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!

Changes to GP Training in the UK

The 'Squinty Bridge' - Ran across it on Sunday

In the BMA News this week:

 

The Scottish Government has suggested that it might welcome 'something different' and a 'different approach' when it comes to reforming the NHS pensions scheme. The outcome of the ballot on industrial action is still awaited. 

Academic medicine and public health medicine are the careers in the spotlight, with redundancies being made in senior clinical lecture posts in London and the warning that public health trainees face a lack of substantive posts to enter into at the end of their training. It seems that in a tough financial climate, these are the kinds of areas taking the biggest hit.

Today's been the hottest day in Scotland in March since the records began (22.9'C in Aboyne, near Mum and Dad in Banchory!). In Wales, the government is considering offering free sun-tan lotion to under 11 year old children. This is being considered to help protect children from UV radiation, along with other measures such as better provision of shade in schools.

GP training has changed recently to update the existing three year specialty training programme, to a four year programme. Apparently the existing programme is one of the shortest in Europe and has left some trainees feeling 'competent but not confident'. The RCGP plan is to increase the training from three to four years. The cost of each trainee going through an additional year is approximately £63,500 and the extra cost of the whole current cohort of trainees doing an ST4 year is approximately £209 million. However, it is believed that this will help to create doctors who are less likely to refer people to hospital and more likely to rationalise inappropriate prescribing. Apparently a reduction of inappropriate prescribing of just 2 percent could save £164 million a year, whilst a reduction in the total number of in-patient days by just 1% (through less people being referred to hospital) could save £267 million a year. But just how useful will an extra year be? The argument for is that doctors training for longer will be more experienced and competent when they finish. The argument against is that this extra year will simply involve filling gaps in rotas in hospitals where there is no time for learning anyway. The jury's out on this one but there seem to be pretty strong opinions out there for both sides!

Should we Screen more Healthy Individuals for Cardiac Abnormalities?

 41 minutes into Tottenham and Bolton's FA cup game yesterday, Fabrice Muamba, the 23 year old Bolton mindfielder, suddenly collapsed. As the paramedics rushed to his attention, it became apparent that he had suffered from a cardiac arrest. CPR was commenced and the patient taken immediately by ambulance to the London Chest Hospital where cardiac output was re-established and he was admitted to the intensive care unit. According to statistics, every week in the UK 12 apparently fit and healthy individuals under the age of 35 die from an undiagnosed cardiac condition. Often this is brought on by extreme exercise, as happened in this case. Common causes include obstructive hypertrophic cardiomyopathy, long-QT syndrome and coronary artery abnormalities. A family history of sudden cardiac arrest should prompt further investigation in a healthy individual, particularly if they are about to start an exercise programme. Professional footballers all receive medical assessments before signing a contract but should we be screening more individuals? I'm meant to be running a marathon in seven months - maybe I should have some kind of screening assessment? Or would people prefer to get on with their lives, enjoy sport and accept the risk? Perhaps after what happened to Fabrice Muamba there will be an influx of worried healthy people wanting referred to a cardiologist or investigated further.

Other things which I've been reading about this week:

BMA announces paid shadowing for FY1 doctors - After lobbying the Department of Health, the BMA has announced that all newly starting FY1s this August will have a paid four day 'shadowing' period before starting work. I think that it is good that the Department of Health have recognised that this is a necessary implementation (not optional) for new doctors starting work and should therefore be counted as paid work. Hopefully this new plan will ease the stress of the new doctors starting in August and help to improve patient safety.

People over 65 years old should be screened for atrial fibrillation. A BMJ poll asked whether everyone over 65 be screened for atrial fibrillation. In the poll 61% of respondents answered yes. It seems that there are still high numbers of patients not being treated effectively for atrial fibrillation. Improved management of patients with this condition could greatly reduce the numbers of patients having a stroke each year.

A man with 'locked-in syndrome' has been granted permission by a high court judge to apply for a court declaration that would allow a doctor to kill him without risking a murder charge. He is arguing for voluntary euthanasia rather than assisted suicide. This whole issue is extremely complex - does a person have the right to end their life? Is there ever a case for someone to assist someone to end their life? The condition which this man has is truly awful but even if he is successful with his case, I do not think he will be able to find a doctor who would assist him to end his life.

And finally...I've been reading more in the BMJ Careers section about the topics which I've raised previously about out-of-hours care and the surplus of doctors in training. It seems increasingly likely that consultants in the future will be expected to provide more out-of-hours care including night shifts and weekends. Reading this is drawing me more and more towards pursuing the general practice career route!

Medical Ethics in Everyday Clinical Practice

It's interesting to read that medical ethics and law can be studied at a post-graduate level in the form of a masters degree. Ethical situations are encountered frequently in everyday practice however the demands of busy hospital workloads mean that often ethical situations are overlooked. I remember in 5th year when we were choosing a topic for our ethics essays, people would often email the professor in medical ethics at Dundee, saying that they couldn't find an ethical dilemma which they had encountered which would be suitable for an essay. She emailed all of the 5th year students to say that this was 'nonsense' and that ethical dilemmas are encountered everyday. Courses in medical ethics tend to focus around big moral questions, such as euthanasia, but an example of everyday ethics would include, for example, responding to competing demands by prioritising, and speaking to families who are frightened or angry. It is important to recognise that, the same way confidence and expertise in other aspects of medicine develops with practice and experience, so does ethical awareness. The University of Edinburgh offers a distance learning course in medical ethics which looks interesting.

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

Illegally produced alcohol - In the UK there are increasing amounts of illegally produced alcohol entering the market. In a society which consumes alcohol as heavily as our own in Scotland, it is hard to know how much could be produced illegally. The potential health hazards are very serious. The different categories include counterfeit alcohol designed to look like 'the real thing'. There is also homemade spirits imported from Europe, and then there is the consumption of other industrially produced chemicals, such as ethanol (which can lead to blindness).

How can we treat multiple chronic conditions? - An article written by the associate editor of the BMJ relating to the difficulty of treating multiple chronic conditions. Chronic illnesses are much more common now that acute illnesses and with people living for many years, there are often multiple co-morbidities. In fact it is rare these days to see a medical admission without something in the 'past-medical-history' section. But how do we treat patients with multiple co-morbidities? Guidelines for practitioners on this topic is thin on the ground but apparently it is a rapidly expanding area of research.

After the annual leave....

I can't believe we're into March already - this year's flying in. Less than four months until the wedding now and summer's just round the corner so lots to look forward to after a great week off. Feeling re-energised and ready to go. 

Some interesting articles which I've been reading over the past week or so:

1) The BMA council is going to ballot it's members on industrial strike action for the first time in almost 40 years. This relates to the government's new offer on pensions for public sector workers which will see an increase in contributions for a lower final pension for doctors.

2) Sudden death in epilepsy: Patients with epilepsy are more likely to die pre-maturely than the rest of the population. SUDEP stands for 'sudden, unexpected, non-traumatic and non-drowning death in patients with epilepsy'. The profile of patients most likely to be affected are young age of onset, male and a longer duration of epilepsy with frequency of seizures one of the most important risk factors identified. This adds further evidence to support the need for good compliance with treatment amongst patients with epilepsy. One of the major drives in the place I work in is the medicines reconciliation process - ie. ensuring that patients admitted to hospital as an emergency have an up-to-date prescription made for their regular medications. Missing doses such as anti-epileptic treatments in this case or prescribing the wrong dose could have a potentially catastrophic impact.

3) Air pollution is associated with a higher risk of myocardial infarction within just one week of exposure to a high concentration. The associations for this are most highly linked to 'traffic' pollution. The same meta-analysis study also recognised that higher levels of air pollution are also associated with faster rate of cognitive decline. So in other words, avoiding pollution will lead to all-round health benefits, not restricted to the incidence of respiratory conditions.

4) In the BMJ careers section last week there were some interesting articles about the career progression of FY2s entering specialty training. In less than 12 months I'll be applying for specialty training so these issues are particularly relevant to me. Last year a third of UK foundation doctors did not directly enter specialty training. Reasons for the third who didn't include taking a career break, experiencing medicine abroad and just locum working. At the moment the plan is to apply for GP training and Core Medical Training but that could change over FY2 depending on how things go.

Finally, my parents are off to Grenada (my favourite place) for a holiday and I'm just a little bit jealous that I didn't get invited so I thought I'd put a picture from my elective up to help things. I'll have the last laugh when I'm in the Maldives on the honeymoon in four months time anyway!