Adrenal Crisis, Public Health and Unilateral Leg Swelling

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

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

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

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

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

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

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

Punctate Palmoplantar Keratoderma

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

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

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

What does 'Dermatologically Tested' Actually Mean?

At the finish!

Peripheral Venous Cannula

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

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

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

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

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

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