffs PRN (symptom relief)  β-blockers – 1st line tx  symptom control and prevents events  check adequately blocked (resting <60 bpm, post-exercise <90 bpm)  CI: LVF, asthma  Verapamil – use if β-blockers not tolerated  Other Ca++ Channel blockers  All effective for symp control, but no evidence that cardioprotective  Nitrates (e.g. isosorbide mononitrate)  PO / transdermal preparations; start with low dose and increase as tolerated. SFx – headache, postural hypotension, dizziness Myocardial Infarction  Presentation  Sustained severe, central chest pain, not relieved with GTN  +/- collapse, sweating, SOB, nausea, referred pain etc.  Emergency Management – Call ambulance      ABC’s if collapsed Give oxygen / GTN Aspirin 300mg PO – patient should chew it IV access IV analgesia: 2.5 – 5mg morphine repeated PRN (max 15 mins)  IV antiemetic: metoclopramide 10mg  GTN spray if SBP >90mmHg and pulse <100 bpm Myocardial Infarction • Medication Post-MI – Secondary prevention • Statin and aspirin for all unless contraindicated • Β-blocker for all unless CI – estimated that prevents 12 deaths/1000 treated/yr – benefit in the first year post MI • ACE inhibitor for all - ↓ myocardial work and ↓ mortality long-term (and w/in 1 month of MI by 5 per 1000 treated); fx greater if heart failure at presentation Myocardial Infarction  The Role of the GP Post-MI  Ongoing follow up and monitoring of risk factors (?)  Support and advice after discharge:  Gradual increase in activity: @ 2wks post-MI – stroll in the garden; 4 wks – ½ mile per day; increase gradually up to 2 miles/day at 6 wks; from 6 wks on, increase speed. (Cardiac rehab imps outcome sig..)  Sexual activity can resume from 6 wks  Depression – 50% at 1/52, 25% at 1 year  Work after uncomplicated MI : sedentary work at 4-6 wks; light manual work at 6-8 wks; heavy manual work at 3 months.  Driving – nil X 1 mth. HGV / Bus drivers may need driving assessment  Flying – not for 2 weeks Diabetes Diabetes Mellitus • Case Study – KC is a 62 y.o. Irish lady who presents for a repeat prescription of bendrofluazide 2.5mg, which she takes for HTN. She is well. – Her BP is 138/88 – On questioning, she has never had her cholesterol or blood sugar checked. – You send her for fasting lipids and glucose and a U+E Diabetes • Then and now..... 1400’s 1600’s 1900’s 2012 NICE (2002 / 2008) Take a somewhat scholarly interest..... Pop. Prevalence 5 %; > 80% of 80 yr olds Diabetes Mellitus • Case Study – Her fasting blood sugar is 7.9mmol/L • What does this mean? – She tells you that her sister has diabetes. – What other questions do you want to cover in the history? – What is the next step? Diabetes Mellitus • Case Study – OGTT with 75g glucose load (??) • Fasting blood sugar = 7.3 mmol/L • 2 hr PP = 12.3 mmol/L • FBG > 7, or HbA1C > 48 mmol/mol (IFFT) – She comes back for the results. – What will you tell her about diabetes? – What medication should she be started on? Diabetes Mellitus • Case Study – She has been stable on metformin 850mg TID – She attends for her 6 monthly review. • HbA1c = 70 mmol/mol • BP 129/80 • Total cholesterol 5.4, LDL 3.4, HDL 1.0, TG 1.4 – What should be covered at the 6 monthly review? – What medication changes should be made? Diabetes Cover Insight Tobacco Exercise Alcohol Diet Compliance BP, BMI, Bloods, Fluvax / Pneumovax Dietician / Opthalmology ECG Medication     Add Glicazide CE or ARB Statin (Rosuvastatin) ? Antiplatelet Rx  Planned Review  Disease Register  ? Diabetic Referral Diabetes • Definition – Syndrome of increased blood sugars and abnormalities of carbohydrate and lipid metabolism – Type 1 (IDDM) • Usually <35y.o. • Acute onset due to failure of insulin production – so need insulin replacement from diagnosis • Islet cell Ab’s may be present • Prone to profound weight loss and ketoacidosis – Syndrome X (Metabolic Syndrome) • Insulin resistance + other metabolic d/o’s of ↑ CVD risk: visceral adiposity, HTN, dyslipidaemia (↑TG, ↓HDL), hyperinsulinaemia, obesity, Diabetes  Type 2 (NIDDM)  80-90% of patients; M:F = 3:2  ½ have complications at dx  Insidious onset d/t impaired insulin secretion and insulin resistance in liver, adipose tissue and skeletal muscle  Life expectancy ↓ by 30-40% in 40-70 y.o. (loss of 810 yrs)  Risk Factors:  Age >65 y.o. Obesity +FHx (100% concordance in MZ twins)  Ethnicity (South Asians, Afro-Caribbean, Hispanic)  PMHx of gestational DM or baby >4kg  Prevalence (Type 1 and 2 DM) Diabetes • Presentation – Asymptomatic – opportunistic / routine screening – Subacute – weight loss, polydipsia, polyuria, lethargy, irritability, infections (esp candida, skin infxns, ulcers), genital itching, blurred vision – Acute • Ketoacidosis (Type 1) • HONK (Type 2) – Complications – neuropathy, nephropathy, CVD, retinal disease • Screening Diabetes • Diagnosis – ADA / WHO criteria (need 2 abnormal readings) • Fasting venous plasma glucose ≥ 7.0 mmol/L • 2 hr PP / Random venous plasma glucose ≥11.1 mmol/L • HbA1C > 44 mmol/mol • Pre-Diabetes – Impaired fasting glucose (IFG) • Fasting glucose ≥ 6.1 and < 7.0mmol/L (check OGTT) – Impaired glucose tolerance (IGT) • Fasting glucose < 7.0 and 2hr PP glucose 7.0 – 11.1mmol/L – Screen annually, as 4% per year will develop diabetes Management of Type 2 Diabetes  Initial  Patient Education  Diabetes knowledge, complications, need for lifelong tx, aims of management, long-term illness scheme  Home monitoring of blood glucose  Diet – similar to DASH diet; high fibre, low fat; ideal weight  Exercise – ↑ insulin sensitivity, ↓ BP and lipids  Smoking cessation  Driving – ok if not on insulin, should inform insurer, caution for HGV etc  Employment – most jobs ok if not on insulin  Psychological problems  Immunisations – influenza and pneumococcal vaccines  Modification of CVD Risk Factors  Statin, ACE inhibitor / ARB (even if BP normal), antiplatelet Rx. Management of Type 2 Diabetes • Initial – Patient Education – most N.B. component – 3 month trial of diet alone for most patients • Medication (Oral Hypoglycaemic Agents) – Biguanides (Metformin) • • • • 1st line tx for obese pts ↓ gluconeogenesis, ↑ peripheral utilisation of glucose Only work if some endogenous insulin production Side Fx: N/V, abdo cramps, lactic acidosis Management of Type 2 Diabetes  Medication (cont.)  Sulphonylureas (e.g. Gliclazide (Diamicron), glimepiride (Amaryl), glibenclamide)     1st line tx for non-obese patients (can cause weight gain) Augment insulin secretion – so need some residual insulin Modified release – taken before breakfast, last 24 hours Risk of hypoglycaemia, esp if miss meals  Repaglinide (Novonorm)  Very short-acting OHA, usually used with metformin  Taken before meals and omitted if don’t eat – helps PP glucose only  Thiazolidinediones (e.g. rosiglitazone (Avandia))  Cause ↑ insulin sensitivity and ↑ insulin secretion; improve lipid profile  Used with metformin (2nd choice sulphonylurea), but only if metformin sulphonylurea combo failed)  Need to monitor LFT’s; can’t be used with insulin  Recent concern re this class of drugs: double the rates of heart failure (class effect) and 42% increased risk of MI (rosiglitazone) Management of Type 2 Diabetes • Ongoing – Routine review (every 3-6 months) • Continuing Patient Education – most N.B. component • Glycaemic control, weight, BP, lipids, foot care, set targets – Annual Review • Screening for complications (neuropathy, retinopathy, renal disease (microalbuminuria, U+E), CVD, PCD), foot care, set targets • Ophthalmology – annual slit lamp examination – 20-40% type 2 diabetics have retinopathy at diagnosis • Specialist Referral Diabetes (Conclusions)  Primary Care Issues  Practice Registers  Recall and review systems  Special diabetic clinics (often nurse-led)  Shared Care  Studies  UKPDS - Tight glycaemic contol reduce microvascular complications only – NNT 196/yr – no effect on mortality; Tight BP control  complications and all-cause mortality – more useful than glycaemic control; beware the U shaped curve tho’  HOT trial - tight BP control more effective in DM patients LTC Management • Definition of a CD / LTC ; likely to be present at 6 months • Multimorbidities • Features of good LTC Management Clear, earliest consistent Dx Ongoing practice management Detailed, standard driven care Disease register, recall system Information: Enfranchised, enabled patients Extended Team (1 & 2 Care, plus Social) LTC Management ‘Make everything as simple as you can, ........but not simpler.’ Chronic Disease Management Problems Un co-ordinated care Disorganised care Patients do not fully co operate Cost – in the broadest sense The fallacy of cheating death Resourcing Complexity Thoughts on LTC Management  Cochrane Review on Combined Care  Closer to home (Houlihan & Mitchell) 2010 - In Cycle 1 (MODDM) (n = 70) - Only 48 patients (68%) were on ACE / ARB - 22/70 patients were not on either (32%) How could this happen ? How could this happen ? • • • • Non systematic approach Woolly thinking by GPs / NCHDs Inadequate input by Specialists Failure of joined up thinking Respiratory Tract Infections • Acute RTI – 25% of GP workload – 90% viral – aetiological agent rarely identified – Diagnosis • Short history of upper and lower respiratory symptoms • Multiple mucous membranes involvement => likely viral • Common Cold (rhinovirus, adenovirus, picornavirus) – Av. Person has 2-3 per annum – Symps resolve in 4-10 days – Tx: paracetamol / ibuprofen, fluids, vitamin C, cough suppressant, decongestant Respiratory Tract Infections  Tonsillitis / Pharyngitis  Each GP sees approx 120 cases/yr  70% viral, rest mostly group A β-haem strep – clinically indistinguishable  90% patients recover within a week (consider glandular fever if prolonged / severe sore throat in a young adult)  Throat swabs unhelpful as 40% of population +ve for strep  ABx reduce symptoms x 8 hours and reduce complications  Penicillin V / erythromycin x 10 days (delayed)  Referral for tonsillectomy     >5 attacks of acute tonsillitis causing school absence / yr, for 2 years Airway obstruction d/t very large tonsils causing sleep apnoea Recurrent quinsy Chronic tonsillitis >3 months, + halitosis Respiratory Tract Infections  Otitis Media  P/C: painful ear (often unilateral), deafness, systemically unwell, pyrexia, perforation (assoc with pain relief)  Signs – fever; bulging, red TM / perforation  Aetiology: clinically impossible to tell if bacterial / viral  80% resolve in <3 days without tx  Tx: analgesia; ABx – symps resolve 24 hrs quicker, but no diff in days off school; usually used if perforation at presentation  Advice parents re smoking cessation  Sinusitis  Usually post-URTI, but 10% dental origin Respiratory Tract Infections  Pneumonia (BTS Guidelines)  90% in patients >65 y.o; 5% mortality; 10% need hospitalisation  Aetiology (UK)     60-70% Strep pneumoniae 4-5% Haemophilus influenzae 1-5% Staph aureus (esp assoc with influenza) 20% Atypical – e.g. Mycoplasma, influenza A virus, Chlamydia, Coxiella burnetti  Presentation  Acute illness with cough, fever, purulent sputum +/- malaise, aches and pains, vomiting, anorexia, pleuritic chest pain, dyspnoea  Signs  Fever, tachycardia, central cyanosis (esp COPD), consolidation, creps, +/- CAP: (BTS Guideline 2009) For the purposes of these guidelines, CAP in the community has been defined as comprising... ► Symptoms of an acute lower respiratory tract illness (cough and at least one other lower respiratory tract symptom) ► New focal chest signs on examination ► At least one systemic feature (either a symptom complex of sweating, fevers, shivers, aches and pains and/or temperature of 38°C or more) ► No other explanation for the illness Respiratory Tract Infections • Pneumonia – Investigations – usually diagnosed on clinical picture • CXR if diagnosis in doubt; (esp smokers). X-ray changes should resolve in 6 weeks – refer if not • Bloods – FBC, ESR, titres for atypical pneumonia • Sputum – microscopy, C+S – Management • Analgesia and antipyretics, bed rest, fluids • Antibiotics – Amoxycillin 500mg – 1G TID x 1/52 – Erythromycin – can be used first-line as will cover atypicals too – Complications – pleural effusion, lung abscess, septicaemia, respiratory failure, jaundice, metastatic Going Global – it’s the only way….. • • • • • • • Gastroenteritis Malaria Malnourishment Maternity / Post Partum related illness Trauma Tobacco related diseases Infectious Diseases (other !) Some Big Ideas • • • • • • • The Prevention Paradox The Inverse Care Law Conventional ‘Western’ Medicine Social Humane Medicine – Archie C. ‘For Profit’ Private Medicine The fallacy of cheating death Life, Death and individual Patients