DVT Assessment, Wheezy Children, Surfactant Replacement Therapy

Got loads to talk about this week.

Probably the most important was presenting my BMSc work at the ATRIUM conference last week and how it's really got me thinking about the possibility of a career in academic medicine. I know now that the first thing I need to do is to apply for the academic foundation posts. They're avaliable in Dundee, Glasgow, Edinburgh and Aberdeen. So far I've spoken to Dr Berg, Sam, Amy Martin and Tommy about these and had an email reply from Glasgow about what kind of things they're looking for from applicants. From what I can tell so far, I've got nothing to loose and it sounds like they don't mind doing telephone interviews if I'm on my elective. The TCGP open day with Amy gave me a good idea of the kind of things she's going to be starting to consider and tackling over the forthcoming years and also opened my eyes to the possibility of academic GP and teaching whilst stil maintaining clinical practice doing out-of-hours work etc.

This week I've been attached to the Neonatal unit (Ward 40) in Ninewells. One of the most interesting cases of the week was discussed in the unit MDT meeting about a woman pregnant with triplets currently in the Tayside area. She presents a real challenge to manage due to her vegan diet (she has insisted that all medications she is given are checked for correct ingredients), she has a metal phobia and she want's to have either a home birth or a water birth!

On the first day of the block we looked a paper which considers the definition of wheeze:

Cane RS, Ranganthan SC and McKenzie SA. What do parents of wheezy children understand by "wheeze"? Arch. Dis. Child. 2000; 82; 327-332

The aim was to find out what parents understand by wheeze and the results showed that understanding of the definition varied enourmously from what epidemiologists define as wheeze. There is also a label attached to wheeze that parents immediately understand as asthma. 23% of respondents said a wheeze was not something you hear. Of patients who doctors diagnosed as having wheeze, 39% of parents described their child's symptoms as having a different cause eg difficulty in breathing, or cough. The advice at the end is not to use the word 'wheeze' when talking parents but see if they volunteer it themselves. If they do, clarify what it means.

When I was researching my case presentation, I found out some interesting info about the use of surfactant in pre-term infants:

Engle WA. Surfactant-Replacement Therapy for Respiratory Distress in the Preterm and Term Neonate. American Academy of Pediatrics. 2008;121(2)

My case was a baby boy born at 28+4 weeks gestation. Presenting complaints were extreme re-maturity and respiratory distress syndrome. A premature infant is one born before 37 weeks gestation (approx 7% of all pregnancies). Incorrectly, I said in my talk that prematurity can be avoided by good antenatal care, however apparently the rates of pre-maturity have not decreased in recent years but have actually increased due to the increase in interventions people are having for their pregnancies. The study was a review of the current literature and concluded that in infants born before 30 weeks gestation, prophylactic surfactant administration has a better outcome than 'rescue' surfactant therapy.

Amy brought back a load of information from the GP conference she attended in Glasgow about genetics. I realised flicking through the info that alot of it was information aimed at GPs which I already knew about - I wonder if I could be taking more advantage of what I know by writing something, maybe an article in the Student BMJ?

At theme therapeutics this week (Case 12), the tutor highlighted a paper for us to look at considering the use of D-Dimers in diagnosis of a DVT.

Fancher TL, White RH and Kravitz RL. Combined use of rapid D-Dimer testing and estimation of clinical probabilityin the diagnosis of deep-vein-thrombosis: systematic review. BMJ. 2004; 1136

Well's probability tool is a useful assessment. Each positive response is one point, except if an alternative diagnosis is as likely as or greater than DVT, where 2 points are deducted. 0 or fewer points: low probability; 1-2 points: moderate probability; 3 or more points: high probability.
The criteria are as follows:

• Active Cancer
• Paralysis or recent long period of immobilisation of lower limb
• Recently bedridden for more than 3 days or major surgery in the past four weeks or more.
• Localised tenderness
• Entire leg swollen
• Calf swelling greater than 3cm compared with asymptomatic leg.
• Pitting oedema
• Collateral superficial veins
• Alternative diagnosis as likely or greater than deep vein thrombosis.

The study concluded that a normal result from a highly sensitive D-dimer test effectively rules out DVT among patients classified as having either low or moderate clinical probability of DVT. Perhaps an audit into the use of a tool like this is the kind of thing I could do during my elective?

New album on the christmas wish list! Conditions - The Temper Trap