Aust Fam Physician
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Many patients with type 2 diabetes need to progress to insulin use when oral glucose lowering therapies fail to maintain adequate glycaemic control. ⋯ In general, initiation of insulin should be considered in individuals on maximal tolerated doses of metformin and sulfonylureas with HbA1c levels >7.0% over a 3-6 month period. Current Australian guidelines recommend initiating insulin therapy as once daily basal therapy or as premixed insulins.
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Prescribed career paths are not for everyone and there are other, less obvious options that can lead to an interesting and varied career. Below are some reflections on my own career aimed at helping doctors of tomorrow find their way - especially if they are prepared to work in remote or developing world settings and possibly follow a path toward working in public health.
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Warfarin is a commonly used medication for the prevention and treatment of venous thromboembolism. It can be challenging for both the patient and the prescriber to manage at times. ⋯ The common indications for warfarinisation are atrial fibrillation, venous thromboembolism and prosthetic heart valves. Contraindications include absolute and relative contraindications, and an individualised risk-benefit analyses is required for each patient. There are many interactions with warfarin, including pharmacokinetic and pharmacodynamic. Pharmacokinetic interactions can be monitored by using International Normalised Ratio levels. Pharmacodynamic interactions require knowledge by the prescriber to predict any interactions with warfarin, and International Normalised Ratio monitoring assists.
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Pulmonary embolism remains a common and potentially preventable cause of death. ⋯ Well recognised risk factors include recent hospitalisation, other causes of immobilisation, cancer, and oestrogen exposure. Diagnostic algorithms for pulmonary embolism that incorporate assessment of pretest probability and D-dimer testing have been developed to limit the need for diagnostic imaging. Anticoagulation should be administered promptly to all patients with pulmonary embolism with low molecular weight heparin being the initial anticoagulant of choice, although thrombolysis is indicated for patients presenting with haemodynamic compromise. Following initial anticoagulation warfarin therapy should be continued for a minimum of 3 months. Long term anticoagulation with warfarin should be considered in patients with unprovoked pulmonary embolism, due to an increased risk of recurrence after ceasing anticoagulation. The availability of new anticoagulants is likely to significantly impact on the treatment of patients with pulmonary embolism, although the exact role of these drugs is still to be defined.
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The spleen plays a crucial role in human defence against infection. Patients who are asplenic or hyposplenic are at increased risk of severe sepsis due to specific organisms. Overwhelming postsplenectomy infection (OPSI) has a mortality rate of up to 50%. ⋯ Streptococcus pneumoniae is responsible for over 50% of cases of OPSI. Strategies to prevent OPSI include education; vaccination against S. pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis and influenza (annually); and daily antibiotics for at least 2 years postsplenectomy and emergency antibiotics in case of infection. Asplenic patients should carry a medical alert and an up-to-date vaccination card. Asplenic patients require specific advice around travel and animal handling as they are at increased risk of severe malaria, and OPSI (due to Capnocytophaga canimorsus) may result from dog, cat or other animal bites. The Victorian Spleen Registry was established to improve adherence to best practice preventive guidelines and thereby reduce the incidence of OPSI.