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!

NHS Hack Days

I'd heard about this idea a few months ago but only recently came across the website to find out a bit about what it is (www.nhshackday.com). The idea of the NHS Hack Days are for like-minded people who are interested in improving IT services in the NHS to meet to talk about ideas and solutions for common problems encountered in the NHS. The events are for self titled 'geeks who love the NHS'. the NHS suffers a serious problem with it's IT support partly due to the size and complexity of the organisation. The amount of information is immense with every patient having their own set of case notes and letters. Some hospitals seem to have adapted better than others when adopting IT but I've yet to work in a hospital where the whole system works well. In some places there are efficient ways of requesting, ordering tests and viewing results, while in other hospitals there are excellent systems for keeping track of patients in the hospital and admitting patients to hospital wards. One of the problems is that different health trusts have adopted different pieces of software meaning that there is a lot of variability between hospitals. Every new place I work in I have to be inducted into the new IT system which has been adopted for that particular hospital. Surely there has to be a way of agreeing on a single system for all IT services in hospitals in Scotland? 

While this may seem like a distant dream at the moment, in the meantime I believe there are ways that IT can be adopted to create simple solutions to common problems in the hospital wards. For example, one of the things I am trying to look at in the hospital where I work at the moment is a good way of tracking and recording patients admitted to medicine (while on-call). I've found a few simple apps online which have been created, some as a direct result of the NHS hack days which I have mentioned already. an article appeared in the BMJ recently talking about how doctors could learn to become 'coders' who help to develop new apps. One of the apps I've looked at is 'Patient Handover', developed by a group of doctors who wanted a simple electronic way of keeping track of patients admitted 'on the days take'. This simple app allows the user to enter patient identifiable information (name, CHI, DOB, diagnosis, ward) and store it safely pin-protected. Different users who share the app can sync the information at handover to ensure it works properly. I'm going to see if we can run a trial of using the app in the near future, perhaps when I'm next on-call, to see if it helps the process. The only problem is that it only runs on an iPad, iPhone or iPod touch - so first I need to either borrow one, or see if I can convince the powers that be in the hospital that I need £200 to buy one!

Patient Information Leaflets

Patient information leaflets - are the helpful? Or a waste of time? Margaret McCartney is a GP who writes for the BMJ and this week she focuses on the pros and cons of patient information leaflets. Any hospital clinic, GP practice and waiting room in the UK tends to be awash with a range of patient information leaflets. The source of the leaflets is variable - some originate from individual trusts, while others come from charities and external organisations. 

A recent review of practice saw 128 trusts asked to send in the leaflets they gave patients after inguinal hernia repair. The researchers found that information in the leaflets was variable - for example the information on when it would be safe to return to work was variable. So who develops these information leaflets and checks the content? It seems that there isn't a single rigorous process for developing them and that practice is variable, meaning that information given to the public may be of poor quality. Patient information leaflets are used for giving patients information which cannot all be given in a short appointment. They also give the patient something to read when they get home in case they forget what has been discussed, and most leaflets offer contact information should the patient have further questions. Patient information leaflets also help to reduce litigation. One private company has been set up which provides patient information leaflets, 'Eido', set up by a surgical registrar in England. Hospital trusts can pay in excess of £6000 a year for the right to distribute these leaflets. Some trusts, such as Guy's and St Thomas' in London have a bank of their own leaflets, developed 'in house'. 

Concerns about inconsistent and inaccurate information in these leaflets is not new but progress in the area has been slow. There have been calls for a national strategy to tackle the problem: a single source of peer-reviewed, accurate information leaflets for the NHS which reduce problems with inconsistency and provide standardisation. In a company as large as the NHS, this may be very challenging, but I would like to see NHS Scotland take on that challenge to reduce replication and improve patient communication. A link to the article can be found here.

NHS Safety and Lord Sugar's new Apprentice

Prof Don Berwick

Today Professor Don Berwick published his review into patient safety in the NHS in England following the recent Stafford Hospital enquiry. He is an international expert in improving patient safety and was formerly President and Chief Executive Officer for the Institute of Healthcare Improvement (IHI). He was also former health advisor to Barack Obama. After the enquiry into deaths in Staffordshire, the NHS in England asked for his analysis and recommendations for improving the NHS. Most of his recommendations don't come as much of a surprise to doctors who are already be familiar with the work of the IHI but here are some of the most important points:

• The NHS remains an international gem and could be the safest system in the world.
• Cultural changes are needed, criminal sanctions are only required in extreme cases of wilful or reckless neglect.
• The NHS should be compelled to inform patients if serious errors are made in their care. 
• Trusts should be keeping a close eye on staffing levels to make sure patient care is not suffering.
• Staff must be given good support and training to help make sure they take pride and joy in their work.
• Patient harm shouldn't be accepted as being inevitable.

A BBC news article summary of the report can be found here: http://www.bbc.co.uk/news/health-23572696

The winner of BBC's The Apprentice this year had a controversial plan to start up skin aesthetics clinics which offer topical cosmetic procedures such as Botox in the UK. The doctor who won the Apprentice, Dr Leah Totton, did well to beat off the candidates and showed her quality as an investable candidate during the tasks but her business plan does seem poorly contrived. Her claims to be 'an expert' in the field who can teach her s

Dr Leah Totton

taff to run the clinic are hard to believe. It has to be born in mind that although she is a qualified doctor (at exactly the same stage in her career as I am today), she has only two years of experience as a post-graduate (and given that she must have taken a few months out to film The Apprentice I doubt she has met the requirements to complete FY2) and cannot possibly have learnt the skills required to carry out the techniques she wants to offer in such a short period of time. She has done well to win the process and I did want her to win the final, but I have to doubt the ethical grounding of her decision to leave NHS practice to start a chain of clinics offering private cosmetic dermatological procedures.

One thing which is certain is that the professional organisations who represent the kind of work she is looking to become involved in have unanimously rebuked her proposals and will definitely not be supporting her clinics. The British Association of Dermatologists (BAD) and other organisations released the following press statement a couple of weeks ago:

The main professional bodies for plastic surgery and dermatology today jointly and unequivocally condemn BBC Apprentice winner Dr Leah Totton’s capacity to set up and run a chain of outlets offering injectable facial treatments such as Botox and fillers. Not only the British Association of Dermatologists (www.bad.org.uk), the British Association of Aesthetic Plastic Surgeons (www.baaps.org.uk) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (www.bapras.org.uk) but a whole host of high-profile clinicians have taken to social media in a Twitter storm denouncing the junior doctor’s dangerously inadequate credentials for the project.

The extensive independent Review of Regulation on Cosmetic Interventions led by Sir Bruce Keogh (which issued its report earlier this year) highlighted problems within the non-surgical cosmetic sector and called for urgent development of an accredited training framework by Health Education England. The recommendations of the Review were welcomed by specialist professional groups who emphasise patient and public safety must be put ahead of commercial interests. They continue to urge rapid Parliamentary approval in order to take the recommendations forward and ensure that proficient implementation and improved patient care is in place – but in the meantime, the public remain at risk.

Mr Graeme Perks, President of the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) says “At a time when all professionals are collaborating with Sir Bruce Keogh to improve cosmetic surgery practice and protect the vulnerable, it is a concern that a very junior doctor can make claims to be an authority in this field and provide the direction and clinical judgement that only comes with experience. The results of BBC Apprentice provide yet another demonstration of why Parliament must act fast.

Prof Chris Bunker, President of the British Association of Dermatologists states  “We are seeing more and more complications at the hands of inadequately trained practitioners and counterfeit products. These adverse events can be permanent and life-ruining, and there are even reports of blindness being caused by inappropriate injection of fillers. Many patients require continued treatment and support on the NHS.

According to Rajiv Grover, consultant plastic surgeon and BAAPS President“What this debate needs is a strong injection of common sense – if Dr Leah Totton were training to be a GP she would not be able to work unsupervised for another four years after qualifying. Yet in the private sector she is setting herself up to train others. Having a stab at running a business shouldn’t be taken literally.

According to Dr Tamara Griffiths, dermatology representative on the European Committee for Standardisation (CEN) which has been developing EU-wide standards for cosmetic surgery “Dr Totton is a very junior doctor and her claim to be an expert in the field of cosmetic procedures may not measure up to the review by the European Committee for Standardisation, where international consensus has been reached regarding the imperative of adequate and accredited training.”

New Research into Atopic Eczema

Viewpoint at Glenashdale Falls

Sannox Bay

Atopic Eczema - What's New? A review of the condition was published in the July edition of CED (Clinical and Experimental Dermatology) by Dr Donna Torley from the department of dermatology at the Southern General in Glasgow (my local hospital). A systematic review of the key findings from 24 summaries published between August 2010 and December 2011. Here are some of the key findings:

Epidemiology: antibiotic use in early life may increase risk of atopic eczema whereas exposure to dogs and consumption of unpasteurised milk may reduce risk. There is no strong evidence that exclusive breastfeeding, hydrolysed protein formulas, soy formulas or fatty-acid supplements help to prevent atopic eczema.

Treatment: In patients with moderate to severe disease, pro-active treatment with topical corticosteroids and calcineurin inhibitors can be used to prevent flares. An example of this which has been tried is 'weekend therapy' which consists of preventative topical therapy being applied on two consecutive days each week (such as the weekend) to prevent flares.

Patient education about the condition produced mixed results with no high quality randomised trials to compare effectiveness and make reliable conclusions. Also in treatment, tacrolimus was shown to have a comparable efficacy to mild to moderate topical corticosteroids. There was little evidence found to support the use of coal tar in the management of the condition. Again, the lack of large and well designed randomised controlled trials led the authors to conclude that there was no clear evidence for the efficacy of homeopathy, botanical extracts or Chinese herbal medicines in the treatment of atopic eczema.

Also, a couple of photos from last weekend in Arran - great weather, food and company meaning a fantastic weekend away!

What an amazing few weeks!

It's been a busy few weeks and lots going on: Glastonbury festival at the end of June, then Liverpool for the British Association of Dermatologist's (BAD) annual conference in July and Amy and I are off to Arran this weekend. 

A moment of praise for Andy Murray on winning Wimbledon. He's an inspirational character to me and I admire him for his drive and determination to succeed, particularly in the face of previous disappointments such as the Wimbledon final which he lost in 2012. While several of the top tennis players such as Nadal and Federer started winning Grand Slams when they were younger (Nadal age 19, Federer age 21, Djokovic age 20), Murray has pushed ahead when many had written him off and his constant desire to improve has seen him finally deliver the success which he so rightly deserves. 

Improving patient safety and delivering better standards of care for patients in NHS Scotland is something which I am passionate about. I believe that there are two aspects to this for everyone who works in healthcare. One is personal improvement - looking at how we can get better at what we do as individuals. This helps to set example and is a good way to develop leadership. One of the speakers at the BAD last week was Professor Wendy Reid, who is Medical Director of HEE (Health Education England). She spoke about the importance of doctors acting as clinical leaders in hospital and how we are in a position where can initiate change. The other is looking at the wider picture, and how we change the cultures and systems that exist to create a safer environment. I feel that as junior doctors who regularly move between hospitals and departments, we have a unique opportunity to share our ideas and experiences. I hope to share some of the ideas I have and experiences (both good and bad ones) when I move to my next hospital job in August.

I was sent round an email for induction for the new job last week and the consultant who sent the email sent a link to the following video on youtube. It's a good one to watch - because it accurately depicts a realistic hospital scenario where a patient is identified as having sepsis. The sepsis 6 bundle is just one of the initiatives which has been worked on by healthcare improvement scotland (the project which I worked on in Ninewells on venous thrombo-embolism prevention was with them also). They have a youtube channel and there are several other videos there which explain who they are and what they aim to achieve and I would recommend that anyone interested have a watch.

http://www.youtube.com/watch?v=CrUHnYIZbpM

Hypocalcaemia Investigation

Glasgow in the Sun

No more Part 1 revision - found out this week that I passed! Part 2 next sitting isn't until December so a chance to take to foot off the gas a bit for a couple of months before CMT starts up.

It's June, the sun is shining and summer is here. Lots of good things going on right now. Finalising my poster presentation at the moment for the British Association of Dermatologists' annual meeting in Liverpool and putting together an audit presentation for the West of Scotland Dermatology regional audit meeting later this month

Investigating Hypocalcaemia: This topic of discussion occurs in an educational article in this week's BMJ and covers an area which often causes me confusion as calcium metabolism is a complex process. It is not uncommon for a patient admitted acutely to hospital to be calcium depleted and a 'bone profile' investigation is a useful blood investigation to carry out on any unwell acute medical admission. Adjusted calcium levels (that is, serum albumin adjusted calcium concentrations) are the most informative. Common causes of hypocalcaemia include drug related causes, chronic kidney disease and post-operative hypoparathyroidism. In a patient with a low serum adjusted calcium level, a serum parathyroid hormone level is informative. Low serum calcium frequently occurs alongside low phosphate and magnesium levels and these should be checked. A cause of hypocalcaemia which seems to be coming increasingly frequent is due to inadequate sunlight exposure leading to lack of vitamin D. Vitamin D levels can be checked in patients believed to be at risk, although Vitamin D deficiency would not cause acute hypocalcaemia. 

Here is an example of how the serum phosphate and PTH levels can help in investigating the cause of hypocalcaemia:

Low phosphate + High PTH: ?Acute pancreatitis or drug induced eg. secondary to bisphosphonates

High phosphate + Low PTH: ?Hypomagnesaemia, hypoparathyroidism

High phosphate + High PTH: ?CKD or rhabdomyolysis

Patients with severe hypocalcaemia may become symptomatic with neuromuscular irritability and paraesthesia (think Chovstek & Trousseau's signs!). There may also be prolonging of the QT interval and therefore an ECG is indicated. Treatment may involve oral calcium supplementation if hypocalcaemia is mild, or IV calcium gluconate in the treatment of severe hypocalcaemia.

CT Radiation, Weekend Safety, COPD and Acute Leg Ischaemia

Anonymous clinical image
courtesy of (Aaron G. Filler MD PhD FRCS)

Dangers of CT Radiation

CT scans are now widely available and accessible. In my experience, a relatively large proportion of patients admitted under medicine / surgery in our hospitals undergo CT scanning as part of their investigation - eg. Head CT to diagnose a stroke, CT Pulmonary Angiogram to diagnose a PE, CT KUB to diagnose stones or CT Chest/Abdo/Pelvis to investigate weight loss and search for malignancy. The risk of radiation posed by CT scans have long been known about and a new study published in the New England Journal of Medicine this week offers compelling evidence linking risk of cancer with radiation exposure. The study followed up young patients who had been scanned and looked at subsequent risk of cancer. The RELATIVE increased risk of malignancy was in the region of 24%. It is important to note though that the ABSOLUTE risk of malignancy was only marginally increased. This is because the baseline rate of childhood cancers is very low to start with. There was roughly one excess cancer per 1800 CT head scans performed. Although the benefits of CT scanning at the time are often likely to far outweigh the later increased risk of cancer, this piece of research can serve as a reminder (particularly in young people) that scans should only be requested where there is a clear indication and where the results will affect clinical decision making or treatment.

Safety at the Weekend

A big story in the news this week came with the publication of a retrospective study in England which has shown that patients who undergo elective surgery on a Friday or at the weekend have a greater risk of complications and death. So why might this be? The patients operated on at the end of the week had a lower index of comorbidity but still had worse outcomes. One of the most dangerous times following an operation comes in the days immediately after the operation as opposed to the time of the operation itself. Early identification of complications is essential and perhaps due to reduced staffing levels at the weekends it is the management of the patient in the peri-operative period which is most likely to contribute to adverse outcomes.

Treating an Acute Exacerbation of COPD

According to research published in JAMA this week, five days of high dose prednisolone is enough to treat most acute exacerbations of COPD. In this head to head trial in Switzerland there wasn't a statistically significant difference in outcomes between patients treated with five or fourteen day courses. The study shows that a five day course works just as well as fourteen and limits patient exposure to systemic steroids which can cause side effects and toxic accumulation.

A Diagnosis not to be Missed: Acute Leg Ischaemia

There are many conditions which could present with acute leg pain however this is one not to be missed. It results from thrombotic, embolic or traumatic arterial occlusion of the vessels of the leg.

Presentation can be remembered by "The 6 Ps":Pain, Pallor, Perishing with cold, Pulselessness (always present), Paraesthesia and Paralysis. It may be missed because it can be mistaken a lumbar disc prolapse or a Bakers' cyst and risk factors for vascular disease may not always be present. Immediate referral to a vascular surgeon is necessary as urgent limb-saving surgery may be required. 

Whole Genome Sequencing - Yes or No?

One of the most significant scientific developments over the past decade has been the ability to rapidly sequence the entire human genome. The success of this technology has led to a rapid increase in the detection and diagnosis of genetically inherited diseases. One use has been to identify specific disease causing mutations, while another use has been to identify susceptibility loci and polymorphisms which combine to increase a patient's risk of developing a disease which may be caused by not one, but many genes. It can also help to predict how a patient will respond to certain types of medications (pharmacogenomics). 

So should we sequence every person's genome? There are obvious arguments for: personalised medication, screening for disease etc. However the counter-arguments are also significant ie. screening for diseases which cannot be treated. There is risk of harm by screening a person's entire genome. For example, it may suggest that a patient has a predisposition to certain conditions and may lack clinical significance. Would it be useful to know that you carried a gene for an inherited condition? This could lead to a world of 'genetic compatibility' testing between partners before having a child. It would be useful for doctors to know if patients are going to respond / not respond to certain drugs eg. warfarin or chemotherapy before they are prescribed. 

A number of ethical implications need to be considered: for example how will implications for relatives be handled - who owns the genetic information? How can we ensure that the information obtained is kept private and not shared with research or pharmaceutical organisations? The discovery that a patient may be at a slightly increased risk of coronary heart disease could lead to a rise in un-necessary investigations (particularly in the private sector) eg. unnecessary imaging, while a result showing low risk could also be harmful, leading to a person becoming too relaxed about their health and abandoning healthy diet and exercise as it is felt un-necessary due to low genetic risk. At the moment, in my opinion there is too much risk of harm to be caused by screening everyone's human genome. However once our knowledge expands and our ability to handle the information improves, I honestly believe that in my lifetime it will become routine medical practice (ie. genome sequencing at 18th birthday or on registering with a new GP practice).

One of the big medical news stories last week was the revelation by Hollywood actress Angelina Jolie that she had undergone a double mastectomy to prevent her risk of developing breast cancer, caused by her carrying the BRCA1 gene. I think it is highly commendable that she went public with this - helping to increase awareness of the risk of breast cancer. The question this raises and which is the title of the article in the BMJ this week which I am referring to is the 'who owns our genes?' question. Unbelievably, in the US it costs about $3000 to undergo testing for BRCA1 and BRCA2 because one biotechnology company owns the patent and hence has a monopoly over the testing (the company's share prices jumped 3% after Jolie's announcement). These patents are set to expire in 2014 as it has now been argued in the US Supreme court that human genes are 'natural' and therefore cannot be patented. 

Is Patient Involvement the Key to Improvement?

Would you recommend this hospital to your friends and family?

One of the suggestions which came from the recent enquiry into Mid-Staffordshire was that patients be asked for feedback on their experiences. The value of this would in theory be to help identify areas of under-performance. Although this measure has been introduced without a great deal of evidence to back it, on the surface it appears sensible. Patient experience in hospital is of course likely to vary enourmously from patient to patient, but this method could pick up trends and help to highlight areas needing improvement.

But what if we take this a step further. What if the solution to improving healthcare is by asking patients what they want to get out of their interaction with the medical services. The old 'ideas, concerns and expectations' set of questions was drilled into us at medical school (although from personal experience it is all to often left out of consideration). The focus of the BMJ this week is on this concept, empowering patients to take responsibility in working in partnership with doctors.

Working in collaboration with our patients is by no means a new idea, but perhaps a fresh reminder is necessary. Social media and networking could be one way of doing this - examples are given of patients who are able to reach thousands with their blogs describing their experiences. For example 'rheumatoid arthritis warrior' Kelly Young shares her online blog rawarrior.com with almost 2% or patients with RA in the US. 

Patient support groups are plentiful, and are able to connect patients to share experiences, and perhaps more doctors should be engaging with these communities. Where the patient brings the value of their personal experience, the doctor can bring their knowledge of medicine and treatment. A doctor for example could help to prevent conversations from going down incorrect paths and share up to date knowledge of treatments (allowing information to filter down from clinical research to the lay person).

Engaging patients in decision making could also help to reduce costs through unnecessary over-investigation. Choosing Wisely (www.choosingwisely.com) is an initiative which has been set up in the US which aims to reduce over-investigation of patients and encourages patients and doctors to work together to come up with solutions.

All of these ideas fit perfectly with the GMC guidance on Good Medical Practice and agree with the ethical principles which doctors abide by. I'm pleased to read that this concept is being given increased attention and hope that some of these ideas could help to develop the NHS which I want to be a part of in years to come.

Measles, Acne, Heart Failure and Anti-Depressants

Now that the MRCP exam is out of the way, I've been catching up on few interesting articles which have featured in the BMJ over the past few weeks. 

Measles

This can is a disease which can be effectively prevented by vaccination, yet most of the UK has not reached the levels of immunity necessary to achieve herd immunity (estimated to be around 95% of the population immunised). The number of people not immunised may in fact be greater than known, particularly in the age group of children who should have received vaccination around the time of the widely spread reports about a possible link with autism (a link which has now been rebuked and disproved). Indeed I found out recently that I did not have immunity to measles, and have begun my MMR vaccination schedule to ensure that my risk of catching the disease is diminished. In Swansea this year there has been a surge in the number of cases, and in the north of England there have been 354 cases so far this year (2013). The condition is largely self-limiting but complications can occur including permanent disability and death, and it is highly infectious. And yet an effective vaccine is available. So should we be doing more to prevent this disease? In the US, cases of measles are treated as an emergency, and this may be a contributing factor which has led to the elimination of endemic measles in the Americas. Any child death due to measles should be a 'never' event because it is avoidable. It would be reasonable for me to expect that global eradication of measles will be achieved in my lifetime but we cannot be complacent and must do more as doctors to help eradicate the world from measles permanently.

Acne Vulgaris

Acne vulgaris is a distressing condition which commonly affects adolescents and can have a profound impact on quality of life. It shouldn't be underestimated how often the condition continues into adulthood and permanent scarring may occur. Acne is considered to be severe if there are nodules and cysts present. It is an inflammatory condition of the pilosebaceous unit where there is abnormal keratinocye proliferation, an androgren driven increase in sebum production, proliferation of Propionibacterium acnes and inflammation. Topical retinoids are the mainstay of treatment although oral isoretinoin is the most effective treatment.

Are Anti-Depressants Overprescribed?

There is a strong feeling amongst many doctors that anti-depressants are over-prescribed and a recent poll on the BMJ's website saw 79.3% of respondents vote in agreement. The reasons why are suggested to be due to influences of the pharmaceutical industry, the broad definition of depression and perceived 'quick fix' solutions from patients and doctors. There are however explanations for the increase in anti-depressant prescribing, according to one psychiatrist (who does declare receipt of payment in an advisory role to a pharmaceutical company). He gives the counter-side of the argument in the BMJ this week. His arguments (amongst others) are that anti-depressants are effective in treating depression, and that the increasing numbers of patients taking the medications may reflect improving practice amongst doctors in understanding that patients need to take the medications for at least 6 months for an effect to be seen. 

Investigating Suspected Heart Failure

A review article on the initial investigation of heart failure places a strong emphasis on the use of B-type natriuretic peptide (BNP) as a predictor of disease. A normal 12-lead ECG and BNP has a high negative predictive value for excluding heart failure although this is recommended for use in a non-acute setting. A BNP result of >400pg/mL confers a poor prognosis and it is recommended that these patients are reviewed by a cardiologist within 2 weeks. Echocardiogram does however remain the investigation of choice in confirming the diagnosis of heart failure. It has to be noted though that there are a number of other causes for a modestly raised BNP result, such as COPD, hypoxia and diabetes therefore results need to be interpreted with caution.

MRCP Revision Notes

Another random selection from MRCP Part 1 practice questions - normal updates will resume in May!

Treatment of Hyperlipidaemia - Elevated cholesterol and triglycerides are suggestive of remnant hyperlipidaemia. The most appropriate treatment in this case would be a fibrate. Statins are predominantly used to treat cholesterol. Nicotinic acid lowers cholesterol and triglycerides but it is poorly tolerated (primarily due to cutaneous flushing). Bile acid sequestrants reduce cholesterol but may actually increase triglyceride concentrations and are poorly tolerated. The effects of statins are usually maximal by about 4 weeks after an increase in dose. Fibrates in combination with statins are effective although there is a theoretical risk of myositis when used in combination. In a patient with high cholesterol not responding to a statin, ezetimib may be helpful. Ezetimib inhibits cholesterol absorption from the gut.

Resting Membrane Potential - The resting neurone is polarized (-ve on the inside, +ve on the outside). At rest, the cell membranes are less permeable to sodium than they are to potassium. The outside of the neurone is rich in sodium ions. When stimulated, the neurone permeability changes allowing sodium in and postassium out. The depolarization resulting from this movement causes the generation of an action potential.

Myelodysplastic Syndrome - This is characterised by peripheral cytopenia with marrow full of developing cells. Maturation is abnormal and there is reduced cell survival. It can initially be detected from the presence of abnormal red cell maturation (ie. a raised MCV) in the absence of other causes of anaemia. The most common presenting symptom is fatigue and this condition is far more common in the elderly population.

Rheumatic Fever & Differential - This condition affects children in the age 4-15 group as a result of Group A streptococcal infection. It is common in the middle east, eastern Europe and South America. The arthritis is classically a fleeting migratory polyarthritis affecting the large joints although isolated arthritis is the presenting symptom in 15-40% of cases. Differential diagnosis includes:

Still’s disease (arthritis is usually much more persistent in the affected joint)

Polyarticular juvenile idiopathic arthritis (small joints initially affected, no fever)

Childhood dermatomyositis (age 4-10, classic rash + muscle weakness)

Familial Mediterranean Fever - autosomal recessive in certain ethnic groups, characterised by recurrent attacks of fever, arthritis and serositis. Abdominal or chest pain due to peritonitis / pleurisy may occur.

Chagas Disease - This is a tropical parasitic disease caused by infection with the flagellate potozoan Trypanosoma cruzi. It is associated with sudden cardiac failure due to dilated cardiomyopathy. It is a protozoan parasite, known as the ‘kissing bug’. Patients are often asymptomatic for many years following infection but may develop cardiac failure. It is most prevalent in Central and South America and may cause mega-oesophagus and mega-colon as a complication.

More MRCP Revision

Acute Intermittent Porphyria - Does not typically result in skin manifestations but presents typically in a young woman admitted to hospital with severe abdominal pain, bilious vomiting and postural hypotension. AIP occurs due to the absence of porphobilinogen (PBG) deaminase and the combined oral contraceptive pill can precipitate an attack. Porphyria Cutanea Tarda on the other hand presents with a blistering skin rash on sun exposure, typically precipitated by alcohol.

Marfans Syndrome - This condition follows an autosomal dominant mode of inheritance and is caused by mutations in the fibrillin gene on chromosome 15. The diagnosis is made on clinical grounds. Major diagnostic criteria includes an early diastolic murmur, indicating aortic valve incompetence, likely to be secondary to aortic root dilatation requiring annual cardiology follow-up. Upwards lens dislocation (ectopia lentis) may be seen and minor criteria for diagnosis include arachnodactyly, minor valve prolapse and joint hypermobility.

Familial Hypocalciuric Hypercalcaemia - Is caused by a mutation of the calcium-receptor sensing gene leading to reduced calcium excretion and mild to moderate hypercalcaemia. Renal stones frequently occur in this condition and acute pancreatitis is rare. It is recommended that the patient maintains adequate hydration to reduce their risk of renal stones.

Sclerosing Cholangitis - Occurs classically in a patient with an inflammatory bowel disease. There is inflammation and fibrosis of the bile ducts with multiple areas of narrowing throughout the biliary system. The patient may be asymptomatic or may present with jaundice, pruritis and intermittent abdominal pain. There is a strong association with inflammatory bowel disease and men are more commonly affected than women.

Hodgkin's Lymphoma - The classic presentation is in a young woman presenting with weight loss and lymphadenopathy. Raised eosinophils in the full blood count are a strong clue towards the diagnosis and lymph node biopsy is necessary to confirm the diagnosis. Prognosis is related to clinical stage, bulk of tumour and histopathology. Presence of the 'Reed-Sternberg' Cell (with giant 'owls eye' nucleoli) are useful diagnostically.

IgA Nephropathy - This would typically occur in a young man who has repeated episodes of painless macroscopic haematuria following a upper respiratory tract infections. On a renal biopsy there will typically be diffuse mesangial proliferation and the condition results in chronic kidney disease in approximately 30% of cases. Heavy proteinuria, raised blood pressure and renal impairment are indicators of a poorer prognosis.