BMJ Articles from July

Diabetic Ketoacidosis - For children and adolescents with type 1 diabetes this remains a major cause of morbidity and mortality. The most dangerous aspect of the condition is cerebral oedema but other life threatening aspects of the condition include hypokalaemia, pulmonary oedema and cerebral thrombosis. So what are the factors which can predict patients at risk? Younger age of onset of diabetes, missed diagnosis and certain ethnic groups are at higher risk. Protective factors include family history of diabetes and improved education levels. There has been a drive to increase doctors' abilities to recognise the signs of DKA and all hospitals should now have protocols in place which can be followed in the event of an emergency.

Malnutrition and Mortality in Africa - There hasn't been an awful lot of media coverage of the devastating droughts which have hit several countries in the Horn of Africa this year. Countries such as Ethiopia, Kenya and Somalia and in desperate need of aid. Acute malnutrition is a major health risk in these countries. The situation worst for the thousands of refugees who have been displaced from Somalia who are crossing into Ethiopia and Kenya. The WHO has set an emergency acute malnutrition threshold of 15% yet as many of 55% of children from arriving in refugee camps from Somalia are malnourished. Unicef have regional emergency health centres with experience in nutritional rehabilitation activities to try to tackle the ongoing problem.

What is the Evidence for Drinking Water? - Margaret McCartney, a GP from Glasgow, writes in the BMJ about the real evidence behing claims that we are not drinking enough water. It is recommended that adults drink 1.5 to 2 litres of water per day. But who is providing the evidence behind all of this? It's all backed by mineral water companies and food giant Danone. They all say that we are not drinking enough, however independent research has concluded that not only is there no scientific evidence that we need to drink that much, this recommendation could actually be harmful by precipitating hyponatraemia. Closely examining the evidence supported by Danone finds it to be weak and subject to selection bias. I think this is a good example of why it is important to see who is sponsoring research articles and to use critical appraisal when searching for information.

Pain Management to Treat Agitation in Dementia - Lastly, in this weeks BMJ is an article about treating agitation in patients with dementia. While neuropsychiatric symptoms are very common in dementia, it is often not managed well. New evidence published this month shows that treating underlying pain may be an effective method of intervention. The authors hypothesised that undertreated and underdiagnosed pain is associated with agitation in dementia. They carried out a randomised controlled trial and were able to show improved outcomes for patients given analgesics. This study opens up a new opportunity for improving the way we look after agitated patients with dementia.  

Graduation and Summer Holiday

Graduation (24th June 2011) Caird Hall, with Heather

Garden Party - Outside the Union

Graduation Ball (4th June 2011) Aviemore

A few things that have been going on since last month - Grad Ball in Aviemore, Rockness, T in the Park, Graduation in Dundee and the University Grad Ball, Northern Ireland for MacFest and Banchory. Here's a couple of photos.

Start my shadowing at the end of the month so enjoying a final week off and getting organised before it all kicks off!

Updates from the BMJ

Preventing Stroke in Atrial Fibrillation

New guidelines have recently been published by the European Society of Cardiology on the management of patients with atrial fibrillation. They are summarised in the article New European Guidelines on Atrial Fibrillation BMJ 2011;342:d897. Two of the most important recommendations are the increased identification of patients at risk of stroke, and wider use of anticoagulants. The original CHADS2 score has now been replaced with the CHA2DS2-VASc system. Patients with each of the following demographics score a point (congestive heart failure, hypertension, diabetes, vascular disease, age >65 and female). Patients with each of the following score an additional 2 points: previous stroke or TIA, age >75. For a patient with a score of zero, no anticoagulant is required. For those with a score of 1 or greater, oral anticoagulants are recommended over aspirin 75mg. Although aspirin is still considered a reasonable option for patients with a risk score of zero to one following initial assessment, it is no longer the preferred option for most patients.

The new guidelines have been created following a wave of evidence of the benefits of oral anticoagulants over aspirin and new evidence has been released which shows that patients on warfarin or aspirin have a similar risk of bleeding. In addition, new oral anticoagulants are beginning to emerge which may replace warfarin in the future because they don't require therapeutic monitoring of levels. Dabigatran is a direct thrombin inhibitor that does not require therapeutic monitoring. Patients who are on warfarin presently and stable on the drug should not be changed to dabigatran but pending approval of the direct thrombin inhibitor, it may replace warfarin in the forthcoming years.

National Patient Safety Agency: NG Tube Placement

On a separate note but carrying on with the national patient safety agency theme, an article appeared in the BMJ this week on the topic of Checking placement of NG feeding tubes in adults. BMJ 2011;342:d2586. NG feeding tubes are frequently used for patients who develop dysphagia or those on ventilators in intensive care for short to medium term use as an alternative to longer term feeding via a PEG tube. Most NG tubes are inserted safely however there is potential for serious patient harm to occur should the tube become displaced from the stomach. Aspiration pneumonia following incorrect NG tube insertion can be potentially fatal. So how do we reduce the risk of this occurring? Testing acidity of stomach contents by using pH litmus paper is the gold standard first line check, with X-ray interpretation as second line. However, since 2005 in England there have been 21 reported deaths resulting from misplaced NG tubes with misinterpretation of xray images the leading contributary factor. This is a serious avoidable event, and in one audit, less than one third of junior doctors had received training on interpreting Xrays for misplaced tubes or were aware of existing guidelines. Ways to stop adverse events from occurring:

• Avoid placing NG tubes outside normal working hours wherever possible.
• Do not give NG tube feeding to patients at high risk of aspiration
• Do not place NG tubes without prior training including how to interpret the xrays
• Use the online website www.trainingngt.co.uk for guidance
• Do not flush the NG tube with anything until pH testing is completed
• pH level of between 1 and 5.5 is acceptable. No more.
• If no aspirate can be obtained or the pH level is >5.5, Xray request asking specifically for interpretation of NG tube placement. Ask a radiologist for interpretation advice if unsure.
• After radiography, clearly document decision and next steps for the patient eg. safe to use.
• Tubes should be checked once daily for correct placement and before giving feed or medication because they may have become displaced.

Scottish election - SNP win an overall majority

The major news in Scotland this week was the Scottish election. The map on the left shows the SNP (yellow) dominance and the Scottish National Party have won an overall majority in the Scottish parliament (Scottish election: SNP majority for second term). Like it or not, the SNP are going to be at the centre of any decision making processes in Scotland over the next five years, but what does this mean for healthcare and the NHS in Scotland? The SNP outlined in their manifesto that they would "ring-fence" NHS spending in their budget, but is this enough? Over the next five years the NHS in Scotland is going to need significant amounts of investment in order to carry on providing a high-quality service to its patients. Continuing with the current level of spending may not be enough. Scotland is facing an ageing population and the government is going to be expected to foot the bill of the countries increasing health burden. But where is this money going to come from? The SNP have said that they will freeze council tax for five years, so not from there. Prescription charges, they were abolished as well. Perhaps the SNP's proposal for minimum-pricing on alcohol will make a return to the forum after it was rejected last year. What will Scotland's reaction be to any proposed NHS reforms in England, will Scotland follow suit? Even the government in Westminster cannot seem to agree on the correct course of action (Clegg fights back with NHS pledge - BBC News). It has been quite widely commented that the SNP defeated Labour in the election due to Labour's 'negative' tactics in contrast to the SNP's 'positive' visions. I just hope that behind the promises and pledges which won the SNP the election there is a sustainable vision for the future of Scotland's economy. And what about the independence referendum? Surely that is something that the country can ill afford at this point in time and could turn out to be a costly waste of time. On the other hand, with the SNP winning such a large majority of seats in the government, perhaps Scotland will become an independent country within my lifetime. I never thought I'd see the day but all of a sudden it becomes quite a realistic, albeit concerning prospect. On one hand, the next five years could either be one of many successes and improvements for Scotland, but on the other it could be a very difficult one if the correct decisions are not made.

Patient Safety in the Undergraduate Curriculum

Furnace, near Inveraray

First photos from the rural GP placement here, one from Furnace with a view of Loch Fyne on the background, and another of Inveraray castle. Don't think it has rained a single day since I got here 3 weeks ago, maybe a first for the west coast of Scotland.

Inveraray Castle, home of the Duke of Argyll

I read the following editorial in the BMJ this week with interest: Paterson-Brown S. Improving patient safety through education. BMJ 2011;342:d214. According to the author "a window of opportunity exists to include training in human factors in undergraduate and postgraduate training". I thought that what we'd done over the past four months was pretty relevant, so submitted this to the BMJ as a 'rapid response'...

" Teaching undergraduate students about human factors and how to investigate adverse events should become part of the curriculum. In some places, teaching on this subject is already attracting the attention it deserves. Here, a small group of medical students undertook a selected study module in patient safety in their final undergraduate year. Clinical supervisors identified areas where patient safety was at risk, including shift handover, venous thromboembolism prophylaxis and oxygen prescribing. Using guidance from the Institute for Health Improvent, the students spent four weeks carrying out improvement projects using ‘plan, do, study, act’ (PDSA) cycles. The “bundles of care” or changes otherwise introduced resulted in improvements in patient outcomes by the end of the project period. The efforts resulted in benefit for the students who learnt about patient safety, and the patients who received better care. One way of teaching this subject is by investigating either incidents where errors have occurred or areas where improvement is required. Patient safety is not currently as high up the educational agenda as it should be. An opportunity exists now to introduce this into the undergraduate curriculum for the benefit of the next generation of doctors and patients."

I'm lucky to have had teaching on this already as an undergraduate but I don't think everyone is being given the opportunity at the moment. It seems to me that this is pretty important for all future doctors to know so I think the emphasis should be placed on teaching students, rather than postgraduates, in order to make improvements from the bottom upwards.

Better: A Surgeon's Notes on Performance

Just finished reading this book and I'd highly recommend it to anyone who has anything to do with healthcare and improvement. Atul Gawande is a surgeon who lives in Boston and works as an assistant professor at Harvard Medical School. This is his second book (after 'Complications' several years ago). The book is basically a series of short stories of success within medicine where resources are stretched and tasks seemingly impossible. Examples include the WHO's worldwide polio vaccination programme, treating polytrauma casualties in Iraq and the medicine's constant battle against hospital acquired infections. His stories all revolve around a common theme of improvement in face of adversity. He makes his point in the final part of the book where he talks about the 'young science of improvement'. His argument is that not enough is being done to make the most of what we already have and changing the systems we work in.

There's a very good chapter near the end of the book about how the practice of obstetrics has dramatically improved outcomes for mothers and children over the past 100 years. He tells us that most of the changes did not come down to randomised controlled trials, double-blinded studies etc, but rather keen observations of outcomes and comparisons. The practice, he writes, was changed forever with the introduction of the Apgar score. This gave a score of the outcome of new born babies immediately after birth. This score allowed for comparisons between outcomes (outcome measures). In the next chapter about cystic fibrosis, he tells us about how all CF specialist centers make their outcomes and patient results (ie. average life expectancy of their patients) known to each other. Apparently in medicine, most outcomes form a 'bell-curve' distribution, so there are always some poor performers and some exceptionally good performers. Although comparison of outcomes increases competition, it drives improvement and change.

In the final afterword, Atul Gawande sets out his five suggestions on how to become a positive deviant (part of a lecture he gives medical students each year):

1. Ask an unscripted question. Medicine can feel at times like a machine with the doctor and patient small cogs in the process. Asking a patient (or indeed a colleague) a simple question, such as 'what do you do for a living?', 'did you watch the game last night?' makes a human connection.

2. Don't complain. Nothing is more dispiriting than hearing doctors complain. I agree with this point. Resist it it because it is boring, be prepared to have other things to discuss, such as something interesting which you saw, or even the weather if nothing else.

3. Count something. If you count something interesting, you will find something interesting.

4. Write something. Whether it is a few paragraphs in a blog, a paper for a journal or even a piece of creative writing. Make your reflections available to a wider audience, because an audience is a community and the published word is a declaration of membership of this community, as well as a willingness to contribute to it.

5. Change. The final suggestion for a successful life in medicine. Become an early adopter. Some of the best ideas and revolutionary concepts in medicine initially met large resistance. Be willing to recognise inadequacies of what you do and try to find solutions.

So always try to be better. Find something new to try, count how often it fails, or succeeds, and write about it. I think these sound like good words of advice. To anyone who finds these ideas interesting, I'd highly recommend this book.

Inveraray Rural GP, Exams and Management of Hypertension

I don't think I could have been much luckier than being sent to Inveraray for my GP placement! I'm actually living in a B&B in a small village called Furnace about 7 or 8 miles south west of Inveraray. Here's a link to the website. www.maggiesbedandbreakfast.com

My tutor asked me to identify an area of general practice which I wanted to investigate / look into in a bit more detail. When I was looking out for ideas, I found this article in the BMJ this week titled 'Angiotensin converting enzyme inhibitors and angiotensin receptor blockers in hypertension'. The ABCD management of hypertension has changed since I was in first year in 2005 (beta blockers are no longer preferred as a routine first line initial treatment for adults with hypertension), meaning it's now more of the A-CD rule of treating hypertension. I thought that I would take a look at patients with hypertension under the age of 55 and the treatments which they were on. NICE guidelines recommend that white patients <55 years old are started on an ACE inhibitor. The target systolic blood pressure for these patients should be <140mmHg (<130mmHg for patients with higher cardiovascular risk). The guidelines (NICE Clinical Guideline 34) recommend that if the target blood pressure is not achieved, a second agent should be introduced. According the BMJ, 4-30% of long term users of ACE inhibitors have a dry cough and if this is intolerable, an ARB, such as losartan should be introduced. Treatment with an ACE inhibitor and an ARB together was shown to worsen decline in renal function and the two together are contraindicated. So the questions I want to try and answer as agreed with my tutor are:

1. Are there any patients on ACE inhibitors and ARBs?
2. Are patients <55 years old being started on ACE inhibitors?
3. If target BP is not reached, are patient's being offered a second drug?

On another note, I'm spending quite a lot of time at the moment getting my portfolio organised and preparing for my fifth year exams which are looming ever closer. I did however read this blog, and realise that exams are something I'm going to have to deal with beyond medical school! In this post on the BMA website, Ben Molyneux writes that sometimes it seems as if medical recruitment is a merry-go-round of problems and that an average trainee can expect to fail his MRCP exams 1.5 times before passing at an average cost of £2,399! Whats more, there doesn't seem to be agreement between different stages of postgraduate training as to when MRCP exams should ideally be sat. The College suggests that exams be taken during the foundation years, while the Foundation Programme advise that no exams should be taken during the foundation years. Fantastic.

April Reading Week

 I managed to pack a lot in to the reading week, including the trip to Amsterdam to the International Forum on Quality & Safety in Healthcare and finishing up with the Edinburgh Half Marathon this Sunday. I managed to beat my half-marathon time from the last one which I did a couple of years ago in Dundee so I was pleased with how it went. Perhaps next step up to the marathon? I'll be watching the London marathon this weekend!

The conference was a great experience. I was there with three other students (see left) and we met up with elective Rob! (Glasgow final year student) who happened to be there at the same time. It was good to see that the UK was the most represented country at the conference and this reflects the amount of work being carried out in the NHS. I was amazed that our poster on venous thrombo-embolism prevention was one of literally hundreds at the reception on the Wednesday evening and there was an entire section of posters dedicated just to VTE prevention. The conference was quite inspiring and I had a chat with some FY1s/FY2s who had done similar work. I had been concerned about the difficulty of undertaking improvement work during the foundation years due to the clinical workload I would be faced with but they provided some encouraging advice which has given me some more confidence that it is possible.

The most interesting talk was given by Professor Emily Friedman from Boston University on the topic of global health and the dramatic changes to healthcare provision which have taken place in Cambodia over the past 50 years since the devastating genocides which took place previously. I'm now in Inveraray to do my one month GP placement, to give me a taste of health-care provision in a rural community and looking forward to the next few weeks!

Reucing Harm, Improving Healthcare

 <---- Photos from yesterday at the 'Reducing Harm, Improving Healthcare' conference at the Suttie Centre in Aberdeen.

The day involved a combination of lectures and small group workshops on different aspects of improving patient safety. It was good to see a whole range of people there, not just medical students. Our Tayside cohort did however dominate the poster presentation at lunch time with over half of the posters on show being from Dundee University! The first workshop I attended was on 'Speaking Up' and we were given a scenario which really happened where a final year medical student noticed an error when watching a patient having a major operation. We discussed the differences between 'mitigating speech' ie. the hint and hope method, as opposed to direct messages ie. Stop now. Also we talked about how as a trainee, a query can be raised as a question, ie. Can I just check that this is what you want to do. Or why are we not doing it this way. I think this is something I'll probably try and do alot as a foundation doctor with the exception of being emergency situations where I hope to think that if I see something being done wrong I would be able to say STOP or WAIT etc if I thought it was incorrect. We talked about critical language approaches, such as the 'probe, concern, alert' method and 'I'm concerned, I'm uncomfortable, I'm scared'.

The second workshop was on antimicrobial prescribing. We were given scenarios where antibiotics had been given and asked questions such as 'What are the risks to the patient', 'What are the information gaps' and 'What are the issues/risks for staff?'. I now know that Tazocin and Co-Amoxiclav contain penicillin and are contraindicated in patients with penicillin allergy. There are some antibiotics such as Ceftriaxone which can be given to penicillin allergic patients but only in an emergency situation. The '4Cs' of C.Diff i.e. the antibiotics which are most likely to cause C.Diff are Co-Amoxiclav, Ciprofloxacin, Ceftriaxone and Clindamycin. There is also some evidence that Tazocin also leads to increased rates of C.Diff although this is yet to be confirmed.

Take home message of the day, in the words of Tommy who is an FY1 at the moment in Ninewells is to make friends with your ward pharmacist when you start work because when it comes to prescribing they are the fountain of all knowledge.

Some useful websites for more information:
www.abdn.ac.uk/iprc - Industrial Psychology Research Centre
www.chfg.org - Clinical Human Factors Group
www.who.int/patientsafety - World Health Organisation

Photos and Update on Legionnaires' Disease + NHS Reforms

Laparoscopic Surgery - Wellcome Image Awards 2011

After last weeks report about the dangers of imaging, a letter to the BMJ this week points out that reluctance to image pregnant women contributes to maternal mortality. On one hand, there is evidence that imaging mothers during pregnancy increases the risk of childhood cancer and leukaemia, however it is not clear that the risk of this is very small and relatively insignificant. The writer of the letter argues that the evidence described in the previous report is outdated and not relevant to modern day practice. The letter states that this kind of information could be dangerous in the wrong hands and could almost be described as 'scaremongering'. There have already been lots of high profile examples of hiw evidence has been mistaken and led to the public being misinformed.

In the BMJ News this week, the lead article is on doctors' opposition to the English health care bill. The feeling is that the Health and Social Care Bill is too rushed, too much, too soon. Fragmentation of care and undermining of doctors' ability to make decisions in the best interests of their patients have been highlighted as potential problems with the new system. On the other hand, doctors have reportedly always been resistant to change. The reaction to the new healthcare bill has been compared to doctors' initial negative reactions to the introduction of the NHS. The BMA is continuing to press for changes to these new healthcare bills and it will be interesting to see what happens over the forthcoming months and the effect that this has on the NHS in Scotland. GPs in Scotland have already voiced their opinions against the controversial health reforms being proposed in England.

An interesting article on the BBC News website this week was that a patient is currently being treated in Ninewells Hospital for Legionnaires' Disease. The patient had been staying at the Landmark Hotel (by the roundabout on the Kingsway where the Swallow hotel used to be) and used the leisure club facilities. This story came the same week that Piperdam Holiday Resort was fined £120,000 for breach of health and safety back in 2008 where a patient died following exposure to the disease. Legionnaires' disease is a potentially fatal infectious disease caused by Gram negative aerobic bacteria. Potential sources for contaminated water include the hot water systems of some hotels where disinfection and maintenance programmes are not closely adhered to. Interestingly, in 2010 a report published in the European Journal of Epidemiology identified car windscreen washer systems as a potential source.

In January this year I helped to develop an online dermatology tutorial on the treatment of psoriasis and it can now be downloaded online from the following link: Psoriasis Treatment Tutorial.

Here are some of the best photos from a recent trip to visit my flatmate Scott who's on his rural GP placement in Islay!

Salago Bay

Kindalton Cross (early Christian, 8th century)

Gordon and I, Jura in the background

How have prescriptions changed over the past 20 years?

I saw an interesting article in the Guardian newspaper health section on Tuesday 15th March titled "Drug Culture: How have prescriptions changed over the last 20 years, and what does this tell us about our health?"

Top 5 Drugs Prescribed in England in 2011
1. Simvastatin
2. Aspirin
3. Levothyroxine Sodium
4. Ramipril
5. Bendroflumethiazide

Top 5 Drugs Prescribed in England in 1991
1. Salbutamol
2. Amoxicillin
3. Paracetamol
4. Co-proxamol
5. Beclometasone

So 20 years ago if you went to your GP, you would be most likely to receive an inhaler or an antibiotic whereas today, treatments for hypertension and hypercholesterolaemia are the most common. Simvastatin is the most commonly prescribed medication and approximately 1 in 4 people in the UK are on a statin. When statins were first introduced, they were only given to patients with very high cholesterol however now they are started in patients with lower cholesterol levels. Statins have definitely had a positive impact on atherosclerotic vascular disease over the past 20 years, however they still have undesireable side effects and are not suitable for all patients.

The incidence of antibiotic resistant bacteria and healthcare associated infections has increased over the past 20 years and this has led to a major change in the way which antibiotics are prescribed. Antibiotics now only make it to number 14 on the list of commonly prescribed drugs in 2011. Other major differences have been in prescribing of paracetamol and levothyroxine. Looking ahead to the next 20 years, it is predicted that whilst treatments for blood pressure and heart failure will remain high, drugs used to treat neurological conditions such as Alzheimers disease may overtake them as the most commonly prescribed medications if there are significant breakthroughs in the treatment of these diseases.

Focus on Japan

Japan was struck this week by a devastating earthquake which measured 9.0 on the richter scale. The compounded effects of the earthquake, a tsunami and damage to nuclear power stations has meant that Japan faces the worst catastrophe since World War II. I heard that doctors from the UK were flying out to offer assistance in the on-going relief effort and I started wondering. Who are these doctors? How are they contacted? Do they just drop all of their clinical workload at short notice and shoot off to the far-east, or are they already contracted to help wherever they are required? I wondered whether there is something I can do in future to help with scenarios like these. Once I have the experience I need, I hope that one day I'll be able to help those in desperate need in parts of the world. I feel that in the role of the doctor, there is a duty to help out our neighbours, even if they are on the other side of the world.

For the past few weeks I've been watching the BBC Three programme "Junior Doctors: Your Life in Their Hands". It's half-way through the series now and I have to admit that it's been quite compelling viewing. It's on BBC Three at 9pm on Tuesday nights. The programme follows 6 FY1/FY2 doctors in their work and home life during the first four months of their new jobs. I don't think I would have agreed to take part in the programme if I had been asked. I'm always skeptical about how the media portrays these things and I thought that the BBC would edit the programme to make it seem more drammatic than it actually is. What I've found though is that it looks like quite a realistic portrayal of life on the wards. Talking to Amy (who's an FY1 in Glasgow), she agrees. It's interesting hearing about the doctors' thoughts and attitudes towards their new jobs. Some of the FY2s offer very good advice to the FY1s and I hope that that is always the case. It's good to have role models to look to support when times are tough. Fortunately the programme hasn't put me off medicine and in fact the effect has been quite the opposite!

On a good news note, there is an article in the BMJ about Cystic Fibrosis this week which follows on quite nicely from the talk given by Dr McCormick at the paediatrics symposium earlier this week. It reports the results from a cohort study carried out between 1990 and 2007 which has found improved survival rates in patients with low respiratory function. Over the past 20 years, CF patients with FEV1 of <30% have seen an increased median survival from 1.2 years to 5.3 years. The study reflects the major improvements which have taken place in the management of CF over the past 20 years, however much more work needs to be done to look after these young patients.

Annual MSC Symposium: Medicine and Crime (+Paediatric Symposium)

Here are some key learning points I picked up from todays talks:

1. The Role of the Forensic Pathologist
Atherosclerotic cardiovascular disease is the most common primary cause of death on a death certificate. A post-mortem examination should never be carried out without the context of the death being known ie. what the circumstances of the death were. The aim of the autopsy is to work out the cause of death, the mechanism of death and the manner of death.

2. Witness Familiarisation
This talk was all about what to expect if asked to attend court as a witness. It was interesting to give an insight into how the court system works. Familiaristation is now recommended for all witnesses but it is important to stress that this is not the same as "coaching" which is an illegal process where witnesses are coached on what to say when cross-examined in court. Most people who go to courts are disadvantaged by ignorance of the court process. In Scotland there are three courts: high court, sheriff court and district/JP court.


3. Forensic Psychiatry
The Mental Health (Care + Treatment) Scotland Act (2003) applies to forensic psychiatry patients. CORO is a type of restraining order. Detaining someone in hospital is effectively "taking away somebody's freedom in order to treat them". These patients do not have insight into their conditions. For a successful outcome, reciprocity is of paramount importance. Balanced attitudes towards offenders is required. Have the ability to step back and not get involved with what patients have done in the past. The role of the doctor is not to be judgemental.

Folie A Deux is "shared psychosis", a rare psychiatric phenomenon where symptoms of a delusion are transferred from one person to another.

Paediatric Symposium:
1. Paediatric Prescribing
Lack of evidence in paediatrics leads to increased errors in prescribing. In children there are changes in absorption, distribution, metabolism and excretion. IM injections should be avoided in children where possible. For IV injections / cannulas, local anaesthetic cream can help. Dose calculation is based on age, weight and surface area but the dose MUST NOT exceed the adult dose. Round off the calulated dose for easier administration. Be careful with DECIMAL POINTS! Be very cautious about ALLERGIES in children. Licensed medicines should be used but this is not always possible. A good idea is to keep a prescribing checklist ie. dose and frequency of medications. If prescribing unlicensed products, the prescriber must take full responsibility.

2. Cystic Fibrosis
Scottish newborn screening for CF was introduced in 2003. Presentations of CF: newborn screening, failure to thrive, steatorrhoea and recurrent LRTIs. There are >8000 patients in the UK with CF today. Males generally live longer than females. Respiratory failure is the commonest cause of death. CFTR channel is anapical membrane chloride channel of exocrine epithelial cells which is defective. CFTR gene is located on chromosome 7. Respiratory exacerbations of CF can be identified by change in sputum colour/volume, increased cough, dyspnoea, haemoptysis, fatigue, lethargy, fever and weight loss. Meconium ileus presents in the newborn period with bowel obstruction and insippated viscid meconium in the bowel. Laparotomy, small bowel resection and temporary ileostomy may be required. Pancreatic insufficiency occurs in 85% of patients with CF. A,D,E and K are fat soluble vitamins. CF related diabetes occurs in 12% of CF patients age 15-19 years. Young women with CF often develop secondary amenorrhoea and men are almost always infertile.

3. Childhood Leukaemia
Dramatic improvements in survival rates have occurred in the past 30 years. AML and ALL are the most common forms of childhood leukaemia in children. Leukaemia is the commonest form of cancer seen in childhood.


4. Faints, Fits and Funny Turns
Seizure is a transient abnormal excessive discharge of neurons residing primarily in the cerebral cortex. The diagnosis is ALL IN THE HISTORY. Status epilepticus is the commonest neurological emergency. Ask how the child's general school development has been. A witness report of a seizure is VERY IMPORTANT. What were they doing at the time, sleeping? LOTS of differential diagnoses exist which are NOT epilepsy. Day dreams and absence seizures can be hard to tell apart. Absence seizures never last more than 30 seconds. Cardiac symptoms of a vaso-vagal attack include sweating, palpitations, pallor, tunnel vision are tinnitus. Conscious level tends to return FAST (unlike in epilepsy). Investigations are often not require. Negative effects of too many tests can include excessive worry and anxiety for the family.

5. Neonate - Newborn Examination
Cephalohaematoma doesn't cross suture lines. Caput succadaneum can cross suture lines. Thin upper lip, smooth philtrum - signs include fetal alcohol syndrome. Pre-auricular skin tags can be a sign of kidney disease. Barlows/Ortolani's tests are only 30% - 40% sensitive. Erb's Palsy (birth trauma) leads to the "waiter's tip" sign. Erythema toxicum is a harmless dermatological syndrome.

6. Neonatal Transport
Fascinating lecture from one of the new paediatric consultants in Ninewells on his experiences transferring neonates between hospitals in England, Scotland and Australia. ECMO stands for extra-corporeal membrane oxygenation.

Minimum Pricing of Alcohol - Is it too little, too late?

Victoria Infirmary, Glasgow

A quick run through of some of the most important messages and articles from the BMJ this week:

After the minimum pricing bill failed to pass through parliament in Scotland last year, now it's England's turn to try to introduce the incentive. The plan is for minimum prices to be 21p per unit of beer and 28p per unit of spirits (ie. 38p would be the cheapest price for a can of weak lager and £10.71 for a litre of spirits. Could this make a real difference in the alcohol consumption levels and associated harm in the UK? Doctors groups are unhappy with the preposals because they are seen to be "too eak" and not significant enough to make a difference. I would be inclined to agree with them however it may be necessary to start with these minimum prices before higher prices can be introduced. Every year in the UK approximately 40,000 deaths are partly attributable to alcohol and hospital admissions amongst 16 - 24 year olds related to alcohol are rising fast.

A Swedish study of young army conscripts has found that high blood pressure in young adults is a risk factor for premature death. In particular, a diastolic blood pressure above 90mmHg is linked to increased risk of death. What is not known, is whether treating high blood pressure in young adults would necessarily reduce risk of premature death in these young people.

No longer can people say that mental health and physical health are separate entities. There is now considerable evidence to show that patients with psychiatric disease are at increased risk of other medical co-morbidities. In a letter to the BMJ this week, Beary and Wildgust say that their research shows that schizophrenia is associated with a 25 year reduction in life expectancy with the top four most common risk factors being low fitness levels, hypertension, smoking and diabetes. These same four risk factors were identified by the World Health Organisation in 2009 as being the causing the biggest risk of mortality.

And in some good news this week, the European parliament have overwhelmingly approved new legislations to prevent the sale of "false medicines" to the general public. Estimations show that approximately 1% of all medicines legally sold to the European public are in fact false but in other parts of the world, this figure can be as high as 30%. Falsified medicines have in the past been called "silent killers".  The new laws cover internet sales, penalties for violations and improved traceability of the exact origins of where a drug comes from.
The ultimate goal is to reach a point where all pharmacists will be able to verify the authenticity of a drug before it is dispensed.

Breast Feeding, Diabetes and Explaining the Unexplainable

Random orienteering photo

Big news this week is that I have a job lined up for later this year! If all goes to plan I'll be starting work at the Victoria Infirmary, Glasgow in July.

Several interesting articles in the BMJ this month and alot to talk about. Here's a brief overview of some of the features which caught my eye:

Six months of exclusive breast feeding: how good is the evidence? - Back in January this year, Fewtrell et al published a review article which questions the advice to mothers to breast-feed exclusively for the first 6 months of life. This has unsurprisingly led to some uncertainty among mothers, medics and families internationally. A letter to the BMJ this week however criticises the article and some of the references cited. Public health groups have spent years promoting the benefits of breast feeding and it seems to me that before releasing an article such as this which throws all of the advice info doubt, more scrutiny should have been placed on the original evidence.

Is the NHS failing elderly patients? - This story hit the news in a big way this week with reports of poor standards of care of elderly patients (in England). Pain control, discharge arrangements, communication with patients and their relatives and nutrition are areas which are not being done well. Indeed just recently whilst on my medical shadowing block a complaint was made because a patient had been sent home on the wrong medications. It is improtant to know areas where we need to improve and what this helps to do is to highlight the simple things which can be done much better. Several of these measures are in areas where the FY1 is directly involved eg. discharge scripts for patients therefore its good to know areas where mistakes are more likely to be made.

Islet transplantation in type 1 diabetes - Is this the answer to finding a cure for type 1 diabetes? Back in 2001 this was the prediction however 10 years on it is only suitbale for a small number of patients who have severe glycaemic lability, recurrent hypoglycaemia and hypoglycaemia unawareness. Most patients do not in fact fit the criteria for islet cell translplantation and it is not a possible treatment for type 2 diabetes. Interestingly although insulin independence can be achieved in some cases, many patients will need to resort back to insulin treatment. Patients with islet cell transplantations must also be given long term immunosupressant agents whose long term dangers are somewhat unclear. The authors conclude that while progress in this field has not been as quick as was once anticipated, more is now known about the technique and advances in transplantaiton and patient management are likely to further improve clinical outcome of islet cell transplantation procedures in the future.

Type 1 Diabetes in Children - Is it easily missed? - The incidence of childhood type 1 diabetes in Europe is increasing and the diagnosis is often delayed. Often teachers and parents may not be aware of noticing children who may be drinking alot or peeing frequently. A child may present with quite non-specific symptoms and the question of new onset diabetes should be raised. Children can develop dehydration and acidosis, deteriorating rapidly on first presentation.

Explaining the Unexplainable - A Glasgow GP writes in to say that doctors are not very good at understanding and explaining the unexplainable. He writes that when he started work, people would say things like "If the symptoms don't make sense then there is nothing wrong with them", "Frequency of attendance is inversely proportional to likelihood of pathology" and that "referring the anxious only makes them more anxious". I think that the difference between him and myself is that he writes with years of experience of medicine under his belt. With more practice I hope that it will be possible to sort the serious from the insignificant, however until that becomes the case, it will be important to stick to what I've been taught at medical school!

Liberation for Egypt

Friday 11th February was a momentous day in Egypt's history when, after 18 days of protest, President Hosni Mubarak stepped down from power after 30 years of rule over the country. The announcement was met with dramatic scenes of jubilation and celebration in Cairo, concentrated around Tahir square. I am relieved that my parents left Egypt having been living there for four years, before the riots began. During the protests, the reports sounded like the city of Cairo which I know fairly well had become dangerous and chaotic. After all of the destruction (and many dead/injured of which I am 100% sure the Egyptian authorities are under-reporting numbers), I hope that the country will become stable and improved in future. I think that the next 12 months will be a very difficult time for Egypt as it tries to recover from the events of the past few weeks but I hope that the people see the benefits in the near future.

The theme of this month in uni is very much on how to improve patient safety in healthcare. I'm working with two other students on a project on improving venous-thromboembolism patients in hospitalised patients. We have found that there is a significant amount of evidence to show that prescribing mechanical or chemo-prophylaxis can improve patient outcomes to prevent deep vein thrombosis or pulmonary embolism. Worryingly though we have also found evidence from a worldwide study to show that prophylaxis is commonly either underprescribed or poorly prescribed. What we want to do is to find out if this is the case in Ninewells Hospital and if so, what can we do about it.

Continuing with the theme of patient safety, there are two articles in the BMJ this month on the same subject. The first: Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation, Benning et al, asks what the impact of this intervention was from the Institute of Health Improvement (IHI). The answer was that the quality of monitoring sick patients on medical wards participating in the project was better than hospitals not taking part. The study shows that quality improvement interventions tackling specific issues such as hospital acquired infection are easier to demonstrate change that massive systemic change in large organisations. The next article: Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase, Benning et al, asks whether the NHS has become safer as a result of the Safer Patients Initiative. They found that while the NHS in England has become safer, hospitals taking part in the initiative were not necessarily safer than those not taking part.

Finally, there was a very interesting article in the BMJ News this week in the "See One, Do One - Working and Surviving as a Junior Doctor" section, written by Dr Freda McEwan, a CT1 trainee in psychiatry. She writes about an instance as a surgical FY1 when she had to break bad news to a patient. Despite evidence of a diagnosis of disseminated malignancy with metestases, she had not been told of the news. Despite the doctor's recommendations that the discussion with her be had with a more senior member of staff and not during the night (she had been asked to see the patient at 1am), the patient was terribly upset saying "why won't anyone tell me" and asking the doctor "do you know what is wrong?". Not wanting to lie, the doctor told the patient the diagnosis, and she was pleased because she said that "finally she would be able to plan for the future". I think that the doctor was correct not lie and was correct by telling the truth. However I do not know if she should have given the diagnosis that night, so late on. She ends the article by saying "as a junior doctor, you often feel that the public has higher expectations of you than you merit. But as any doctor, all you can ever do is your best."

Now on that note I can enjoy my Valentines Day tea which Amy is cooking for me tonight (lucky me!).

Predicting Risk in Atrial Fibrillation

During my medical shadowing block in January, a decision was made for a patient I was looking after to be started on warfarin for anticoagulation. She had been admitted to the hospital with congestive cardiac failure secondary to atrial fibrillation. Patients who have AF are at increased risk of developing a systemic embolism and an ischamic stroke. On admission, this patient was on a low dose of daily aspirin (75mg once daily) however she had several risk factors which put her at increased risk of stroke. The question is which patients with AF should be anticoagulated, if not all of them. Warfarin is a dangerous drug, associated with an increased risk of haemorrhage, particularly if dosing is poorly controlled. In order to justify starting a patient on warfarin, it must be judged that the benefits of reducing risk of stroke outweigh the disadvantage of increased risk of harm.

In the BMJ this week, an editorial was sent on this topical subject titled 'Anticoagulation in people with atrial fibrillation'. The author argued that anticoagulants are underprescribed. In the past, the CHADS2 classification scale has been used to predict patients with AF at risk of stroke. The patient gains a point for each of: Congestive Heart Failure, Hypertension, Age >75, Diabetes and 2 points for stroke. Patients with a score of 2 or more are recommended to be started on warfarin. Now, a new index has been developed called the CHA2DS2VASc score which takes more relevant risk factors into consideration. This new score takes into account sex of the patient and history of vascular disease. The results of the new index is that more patients are recommended to be anticoagulated. In fact, only 8.6% of patients with AF in general practice would be considered low risk. An advantage of the new CHA2DS2VASc score is that it is better than CHADS2 at predicting patients at low risk of developing a stroke.

There has been much discussion recently about developing new anticoagulants to replace vitamin K antagonists. It will be interesting to see whether development of new, safer anticoagulants will result in doctors lowering the threshold for prescribing anticoagulants. Dabigratan is a direct thrombin inhibitor which may result in fewer intracranial haemorrhages than warfarin. It remains unclear whether prescribing trends with anticoagulants will change in the forthcoming years as they become safer.

Royal College of Physicans and Surgeons of Glasgow Undergraduate Conference

Outcomes from the Royal College of Physicians and Surgeons of Glasgow Undergraduate Conference - January 15th 2010

Dr Pauline Gross – Acute Medicine

·      Acute Medicine is a subspeciality which has only been recognised for about 10 years.

·      It is possible to specialise between general medicine and acute care

·      Top 10 A&E admissions – no.1 cause for presentation is chest pain.

·      Non rebreather mask and a reservoir mask are the same thing.

·      Respiratory rate is often not measured accurately yet it is the most sensitive physiological parameter of acute illness.

·      Even if you have a low index of suspicion for sepsis, take blood cultures – wont harm the patient!

·      Shock is inadequate tissue perfusion, not just hypotensive. Elevated lactate levels are a simple test. Elevated in patients who will be in shock.

·      Cardiogenic shock will lead to an increase in JVP.

·      Septic / hypovolaemic shock will cause a decrease in JVP.

·      Fluid challenge is a useful diagnostic tool.

·      Creatinine levels should always be compared with what is NORMAL for the patient.

·      Remember after finishing ABCDE, RESTART at the beginning.

·      Sepsis is often missed in its early stages yet early recognition is proven to improve outcomes.

·      SIRS = a clinical response arising from a non-specific insult. When infection is confirmed, it is sepsis.

·      Less fluids over a fast period of time leads to better outcomes than lots of fluids over a long period of time.

·      Management of organ failure = early involement of critical care and HDU.

Dr David McCarey – Rheumatology

·      Osteoarthritis is much more common than rheumatoid arthritis.

·      ANAs is a sensitive test for all inflammatory rheumatology disorders.

·      Joint pain – is it inflammatory or degenerative? Inflammatory will include morning stiffness, joint swelling and synovitis. Also rapid onset and functional loss.

·      Inflammatory back pain vs degenerative can be hard to distinguish. Does the pain move site?

·      Reactive arthritis is a more likely diagnosis if recent infection eg. UTI, LRTI.

·      Pseudogout causes calcium pyrophosphate crystals.

·      Very early use of methotrexate in patients with raised antiCCP antibodies and single joint pain can halt early onset of RF symptoms and changes.

·      Ultrasound scans have an important role in diagnosing joint disease.

·      MRI scan = gold standard but is not a routine diagnostic tool due to costs.

·      Three key DMARDS: methotrexate, sulfasalazine and hydroxychloroquine.

·      Anti-TNF alpha and other biological therapies eg Etanercept – can cause as much as £10,000 per patient!

Dr John Leach – Neurology

·      Speed of onset is very important when assessing neurological disease. Ie. Fast onset is likely to be vascular.

·      A pyramidal posture is a spastic posture.

·      UMN lesions cause a ‘spastic’ increase in tone ie. clasp knife appearance.

·      Parkinsonian disorders cause a ‘lead pipe’ consistent resistance to tone.

·      Corneal reflex is a CNV test. Sensation to the eyeball.

·      MRC Muscle Grading = 0 to 5. Tone, Power, Reflex, Sensation and Coordination.

·      Full testing of sensation should include: light touch, pin prick, vibration and proprioception.

·      A cervical myelopathy could cause UMN signs in the legs and LMN signs in the arms.

Dr Allan James – Oncology

·      Usually you cannot have invasion of cancer without metastases.

·      Endometriosis is an example of a metastasising benign process.

·      It is usually metastases which ultimately lead to the patient’s death.

·      Staging is describing a primary cancer and the extent to which it has spread from the site of origin ie. ‘PROGNOSTICATING’ the patient.

·      Therapy: Is this a treatable cancer? Is this a treatable patient?

·      MDT is the cornerstone of cancer treatment. Don’t engage in a discussion about this in the exam without mentioning the MDT!

·      Radiotherapy causes molecular DNA damage. This may be enough to cause cell death.

·      All cancer can be eradicated by radiotherapy. The skill is delivering it without causing the undesireable side effects which can be short term or long term (long term are much more worrying).

·      Good cancer medicine is often not knowing WHO to treat but knowing who NOT to treat.

·      Don’t forget about oncological emergencies such as neutropaenic sepsis, spinal cord compression, stridor and hypercalcaemia.

Dr Mitchell – Palliative Care

·      Good palliative care is the responsibility of ALL doctors.

·      Intrathecal local anaesthetic drug delivery into the CSF: leads to a lower incidence of side effects. It is a subcutaneous device and knowing about its existence is important.

Dr Colin Perry – Medical Training

·      Look up postgraduate medical training: The Gold Guide.

·      This contains the Core Medical Training curriculum.

·      Try and sit Part 1 of the MRCP exam as an FY2. There is still credit for trying even if it leads to failure because it shows commitment to the specialty.

·      The MRCP has 3 parts: Part 1, Part 2 and PACES.

The Jewish Surgeon and the Patient with a Nazi Tatoo

Sunset in Aberdeen with Girdleness Lighthouse in the background

This was an interesting case which was reported recently in the Telegraph newspaper. A Jewish surgeon at a German hospital reportedly walked out of an operating theatre and refused to operate on a patient requiring thyroid surgery because he spotted the patient had a swastika tatooed onto his arm.

The family of the patient want this doctor struck off because he didn't uphold the Hippocratic oath and didn't carry out his duty to care for the patient. Others however have praised the doctor for his moral courage. The doctor found another surgeon to carry out the operation but the question remains - was this doctor guilty of misconduct?

On one hand a doctor's duty is to provide care for a patient, regardless of their age, sex, beliefs etc in an unbiased way. However there are exceptions to this rule for example doctors are allowed to opt out of termination of life practice in the field of gynaecology. What if this patient was a convicted murderer. Would I walk out of the operating theatre on the basis of my moral views and beliefs?

The fact that this was probably not a life-saving operation should not affect the case. The only situation I can imagine which would have justified the surgeon leaving and asking another person to carry out the case, would be if the patient was at risk of harm / the surgeon felt that he could not carry out the task asked of him safely after finding out about the patient's past. If the surgeon felt he was not able to carry out the case, perhaps he was right in finding another surgeon to carry out the operation. Of course in private, everyone is rightful to have their own views and moral beliefs. However as doctors and in our service to the public, we must not allow these beliefs to cloud our judgement or to affect our decisions.

In my opinion I believe that this surgeon should not have walked out of the operating theatre. He should have withheld his duty of care to the patient, irrespective of his past history and carried out the operation.

A New Year, New Resuscitation Guidelines

 Happy New Year!

In her first editorial of the new year, the BMJ editor chose to wish everyone 'a rational new year'. The emphasis is definitely placed on promoting rational healthcare decisions which are based on the best available evidence. A good example of using evidence to change medical practice is shown in the changes to resuscitation guidelines released towards the end of last year:


New Guidelines on Resuscitation - Student BMJ, January 2011. In October last year, a large review of available literature on resuscitation guidelines was carried out and there have been new recommendations made following this.

• Chest compression only CPR is recommended if a rescuer is not trained in CPR.
• Compressions should now be delivered to a depth of 5-6cm, not 4-5cm as was previously recommended.
• Rescuers (wearing gloves) should continue compressions while the defibrillator is charging.
• Use of three consecutive shocks may be considered in VF/VT during cardiac catheterisation, in the early post-op period after cardiac surgery, and in a witnessed VF/VT cardiac arrest when the patient is already connected to a manual defibrillator.
• Every patient in hospital should have a documented care plan for monitoring vital signs including criteria for escalation of care to prevent cardiac arrest.
• If IV access is not available, the intraosseous route should be used.
• When treating a VF/VT cardiac arrest, adrenaline 1mg and amiodarone 300mg are given after delivery of the third shock once chest compressions have restarted. Adrenaline is otherwise administered during alternate cycles of CPR.
• Atropine is no longer recommended for routine use in asystole or PEA.
• Real time use of echocardiography increases chance of diagnosis of potentially reversible causes of cardiac arrest eg.cardiac tamponade or pulmonary embolism.
• Oxygen saturation rates of 94% - 98% should be targeted when spontaneous circulation has been re-established.
• There are also slight changes to the paediatric guidelines.

Links to the new guidelines are available here: http://www.resus.org.uk/pages/guide.htm
 Doctors in Scotland recommend radical cuts to medical school intakes (Student BMJ News December 2010) - Doctors in Scotland have called on the government to reduce the numbers of medical students in the forthcoming years in order to stop the oversupply of doctors applying for registrar positions. In an article in the Student BMJ News, the current projections for specialty training numbers from 2011 to 2015 indicate that 21 percent of Scottish foundation doctors are unlikely to progress further in Scotland.

Registration cuts fees for foundation years (Student BMJ News January 2011)  - Some good news! The GMC has agreed to cut down registration fees for junior doctors. According to the student BMJ in January, FY1s will now pay £100 for provisional registration (down from £145), and in FY2 will pay £210 (down from almost double this amount). Perhaps this is a positive sign that some attention is being taken the BMA about the high costs for training in medicine.