Hormonal replacement therapy confers cardiac protection in post-menopausal women. True or False

False. Although there has been great enthusiasm on the use of hormonal replacement therapy (HRT) to prevent coronary artery disease in post-menpausal women, recent randomized control trials failed to prove its usefulness. For example, The Heart and Estrogen/ Porgestin Replacement Study (HERS) was a randomized, controlled trial of combined continuous HRT as a secondary prevention in women with known coronary artery disease. In this study, the rate of coronary events increased in the first two years and decreased in the third and fourth year, with no net benefit over the study period. Another other trial, the Women's Health Initiative (WHI) was a randomized primary-prevention trial of estrogen plus progestin in 16,608 postmenopausal women who were 50-79 years of age at baseline. After a mean follow-up of 5.2 years, the study was terminated prematurely (planned duration, 8.5 years) due to an excessive risk in the treatment group. HRT was associated with a hazard ratio for coronary artery disease of 1.24. The elevation in risk was most apparent at one year.

In conclusion, current evidence suggests that HRT should not be prescribed for primary or secondary prevention of cardiovascular disease in post-menopausal women.

Back to top

Aspirin is indicated for her as a preventive drug intervention. True or False

False. Aspirin therapy should only be used in high risk women with high risk criteria being established coronary artery disease, cerebrovascular disease, peripheral arterial disease, abdominal aortic aneurysm, end stage or chronic renal disease, diabetes mellitus and 10-year Framingham risk >20%. Routine use of aspirin for healthy women <65 years of age is not recommended to prevent coronary artery disease.

Back to top

False. Antioxidant vitamin supplements (e.g. vitamin E, C and beta carotene) should not be used for the primary or secondary prevention of cardiovascular disease.

Back to top

False. Folic acid, with or without B6 and B12 supplement, should not be used for the primary or secondary prevention of cardiovascular disease.

Back to top

What is the diagnosis?

The diagnosis is pincer nail deformity. It is a common toenail disorder. Pincer nail most commonly involves the big toenails but other toenails and finger nails can also be affected. The condition is characterised by an increase of transverse curvature of the nail plate along its longitudinal axis. The curvature increases progressively from proximal to distal, producing a "trumpet" appearance in severe cases. The deformed nail plate compresses or impinges on the nail bed and underlying dermis, producing pain and discomfort.

Back to top

What is underlying cause?

It is most commonly caused by pressure from tight shoe. Other causes include onychomycosis, subungual exostoses and congenital.

Back to top

What investigation may be required?

X ray may be required to rule out subungual exostoses.

Back to top

What are the treatments?

If pain is significant, surgical removal or reconstruction of the nail unit may be required. Commercial plastic braces can also be considered.

Back to top

She complained that her toenails do not grow as she doesn't need to trim. How would you advise on her?

Linear growth rate of a nail should not be assessed by rate of trimming nail. Instead, it can be assessed by observation of the distal movement of a reference point on the nail plate, which can be marked by physical method. In general, finger nails grow 1 cm every 3 months and toenails at half this rate. Slower linear growth occurs in conditions such as old age, poor nutrition, hypothyroidism, cold environment, immobility and yellow nail syndrome.

Back to top