Merry Christmas and a Happy New Year!

It's Christmas eve and it's time to say Merry Chirstmas and a happy new year!

All the best for 2013 - this year will be a tough act to follow!

(Could this be the year that the Gunners pick up some more silverware? - Hope so!)

Gordon

NICE Guidelines on Ectopic Pregnancy & Miscarriage + Update on SVT

Ectopic Pregnancy and Miscarriage - Summary of NICE Guidance

NICE have released new guidance on the management of ectopic pregnancy and miscarriage in women and given that my current post is in obstetrics and gynaecology I felt that this was particularly relevant! Complications in early pregnancy are common and distressing for the patient. Historically, in cases where ectopic pregnancies have led to patient deaths, a common contributing factor has been the failure of team looking after the patient to make the correct diagnosis in a case where the presentation was atypical. Clinicians should therefore have a higher index of suspicion for ectopic pregnancy as a cause of acute illness. 

Common symptoms of ectopic pregnancy include: abdominal or pelvic pain, amenorrhoea or a missed period, PV bleeding, dizziness/syncope, shoulder tip pain, urinary symptoms, breast tenderness and pain on defecation. Any patient with pain and abdominal tenderness, pelvic tenderness and cervical motion tenderness should be referred immediately to gynaecology services, ideally an early pregnancy assessment service offering serum hCG measurement and trans-vaginal / abdominal US scanning.

Management of miscarriage - expectant management should normally be the initial management strategy (7-14 days). Explore other options if late in 1st trimester and at increased risk of haemorrhage or previous traumatic experience eg. still birth.  Medical management involves vaginal misoprostol for treatment of missed or incomplete miscarriage.

Terminology used in Describing Miscarriage in the First Trimester:

• Complete miscarriage - all of the tissue has left the uterus
• Confirmed miscarriage - a non-viable intra-uterine pregnancy diagnosed on US scan
• Incomplete miscarriage - non-viable pregnancy in which the process of miscarriage has begun (eg. bleeding, pain), but pregnancy tissue remains in the uterus
• Missed miscarriage - a non-viable pregnancy identified on US scan without bleeding and pain
• Threatened miscarriage - Vaginal bleeding in the presence of a viable pregnancy

Diagnosis and Management of SVT

SVT comprises a group of conditions where atrial or AV node tissues are essential for sustaining the arrhythmia, produced either by disorders of impulse formation and/or disorders of impulse conduction. Symptoms include palpitations, chest pain, anxiety, light-headedness, shortness of breath and (uncommonly) syncope. Initial management is to slow AV node conduction either using vagal manoeuvres or adenosine. Catheter ablation is usually curative and has high long-term success rates. Every effort should be made to capture the arrhythmia on a 12-lead ECG. Giving the patient a copy of the ECG to keep can be useful. Echocardiogram is an imprortant investigation to identify underlying structural abnormalities such as left ventricular impairment.

Differential Diagnosis of a Narrow Complex Tachycardia:

• Sinus tachycardia
• AV nodal re-entrant tachycardia
• Atrioventricular re-entry tachycardia
• Atrial Tachycardia
• Atrial Flutter
• Atrial Fibrillation

Emergency Oxygen Therapy

Emergency Oxygen Therapy 

This features in an educational article in the BMJ this week. Oxygen used to be given routinely for a wide range of acute medical presentations, however increasingly it is only being recommended if the patient is hypoxaemic. Oxygen should be prescribed and given in a controlled manner. A number of publications in the medical literature have raised concerns about the risks of insufficient or excessive oxygen therapy. The main indication for oxygen therapy in an emergency setting is to protect patients from the harmful consequences of hypoxaemia.

The common acute medical presentations can be broadly categorised into those who require high concentration oxygen in all cases, those likely to require oxygen therapy, and those where patients are likely to need controlled oxygen.

1) High Flow O2 in all cases - Shock, sepsis, major trauma, anaphylaxis, cardiac arrest, carbon monoxide or cyanide poisoning.

2) O2 Therapy (Aim sats 94-98%) - Pneumonia, asthma, acute heart failure, PE

3) Controlled O2 (Aim sats 88-92%) - Exac. of COPD, acute illness in CF, acute illness in patients with obesity hypoventilation syndrome or morbid obesity, or with chronic neuromuscular / musculoskeletal conditions.

The following are common medical emergencies where oxygen was given routinely in the past but is now only advised if the patient is hypoxaemic:

MI/ACS, survivors of cardiac arrest with ROSC, sickle cell crisis, obstetric emergencies, most poisonings and metabolic/renal disorders with tachypnoea due to acidosis (Kussmaul breathing). In acute stroke, there is uncertainty in the literature as to whether routine oxygen supplementation actually improves outcomes and these patients should only be given oxygen to maintain saturations within the normal range (94-98%).

Approximately half of UK hospital patients receiving oxygen therapy do not have a prescription for this treatment or any valid written documentation. There is no evidence that oxygen therapy can relieve 'breathlessness' in non-hypoxaemic patients with acute illness. High concentration of oxygen in patients with acute exacerbations of COPD increases the risk of hypercapnic respiratory failure. High concentrations of oxygen has also been shown to increase the risk of hypercapnia in acute asthma and pneumonia.

Venturi masks are a useful way of delivering controlled oxygen to a patient. They are available in five types: 

24% O2, Blue, 2 litres

28% O2, White, 4 litres

35% O2, Yellow, 8 litres

40% O2, Red, 8 litres

60% O2, Green, 15 litres

If oxygen requirements increase, the patient requires a medical review and the underlying cause of the increased requirements should be sought. Beware that in some cases, pulse oximetry may be misleading (eg. in carbon monoxide poisoning). Clinical signs such as tachypnoea and chages in other vital signs may occur before a change in oxygen saturations.

Finally, it is very important to recognise that hypoxia is a sign of underlying illness (problem with gas transfer or regulation of respiratory activity) and not a disease in itself. Blind treatment of hypoxia may lead to a delay in identification of an underlying life threatening condition. 

Movember, Health Screening and Resistant Hypertension

Movember - Truth behind the 'Tache'

Men in the UK and around the world are raising money this month to promote men's health as part of Movember. The campaign takes place once a year in November and encourages men to grow a moustache to raise money for men's health. Initially this was focused on prostate cancer however since 2010 funds have also been used for testicular cancer research. The slogan is "knowledge is power, moustache is king". But an article in the BMJ this week written by a GP questions whether Movember is actually misleading men on some of its advice. 

The charity has obviously built a huge profile and the amounts of money raised is laudable, however some of the advice on the charity's website contradicts NHS advice, particularly with regards to screening tests. For example the website at one point suggested that all men aged 50 or above should seek a baseline PSA test. This has been recently updated but it recommends that men over age 50 should ask their doctor for a bowel cancer screening test annually (in contrast to NHS bowel screening programme recommendation of screening every two years) and that all men age 45 should undergo an HbA1c test. Aortic aneurysm screening is only relevant for men age 65-75 who have smoked and from age 20 men should have their BP checked every 2 years (or annually if high or low). The advice can be found here: http://uk.movember.com/mens-health/health-checklist/. It is unclear where Movember have sought this information. This frequency of screening tests is not based on evidence and may result in patients having conflict with their doctor. Also some of the more pressing issues on men's health receive very little if not no information, such as mental health, substance misuse, smoking, alcohol and obesity.

Periodic health checks

A recent Cochrane review looked at the benefits and harms of general health checks in terms of outcomes relevant to patients. Health checks such as these are generally assumed to be effective in reducing morbidity and mortality but these effects have not been effectively demonstrated. In fact these checks may result in overdiagnosis and overtreatment. 

While this study has looked at routine health checks in patients who are not known to have any medical condition, annual health checks are more likely to be of benefit in patients with chronic conditions. For example, in 2006 the Disability Rights Commission recommended the introduction of annual health checks for people with intellectual disabilities in an attempt to reduce health inequalities in this population. Mortality from preventable causes is three times higher in people with moderate to severe intellectual disabilities than it is in the general population, and the number of emergency admission to hospital is substantially increased. It is not yet known whether these checks will lead to fever hospital admissions but clearly it is important that attempts are made to reduce the health inequality between this group of patients and the general population and health checks may be a potential solution.

Resistant hypertension

Resistant hypertension is defined as high blood pressure which remains uncontrolled despite treatment with at least three anti-hypertensive agents at best tolerated doses. These patients are at greater risk of experiencing an adverse cardiovascular event. 5-10% of cases of resistant hypertension have a secondary underlying cause. Drug related causes include NSAIDS, oral contraceptives, adrenal steroid hormones, erythropoeitin, ciclosporin and tacrolimus. Target organ damage may occur eg. LVH, hypertensive retinopathy and renal disease - these patients should be referred to secondary care.

Examples of secondary causes of resistant hypertension (+symptoms):

• Primary hyperaldosteronism (Conn's syndrome) - hypokalaemia, fatigue, low renin, raised aldosterone levels (check plasma renin or aldosterone levels)
• Renal artery stenosis - carotid,, abdominal or femoral bruits, atherosclerotic disease, pulmonary oedema
• Renal parenchymal disease - albuminuria, micro-haematuria, nocturia and oedema (urinalysis)
• Obstructive sleep apnoea - obestiy, short neck, daytime somnolence, snoring, apnoea.
• Phaeochromocytoma - episodic palpitations, headaches and sweating (check 24hr urnary metanephrines or normetanephrines)
• Thyroid disease - hyperthyroidism increases systolic BP, hypothyroidism increases diastolic BP
• Cushing's syndrome - centripedal obesity, moon facies, abdominal striae, interscapular fat pad
• Coarctation of the aorta - radio-femoral delay, diminished femoral pulses, rib notching on CXR
• Intracranial tumours - early morning headache, positive family history

Aspirin for VTE, CABG and Fasting Lipids

Plenty of interesting research published this week and reviewed in the BMJ:

Aspirin Prevents Recurrent Venous Thromboembolism (N Eng J Med 2012; doi:10.1056/NEJMoa1210384) - At the moment gold standard treatment following VTE involves oral anticoagulation with warfarin after which treatment is either stopped altogether, or continued with increased risk of bleeding. Now research has been published which shows that long term treatment with aspirin may be good alternative to stopping altogether. Aspirin was shown in a placebo controlled trial to reduce the risk of major cardiovascular events in this group of patients although it did not significantly reduce the rate of VTE recurrence. Aspirin is cheap, easy to take, does not require monitoring and has a reasonable safety profile.

CABG not PCI for Adults with Diabetes (N Eng J Med 2012; doi:10.1056/NEJMoa1211585) - A newly published trial compared CABG vs. PCI in patients with diabetes and multivessel coronary artery disease and found that those treated with CABG lived significantly longer and had significantly fewer MIs than those treated with drug eluting stents. PCI has rapidly overtaken CABG as the most commonly used treatment for multi-vessel disease in the UK due to its increased affordability and availability, however this research may suggest that in patients with diabetes, CABG is still the gold-standard treatment and results in better outcomes.

Is Fasting Necessary before Lipid Tests? (Arch Intern Med 2012; doi:10.1001/archinternmed.2012.3708) - I recently asked a patient to attend the dermatology department for fasting lipids and this article caught my attention. Fasting overnight is inconvenient for the patient and unpleasant. A cross-sectional analysis of 209,180 results from Canada shows that overnight fasting makes little difference to total cholesterol and HDL cholesterol. The study adds to evidence that fasting may not offer any benefit for the patient or doctor in terms of predicting risk of cardiovascular disease.

And finally...interesting fact for the day - in pregnancy, 80% of DVTs occur in the left leg. Why? Well the reason for this is that pregnancy is a hypercoagulable state and this is exacerbated by venous stasis. This occurs when the gravid uterus obstructs the IVC, causing decreased venous tone in the legs, which is greater in the left leg than in the right.

In Defence of the Liverpool Care Pathway

Liverpool Care Pathway:

In the past couple of weeks the Liverpool Care Pathway has come under attack from the press with a number of damaging and critical headlines, such as accusations that the pathway is being used to kill terminally ill patients. The Liverpool Care Pathway was first described in 2004 as a means for allowing the rapid discharge home of the dying patient. It is now used in hospitals throughout the UK and has transformed the way end of life care is achieved in the UK. It was recognised that many patients terminally ill patients were dying in acute hospital wards before they could be transferred to a hospice. Before the introduction of the pathway, there was a lack of common consensus about the best way to ensure that patients at the final stages of life are kept comfortable and that distress is alleviated. All of the negative publicity focused around the pathway appears to be that it hastens death through withdrawal of fluid and nutrition. The pathway does not preclude artificial hydration but seeks to prevent harmful interventions such as IV cannulation which will be harmful and not in the best interests of the patient. These headlines have consequences for doctors, patients, families and healthcare staff. Scaremongering could lead to fears from doctors about using appropriate analgesia and reluctance to use the LCP, leading to more painful deaths. The LCP does have the flexibility to be rescinded if clinically appropriate (occurs in approximately 4% of cases). Fortunately a number of organisations have rallied in support of the LCP following these allegations and having been involved in use of the LCP in hospital I too am in favour and hope that there is an end to the irresponsible journalism which has led to this situation.

Content Area Experts for Reviews:

A couple of weeks ago I was discussing with one of the dermatologists about which article or topic to include for a 'journal club' discussion. One option would be to present a 'meta-analysis' or systematic review of a clinical topic. The purpose of this is to draw together and summarise all of the available evidence. I was surprised to hear that in some cases an expert in a field is asked to write the publication, while in others it may be someone who has no expertise in the field who writes the paper. Systematic reviews often include experts as authors, however this may be create bias. No studies exist which look at whether is is harmful or helpful to have content area experts as authors. Potential benefits could be inside knowledge of unpublished trials. Potential harms include strong opinions due to prior personal experience and differences in conclusions between specialists in the same field. An article in the BMJ this week argues against using experts in systematic reviews and this is not something which I had thought about before now. I assumed that it was always area experts who wrote reviews but I can see the reasons why this may not always be beneficial.

Psoriasis - New NICE Guidelines

The BMJ this week includes an article on summary of the new NICE Guidelines on assessment and management of Psoriasis. This common inflammatory skin condition affects 1.3-2.2% of the UK population and can be associated with psoriatic arthritis. It can have a serious impact on social, functional and psychological morbidity which is often under-recognised. This often occurs despite very effective treatments available to help improve outcomes.

Recommendations:

• A single point of contact for people with all types of psoriasis to aid access to appropriate information. 
• Assessment should include a 'physician's global assessment' and a 'patient's global assessment', body surface area affected, involvement of nails or difficult to treat areas eg. scalp, any systemic upset. Ask about how a patient's daily living is affected, how they are coping with their skin condition, and if any treatments are being used. 
• Indications for referral: diagnostic uncertainty, a severe or extensive type of psoriasis eg >10% body surface area, cannot be controlled by topical therapy, acute guttate psoriasis requiring phototherapy, nail disease with functional/cosmetic impact, psoriasis with major impact on social/psychological/physical well-being. Also any type of psoriasis in children and urgent/same day assessment for generalised pustular psoriasis/erythroderma.
• NICE recommend the Psoriasis Epidemiological Screening Tool for assessment of psoriatic arthritis.
• Cardiovascular risk assessment at presentation for adults with severe psoriasis of any type.
• Offer topical treatments as first line, followed by 2nd/3rd line if these do not succeed. Offer practical support and advice about the use and application of topical treatments delivered by trained healthcare professionals. 
• Arrange a review appointment after starting a new topical treatment (4 weeks in adults, 2 weeks in children).
• Phototherapy - offer narrowband UVB to patients with plaque or guttate psoriasis that cannot be controlled with topical treatments alone.
• For systemic, non-biological therapy the following conditions must be met: psoriasis cannot be controlled with topical therapy, it has a significant impact on physical, psychological or social wellbeing, is extensive (>10% body surface area affected) or localised and associated with significant functional impairment, or not suitable for phototherapy.
• Methotrexate should be offered as first line systemic treatment except if contra-indicated or the patients meet the criteria for ciclosporin (rapid or short term disease control, palmo-plantar pustulosis, considering conception and systemic therapy cannot be avoided).

I'll be presenting a summary of the new NICE Guidelines on Psoriasis and comparing them with the recent SIGN guidelines on psoriasis at a the dermatology journal club meeting on the 22nd November.

Adrenal Crisis, Public Health and Unilateral Leg Swelling

I thought that things were looking very Autumnal today when I was in Aberfoyle today - hence the reason for the photo.

Interesting articles which I've been reading this week in the BMJ:

Adrenal Crisis - Since I've been revising endocrinology today for the MRCP, this article was particularly relevant. There are two serious hormone deficiency syndromes which if left untreated can be fatal. Everyone knows about the first one - diabetic ketoacidosis, but a lot less is known about acute adrenocortical insufficiency. This requires urgent treatment with hydrocortisone, IV fluids and correction of biochemical abnormalities. If steroids are stopped in patients on long term steroid treatment (Addisons Disease) or during periods of increased stress / illness, a crisis can occur. Clinical features include hypotension, shock, hyponatraemia and hyperkalaemia. One trick is to never ignore an informed patient's request for steroids. Chances are that they have Addisons Disease and are aware of the consequences of under-treatment. Peri-operative is also a dangerous time for patients with Addisons Disease if they are not being correctly managed. Adrenal crisis is regularly seen in patients with congenital adrenal hyperplasia as they are unable to mount a normal cortical response to stress. Adrenal crisis has been reported in patients on high doses of topical steroids. Patients on steroids should carry a 'Medic-Alert' card or bracelet. Doctors must not suddenly stop steroid treatment in patients who are admitted to hospital. Ideally a 'Red-Flag' system needs to be identified to alert staff when these patients are admitted.

Chocolate at the Checkout - In most shops when you get to the check out there is an array of tasty treats awaiting the consumer. Who hasn't picked up the odd chocolate bar or drink at the check-out!? The public health team have picked up on this and are suggesting that such sales technique should be removed to stop tempting people. Impulse buys are particularly common when patients are tired and stressed. Maybe we should put chocolate bars in special locked cupboard behind the counter (like cigarettes) if that's the case! I don't think that the supermarkets and shops are going to change their marketing techniques very quickly on this one but any idea is worth pursuing to help reduce the growing incidence of obesity in the UK.

Discouraging Health Checks - It seems like a good idea. 'Free health checks to all'. A definite political winner. However a review of 16 large trials of health checks to asymptomatic adults aged 40-74 found that checks were unlikely to save any lives. The problem with this I think is that it's always the healthy people who are the ones coming forward for these checks. These are not the people that need to be targeted in this type of public health campaign. How to engage the people who really need checks is the golden question which public health researchers are going to be forever scratching their heads about.

Swollen Leg in the Middle of the Night - Finally, this appeared in the 'Picture Quiz' section of the BMJ and just serves as a reminder of the importance of clinical examination and considering a differential diagnosis when the symptoms and signs just don't quite match up with what you're thinking about.

A doctor reviews a 47 year old man in the night who is complaining of leg pain and swelling of his right thigh. The doctor diagnoses a DVT and heparin treatment is started, pending a Doppler  ultra-sound scan to confirm the diagnosis. Examination isn't documented. A few hours later the patient is in agony and a second doctor comes to review. The patient now has cool peripheries, tachycardia, hypothermia and an area of violaceous discolouration on his thigh. An X-ray is performed, and the findings are in keeping with necrotising fasciitis (caused by a Clostridium sp. bacteria in this case). Urgent fluid resuscitation, transfer to HDU, broad spectrum antibiotics and surgical debridement is required.

Punctate Palmoplantar Keratoderma

Scientists in Dundee Discover the Gene which Causes Palmo-Plantar Keratoderma

I saw this story on the BBC News website this morning. Another key discovery from Irwin McLean's team in the epithelial genetics lab in Dundee as they have discovered the gene which causes punctate palmoplantar keratoderma. Similar to Pachyonychia Congenita, it is a disorder which causes kyperkeratosis, most commonly of the palms and soles. This can become very painful and debilitating if the lesions on the soles in particular are diffuse. The condition one of a group of disorders classified as 'palmoplantar keratodermas'. It is inherited in an autosomal dominant manner and it is estimated that approximately one in 15,000 people in the UK are affected by the condition. The gene was primarily discovered using whole-genome sequencing, much less time consuming than the 'old fashioned way' of testing for inherited mutations using repeated PCR (polymerase chain-reactions) in the lab. Whole genome sequencing is becoming faster, more accessible and cheaper at a rapid rate and is likely to have a major impact on medicine in the coming 50 years.

The article can be found at: Haploinsufficiency for AAGAB causes clinically heterogeneous forms of punctate palmoplantar keratoderma. E. Pohler et al. Nature Genetics (2012) doi:10.1038/ng.2444 Published online 14/10/12.

What does 'Dermatologically Tested' Actually Mean?

At the finish!

Peripheral Venous Cannula

Marathon completed - 3 hours, 30 minutes and 37 seconds of pain (probably) never to be repeated. Still smiling at the end though!

Peripheral Venous Cannulas - A new study published in the Lancet this week looked at whether there was a difference in the incidence of phlebitis in patients who had their cannulas re-inserted after 3 days, compared to those where they were left alone. There was no greater incidence in phlebitis in either group. This could lead to an end of unnecessary replacement of IV cannulas on the wards. I think that the most important way to reduce risk of phlebitis and bloodstream infection is good, clean and sterile technique on insertion but I agree with the study conclusion that clinical judgement is the best way to decide if a cannula needs replaced.

'Gut Feeling' About Serious Infections in Children - This was an interesting study which asked whether 'gut feeling' had any merit in identifying acutely unwell children with normal parameters. The study researchers found that in children with a reassurring clinical assessment, serious illness was 25 times more likely in with gut feeling - parental concern was the feature most strongly associated with gut feeling. I expect that the 'gut feeling' principle could be extended to adults.

Is patient education the key to longevity? - As the competition rages for the election of the next US president, the observations column in the BMJ this week comes from America. Studies carried out across the pond have led to claims that education could actually be the fundamental cause of better health and longer life. According to the New York Times, poorly educated Americans die younger and life expectancy of those lacking a high school diploma is actually getting shorter. As doctors there may not be an awful lot that we can do to improve the education and economic status of a nation, however it may affect opinions when it comes to voting for future local and national elections.

Medicine and the Media - "Dermatologically Tested" - What does this phrase mean? I don't know, but I've seen it a lot on advertisements and skin products. Another doctor investigated further by getting in touch with several of the companies who promote their products in this way, such as Boots, Johnson and Johnson, Persil etc and found that they were reluctant to describe the testing processes which lead to these tags, quoting reasons such as 'commercial confidentiality' as the reasons for non-disclosure. It seems that there is not a common standard required to meet this label and that often it just means that there is an absence of proved harm, rather than evidence of benefit. There is a great deal of inconsistency in what these labels mean but currently a European Commision is working on a paper for creation of common criteria for claims made by cosmetic companies.

Long QT Interval - An interesting learning point. Long QT syndrome can lead to sudden cardiac arrest in previously asymptomatic individuals. It can either be genetic or caused by severe electrolyte imbablances and several drugs. A history of syncope or previous cardiac arrest are the strongest predictors of sudden cardiac death. A QT interval of greater than 450ms in males and 460ms in females is considered to be abnormal. The best ECG leads to measure the QT interval are II, V5 and V6.  In outpatients a beta-blocker should be prescribed and a pacemaker fitted with strenuous high intensity exercise avoided. First degree family members should undergo genetic screening for the condition.

Corticosteroid-Induced Osteoporosis

Route Planning, Glencoe

At the Drift Inn, Arran

Only 3 days to go now until the marathon. Can't wait to get it over with! Went out for the last run today and apart from a bit of 'runner's knee' feeling generally ok. The last couple of weekends have been busy so looking forward to a week off next week.

I've decided on a new audit to start whilst I'm working in the dermatology department. A couple of ideas were suggested, such as monitoring of second line psoriasis treatments eg. acitretin (too similar to my last audit) and investigating melanomas referred to secondary care as 'routine' when they should have been urgent (very interesting and important but difficult). I've settled on the topic which my supervisor had suggested - prevention and treatment of glucocorticoid-induced osteoprosis. The basis for this is that systemic glucocorticoids ie. prednisolone are commonly used and patients may be prescribed them long term for immunosuppression. Patients on prednisolone for greater than three months are at increased risk of complications eg. fragility fractures and avascular necrosis of the femoral head. National and local guidelines recommend that patients greater than old should be given bone-protective therapy at the time of starting corticosteroids, whilst those less than 65 years old should be assessed for bone density following three months of treatment to determine fracture risk.

I'm also going to get back involved in the gentamicin project now that the initial audit and change has been carried out. I've just emailed out to the FY1 doctors working at the Victoria this year to recruit some volunteers to repeat the audit, now that the new prescribing and monitoring form is in place. Hopefully we can repeat the audit and see if gentamicin is being prescribed in a safer way now that the new form is being used.

A Few Interesting Case Studies and Research Articles

Three weeks to go until the marathon! From this point on the running distances shorten, this past week has been the longest yet. Probably ran about 40-45 miles altogether, including a 22.6 mile run today - a long loop from the flat to the Clyde then linking the parks in the Southside of Glasgow (Bellahouston, Linn, Rouken-Glen and Pollok Country Park). Really pleased that the training seems to be paying off - for the past four long runs I've increased the pace while also increasing the distance:

Saturday 11th August - 16 miles - 2hrs 11mins - Pace: 8:13 per mile

Monday 20th August - 17 miles - 2hrs 15mins - Pace: 7:59 per mile

Friday 31st August - 20 miles - 2hrs 37mins - Pace: 7:54 per mile

Sunday 9th September - 22.6 miles - 2hrs 57mins - Pace: 7:50 per mile

Sunday 30th September - 26.2 miles - ???

That was the last of the 'long runs' but hopefully if I can keep up a good pace on the day I should be able to make 3hrs 25-30mins, that would be a brilliant time considering my initial aim was under 4 hours. I just hope I can get through the last 3 weeks without any set-backs and get the start line in a good condition!

Case Studies:

Back Pain in a Teenager - Psoas Abscess. A 'Picture Quiz' in this weeks BMJ. A 16 year old patient presents to A&E with a two week history of back pain in the left lower lumbar region. Onset was sudden after bending over and is now a dull ache. He has been feeling feverish. Urinalysis is positive for protein and blood. CRP, WCC and Neutropil count are raised. On examination there is tenderness over the left paraspinal region but no skin changes. MRI is carried out which shows a large paraspinal high signal area with lateral displacement of the left psoas muscle. Underlying causes should be considered, including immunocomprimise, inflammatory bowel disease and diverticulitis. Investigations include blood cultures, aspiration, CXR (?underlying TB) and consider colonoscopy +/- barium enema.

Skin rash in a preterm infant - HSV Infection. A BMJ Case Report: a baby girl born at 30 weeks gestation develops 3-5mm vesicular skin lesions on the face, trunk and chest at age 9 days. Shortly after this lesions appear on the hard palate. These develop into pustules with an erythematous base which soon erode, leaving a shallow ulcer. The pustules all resolve after four weeks with no scarring. Given the distribution of the vesicles and oral/baccal involvement, the most likely diagnosis is Herpes Simplex Virus, transmitted from the mother perinatally. Treatment is with IV aciclovir for 3 weeks in disseminated disease or CNS involvement. Complications include severe hepatitis, CNS involvement, ocular disease and neurodevelopmental delay.

Difficult to spot - Amelanotic Melanoma. Included in this weeks 'Picture Story' in the BMJ. A 45 year old woman presents with an 8 month history of a mildly pruritic lesion on her left thigh, measuring 1cm in diameter and with no dark pigment. Dermoscopy revealed scattered dotted vessels and no pigment network. Skin biopsy was carried out and histology revealed an amelanotic melanoma. These count for 2-8% of malignant melanomas and should be considered in the differential diagnosis of a new, red evolving patch or nodule.

Research:

Evidence for organic food lacking - A published article in the Annals of Internal Medicine this week looks at the evidence for organic food - and finds it lacking. A review of five studies of patients who ate only organic food looked at clinical outcomes. Apart from higher phosphorous levels and a 30% lower risk of contamination with pesticide residue, there were no differences in nutritional biomarker levels between patients eating organic vs non-organic food.

Longer resuscitation pays when cardiac arrest occurs in hospital - I feel like this is pretty topical given that I've just completed my ALS course, but a study published in the lancet this week reports that in an observational study of 64,339 cardiac arrests in US hospitals, survival to hospital discharge was more common in patients who were resuscitated for longer. One could speculate a number of reasons why this may be the case but perhaps we should be continuing CPR for longer. In 15.8% of cases resuscitation attempts lasted less than 10 minutes. Patients without systolic activity or a pulse had the worst outcomes. There was no difference in the proportion of patients who were discharged without major neurological impairments. 

Both Ends of the Spectrum in Dermatology

The BMJ this week includes two very different and contrasting dermatological conditions. In one hand there is the extremely common but relatively benign basal cell carcinoma, whilst at the other end is the rare but potentially fatal toxic-epidermolysis-necrosis occurring as a result of an adverse drug reaction.

Facial Basal Cell Carcinoma:

BCC is the most common human cancer. The incidence of BCC is increasing and the cost to the NHS of treating non-melanoma skin cancers is high. Timely recognition and treatment of BCCs usually results in excellent outcomes but specialist intervention is required for BCCs in difficult to treat areas. The definition of BCC is locally invasive cancer if the epidermal basaloid cells. Up to 85% of BCCs are found on the head and neck. Early recognition can limit the extent of facial tissue involvement. The main risk factor for development of BCC is exposure to UV light, explaining why there are such geographical variations in the incidence of the cancer with sun exposure in childhood being of particular importance. BCCs are more common and more aggressive in men compared to women. BCCs are less likely to occur in pigmented skin due to the protection provided by melanin. Immunosuppression and radiotherapy are other risk factors.  Most patients describe a non-healing 'lump' or 'sore spot' which grows slowly but is otherwise asymptomatic. 

Different subtypes of BCC are: nodular, nodulo-ulcerative, superficial, morphoeic, or infiltrated and pigmented. Nodular BCC is the most common type found in the UK. Classic features include: overlying telangectasia, central crusting, raised rolled edge and ulceration. Following diagnosis, the risk of a further BCC is 10x greater than the general population. The differential diagnosis includes: solar keratosis, SCC, seborrhoeic keratosis, intradermal naevus, psoriasis and eczema. High risk BCCs are those >2cm in diameter, located in high risk anatomical areas, poorly defined edges and recurrent or poorly defined BCCs. Treatment options include wide local excision, MOHS microgaphic surgery, radiotherapy, photodynamic therapy, imiquimod, curettage and cautery, cryotherapy and lasers. Wide local excision can be used to treat most facial BCCs as long as there is a successful clearance margin. Most BCCs grow slowly and follow a non-aggressive course but if neglected for a long time they can offer a therapeutic challenge. 

Toxic Epidermolysis Necrosis:

A patient is prescribed amoxicillin for a sore throat and mouth. Five days later he is admitted to the general medical ward with a fever and rapidly spreading burning rash on his trunk, palms and soles. He also has painful red eyes and inflamed ulcers in his mouth. The next day he develops blisters and loss of the top layer of his skin on gentle touch. He then developed respiratory failure, requiring intubation and transfer to the Intensive Care Unit. 

The diagnosis is a severe adverse cutaneous drug reaction with epidermal detachment, classified as Stevens-Johnson syndrome - toxic epidermal necrolysis overlap. The diagnosis is confirmed by taking two skin biopsies - one for immediate cryosection and one for confventional formalin fixed analysis. Skin biopsy shows detatchment of the epidermis from the dermis and apoptosis of keratinocytes. The main causes of this syndrome are drug hypersensitivities but others include infections eg. Herpes Simplex Virus. Management is to withdraw the offending drug and provide supportive care in an intensive care environment with special attention to fluid resuscitation, skin care and eye care. 

Pelvic Organ Prolapse and the Use of Transvaginal Mesh

This week is a guest post from Jasmine McCarthy who works in the Public Outreach Department from www.drugwatch.com.

Pelvic organ prolapse (POP) is a condition that occurs when the internal structures that support pelvic organs become weakened or stretched to the point that they allow those organs to fall lower in the body, pressing into the vagina. While POP is not life-threatening, severe cases can cause an array of symptoms that have a substantial effect on a woman's quality of life.

Corrective surgery is often recommended in such cases, which can resolve symptoms in many women. However, over the last decade, the use of transvaginal mesh implants has become common in POP repair surgeries — an addition that has proven problematic for a significant number of women who have undergone these procedures.

Pelvic Organ Prolapse

Pelvic organs, such as the bladder, uterus and rectum, are supported by the pelvic floor, which is made up of muscles and connective tissues. Over a woman's lifetime, the pelvic floor can be gradually weakened and stretched as it is exposed to stress. The most common cause of that damage is childbirth, but factors like obesity, chronic constipation and a family history of POP can contribute.

When the pelvic floor is weakened significantly, one or several of the pelvic organs can drop out of their normal position, placing pressure on the vagina. Mild cases may produce no symptoms, but women with more serious POP may experience symptoms that include pain and pressure in the pelvic region, urinary leakage, difficult bowel movements, pain during sex, a bulge in the vagina, or organs that protrude through the vaginal opening.

Transvaginal Mesh and POP Procedures

Approved by the Food and Drug Administration (FDA) for POP repair procedures in 2002, transvaginal mesh is a medical device that is permanently implanted in patients to reinforce the weakened tissues that are at the root of pelvic organ prolapse. Constructed of synthetic surgical mesh, these devices are hammock-like in design to support prolapsed pelvic organs and are inserted into the pelvic region through the vagina. This method of POP repair has become quite prevalent, used in 75,000 procedures in 2010 alone.

Complications

The most common complication associated with transvaginal use for pelvic organ prolapse repair is mesh erosion. Also referred to as mesh extrusion, this occurs when rough edges of the mesh cut through the vaginal tissue and nearby organs. Results of mesh erosion can include organ perforation, infection, bleeding, pain, urinary issues and sexual dysfunction.

Mesh shrinkage is another common problem, and can cause vaginal shortening and intense pain. Addressing these complications often requires multiple surgeries, and since tissues grow into and around the mesh implants, they are not always effective. Thousands of women have been affected by these complications and have filed transvaginal mesh lawsuits against mesh manufacturers.

FDA Information

In a 2011 alert, the agency reported the results of a systematic review of scientific studies on the use of transvaginal mesh in pelvic surgeries. Those results showed that there is a significant risk of serious complications with the use of these products, and that those risks came with no significant benefits, since procedures that use transvaginal have not proven to be more effective than traditional POP repair.

According to that report, among the most common complications reported were mesh erosion, mesh shrinkage, organ perforation and infection, and reports of these serious complications rose fivefold between 2008 and 2010, as compared with reports during the previous three years.

Refusing Organ Donation

Organ Donation - In the BMJ this week Dr Shaw writes an article which I have no doubt will stir up some debate. He tackles the complex ethical issues of organ donation and particularly the situation when a family choose to over-rule a deceased patient's decision to donate their organs. Veto by the family is the main impediment to an increase in organ donation in this country and at least 10% of families refuse to allow organ donation in cases where the deceased has expressed an intention to donate their organs, eg. by carrying an organ donor card. 

While the family's wishes are respected in these situations, legally they have no grounds to over-ride the dead person's wishes. Clearly the stress and emotion of the situation affects the decision, but families often regret the decision not to allow the donation within two days. Dr Shaw argues that doctors who allow this to happen are not doing their jobs properly(!). The doctor's concerns about causing more distress to the family by pressing the issue may cause greater consequences in the long run if up to seven more lives are not saved due to the failed organ donation. Of course the family cannot be blamed for refusing to allow donation under such an awful situation, but the same cannot be said of the doctor. Ethically this is difficult because we have to consider the patient who has died, their family and the patients on the organ donor list who could die without a donation. As doctors we have a duty to promote the health of the public, and that includes patients on the organ donor register. However it must be an extremely difficult conversation to have with a family to persist in recommending that they allow the organs to be donated against their wishes. If the family have no legal grounds for over-ruling the patient's wishes, and there is evidence to show that those refusing donation later regret their decisions, perhaps we should be looking at whether families should play a part at-all in this complex end-of-life decision making. Although on the other hand, taking away the families' input into this process would seem harmful to the relationship between the public and the profession which would likely be a bad thing. In summary I think that although there is no easy answer, there is ample material for debate.

Implementing a National Early Warning Score - In order to help identify patients early who become acutely unwell in a hospital ward, the Royal Collect of Physicians has now introduced a national early warning score. The idea of this tool is that patients at risk are identified early through monitoring of basic clinical observations such as pulse rate and respiratory rate. Having a national early warning score system allows an adequate standard of care to be delivered to all patients, regardless of their geographical location. The hospital I work in now has an "Emergency Response Team" which can be called to patients who nurses or doctors feel may be deteriorating. The effect of this identification process has also been called "critical care outreach". This is the idea that a critical care department may help with deteriorating patients in the ward environment. Having just moved to work in a new hospital, I feel that standardising the approach to the acutely unwell patient is an important idea, which could ultimately mean that there is a common method for describing and acting on unwell patients throughout the UK.

Information Overload

Today, for the first time, I was asked to dictate a letter. This came after a following clinic encounter with a patient who had been referred to hospital by her GP. Having never dictated a letter before, I asked my supervisor what to include. I was told that a useful way to structure a clinic letter is to have the patient's details, followed by three headings:

Diagnosis

Management

Follow-Up

The bulk of the text should then follow. The reason for this is that it means the GP can read the headings and get a summary of the outcome of the clinic appointment without spending a lot of time reading all of the text. The rest of the letter is available in the patient's notes, should the GP or a doctor need to refer to it in the future.

I realised that this approach is almost exactly the same as how many doctors must try to keep up with new guidelines and evidence. Work is busy and often there is rarely enough time to trawl through journal articles to try to keep up-to-date with all of the medical news. With evidence changing all of the time there are lots of ways to keep up. Guidelines produced by the SIGN or NICE are developed by researchers who collate all of the relevant research into easy to access guidance. These guidelines are now being made more widely and easily available through websites, apps and publications. The BMJ offers a useful summary of some of the most relevant articles. BBC News will pick up on major new studies as they break however will often present them in a way which is more suited to the lay public. Another way to keep up is through reading publications from more specialty specific organisations, such as the British Journal of General Practice. Lectures, talks and presentations from experts are also a useful way to learn new information.

In my opinion, the weekly BMJ offers one of the best ways to keep up with new developments. It summarises key evidence with a 'study question', 'summary answer' and 'what this paper adds'. Realistically this is a sensible way to condense a large amount of information into a more digestible amount. For example one of this weeks articles relates to the risk of pneumonia associated with the use of ACE inhibitors.

Study question: Do ACE inhibitors and ARBs decrease the risk of pneumonia?

Study answer: ACE inhibitors may be important in reducing the risk of pneumonia. This data could discourage the withdrawal of ACE inhibitors in some patients with cough who are at particularly high risk of pneumonia.

What is known and what this paper adds: ACE inhibitors have secondary effects on the respiratory system, which may protect against pneumonia. In pooled results from interventional and observational studies, ACE inhibitors had a significant protective role against pneumonia.

In an attempt to do my bit to reduce the amount of information overload which is often starting to occur in medicine, I'll try and keep my letters, presentations and discussions short, because the danger is that if there is too much information, the key points of most importance could be lost.

And of course this week wouldn't complete without mentioning some of the amazing successes of Team GB in the Olympics! Congratulations to all of the medal winners - so great to see all of the hard work pay off.

Keeping up with the NEWS

The London Olympics kicked off in dramatic style this weekend with a stunning opening ceremony. I've been hooked to the TV all weekend - hopefully some gold medals to come for Team GB! Apparently the GMC has granted temporary GMC registration for 849 doctors from 141 countries to help support the athletes. France has sent the most doctors (58 to support their 333 athletes). Compare this to the 18 doctors who are going to be supporting Britain's 542 athletes! We must be confident! It was good to see the NHS represented in the opening ceremony - the trampoline hospital beds for the kids was a fantastic idea.

Tomorrow is my last day as an FY1 doctor and I'm about to start at a new hospital at the dizzying new heights of FY2 (foundation doctor two). It's been a good year, ups and downs but overall enjoyable. Not long now until the serious matters of application to specialty training come into the fold. I'll probably put that off until AFTER the marathon (running 5 times a week and working full time doesn't leave much time for anything else!).

New Maggies Centre at Gartnavel, Glasgow

 <----This is the new Maggie's Centre which has been shortlisted for the Royal Institute of Architects' Stirling Prize. I visited the Maggie's centre in Dundee which I'd probably describe as a resource or meeting place for patients with cancer, offering a tranquil and relaxing environment away from the miserable hospital wards which can be depressing places to spend time, particularly I'd imagine for patients visiting regularly for chemo/radiotherapy. I think that these buildings are fantastic and looking at the photos of this new centre in the Glasgow's west end I think it will be equally successful. 

An article which I read in the BMJ News caught my attention this week. This was the proposal that a national early warning prediction score is adopted which is the same in all NHS hospitals. When I learnt about improving patient safety as a fifth year medical student, much emphasis was placed on the importance of reducing variation to improve patient safety. Currently in the Victoria Infirmary we use a "SEWS" (systemic early warning score) but in other parts of Scotland a "NEWS" (national early warning score) is being introduced. I think that this is a great idea. There must be more areas where we can reduce variations in our hospitals, such as with national agreements on evidence based best practice. With Wednesday being the big 'change-over' day, many doctors will move to new hospitals in new cities and health boards. If everything was standardised, less mistakes would be made and no doubt patients would benefit. I am a big believer in reducing variation to improve patient safety in our hospitals.

Sports Energy Drinks

Bradley Wiggins - Amazing Achievement!!

It was great on Sunday watching Bradley Wiggins cross the finish line of the 99th Tour de France as overall winner. What made the day even better for Team Sky was that Mark Cavendish won the sprint on the day, his 23rd stage win. While Bradley Wiggins took much of the attention, Team Sky showed that it really was a team effort in the end. Wiggins could have just let up in the last few laps of the Champs-Elysees, savouring the moment, waving to the crowd - but instead he was leading the peloton into the final sprint to help tee up Mark Cavendish to sprint to the finish for the win. It was an amazing achievement for British cycling and with Chris Froome finishing second overall, I don't think we'll ever see such a dominant performance from a British team in the Tour de France. It's incredible to think that some of these guys will be getting up, dusting themselves off and starting training for the Olympics, which starts in just four days time.

Keeping on the subject of sport, the BBC's Panorama ran an episode last week in conjunction with the BMJ about "The Truth Behind Sports Drinks" (it'll still be available on BBC iPlayer for a week or so). Sports marketing is big business, praying on the needs of sportsmen and women seeking to improve their performance, or just as a "fashion accessory" to be seen using whilst taking part in sport. Energy drinks such as Lucozade and Powerade make claims on the adverts and packaging about "boosting performance" and are becoming an "essential piece of sporting equipment". They advise people to drink before they feel thirsty. This is all a new concept. In the 1970s, runners were discouraged from drinking too much for the fear that it would slow them down. When the evidence is carefully scrutinised, it doesn't hold up. A lot of the studies cited are sponsored by the companies wishing to promote their products and the evidence is weak. What the promotion of these products has achieved is to undermine the importance of thirst. This is the basis that the only symptom of dehydration is thirst. Drinking too much can lead to exercise associated hyponatraemia, with 16 marathon deaths recorded due to a drop in sodium levels. The most effective way to prevent hyponatraemia during marathin running is said to be to prevent having a positive fluid balance. When the BMJ asked the major manufacturers of sports drinks to supply evidence, only GSK (who make Lucozade), supplied evidence. Other problems arising from sports drinks are the risks of obesity (people drinking too much - one in four American parents believe sports drinks are healthy for their children), and increasing numbers of patients with diabetes. So in conclusion, the evidence is not all there - sports drinks are not all that they are cracked up to be, and only drink water when you're thirsty. Plus it'll save you a lot of money!

The Challenges Facing New Doctors

Only one more week until the changeover and the new FY1s step up and take over. The media seem to take of advantage of this, by coming up with 'shocking' headlines and describing August as "the killing season" in NHS hospitals. This doesn't really help the confidence of the new doctors who will already be nervous at the prospect of taking on massive responsibility. A column in the BMJ this week written by an inter-calating medical student talks about exactly this. What people often seem to forget is that we've been at medical school for 5, 6 even 7 years sometimes working up to this point, and the new FY1s will be much more prepared than they realise. Studies have shown that the care given by new doctors in training is comparable with that of their senior colleagues. I'm giving a talk to the new FY1s next week to give some advice on how to work as a save, effective FY1 doctor and I'll try and remember how I felt when I was in their shoes only a year ago. I'll be moving on to a new hospital on the 1st August and no doubt I'll have plenty of new challenges to get my head around. 

I presented the gentamicin audit which I talked about in the last post before the wedding to the department in June and it seems as if it was good timing to do an audit on gentamicin because the new prescribing form is being rolled out across NHS Greater Glasgow and Clyde next week. No doubt there will be a few speed-bumps initially as doctors and nurses get used to it but hopefully it'll lead to safer prescribing and closer monitoring of IV gentamicin in the long run. I'll try and recruit some of the new doctors in the hospital next year to repeat the audit next January to see if there really is an improvement with the new prescribing form.

The president of the Royal College of General Practitioners (Dr Iona Heath) this week spoke out in praise of young doctors. In a letter to the BMJ she wrote that too much emphasis from an early stage of training new doctors is on science and understanding. However science is never enough in a profession which seeks to try to alleviate human suffering. Students and doctors are not being encourgaed enough to think and question assumptions about the nature of science and medicine. She continues in the letter to talk about the erosion of continuity of care, and the lack of a 'team based' attitude to practicing medicine (only this week we had to our FY1 end of year ball due to a lack of interest from our senior colleagues). She highlights that with shift patterns and the European Working Time Directive, it is difficult to learn from our actions (I used to see patients on night shift and then wonder what had happened to them the following day - I would sometimes go and check out patients at the start of my next shift to see what had happened but often time wouldn't allow). 

She also argues that there is a rapidly changing culture in medicine of 'protocol and guideline medicine'. Many doctors are now afraid not to follow the guidelines and although I've only had one years experience, I am already starting to feel that there is a great deal of "over-treatment" and "over-diagnosis" in the NHS at times such as end-of-life care which can be dangerous and un-necessary. According to Dr Heath this is "destroying the confidence of many young doctors, so that they no longer feel able to make the courageous professional judgements necessary to tailor treatment to the needs, aspirations, value and context of individual patients". Finally she says "as I grow old and frail, I want a doctor who thinks and questions, not one who feels obliged to blindly follow protocols".

Wedding and Honeymoon Photos!

It came and went in a flash - the wedding was an amazing day. Great to see so many family and friends on the day, it seemed like all of the guests enjoyed themselves as much as we did!
 

Brig O'Doon, Ayr, Scotland - Saturday 23rd June 2012

Reethi Beach Resort - The Maldives

Gentamicin Pescribing Audit Project

 Last week I presented the results of the audit project I've been working on in the hospital where I work as part of the monthly medical division clinical governance meeting. Audit is an important process whereby everyday practice is compared to the ideal standards and practice. I wanted to audit prescribing of gentamicin in the hospital. It is an antibiotic which has nephrotoxic and ototoxic effects if given in high concentrations. Monitoring of blood levels is very important to ensure safe prescribing and levels should ideally be documented on a monitoring chart, with the dose calculated based on the patient's weight and renal function. Duration of treatment should not exceed 72 hours except in exceptional circumstances. I audited this process and found that in more than half of cases at least one of my outcome measures were not being completed correctly. In these patients, it was more likely that renal function would be affected, leading to my suggestion that patients will directly benefit form improved compliance with these monitoring protocols. The plan is for a new gentamicin prescribing and monitoring chart to be introduced in the hospital in August 2012 which will hopefully improve compliance. There's a lot coming up over the next couple of months (the wedding, portfolio hand-in etc) so I'd imagine that posts on here are going to be a bit more sparse over the next while. More to follow...

Notes From On-line Modules - Monday 16th April

Notes From On-line Modules - Monday 16th April

1. Diabetes Management + Insulin Types

Novorapid, Actrapid, Humulin S and Humalog are fast acting, short duration. Humulin M3 is fast acting, long lasting. Humulin I and Insulatard peak slowly and are long lasting. Insulin Detemir and Insulin Glargine are very long acting. In patients in DKA requiring insulin for infusion - short acting insulin eg. Actrapid should be used.

2. Diabetes Management: Prescribing Insulin Safely

If unsure about the correct type of insulin which a patient normally receives - clarify with the GP. If discharging a patient on Insulin in whom steroids have been stopped - advise the patient to increase the frequeny of blood glucose monitoring (risk of hypoglycaemia increases). If discharging a patient on a new insulin regime they should ideally be seen by the diabetes team as an outpatient in 1-3 days.

3. Information Governance

Next of kin does not have a 'right to know' information about a patient. In a "serious offence" situation the doctor can disclose information about a patient to the police as acting in the "public interest". Inadequate clinical records are cited as a factor in approximately 80% of indefensible medico-legal cases. Ward round notes should include: summary of the case, discussion with the patient, examination findings, relevant investigations, impression/diagnosis and management plan.

4. Palliative Management of Nausea

Chemotherapy induced nausea involves the neurotransmitted 5HT3 - large amounts are released when the gut is irradiated. Ondanstron is a powerful 5HT3 antagonist. Opioids can stimulate the chemoreceptor trigger zone (CTZ) - this is best treated with either haloperidol or metoclopramide. Cyclizine has no effect on the CTZ. Cyclizine acts upon the vomiting centre in the brain. Side effects of ondansetron and cyclizine include constipation. For nausea caused by constipation metoclopramide would be the drug of choice. For nausea induced by hypercalcaemia, this should be treated with haloperidol.

5. Pharmacy: Adverse Drug Reactions (ADR)

These are surprisingly common! And can be fatal! Most commonly they are caused by NSAIDS, diuretics (renal impairment, hypotension and electrolyte disturbance) and anti-coagulants. The main way to report adverse drug reactions is via the "Yellow-Card Scheme". In the BNF new medicines are marked with a small black triangle (these often have a higher rate of ADRs. All health care professionals can report adverse drug reactions using this scheme.

6. Pharmacy: Prescribing in Pregnancy

A teratogen is an agent or factor which can cause congenital malformations. Nearly all drugs cross the placenta. The most susceptible period is 3-8 weeks post-conception. Ideally best practice is to rationalise and alter medication prior to pregnancy through planning (eg. stopping certain anti-epileptic drugs such as sodium valprotae). Sources for doctors if they are concerned about the effects of drugs in pregnancy include: the BNF, Toxbase and EMC (http://emc.medicines.org.uk/emc). Trimethorim, for example, is not recommended in pregnancy. Cyclizine is a widely used anti-emetic in pregnancy for the treatment of nausea.

Filaggrin and Medical Eponyms

Moness Country Club, Aberfeldy

Had a great weekend away over Easter with the family staying up in Aberfeldy for the JK orienteering held over the Saturday and Sunday. Finished 10th on my course but still took over 2 hours both days so lots of space for improvement!

In 2008 for my BMSc in Genetics I carried out some research on the role of genes coding for skin barrier protiens, specifically the keratins. At the time the lab was involved in some break-through research regarding the role of the protein, filaggrin. It is now estimated that as many as one in ten European people have a mutation in the filaggrin gene which results in a dysfunctional skin barrier. This can manifest itself as painful skin fissures in the heels, lips and ears. It is recommended that moisturisers are applied liberously during times of low humidity (such as winter), to help maintain skin hydration. The results of this recent study are summaries in the BMJ this week in the 'Minerva' section.

Medical eponyms are commonplace in medical school or clinical examinations but rarely heard in everyday clinical practice. Des Spence (Glasgow GP who writes a weekly column in the BMJ) visits this topic this week. He argues a time may have come to evaluate the evidence of the usefulness of clinical eponyms and to move on that the 'classic' medical examination taught systematically to all medical students. Of course, all students must learn how to examine patients effectively - this is a key skill for every new doctor, but is it time we updated the clinical examination. Could the increasing use and availabilty of bedside imaging (eg. portable ultrasound) be used to improve clinical practice? Dr Spence thinks we should teach all medical students how to ultrasound patients. Imagine a world with portable ultrasounds in A&E to examine the abdomens of surgical patients, or in the coronary care unit to examine the heart function of new cardiology patients? So much time could be saved! Which would be more sensitive at picking up a physical sign eg. hepatomegaly - the scanner, or the doctor's palm, or both combined?

 

Craig a Barns - JK Day 3

Lung Cancer and Acute Charcot Foot

Detecting Lung Cancer - A man is admitted to the hospital with a history of weight loss, increasing tiredness and chronic cough. He has been a smoker for more than fifty years. After initial investigations, a CT scan is ordered which shows advanced metastatic bronchial carcinoma. At this point the condition is effectively incurable and the prognosis is poor. Scotland has one of the highest rates of lung cancer in the world and as I've written previously on this blog - early detection is crucial to improve outcomes. A large new trial is set to take place in Scotland to assess the reliability of a blood-test for early detection of lung cancer. 10,000 people who have smoked more than 20 cigarretes for more than 20 years (>20 pack years) are being entered into the trial. A screening trial in the US previously looked at 53,000 smokers and found that CT scanning led to early detection and improved outcomes. The problem with CT scanning is that it is expensive and has a false positive rate of approximately 50% (the test suggests the presence of disease but turns out to be incorrect). This new blood test which has been developed can detect about half of lung cancers with a false positive rate of only 7%. The full results of the trial are expected in 2014. In the meantime, chest X-rays are also good imaging modalities for early detection of malignancy and are generally performed on all acute medical hospital admissions (see above example). On another note, further evidence has emerged now to show that aspirin can help to prevent cancer, particularly colorectal cancer, when associated with controls not taking daily aspirin, over a period of five years. On the balance however, patients taking daily aspirin are at higher risk of haemorrhage therefore this needs to be taken into account. It's too early to say that everyone should take aspirin to reduce their risk of cancer.

Charcot Foot - An easily missed diagnosis. A type I diabetic patient is admitted with a warm, swollen red foot. The complications from his diabetes include peripheral neuropathy and nephropathy. Plain X-rays of the foot show metatarsal neck fractures. The patient is advised not to weight bear. MRI confirms a diagnosis of acute charcot joint. This is a destructive joint condition which usually occurs in diabetic patients who have reduced sensory innervation. Even in a diabetic foot clinic, one study showed that 19 of 24 cases were not diagnosed correctly. Differential diagnosis includes cellulitis, gout, DVT or ankle sprain. Failure to diagnose the condition early can lead to joint deformity, particularly if the patient continues to weight bear. Pain is not always present due to peripheral neuropathy. Infection and neuro-arthropathy are not mutually exclusive and may co-exist. Important first line investigations include findings of fractures or bony misalignment in the absence of any obvious trauma. MRI is the most useful diagnostic test. These patients should be advised not to weight bear, and should have their foot in a cast for three to six months ideally. This is an easily missed diagnosis and one to look out for!