Merry Christmas and Happy New Year!

That time of year again! A chance to wish everyone Merry Christmas and all the best for 2014!

MRCP Part 2 Notes

Three weeks today until Christmas - one week until Part 2! Managed to do some case-based learning sessions this afternoon with the Glasgow medical students up at the university (psoriasis & acne) then have got a further two cases to cover on Friday (melanoma and alopecia). The big news in Glasgow this week was of course the tragic helicopter crash at the Clutha pub in town which left 9 people dead - my thoughts go to all of the emergency workers involved in the aftermath of the crash and condolences to those who lost loved ones.

Some MRCP revison notes - this week taken from sample questions on the MRCP website:

Brugada Syndrome: A 26 year old is referred for assessment after their brother suffers a sudden cardiac death age 32. ECG shows sinus rhythm with a partial RBBB pattern and elevation of the ST segment in V1/V2. This history would be characteristic for Brugada syndrome. There may be no evidence of LVH. The condition is inherited in an autosomal dominant manner and there is an increased risk of cardiac death in these patients due to ventricular arrhythmias. 

Minimal-Change Nephropathy: A 22 year old man presents with leg swelling, chest pain, thrombosis and a right basal perfusion defect. What is the likely renal diagnosis? Minimal-change nephropathy. Treatment of this condition with corticosteroids often leads to a rapid resolution in symptoms. NB. In a patient with visible haematuria the most important investigation is cystoscopy to rule out bladder cancer, other investigations would only be carried out once the result of the cystoscopy was known.

Phenytoin overdose: Classical presentation would be with inco-ordination, slurred speech, reduced GCS and nystagmus. Serotonin Syndrome: Classic presentation is with agitation, hyperthermia, tachycardia and severe hypertension with neurological involvement (malignant hyperthermia is usually associated with anaesthetics whilst neuroleptic malignant syndrome typically presents with a 'lead-pipe' rigidity.

Basilar Migraine: Typical presentation would be an 18 year old woman with transient bilateral blindness, slurred speech, a severe occipital headache and neck stiffness.

 

Rheumatoid vasculitis: A 70 year old woman with a 20 year history of rheumatoid arthritis presents with weakness of the right leg and numbness of the right hand with foot drop and a sensory peripheral neuropathy. Examination reveals nail fold infarcts. This presentation has the appearances of a systemic vasculitis and in a patient with such long-standing RA, rheumatoid vasculitis would be the most likely diagnosis to consider. 

TB Diagnosis: The diagnosis relies on culturing of mycobacterium tuberculosis and bronchoscopy will produce the best specimen for acid-fast staining and mycobacterial culture. Routine sputum microscopy and culture will not isolate mycobacterium tuberculosis.

Blood transfusions in Hodgkin's Lymphoma: There is a risk in these patients of transfusion-associated graft vs. host disease (in immunocompromised individuals). These patients should receive X or gamma-irradiated blood. CMV seronegative products are reserved for CMV sero-negative individuals while HLA-matched platelets are used for patients refractory to platelet transfusions or in those who have developed anti-HLA or anti-platelet antibodies.

Some of the Issues Facing our NHS Today

We're in the new house! I now know that night shifts and moving house are a pretty bad combination but having a week off afterwards makes it all worth it. Move in was on Saturday, last box unpacked by Tuesday and the inevitable IKEA trip on the Wednesday. Still had a pot of cash left over from wedding presents so put that to good use. Only thing still missing is the curtains so that's a work in progress.

What's been going on over the past week... As ever, lots of NHS stories in the media, mostly coming from England and talks about big shake-ups to the way in which A&E services will be set out in the coming years, with a focus on greating fewer 'major' A&E departments which will cater for "heart attacks, strokes and major trauma", with a sub-section of 'minor' A&E departments. An interesting prospect, since centralisation of services seems to be a growing trend at the moment, although there are a lot more urgent conditions which have to be considered beyond what has been described here and a lot of clarification is needed. One reporter talked about the success of the recent changes (locally) in Forth Valley where two A&E departments and acute medical receiving units were combined to create one larger unit which was better staffed and has resulted in better patient outcomes.

Much of the talk about A&E seems to revolve around how to reduce the 'pressures on A&E' and there is a lot of talk about how the government's '4 hour waiting targets' were missed in many cases last year. There are still a lot of inappropriate attendances to A&E but the question is how can this be avoided? In Scotland we have an excellent GP out-of-hours service, which enable patients to see a GP out-with practice working hours. Although Amy assures me that GP OOH is very busy, I still feel that this has to be an under-utilised service. I think that a lot of people don't know that GP OOH exists and this leads to more A&E presentations. The GP service runs well so we need to direct more patients to it. Most GP OOH units are attached to A&E (often in the next building). Maybe GPs working out-of-hours could work at the front door of A&E departments to direct patients to the correct places (A&E or GP). GPs are often called the 'gate-keepers' to secondary care so why can't this extend to A&E attendances out-of-hours? The GP contracts have also been 're-drawn this week to reduce the amount of work on meeting targets and increase the amount of time GPs can spend with their patients.

On another note, the Royal College of Physicians of Edinburgh this week held a conference to address improving acute hospital services under times of increasing pressures. The Scottish government this year created a £50 million emergency care "action-plan" to speed up admissions and create more opportunities for treatment in the community. The recommendations from the college were as follows:

• An extension of seven day working by clinicians and support services in hospitals and the community in order to meet demand.
• Working towards "eliminating boarding" (patients being moved to wards inappropriate for their care during busy periods.
• Patients being seen immediately by the right, competent, clinical decision makers.
• A named professional responsible for the patient's care.
• Every acute medical receiving unit to have a dedicated multi-disciplinary team.

Many of these measures are already in place already, such as the named consultant responsible for a patient's care and extension of the working week. I feel that the extension of the working week has to apply to the specialties allied to medicine, such as physio, OT, social work etc. because often I find patients whose medical treatment is completed but are awaiting on-going physio and OT input prior to discharge. If this is the case on a Friday, there is often no progress by the next Monday, and there have been two more days spent in a hospital acute bed. There is no quick fix to improving services in our hospitals but it's reassuring that lots of work is being done to try to tackle these important issues.

House Move and MRCP Part 2

It's all about the house move at the moment - here's a photo taken a couple of weeks ago inside the new house. Still quite a lot of work needing done but things are moving along well. Most of my time at the moment seems be spent either working, packing or studying. First set of CMT nights about to come up this week (starting tomorrow) followed by a week of annual leave!

MRCP Part 2 is about 6 weeks away now so time to do lots of practice questions. Here are some interesting topics which I've been revising over the past few days:

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Post-MI Mitral Regurgitation – A 56 year-old man becomes acutely unwell on the cardiology ward 4 days after an MI with evidence of acute LVF. Cause? Acute mitral regurgitation due to ruptured chordae tendonae. If blood pressure allows, these patients benefit from volume reduction using diuretics and initiation of an ACE inhibitor.

Cholesterol Emboli - The clinical syndrome associated with cholesterol emboli is: low C3 level, eosinophilia, raised ESR and urine proteinuria. Cholesterol emboli occurs in patients with existing arterial disease who undergo arterial manipulation – the patient develops a purpuric rash over the feet with impaired blood supply to the lower limbs.

 

Dermatitis Herpetiformis – This is an immune mediated blistering skin disease associated with gluten-sensitive enteropathy. Characteristically it causes a very itchy rash with blistering lesions over the extensor surfaces. First line treatment is with Dapsone. Dapsone is usually given initially because it allows for a faster recovery compared to a gluten-free diet alone.

Drug-Induced Hepatitis asoc with Anti-TB Therapy – Pyrazinamide should not be used in patients with known chronic liver disease. Rifampicin should be avoided where there is decompensated liver disease. Ethambutol can accumulate in patients with chronic renal failure leading to optic neuropathy and therefore should be given at a lower dose.

Progressive Supranuclear Palsy – This is a rare, progressive disorder that causes adult-onset Parkinsonism with postural instability and multiple falls. Impaired DOWN-gaze is always pathological (impaired upgaze can be seen in normal elderly patients).

Coeliac Disease – This is a common condition, with a prevalence of approximately 1 in 100 people (up to 1 in 30 in parts of Ireland). Severe malabsorption can lead to Vitamin D deficiency with secondary hyperparathyroidism, low albumin, impaired clotting, iron deficiency anaemia and weight loss. Iron deficiency anaemia is the most common presentation of coeliac disease and stool is FOB positive in approximately 50% of cases. The presence of other autoimmune conditions makes the diagnosis much more likely.

Invasive aspergillosis - This condition usually manifests with fever, cough, dyspnoea and pleuritic chest pain in patients with prolonged neutropenia or immunosuppression.

Safer Ward Rounds

HIS (Healthcare Improvement Scotland) was formed in 2011 - the same year I graduated from medical school, to support healthcare providers in Scotland to deliver high quality, patient centered, evidence based, safe and effective healthcare in our hospitals. The organisation links in to the pre-existing work which has been carried out in Scotland in this area, such as NHS Quality Improvement Scotland and the Scottish Patient Safety Programme, both of which I have talked about on this blog before. 

So why am I talking about HIS this week? Recently on the news it was reported that the hospital standardised mortality ratios in three Scottish hospitals were above the national average and as a result an inspection was launched by HIS to try and help find out why that may be the case and to offer assistance with improving the hospitals in question. Seeing as I currently work in one of the hospitals mentioned in the report, I have been aware of this visit for the past month or so and I think it is a definitely a welcome exercise. Hospital standardised mortality ratios are probably not a particularly reliable measure on their own to look at how well a hospital is performing as there are a huge number of factors which could lead to a higher mortality ratio in one hospital compared to another. It could reflect, for example, a more elderly or unwell population which are being treated, as opposed to being solely down to the quality of delivery of care in the hospital of note. I do however agree that these measures can be useful to 'flag' areas of potential concern. HIS is potentially an extremely powerful tool to improve healthcare and I think that helping hospitals which are needing extra support is an extremely worthwhile exercise. The team who visited my hospital this week comprised of almost 30 staff (a mixture of medical and non-medical background) and carried out various exercises such as walkarounds and discussion groups. It was great to see people talking about the processes in the hospital which could be improved. I was chatting to the nurses about things we thought were done well and things which could be improved in the ward we're working in, whereas we may not have been having these conversations had the visit not taken place. I look forward to hearing the outcome of the report although I have to say that since I started work in this particular hospital I've been impressed by the focus on improvement which I've seen with a big emphasis on clinical governance - definitely more prominent than in some previous hospitals where I have worked.

I thought about the meeting I had attended, with several other 'trainees' and thought about the various themes which emerged as people were describing areas where they though improvements could be made. I've decided that I need to take on a new improvement project or audit myself this year but up until now I've been quite undecided about what to do. I think what I might do is have a look at the way we do ward rounds in the general wards in the hospital where I work. A lot of the improvement work focusing on patient safety which I have seen being done or been involved in in the past has related to the use of 'bundles' and 'checklists' and I want to see if I can somehow create a safety checklist or bundle to help facilitate safer ward rounds. Already checklists are being adopted for safety purposes in other areas of medicine eg. surgery and I've ordered a copy of Atul Gawande's new book 'The Checklist Manifesto' which looks at exactly this topic. Once I've had a read through the book and perhaps done an audit to see if there is a problem in the first place, I can see if there is scope to improve our system. In the medical HDU unit in our hospital there is already a 'daily ward round' proforma sheet which is completed and prompts important questions ie. is this patient appropriate for escalation to intensive care if required or can this patient be stepped down to ward level. I don't see why an adapted version of this couldn't be employed in the general wards (ie. would it be appropriate to escalate this patient to high dependency or are they an appropriate patient for boarding out to another ward if necessary). A ward round checklist might not be as useful for the consultants who are much more experienced with ward rounds, but would help the junior medical staff who may be less experienced and therefore more likely to potentially miss things. I think that anything that improves overall communication from ward rounds would be an improvement and hope I can try and come up with something helpful.

A Diagnosis Easily Missed?

I gave a presentation this week at the hospital medical teaching meeting which focused on a case presentation: a diagnosis easily missed. A women in her 40s presents with headache, palpitations, intermittent sweating and flushing (particularly at night time) for about a month. Past medical history was unremarkable except for hypertension, treated with an ACE Inhitor, beta blocker and calcium channel blocker. Fundoscopy reveals hypertensive retinopathy and blood pressure is markedly elevated on examination. Blood results show acute kidney injury, but the full blood count, liver function tests and inflammatory markers are normal. A fasting blood glucose is also normal. Renal US scan identifies a cystic mass in the adrenal gland. Urine catecholamines measured over 24 hours are markedly elevated, as are plasma metanephrines. 

The diagnosis is: phaemochromocytoma. this is a rare tumour arising from the chromaffin cells located in the adrenal medulla. It has a very low population prevalence and there is often a delay of on average three years between initial symptoms and diagnosis. Approximately 1/4 of phaeochromocytomas may be incidental findings when a scan is carried out for another reason and in these cases the patient may be completely asymptomatic. In cases where patients experience symptoms such as the ones described here, they are thought to be casued by the secretion of catecholamines (adrenaline, noradrenaline) from the tumour, often in a cyclical pattern. The management of phaeochromocytomas is alpha-receptor blockade to reduce the effects of vasoconstriction caused by excess catecholmamines. Beta blockers may make the condition worse (think of a phaeochromocytoma in the hypertensive patient who gets worse after a beta blocker has been given). The definitive management is laparoscopic adrenalectomy to remove the tumour and the prognosis following this is excellent. It is worth noting that approximately 10% of phaeochrmocytomas are malignant and patients should be investigated for malignancy. Phaeochromocytomas may also be familial and are seen in conditions such as Multiple Endocrine Neoplasia 2A/2B, and Von-Hippel Lindau syndrome. 

So hopefully not a diagnosis easily missed any more after reading this!