Quick post this week - 4th year just seems to get busier by the week! This week I was reading the student BMJ (March) in which there were several interesting articles. Minimum pricing of alcohol was discussed, this seems to be an ongoing debate and will almost certainly have an important bearing on the next general election. I am definitely of the opinion that in the next 5-10 years there will be a massive change to the way in which alcohol is sold and consumed in the UK. The figures in Tayside alone show the scale of the financial burden to the NHS and the days of heavy boozing may soon be a thing of the past (good job my student days are nearly over then!).
The front page article on this month's student BMJ was regarding stem cell research however I've talked enough about this in previous posts (see below). Also covered in this month's journal was an insight into some disciplines which I previously had not known were present in the hospital. They are the critical care outreach teams and the bereavement officer. The critical care team can be contacted if there is a situation on the ward where a patient's state is deteriorating, presumably contactable at night, therefore it should never be the responsibility of a single doctor to manage a patient's care, nor should the doctor feel alone in this situation.
A moment for teaching: Wilson's Disease. This is an autosomal recessive inherited disorder of copper metabolism. Patients with this condition have impaired copper excretion and metabolism. Clinical signs of the disease are: eye signs (Kayser-Fleisher rings, extra-pyramidal disorders of movement eg. dystonia, psychosis and cirrhosis of the liver. Rarely the nails may appear to be a blue colour due to the effect of the copper.
Finally, there is recently published evidence that most quitters infact stop smoking without the need for additional support. Apparently often these patients are left out of trials and studies, partly because the research is not sponsored by any of the drugs companies which manufacture aids to help patients stop smoking.
Sunday, 21 March 2010
Saturday, 13 March 2010
Blood Pressure Variability
One of the big things which hit the health news headlines this week was the report that patients with 'occasionally high' blood pressure are at greater risk of developing a stroke than those with consistently high blood pressure. Management of hypertension is a vital aspect of preventative medicine, particularly in a primary healthcare setting. I'm seeing this alot at the moment most likely because I'm half way through a 4 week GP placement. The article appeared in The Lancet this week and a review was published today:
Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension Volume 375, Issue 9718, Pages 938 - 948, 13 March 2010
The argument is that up until now, sporadically increased episodes of blood pressure have been ignored and too much focus has been on "widespread belief that underlying usual blood pressure can alone account for all blood-pressure-related risk of vascular events". In fact clinical guidelines recommend that episodic hypertension is not treated. At the moment the NICE guidelines on management of hypertension are currently being re-written and no doubt this new evidence will play an important part in new recommendations.
On Doc2Doc there was a post from the author of the site about parking charges for hospitals, it seems that in Dundee we are not alone in having to pay for parking! In some hospitals there are monthly rates of £50 or more.
A case recently saw a doctor being taken to court for refusing to pay a £10 parking fine 'on principle' for parking in an illegal space whilst on duty. The article seems to focus alot on doctors but doesn't talk about the barrier's this poses to patients coming to the hospital which is probably more of a concern. With failure rates at appointments running at an all time high and constant chat about "increasing productivity and efficiency within the NHS to save costs" this is surely the kind of thing which needs to be looked at.
Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension Volume 375, Issue 9718, Pages 938 - 948, 13 March 2010
The argument is that up until now, sporadically increased episodes of blood pressure have been ignored and too much focus has been on "widespread belief that underlying usual blood pressure can alone account for all blood-pressure-related risk of vascular events". In fact clinical guidelines recommend that episodic hypertension is not treated. At the moment the NICE guidelines on management of hypertension are currently being re-written and no doubt this new evidence will play an important part in new recommendations.
On Doc2Doc there was a post from the author of the site about parking charges for hospitals, it seems that in Dundee we are not alone in having to pay for parking! In some hospitals there are monthly rates of £50 or more.
A case recently saw a doctor being taken to court for refusing to pay a £10 parking fine 'on principle' for parking in an illegal space whilst on duty. The article seems to focus alot on doctors but doesn't talk about the barrier's this poses to patients coming to the hospital which is probably more of a concern. With failure rates at appointments running at an all time high and constant chat about "increasing productivity and efficiency within the NHS to save costs" this is surely the kind of thing which needs to be looked at.
Sunday, 7 March 2010
Differential Diagnosis, Doctor's Handwriting and Medicine Beyond the 9 to 5
Tom Yeoman, one of the 5th years at Dundee at the moment wrote an interesting article in the Lancet Student this week which caught my attention (Not the Flu - March 2010). He describes reports of patients being diagnosed with having swine flu who have ended up being treated from a range of conditions including appendicitis, malaria, acute myeloblastic leukaemia and meningococcal meningitis! It just goes to show that it's always important to think about the differential diagnosis even if the cause seems obvious. Whenever we write up case reports, we always list the differential diagnosis and this is the reason why, to rule out the alternative causes through methods such as investigations. In the cases of swine flu, due to the possible diagnosis of swine flu this patient had not been given a full assessment by the GP.
Reading on doc2doc this week, the medical professionals forum posts included doctor's handwriting - where a study carried out by Diabetes UK found one in six case notes to contain errors in written notes, and a guy who asks the question 'Why is Transgender still classed as a Mental Disorder'. This does seem to be medicalisation of a choice that someone might make and surely does not mean to imply that they have a mental health problem. I guess it comes back to that question which I posed earlier as to whether completed suicide implies that the person had a mental health problem. Homosexuality was deleted from DSM IV in 1973. Another article asks the queston, Would you change career after medical school? I answered yes. To tell the truth I am feeling a bit disillusioned at the moment, the same phrases do seem to be coming up alot 'burn-out', 'don't do it' etc. But a respondant put in a good quote afterwards:
“…Medicine arose out of the primary sympathy of a man with man; out of the desire to help those in sorrow, need and sickness”. …
-Sir William Osler, “The Evolution of Modern Medicine”, Yale University, April 1913.
Perhaps I need to remember this, although I do wonder if there are other ways I can help. The Dundee University Medical School MSC Symposium this week is titled "Medicine - Beyond the 9 to 5". I'll try and get along to some of this, it might give me some ideas!
Reading on doc2doc this week, the medical professionals forum posts included doctor's handwriting - where a study carried out by Diabetes UK found one in six case notes to contain errors in written notes, and a guy who asks the question 'Why is Transgender still classed as a Mental Disorder'. This does seem to be medicalisation of a choice that someone might make and surely does not mean to imply that they have a mental health problem. I guess it comes back to that question which I posed earlier as to whether completed suicide implies that the person had a mental health problem. Homosexuality was deleted from DSM IV in 1973. Another article asks the queston, Would you change career after medical school? I answered yes. To tell the truth I am feeling a bit disillusioned at the moment, the same phrases do seem to be coming up alot 'burn-out', 'don't do it' etc. But a respondant put in a good quote afterwards:
“…Medicine arose out of the primary sympathy of a man with man; out of the desire to help those in sorrow, need and sickness”. …
-Sir William Osler, “The Evolution of Modern Medicine”, Yale University, April 1913.
Perhaps I need to remember this, although I do wonder if there are other ways I can help. The Dundee University Medical School MSC Symposium this week is titled "Medicine - Beyond the 9 to 5". I'll try and get along to some of this, it might give me some ideas!
Sunday, 28 February 2010
BMJ Articles - February 2010
BMJ Podcast - 01/02/10
Treatment of Clubfoot
· Many children suffer from clubfoot.
· Hippocrates wrote the first account of this in 400B.C.
· Most common historical technique for correction – extensive surgery or manipulative techniques. Often associated with stiffness and an associated limp in later life.
· Achilles Ternotomy – Ponsetti’s method is a new cheaply and easily carried out.
· Effective rehabilitation requires the parents to be motivated.
· 90% of children can expect a successful outcome – a pain free foot.
· Children essentially crippled for life can be ‘cured’.
Sharing health research data – research methods and reporting
· Why should researcher’s share their data? People should consider that if they have data they are not using, perhaps they could make it avalible to other people rather than having ‘lost’ data.
· Although studies are often very anonymised but if there is a large data set then it may be possible for patients to identify themselves.
· Come up with a list of 28 identifiers that researchers should take great caution about when releasing data set. These are ‘indirect identifiers’ which may lead the patient to identify their own data.
· Could data sets be shared after a period of ‘fair use’ is information is not published? Patients need to be told about this to give consent.
BMJ Podcast – 05/02/10
Urinary Tract Infections
· Managing these in primary care. This is a common disorder but new research has shed light on a well known condition.
· UTI is one of the commonest acute presentations in primary care.
· Majority are bacterial – usually treated by antibiotics.
· Commonest management is an immediate antibiotic prescription. Gold standard is mid-stream urine sample.
· Urinary dipsticks are also used to diagnose.
· Empirical delayed prescribing of antibiotics.
· Main outcome measure was severity of symptoms in a diary. There was no significance on severity of symptoms in all of the management approaches above. Demonstrated a 20% reduction in antibiotic prescribing.
· Triad of papers - trial / economic analysis / qualitative survey.
· Antibiotic resistance is relatively common in urinary tract infections.
BMJ Podcast – 12/02/10
Prescribing SSRIs with Tamoxifen
· New research shows that these drugs, prescribed together is not safe and leads to an increased risk of death.
· SSRIs interfere with the metabolism of Tamoxifen.
· This used to be a theoretical drug interaction but has now been quantified by a research institution in Toronto.
· Paroxetine was the SSRI involved in the trial and it is an irreversible selective serotonin re-uptake inhibitor.
· Patients should take care not to suddenly stop their Paroxetine.
· They should swap to another antidepressant.
Most medical school in the USA lack rules on ‘ghost writing’.
· Ghost writing is the practice of drug companies presenting a paper to academics and asking them to put their name to a paper they have not actually written.
· Reported authorship is essential for research integrity.
Saturday, 13 February 2010
Why can't Scotland keep their discipline on the rugby pitch!?
It's quite difficult to find the words that can describe that rugby match. Final score Wales 31 - 24 Scotland after Shane Williams scored that last minute try in stoppage time to win the game. Scotland were 10 points up with 5 minutes to go. Unbelievable. Having played so well for 75 minutes it all fell apart when one moment of indiscipline led to a yellow card, Scotland a man down, Wales with all of the momentum, then it was all over. Scotland must do better. So well disciplined for the whole match and then one event to lose it all. Scotland won't have a better chance to beat Wales than that again for a long time. Ah well.
Down to some of the most interesting articles from the Student BMJ this month:
The cover article 'Health in the Homeless' was relevant to this week as one of the patients being seen by the community mental health team in Montrose who I'm spending time with this week are invoved in the care of a young woman who is homeless. As health professionals we are in a valuable position to help the homeless, since health services in the UK are still a relatively easy place for people to get access. It's also important that we engage with the homeless as often their ill health is one of the major barriers to getting them off the street, and also we have invaluable contacts with many other agencies who can help these people. Specifically to mental health, homeless people are 8 to 11 times more likely than the general population to be affected with many being admitted to a psychiatric hospital at some point in time. The incidence of suicide in the homeless is 35 times more than the general population. Alcohol dependence and substance misuse are other major co-morbidities in this demographic group. Unfortunately a lack of a permanent address, chaotic lifestyle and no access to public transport are barriers to health and a general mistrust of doctors can make people reluctant to seek help. An admission to hospital for these patients can be extremely beneficial if it leads to re-connecting them to help from social services and other sources of help.
Another interesting article:
Energy Drinks for Children - in the past 10 years there has been a massive increase in the number of 'caffeinated' drinks avaliable on the market, with sales marketing aiming at promoting their associations with power, youth and danger. Whilst caffeine is generally recognised as safe, it does stimulate the central and peripheral nervous system, improving concentration and performance in small amounts. Excess however can lead to GI upset, anxiety, agitation, sleeplessness and arrhythmias. In children these drinks should be avoided if possible and the long term effects of excessive consumption are unknown. Children and adolescents should be advised to stick to water if possible.
There was a section in the journal this month about notifiable diseases which I thought was useful for revision as one of the practice questions I came across this week was on this topic. A list of notifiable diseases can be found in the BNF. In the event that one of these notifiable conditions is identified, it would be one of the responsibilities of the junior doctor to notify a consultant in communicable disease. Further information is avaliable on the Health Protection Website: www.hpa.org.uk.
Finally, a report out this month shows evidence that antidepressants work only against severe depression and have little use in mild or moderate disease. (JAMA 2010;303:47-53). Drug treatment worked little better than placebo in a meta-analysis of patients with mild/moderate disease. All drugs investigated showed greatest benefits for only the most severely depressed.
Down to some of the most interesting articles from the Student BMJ this month:
The cover article 'Health in the Homeless' was relevant to this week as one of the patients being seen by the community mental health team in Montrose who I'm spending time with this week are invoved in the care of a young woman who is homeless. As health professionals we are in a valuable position to help the homeless, since health services in the UK are still a relatively easy place for people to get access. It's also important that we engage with the homeless as often their ill health is one of the major barriers to getting them off the street, and also we have invaluable contacts with many other agencies who can help these people. Specifically to mental health, homeless people are 8 to 11 times more likely than the general population to be affected with many being admitted to a psychiatric hospital at some point in time. The incidence of suicide in the homeless is 35 times more than the general population. Alcohol dependence and substance misuse are other major co-morbidities in this demographic group. Unfortunately a lack of a permanent address, chaotic lifestyle and no access to public transport are barriers to health and a general mistrust of doctors can make people reluctant to seek help. An admission to hospital for these patients can be extremely beneficial if it leads to re-connecting them to help from social services and other sources of help.
Another interesting article:
Energy Drinks for Children - in the past 10 years there has been a massive increase in the number of 'caffeinated' drinks avaliable on the market, with sales marketing aiming at promoting their associations with power, youth and danger. Whilst caffeine is generally recognised as safe, it does stimulate the central and peripheral nervous system, improving concentration and performance in small amounts. Excess however can lead to GI upset, anxiety, agitation, sleeplessness and arrhythmias. In children these drinks should be avoided if possible and the long term effects of excessive consumption are unknown. Children and adolescents should be advised to stick to water if possible.
There was a section in the journal this month about notifiable diseases which I thought was useful for revision as one of the practice questions I came across this week was on this topic. A list of notifiable diseases can be found in the BNF. In the event that one of these notifiable conditions is identified, it would be one of the responsibilities of the junior doctor to notify a consultant in communicable disease. Further information is avaliable on the Health Protection Website: www.hpa.org.uk.
Finally, a report out this month shows evidence that antidepressants work only against severe depression and have little use in mild or moderate disease. (JAMA 2010;303:47-53). Drug treatment worked little better than placebo in a meta-analysis of patients with mild/moderate disease. All drugs investigated showed greatest benefits for only the most severely depressed.
Sunday, 7 February 2010
Stem Cells, Sex Offenders & Synaesthesia
So many things I could write about this week, it's hard to know where to start really.
Stem Cell Spare Parts - following the story of the woman who had the first stem cell trachea transplant. What is the future of stem cell transplantation? Student BMJ.
In June 2008, a patient became the first recipient of a trachea grown from bone marrow stem cells and chondrocytes. There is still a great deal of ethical considerations and legislation surrounding stem cell transplantation but in this case the treatment was able to save the patient's life. Looking ahead to the future, the author stated that it was unlikely that it would be possible to grow full organs from stem cells because there are too many different cell types (13 in the kidney) whereas in the trachea there are only two. However it may be possible in the near future to develop parts of 'hollow' organs from stem cells, such as the colon, blood vessels and nerves.
Should sex offenders be castrated?
An article appeared in the BMJ this week on this highly controversial topic, written by a professor of criminal psychology and a professor in forensic psychiatry. In Poland in November 2009 following a series of sex offences , the Polish President signed a law allowing the chemical castration of some sex offenders using antiandrogenic drugs. The drugs reportedly offer a dramatic clinical effect with offenders reporting no longer being preoccupied by sexual thoughts and having a markedly decreased sexual drive. Overall I think the general message is that this could only be ethically applied if patients were to consent to having the treatment. Whether or not this has a role in 'forced' castration against the patient's will, I don't think so
Synaesthesia
This is a harmless neurological condition where senser are exaggerated and stimulation of one sense results in a number of abnormal perceptual experiences, such as Tuesdays are green and music is not only seen but tasted. There are a number of different types of synaesthesia described by different people eg spatial-sequence synaesthesia where a person experiences seqwuences of numbers in a 3D form eg Monday is infront of them to the right etc... Perceptions are usually besic eg a colour as opposed to "when I hear that music I see a flowery vase on the table". Synaesthesia was first described in Nature 126 years ago however it is only recently that a diagnostic test for the condition has been created. The abnormal perceptions are thought to originate from 'crosstalk' between areas of the brain which are not normally involved with one another. There is a high prevalence of synaesthesia in the general population although it's important that people with the condition are not labelled and stigmatised. It is apparently harmless but important to know about to save the patient being made concerned for no reason.
WHO Surgical Safety Checklist to be started as of 01/02/2010
In England and Wales as of this date, for every surgical procedure carried out, it will be mandatory to complete this surgical checklist. See the checklist here:
http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html
Depression in Adults with a Chronic Health Problem
NICE have created a new set of guidelines in October 2009 on the management of these patients:
Depression is approximately 3 times more common in patients with long term chronic health conditions, with around 30% of patients affected. Severity of depression is determined by the number and severity of symptoms, and the degree of functional impairment. Presence of a physical illness can complicate the assessment of depression. The key goal of intervention in depression should be to achieve complete remission of symptoms.
Stem Cell Spare Parts - following the story of the woman who had the first stem cell trachea transplant. What is the future of stem cell transplantation? Student BMJ.
In June 2008, a patient became the first recipient of a trachea grown from bone marrow stem cells and chondrocytes. There is still a great deal of ethical considerations and legislation surrounding stem cell transplantation but in this case the treatment was able to save the patient's life. Looking ahead to the future, the author stated that it was unlikely that it would be possible to grow full organs from stem cells because there are too many different cell types (13 in the kidney) whereas in the trachea there are only two. However it may be possible in the near future to develop parts of 'hollow' organs from stem cells, such as the colon, blood vessels and nerves.
Should sex offenders be castrated?
An article appeared in the BMJ this week on this highly controversial topic, written by a professor of criminal psychology and a professor in forensic psychiatry. In Poland in November 2009 following a series of sex offences , the Polish President signed a law allowing the chemical castration of some sex offenders using antiandrogenic drugs. The drugs reportedly offer a dramatic clinical effect with offenders reporting no longer being preoccupied by sexual thoughts and having a markedly decreased sexual drive. Overall I think the general message is that this could only be ethically applied if patients were to consent to having the treatment. Whether or not this has a role in 'forced' castration against the patient's will, I don't think so
Synaesthesia
This is a harmless neurological condition where senser are exaggerated and stimulation of one sense results in a number of abnormal perceptual experiences, such as Tuesdays are green and music is not only seen but tasted. There are a number of different types of synaesthesia described by different people eg spatial-sequence synaesthesia where a person experiences seqwuences of numbers in a 3D form eg Monday is infront of them to the right etc... Perceptions are usually besic eg a colour as opposed to "when I hear that music I see a flowery vase on the table". Synaesthesia was first described in Nature 126 years ago however it is only recently that a diagnostic test for the condition has been created. The abnormal perceptions are thought to originate from 'crosstalk' between areas of the brain which are not normally involved with one another. There is a high prevalence of synaesthesia in the general population although it's important that people with the condition are not labelled and stigmatised. It is apparently harmless but important to know about to save the patient being made concerned for no reason.
WHO Surgical Safety Checklist to be started as of 01/02/2010
In England and Wales as of this date, for every surgical procedure carried out, it will be mandatory to complete this surgical checklist. See the checklist here:
http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html
Depression in Adults with a Chronic Health Problem
NICE have created a new set of guidelines in October 2009 on the management of these patients:
Depression is approximately 3 times more common in patients with long term chronic health conditions, with around 30% of patients affected. Severity of depression is determined by the number and severity of symptoms, and the degree of functional impairment. Presence of a physical illness can complicate the assessment of depression. The key goal of intervention in depression should be to achieve complete remission of symptoms.
Subscribe to:
Posts (Atom)