Dear All,

The Royal College of Physicians of Edinburgh (RCPE) organized its 51st St. Andrew's Day Festival Symposium: Updates on Acute Medicine on Thursday, 1 December 2011 - Friday, 2 December 2011. Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC) telecasted this live via webstream.

There was no fee for attendance at the SKMCH venue. Over 70 participants attended the event over two days. These included GPs, Internists, cardiologists and trainees from different hospitals within Lahore, out-side Lahore as well as from outside Pakistan. The variety of lectures and response from UK organizers in terms of discussion and replying to questions from local audience was well appreciated. Delegates stressed the need to continue such activities on regular basis.
 

Message from Organizers:

The two day St. Andrew’s Day Festival Symposium is the highlight of the College year. Being the flagship educational event it focuses on the breadth of medicine rather than any one medical specialty.  This year’s topics include cardiovascular emergencies, diabetes and endocrinology, medicine for the elderly, acute neurology, gastroenterology, dermatology and problems in pregnancy. The content of the symposium should be of interest not only to physicians involved with acute medicine but also to physicians who require updates on advances outwith their own specialty. It will also be relevant to doctors in training, general practitioners and allied health professionals.

Answers to Our Questions

PROF KEITH FOX
 
Q: Are there any studies comparing warfarin with clopidogrel ?
Answer: Yes, the ACTIVE W trial compared aspirin plus clopidogrel versus warfarin and had to be stopped early as warfarin was clearly superior, and with similar rates of bleeding.

DR GILLIAN MEAD

Q1: How can we define 'moderate intensity" exercise'?
Answer (From Dr Mead): "As I said at the end of the lecture, moderate intensity exercise can be recognized by an increase in breathing rate-that can be recognized by the person doing the exercise. They may also feel an increase in heart rate. Examples of moderate intensity exercise include golf, badminton, doubles tennis, brisk walking, mowing lawn or cycling 10-12mph.  For further information, please see page 18 of the Start Active, Stay Active publication."
 
Q2: Define the role of Yoga as effective means of exercise?
Answer (From Dr Mead): "As I said at the end of the lecture, there is a lack of evidence about the benefits of yoga after stroke. As regards other populations, the evidence is patchy. The best place for them to look for further information is on the Cochrane Library. I've attached one Cochrane review that includes 3D exercise including yoga to improve balance."

Q3: What should be our targets when advising to go for moderate intensity exercise----is it just doing 30 minutes of some activity or ability to achieve a certain heart rate or ability to lose certain percentage of weight?
Answer (From Dr Mead): "As regards the final question-there was a slide in the lecture that stated that older adults should be active daily, activity should add up to 150 minutes of moderate intensity activity in bouts of 10 minutes or more. There was no stipulation about weight loss. For further information, see the attached guidance."
 
PROF SALLY WENZEL

Q1:Thank you for an excellent over-view on asthma, emphasizing an out-of-box thought process. However, in a short clinic visit, although very important but how practical is it to go thru all these to short-list or narrow down to the exact sub-type ?
Answer (From Prof Wenzel): "That is an excellent question and very relevant.  My goal is to make phenotyping a VERY short exercise beginning with asking the question about when the patient developed their asthma.    Childhood more likely to be "traditional" allergic asthma.  After that, becomes much less clear, but important questions for those who develop after childhood are association with Upper respiratory infection, occupation, sinuses/nasal polyps and pregnancy, menopause etc.    Should all be pretty quick.  Getting a blood eosinophil count on a CBC will give you a VERY modest understanding of Th2/eosinophilic inflammation which is all you can do at this point.  But hopefully, blood tests to look for this will be available soon.  This should help with determining what response to steroids you should expect.   The questions on later onset asthma can point you to a trial of a macrolide, consideration of job changes, push for anti-leukotriene therapy (sinus/polyp disease)  and possible hormonal intervention, although that is least understood.   Obesity and later onset disease should be obvious from question and physical exam, such that weight loss is great strategy there.   I know this seems complicated, but I HOPE if you try it  a few times, it will become second nature quite quickly.  Let me know how it works and whether it is at all adaptable to a more general practice!"

Q2: Please comment on asthma(like) conditions linked with low calcium and / or magnesium levels ?
Answer (From Prof Wenzel): I have not found magnesium or calcium supplementation to help in any settings other than acute attacks I am afraid.

Q3: Do you see the phenotyping come out of lab and be part of diagnostic approach ? would it be more practical than hit and trial with targeted therapies?
Answer (From Prof Wenzel): Yes, absolutely!   See my response to question #1 above.   I think EVEN NOW it is possible to target our approaches.  And hopefully we will get better at this!    I should add to above that if you have someone with childhood onset severe asthma, with allergy, this would be one I would consider for anti-IgE therapy as well.

Q4: Can patient's response to beta-blockers also be linked with Th2 ?
Answer (From Prof Wenzel): I am not aware of any relationship of beta blockers to Th2 immunity.

PROFESSOR MARTIN DENNIS

Q: In a patient with LARGE right MCA territory infarct and newly diagnosed atrial fibrillation –when should we start anti-coagulation--right away or wait for 2 weeks ?
Answer: Probably 2 weeks.
 
DR PETER HAMMOND

Q: Is insulin pump therapy useful in the obese or in patients with brittle diabetes?
Answer:  Studies looking at obese patients with type 2 diabetes have disappointingly failed to show an impact on obesity. The expectation had been that as most patients on pumps need less insulin then they might lose weight. In the event the largest RCT (Raskin et al) did not show an effect. However the group with type 2 diabetes who seem to do best are those with severe insulin resistance, and it may be that in these patients there might be a weight loss benefit - an RCT has just started in France/Canada to look at this. Patients with brittle diabetes can benefit from pump therapy depending on the nature of the brittleness and their motivation to use the pump. In a pediatric study of pump therapy in DKA prone children in the first year after starting on the pump DKA admissions were reduced by 2/3 even though HbA1c was unchanged.