Screening for familial hypercholesterolaemia in primary care: Time for general practice to play its part

Fifty per cent of first-degree relatives of index cases with familial hypercholesterolemia (FH) inherit the disorder. Despite cascade screening being the most cost-effective method for detecting new cases, only a minority of individuals with FH are currently identified. Primary care is a key target area to increase identification of new index cases and initiate cascade screening, thereby finding close relatives of all probands. Increasing public and health professional awareness about FH is essential. In the United Kingdom and in Australia, most of the population are reviewed by a General Practitioner (GP) at least once over a three-year period, offering opportunities to check for FH as part of routine clinical consultations. Such opportunistic approaches can be supplemented by systematically searching electronic health records with information technology tools that identify high risk patients. GPs can help investigate and implement results of this data retrieval. Current evidence suggests that early detection of FH and cascade testing meet most of the criteria for a worthwhile screening program. Among heterozygous patients the long latent period before the expected onset of coronary artery disease provides an opportunity for initiating effective drug and lifestyle changes. The greatest challenge for primary care is to implement an efficacious model of care that incorporates sustainable identification and management pathways

Specialist recommendation for chemoprevention medications in patients at familial risk of breast cancer: a cross-sectional survey in England

In England, the National Institute for Health and Care Excellence guideline for familial breast cancer recommends chemoprevention for women at high and moderate familial risk of breast cancer. However, prescribing of chemoprevention has not improved since the introduction of the guideline in 2013. The study aims to identify the current practice, in England, of familial cancer specialists offering chemoprevention and recommending prescribing in primary care. This was an anonymised national cross-sectional survey of familial breast cancer risk services in England. Lead clinicians were sent an online survey link. The survey questions included whether chemoprevention was offered/considered for high and moderate risk women, when chemoprevention prescribing and recommendation to primary care started, medications prescribed, age groups considered for chemoprevention and existence of a shared prescribing protocol with primary care. The survey was sent to 115 hospital services, responses from 50 services (43%) were included in the analysis. Of the 40 services offering chemoprevention for high risk women, 15 (38%) did not prescribe but 31 (78%) recommended prescribing to primary care. Of the 31 services considering chemoprevention for moderate risk, eight (26%) did not prescribe with 26 (84%) recommended prescribing to primary care. Only three services reported having a shared protocol with primary care. Within three years of the guidelines, many services recognised the role of chemoprevention for both high and moderate risk with a key role for primary care to initiate prescribing. However, there is still room for improvement

Impact of Political Instability on International Investment and Trade in Pakistan

This paper focuses on the effect of political instability on international investment and trade in Pakistan. The sample comprised of annual data for a period of 41 years (from 1976 to 2016). To test the long and short run relationships among the variables, ARDL model is applied and particularly Error Correction Model is used for short run analysis. To check the serial correlation in the ECM models, LM serial correlation test is applied. Cumulative sum (CUSUM) is also utilized to test the stability of the ARDL models. The unit root of all the variables is also tested and it is found that all the variables are stationary either at level or at first difference. Findings conclude that political instability badly hampers both the international investment and trade in the long-run. Moreover, in short-run, the political instability significantly hinders the foreign portfolio investment and exports. No significant impact of political instability is found on foreign direct investment and imports in the long run

Impact of Political Instability on International Investment and Trade in Pakistan

This paper focuses on the effect of political instability on international investment and trade in Pakistan. The sample comprised of annual data for a period of 41 years (from 1976 to 2016). To test the long and short run relationships among the variables, ARDL model is applied and particularly Error Correction Model is used for short run analysis. To check the serial correlation in the ECM models, LM serial correlation test is applied. Cumulative sum (CUSUM) is also utilized to test the stability of the ARDL models. The unit root of all the variables is also tested and it is found that all the variables are stationary either at level or at first difference. Findings conclude that political instability badly hampers both the international investment and trade in the long-run. Moreover, in short-run, the political instability significantly hinders the foreign portfolio investment and exports. No significant impact of political instability is found on foreign direct investment and imports in the long run

Recent updates in the management of merkel cell carcinoma

Merkel cell carcinoma is an aggressive non-melanomatous cutaneous tumour of neuroendocrine origin with an increasing incidence in the recent years. It is a tumour of the elderly and immunosuppressed, which most often appears on sun-exposed areas of the body. The clinical features of the cutaneous or subcutaneous lesions hardly contribute to the diagnosis, and, hence, histopathology and immunohistochemistry play a vital role in diagnosis. The latest staging system by the American Joint Committee on Cancer includes non-nodal invasion to adjacent structures i.e. bone, muscle, fascia, or cartilage into the criteria, in additionto size and depth of invasion. The management reliesheavily on a multidisciplinary approach due to rarity of incidence of this disease. According to the international guidelines, surgical management is still the preferred choice. The beneficial role of adjuvant radiotherapy has now been more clearly documented. Data is insufficient to assess whether chemotherapy improves disease-free or overall survival