The headline article on the BMJ website this week concerns a study carried out into predicting the risk of osteoporotic fractures in men and women in the UK.
Hippesly-Cox J etal. Predicting Risk of Osteoporotic Fracture in mena nd women in England and Wales: prospective derivation and validation of QFracture Scores. BMJ 2009;339:b4229
The study altogether covered a massive 24,350 diagnoses of osteoporotic fractures in women and there was a huge difference between frequency in men (only 7,934 in men).
The following factors led to a significant increased risk of fracture in women:
HRT use, age, BMI, smoking status, alcohol use, family history of osteoporosis, rheumatoid arthritis, cardiovascular disease, type II diabetes, asthma, tricyclic antidepressants, history of falls, menopausal symptoms, chronic liver disease and other endocrine disorders.
The results of the study suggest that using a simple algorithm can be more useful at predicting risk of fracture in primary care populations in the UK. The algorithm is known as the QFractureScore and could be used to predict patients at high risk of sustaining a fracture.
Doc2Doc, a website set up to encourage doctors to discuss topical matters, express points of view etc is a site I use sometimes for material. I saw this week that they had provided a handy 'round-up' of whats been in the news this week. Here's what it says:
The BBC have reported tamiflu-resistant H1N1 virus strains in Wales. There have already been five incidents in Cardiff of person to person transmission where this has been the case.
Researchers have shown in the journal 'Biological Psychiatry' that patients who are victims of child abuse actually show premature ageing. This is due to accelerated reduction of telomeres within cells.
Finally on a good note, the BBC's children in need event this year has raised more than 20 million pounds for charity.How good is that! Apparently Comic Relief raised 80 million pounds earlier in the year! Alot of the money goes towards important causes such as youth support services for victims of racism, support centres for visually impaired children, and play centres for children with terminal or life-threatening illnesses.
Sunday, 22 November 2009
Friday, 20 November 2009
DVT Assessment, Wheezy Children, Surfactant Replacement Therapy
Got loads to talk about this week.
Probably the most important was presenting my BMSc work at the ATRIUM conference last week and how it's really got me thinking about the possibility of a career in academic medicine. I know now that the first thing I need to do is to apply for the academic foundation posts. They're avaliable in Dundee, Glasgow, Edinburgh and Aberdeen. So far I've spoken to Dr Berg, Sam, Amy Martin and Tommy about these and had an email reply from Glasgow about what kind of things they're looking for from applicants. From what I can tell so far, I've got nothing to loose and it sounds like they don't mind doing telephone interviews if I'm on my elective. The TCGP open day with Amy gave me a good idea of the kind of things she's going to be starting to consider and tackling over the forthcoming years and also opened my eyes to the possibility of academic GP and teaching whilst stil maintaining clinical practice doing out-of-hours work etc.
This week I've been attached to the Neonatal unit (Ward 40) in Ninewells. One of the most interesting cases of the week was discussed in the unit MDT meeting about a woman pregnant with triplets currently in the Tayside area. She presents a real challenge to manage due to her vegan diet (she has insisted that all medications she is given are checked for correct ingredients), she has a metal phobia and she want's to have either a home birth or a water birth!
On the first day of the block we looked a paper which considers the definition of wheeze:
Cane RS, Ranganthan SC and McKenzie SA. What do parents of wheezy children understand by "wheeze"? Arch. Dis. Child. 2000; 82; 327-332
The aim was to find out what parents understand by wheeze and the results showed that understanding of the definition varied enourmously from what epidemiologists define as wheeze. There is also a label attached to wheeze that parents immediately understand as asthma. 23% of respondents said a wheeze was not something you hear. Of patients who doctors diagnosed as having wheeze, 39% of parents described their child's symptoms as having a different cause eg difficulty in breathing, or cough. The advice at the end is not to use the word 'wheeze' when talking parents but see if they volunteer it themselves. If they do, clarify what it means.
When I was researching my case presentation, I found out some interesting info about the use of surfactant in pre-term infants:
Engle WA. Surfactant-Replacement Therapy for Respiratory Distress in the Preterm and Term Neonate. American Academy of Pediatrics. 2008;121(2)
My case was a baby boy born at 28+4 weeks gestation. Presenting complaints were extreme re-maturity and respiratory distress syndrome. A premature infant is one born before 37 weeks gestation (approx 7% of all pregnancies). Incorrectly, I said in my talk that prematurity can be avoided by good antenatal care, however apparently the rates of pre-maturity have not decreased in recent years but have actually increased due to the increase in interventions people are having for their pregnancies. The study was a review of the current literature and concluded that in infants born before 30 weeks gestation, prophylactic surfactant administration has a better outcome than 'rescue' surfactant therapy.
Amy brought back a load of information from the GP conference she attended in Glasgow about genetics. I realised flicking through the info that alot of it was information aimed at GPs which I already knew about - I wonder if I could be taking more advantage of what I know by writing something, maybe an article in the Student BMJ?
At theme therapeutics this week (Case 12), the tutor highlighted a paper for us to look at considering the use of D-Dimers in diagnosis of a DVT.
Fancher TL, White RH and Kravitz RL. Combined use of rapid D-Dimer testing and estimation of clinical probabilityin the diagnosis of deep-vein-thrombosis: systematic review. BMJ. 2004; 1136
Well's probability tool is a useful assessment. Each positive response is one point, except if an alternative diagnosis is as likely as or greater than DVT, where 2 points are deducted. 0 or fewer points: low probability; 1-2 points: moderate probability; 3 or more points: high probability.
The criteria are as follows:
New album on the christmas wish list! Conditions - The Temper Trap
Probably the most important was presenting my BMSc work at the ATRIUM conference last week and how it's really got me thinking about the possibility of a career in academic medicine. I know now that the first thing I need to do is to apply for the academic foundation posts. They're avaliable in Dundee, Glasgow, Edinburgh and Aberdeen. So far I've spoken to Dr Berg, Sam, Amy Martin and Tommy about these and had an email reply from Glasgow about what kind of things they're looking for from applicants. From what I can tell so far, I've got nothing to loose and it sounds like they don't mind doing telephone interviews if I'm on my elective. The TCGP open day with Amy gave me a good idea of the kind of things she's going to be starting to consider and tackling over the forthcoming years and also opened my eyes to the possibility of academic GP and teaching whilst stil maintaining clinical practice doing out-of-hours work etc.
This week I've been attached to the Neonatal unit (Ward 40) in Ninewells. One of the most interesting cases of the week was discussed in the unit MDT meeting about a woman pregnant with triplets currently in the Tayside area. She presents a real challenge to manage due to her vegan diet (she has insisted that all medications she is given are checked for correct ingredients), she has a metal phobia and she want's to have either a home birth or a water birth!
On the first day of the block we looked a paper which considers the definition of wheeze:
Cane RS, Ranganthan SC and McKenzie SA. What do parents of wheezy children understand by "wheeze"? Arch. Dis. Child. 2000; 82; 327-332
The aim was to find out what parents understand by wheeze and the results showed that understanding of the definition varied enourmously from what epidemiologists define as wheeze. There is also a label attached to wheeze that parents immediately understand as asthma. 23% of respondents said a wheeze was not something you hear. Of patients who doctors diagnosed as having wheeze, 39% of parents described their child's symptoms as having a different cause eg difficulty in breathing, or cough. The advice at the end is not to use the word 'wheeze' when talking parents but see if they volunteer it themselves. If they do, clarify what it means.
When I was researching my case presentation, I found out some interesting info about the use of surfactant in pre-term infants:
Engle WA. Surfactant-Replacement Therapy for Respiratory Distress in the Preterm and Term Neonate. American Academy of Pediatrics. 2008;121(2)
My case was a baby boy born at 28+4 weeks gestation. Presenting complaints were extreme re-maturity and respiratory distress syndrome. A premature infant is one born before 37 weeks gestation (approx 7% of all pregnancies). Incorrectly, I said in my talk that prematurity can be avoided by good antenatal care, however apparently the rates of pre-maturity have not decreased in recent years but have actually increased due to the increase in interventions people are having for their pregnancies. The study was a review of the current literature and concluded that in infants born before 30 weeks gestation, prophylactic surfactant administration has a better outcome than 'rescue' surfactant therapy.
Amy brought back a load of information from the GP conference she attended in Glasgow about genetics. I realised flicking through the info that alot of it was information aimed at GPs which I already knew about - I wonder if I could be taking more advantage of what I know by writing something, maybe an article in the Student BMJ?
At theme therapeutics this week (Case 12), the tutor highlighted a paper for us to look at considering the use of D-Dimers in diagnosis of a DVT.
Fancher TL, White RH and Kravitz RL. Combined use of rapid D-Dimer testing and estimation of clinical probabilityin the diagnosis of deep-vein-thrombosis: systematic review. BMJ. 2004; 1136
Well's probability tool is a useful assessment. Each positive response is one point, except if an alternative diagnosis is as likely as or greater than DVT, where 2 points are deducted. 0 or fewer points: low probability; 1-2 points: moderate probability; 3 or more points: high probability.
The criteria are as follows:
- Active Cancer
- Paralysis or recent long period of immobilisation of lower limb
- Recently bedridden for more than 3 days or major surgery in the past four weeks or more.
- Localised tenderness
- Entire leg swollen
- Calf swelling greater than 3cm compared with asymptomatic leg.
- Pitting oedema
- Collateral superficial veins
- Alternative diagnosis as likely or greater than deep vein thrombosis.
New album on the christmas wish list! Conditions - The Temper Trap
Friday, 6 November 2009
Personal Genomic Screening
Common diseases and traits eg. tendency to balding can be investigated by genomic SNP (single-nucleotide-polymorphism) analysis of healthy people as well as people with diseases. Many associations are not valid and raise or reduce risk of conditions by very small amounts. Colon cancer, diabetes, cardiovascular disease are examples of polygenic conditions with SNPs which if present, correlate to higher patient risk . At the moment different screening companies seem to return different results eg. the same sample sent to 3 different labs may return different results. A family history is a much more powerful tool and genomic screening could be potentially damaging. The demand in the future for genetic councelling (or 'genomic' councelling) for patients could become huge in general practice in the future. One example of how SNP analysis could impact care is adjusted PSA based on presence of SNPs in the assessment of prostate cancer. Currently there is a grey-area between when and when not to send for a PSA test (PSA between 2 and 3.9) and watchful waiting is often the management outcome. However if a patient had a SNP profile showing increased risk of prostate cancer, it may be useful to do a biopsy at an earlier stage.
Information from the BMJ
Information from the BMJ
Published 29 October 2009, doi:10.1136/bmj.b4253
Cite this as: BMJ 2009;339:b4253
Clinical Review
A practical guide to interpretation and clinical application of personal genomic screening
Emily Edelman, project director1, Charis Eng, Sondra J and Stephen R Hardis chair of cancer genomic medicine, professor and chair2
David Nutt, Off-Duty Doctors and Aspirin Prescribing
Wanted to write something about the news of the dismissal of David Nutt, the chair of the government's Advsiory Council on the Misuse of Drugs. He was sacked by the home secretary, Alan Johnson, causing a rift between scientists and the government. It seems like there have been more than one case in recent years when advice to the government has been ignored if deemed an 'inconvenient truth'. I certainly don't agree that he should have lost his job over such an incident, it seems counter-productive to me. The reason he was sacked was due to comments he made about cannabis which contradicted current legislation, saying these didn't reflect clinical evidence. It's interesting that one of his points was that alcohol and tobacco are probably more dangerous than LSD and certain other illicit drugs. I think it's probably true that alcohol and tobacco bear a far greater public health burden than the illicit drugs but it would be dangerous for the public to have a perception that illegal drugs were infact more safe than previously thought. Article avaliable at http://news.bbc.co.uk/1/hi/health/8343004.stm
I read an interesting article about whether doctors off-duty should offer advice to strangers, the example given about an endocrologist telling a woman on a bus to go and have tests having spotted signs of acromegaly. In a clinical setting a patient sees a doctor consenting to be told information about their health, so is it un-ethical to confront someone like this? On the other hand as doctors with greater knowledge, do we have a moral responsibility to point out these things? What if the doctor was wrong? Intervention could cause un-necessary stress and anxiety to the patient. I thought this raised quite a lot of interesting ethical points.
http://www.guardian.co.uk/lifeandstyle/2009/nov/03/doctor-diagnosis-stranger
BMJ Blog 6th November 2009: Prescribing of aspirin - should it be prescribed as a primary preventative? A meta-analysis review of literature has concluded that use in people without cardiovascular disease should not be carried out, in any group of patients. Of course it has huge benefits for patients with cardiovascular disease, eg recently suffered a stroke. Some clinical practice guidelines do still recommend use of aspirin. Risks of taking aspirin largely offset the limited benefits. People who have been taking aspirin for many years need not suddenly stop taking aspirin but should have a discussion with their GP about their use of the drug.
Aspirin for primary prevention of vascular disease in people with diabetes. Published 6 November 2009, BMJ 2009;339:b4596
I read an interesting article about whether doctors off-duty should offer advice to strangers, the example given about an endocrologist telling a woman on a bus to go and have tests having spotted signs of acromegaly. In a clinical setting a patient sees a doctor consenting to be told information about their health, so is it un-ethical to confront someone like this? On the other hand as doctors with greater knowledge, do we have a moral responsibility to point out these things? What if the doctor was wrong? Intervention could cause un-necessary stress and anxiety to the patient. I thought this raised quite a lot of interesting ethical points.
http://www.guardian.co.uk/lifeandstyle/2009/nov/03/doctor-diagnosis-stranger
BMJ Blog 6th November 2009: Prescribing of aspirin - should it be prescribed as a primary preventative? A meta-analysis review of literature has concluded that use in people without cardiovascular disease should not be carried out, in any group of patients. Of course it has huge benefits for patients with cardiovascular disease, eg recently suffered a stroke. Some clinical practice guidelines do still recommend use of aspirin. Risks of taking aspirin largely offset the limited benefits. People who have been taking aspirin for many years need not suddenly stop taking aspirin but should have a discussion with their GP about their use of the drug.
Aspirin for primary prevention of vascular disease in people with diabetes. Published 6 November 2009, BMJ 2009;339:b4596
Sunday, 1 November 2009
1st November 2009
Horrible weather outside for the first day of November, Dundee Utd v Rangers game was called off today due to flooding, Arsenal beat Spurs 3 - 0 yesterday!
I've submitted the abstract from my BMSc to two competitions now:
The ATRIUM (Academic TRaining In Undergraduate Medicine) Society at the University of Edinburgh, and the Royal Society of Medicine Pathology Abstract competition. Fingers crossed! Not sure what I'll do if they ask me for a poster though!!
Reading in the Lancet Student today, forensic psychiatry is a speciality which links between medicine and law and involves the care and management of offenders with mental health problems. In the UK there is a good setup for the management of such individuals however in many countries in the world forensic psychiatry isn't even recognised as a speciality with offenders being placed in public jails which lack the kinds of support services these people require. The article is titled: Forensic Psychiatry: Current Status and Future Impact on Global Mental Health.
We had an email last week from the medical school about avalaibility of the swine flu vaccine.Last year only 16.5% of healthcare workers took the seasonal flu vaccine, so why should this year be any different? Reasons for people not wanting the vaccine include concerns about its safety and the low percieved threat of a pandemic. Interestingly last time there was a swine flu vaccination (1976-7), 12 per million recipients developed Guillain-Barre syndrome. Healthcare staff at the moment are being urged to take up the vaccine to help protect themselves and their patients. Deaths in young adults have occurred, but the current strain (H1N1) is a mild illness for most people. I'm pretty un-decided at the moment.
The most interesting patient who I saw this week during the opthalmology attachment was a 75 year old male with a recently diagnosed Bell's palsy. A Bell's palsy in a unilateral, neuropathy affecting the facial nerve. Opthalmic complications commonly occur due to exposure of the eye as a result of an inability to close the eyelids for protection. This patient had a painful corneal ulceration and a red eye, he was admitted for an intensive course of prophylactic antibiotics, tarsorrhaphy (surgery to close the eyelids) and a botox injection to the upper eyelid to induce a temporary ptosis.
I've submitted the abstract from my BMSc to two competitions now:
The ATRIUM (Academic TRaining In Undergraduate Medicine) Society at the University of Edinburgh, and the Royal Society of Medicine Pathology Abstract competition. Fingers crossed! Not sure what I'll do if they ask me for a poster though!!
Reading in the Lancet Student today, forensic psychiatry is a speciality which links between medicine and law and involves the care and management of offenders with mental health problems. In the UK there is a good setup for the management of such individuals however in many countries in the world forensic psychiatry isn't even recognised as a speciality with offenders being placed in public jails which lack the kinds of support services these people require. The article is titled: Forensic Psychiatry: Current Status and Future Impact on Global Mental Health.
We had an email last week from the medical school about avalaibility of the swine flu vaccine.Last year only 16.5% of healthcare workers took the seasonal flu vaccine, so why should this year be any different? Reasons for people not wanting the vaccine include concerns about its safety and the low percieved threat of a pandemic. Interestingly last time there was a swine flu vaccination (1976-7), 12 per million recipients developed Guillain-Barre syndrome. Healthcare staff at the moment are being urged to take up the vaccine to help protect themselves and their patients. Deaths in young adults have occurred, but the current strain (H1N1) is a mild illness for most people. I'm pretty un-decided at the moment.
The most interesting patient who I saw this week during the opthalmology attachment was a 75 year old male with a recently diagnosed Bell's palsy. A Bell's palsy in a unilateral, neuropathy affecting the facial nerve. Opthalmic complications commonly occur due to exposure of the eye as a result of an inability to close the eyelids for protection. This patient had a painful corneal ulceration and a red eye, he was admitted for an intensive course of prophylactic antibiotics, tarsorrhaphy (surgery to close the eyelids) and a botox injection to the upper eyelid to induce a temporary ptosis.
Sunday, 25 October 2009
New Post 25th October
Admittedly I've been pretty slack on updating the blog recently, mainly because I've decided that I shouldn't use this space to talk about tutorials etc, rather use it to mention interesting articles I've read. Also because it seems that copying and pasting from Microsoft Word is a total nightmare! Not really worth the bother!
The following are some of the interesting things I picket up from listening to the BMJ podcast over the past few weeks:
Firstly, confidentiality rules have been changed with regards to disclosure of genetic information. Previously if a family member was given a risk of inheritance of eg. BRCA1 / 2 genes, if the information directly affected a family member it was at the patient's discretion whether or not to tell a relative. Sometimes eg. in the case of two sisters who no longer speak to each other, the information is not passed on, however now the clinical geneticist is allowed to disclose information to relatives if the information directly affects them, eg. their chance of inheriting the BRCA1 / 2 genes.
Secondly, a revent review suggests that one in four people are victims of domestic abuse. This is a remarkably high number and the article I listened to was discussing the importance of picking up the signs of domestic abuse. Sometimes patients will go at great lengths to hide abuse and doctors are often criticised for treating the acute problem and not recognising the underlying cause. Evidence shows that domestic abuse is predictable up to 3 years in advance.
Tumour markers are often not specific for certain cancers and can be raised in patients with benign tumours. As a result they should not be relied on and certainly not used to exclude presence of an underlying malignancy. For example in its early stages colorectal cancer will not have raised tumour markers. Tumour markers are most useful in monitoring patients with already diagnosed cancer who are undergoing treatment.
Finally, sudden infant death syndrome (SIDS) is the tragic sudden death of a child under the age of one where thorough investigation does not reveal the cause of death. The new campaign 'Back to Sleep' has helped reduce numbers of cot deaths but another message which also needs to be addressed is the dangers of drinking alcohol and sleeping in the same bed as baby. If it's not safe to drive, its not safe to share a bed with an infant. Sleeping on a sofa with a baby carries one of the highest risks of SIDS.
The following are some of the interesting things I picket up from listening to the BMJ podcast over the past few weeks:
Firstly, confidentiality rules have been changed with regards to disclosure of genetic information. Previously if a family member was given a risk of inheritance of eg. BRCA1 / 2 genes, if the information directly affected a family member it was at the patient's discretion whether or not to tell a relative. Sometimes eg. in the case of two sisters who no longer speak to each other, the information is not passed on, however now the clinical geneticist is allowed to disclose information to relatives if the information directly affects them, eg. their chance of inheriting the BRCA1 / 2 genes.
Secondly, a revent review suggests that one in four people are victims of domestic abuse. This is a remarkably high number and the article I listened to was discussing the importance of picking up the signs of domestic abuse. Sometimes patients will go at great lengths to hide abuse and doctors are often criticised for treating the acute problem and not recognising the underlying cause. Evidence shows that domestic abuse is predictable up to 3 years in advance.
Tumour markers are often not specific for certain cancers and can be raised in patients with benign tumours. As a result they should not be relied on and certainly not used to exclude presence of an underlying malignancy. For example in its early stages colorectal cancer will not have raised tumour markers. Tumour markers are most useful in monitoring patients with already diagnosed cancer who are undergoing treatment.
Finally, sudden infant death syndrome (SIDS) is the tragic sudden death of a child under the age of one where thorough investigation does not reveal the cause of death. The new campaign 'Back to Sleep' has helped reduce numbers of cot deaths but another message which also needs to be addressed is the dangers of drinking alcohol and sleeping in the same bed as baby. If it's not safe to drive, its not safe to share a bed with an infant. Sleeping on a sofa with a baby carries one of the highest risks of SIDS.
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