Focus on Japan

Japan was struck this week by a devastating earthquake which measured 9.0 on the richter scale. The compounded effects of the earthquake, a tsunami and damage to nuclear power stations has meant that Japan faces the worst catastrophe since World War II. I heard that doctors from the UK were flying out to offer assistance in the on-going relief effort and I started wondering. Who are these doctors? How are they contacted? Do they just drop all of their clinical workload at short notice and shoot off to the far-east, or are they already contracted to help wherever they are required? I wondered whether there is something I can do in future to help with scenarios like these. Once I have the experience I need, I hope that one day I'll be able to help those in desperate need in parts of the world. I feel that in the role of the doctor, there is a duty to help out our neighbours, even if they are on the other side of the world.

For the past few weeks I've been watching the BBC Three programme "Junior Doctors: Your Life in Their Hands". It's half-way through the series now and I have to admit that it's been quite compelling viewing. It's on BBC Three at 9pm on Tuesday nights. The programme follows 6 FY1/FY2 doctors in their work and home life during the first four months of their new jobs. I don't think I would have agreed to take part in the programme if I had been asked. I'm always skeptical about how the media portrays these things and I thought that the BBC would edit the programme to make it seem more drammatic than it actually is. What I've found though is that it looks like quite a realistic portrayal of life on the wards. Talking to Amy (who's an FY1 in Glasgow), she agrees. It's interesting hearing about the doctors' thoughts and attitudes towards their new jobs. Some of the FY2s offer very good advice to the FY1s and I hope that that is always the case. It's good to have role models to look to support when times are tough. Fortunately the programme hasn't put me off medicine and in fact the effect has been quite the opposite!

On a good news note, there is an article in the BMJ about Cystic Fibrosis this week which follows on quite nicely from the talk given by Dr McCormick at the paediatrics symposium earlier this week. It reports the results from a cohort study carried out between 1990 and 2007 which has found improved survival rates in patients with low respiratory function. Over the past 20 years, CF patients with FEV1 of <30% have seen an increased median survival from 1.2 years to 5.3 years. The study reflects the major improvements which have taken place in the management of CF over the past 20 years, however much more work needs to be done to look after these young patients.

Annual MSC Symposium: Medicine and Crime (+Paediatric Symposium)

Here are some key learning points I picked up from todays talks:

1. The Role of the Forensic Pathologist
Atherosclerotic cardiovascular disease is the most common primary cause of death on a death certificate. A post-mortem examination should never be carried out without the context of the death being known ie. what the circumstances of the death were. The aim of the autopsy is to work out the cause of death, the mechanism of death and the manner of death.

2. Witness Familiarisation
This talk was all about what to expect if asked to attend court as a witness. It was interesting to give an insight into how the court system works. Familiaristation is now recommended for all witnesses but it is important to stress that this is not the same as "coaching" which is an illegal process where witnesses are coached on what to say when cross-examined in court. Most people who go to courts are disadvantaged by ignorance of the court process. In Scotland there are three courts: high court, sheriff court and district/JP court.


3. Forensic Psychiatry
The Mental Health (Care + Treatment) Scotland Act (2003) applies to forensic psychiatry patients. CORO is a type of restraining order. Detaining someone in hospital is effectively "taking away somebody's freedom in order to treat them". These patients do not have insight into their conditions. For a successful outcome, reciprocity is of paramount importance. Balanced attitudes towards offenders is required. Have the ability to step back and not get involved with what patients have done in the past. The role of the doctor is not to be judgemental.

Folie A Deux is "shared psychosis", a rare psychiatric phenomenon where symptoms of a delusion are transferred from one person to another.

Paediatric Symposium:
1. Paediatric Prescribing
Lack of evidence in paediatrics leads to increased errors in prescribing. In children there are changes in absorption, distribution, metabolism and excretion. IM injections should be avoided in children where possible. For IV injections / cannulas, local anaesthetic cream can help. Dose calculation is based on age, weight and surface area but the dose MUST NOT exceed the adult dose. Round off the calulated dose for easier administration. Be careful with DECIMAL POINTS! Be very cautious about ALLERGIES in children. Licensed medicines should be used but this is not always possible. A good idea is to keep a prescribing checklist ie. dose and frequency of medications. If prescribing unlicensed products, the prescriber must take full responsibility.

2. Cystic Fibrosis
Scottish newborn screening for CF was introduced in 2003. Presentations of CF: newborn screening, failure to thrive, steatorrhoea and recurrent LRTIs. There are >8000 patients in the UK with CF today. Males generally live longer than females. Respiratory failure is the commonest cause of death. CFTR channel is anapical membrane chloride channel of exocrine epithelial cells which is defective. CFTR gene is located on chromosome 7. Respiratory exacerbations of CF can be identified by change in sputum colour/volume, increased cough, dyspnoea, haemoptysis, fatigue, lethargy, fever and weight loss. Meconium ileus presents in the newborn period with bowel obstruction and insippated viscid meconium in the bowel. Laparotomy, small bowel resection and temporary ileostomy may be required. Pancreatic insufficiency occurs in 85% of patients with CF. A,D,E and K are fat soluble vitamins. CF related diabetes occurs in 12% of CF patients age 15-19 years. Young women with CF often develop secondary amenorrhoea and men are almost always infertile.

3. Childhood Leukaemia
Dramatic improvements in survival rates have occurred in the past 30 years. AML and ALL are the most common forms of childhood leukaemia in children. Leukaemia is the commonest form of cancer seen in childhood.


4. Faints, Fits and Funny Turns
Seizure is a transient abnormal excessive discharge of neurons residing primarily in the cerebral cortex. The diagnosis is ALL IN THE HISTORY. Status epilepticus is the commonest neurological emergency. Ask how the child's general school development has been. A witness report of a seizure is VERY IMPORTANT. What were they doing at the time, sleeping? LOTS of differential diagnoses exist which are NOT epilepsy. Day dreams and absence seizures can be hard to tell apart. Absence seizures never last more than 30 seconds. Cardiac symptoms of a vaso-vagal attack include sweating, palpitations, pallor, tunnel vision are tinnitus. Conscious level tends to return FAST (unlike in epilepsy). Investigations are often not require. Negative effects of too many tests can include excessive worry and anxiety for the family.

5. Neonate - Newborn Examination
Cephalohaematoma doesn't cross suture lines. Caput succadaneum can cross suture lines. Thin upper lip, smooth philtrum - signs include fetal alcohol syndrome. Pre-auricular skin tags can be a sign of kidney disease. Barlows/Ortolani's tests are only 30% - 40% sensitive. Erb's Palsy (birth trauma) leads to the "waiter's tip" sign. Erythema toxicum is a harmless dermatological syndrome.

6. Neonatal Transport
Fascinating lecture from one of the new paediatric consultants in Ninewells on his experiences transferring neonates between hospitals in England, Scotland and Australia. ECMO stands for extra-corporeal membrane oxygenation.

Minimum Pricing of Alcohol - Is it too little, too late?

Victoria Infirmary, Glasgow

A quick run through of some of the most important messages and articles from the BMJ this week:

After the minimum pricing bill failed to pass through parliament in Scotland last year, now it's England's turn to try to introduce the incentive. The plan is for minimum prices to be 21p per unit of beer and 28p per unit of spirits (ie. 38p would be the cheapest price for a can of weak lager and £10.71 for a litre of spirits. Could this make a real difference in the alcohol consumption levels and associated harm in the UK? Doctors groups are unhappy with the preposals because they are seen to be "too eak" and not significant enough to make a difference. I would be inclined to agree with them however it may be necessary to start with these minimum prices before higher prices can be introduced. Every year in the UK approximately 40,000 deaths are partly attributable to alcohol and hospital admissions amongst 16 - 24 year olds related to alcohol are rising fast.

A Swedish study of young army conscripts has found that high blood pressure in young adults is a risk factor for premature death. In particular, a diastolic blood pressure above 90mmHg is linked to increased risk of death. What is not known, is whether treating high blood pressure in young adults would necessarily reduce risk of premature death in these young people.

No longer can people say that mental health and physical health are separate entities. There is now considerable evidence to show that patients with psychiatric disease are at increased risk of other medical co-morbidities. In a letter to the BMJ this week, Beary and Wildgust say that their research shows that schizophrenia is associated with a 25 year reduction in life expectancy with the top four most common risk factors being low fitness levels, hypertension, smoking and diabetes. These same four risk factors were identified by the World Health Organisation in 2009 as being the causing the biggest risk of mortality.

And in some good news this week, the European parliament have overwhelmingly approved new legislations to prevent the sale of "false medicines" to the general public. Estimations show that approximately 1% of all medicines legally sold to the European public are in fact false but in other parts of the world, this figure can be as high as 30%. Falsified medicines have in the past been called "silent killers".  The new laws cover internet sales, penalties for violations and improved traceability of the exact origins of where a drug comes from.
The ultimate goal is to reach a point where all pharmacists will be able to verify the authenticity of a drug before it is dispensed.

Breast Feeding, Diabetes and Explaining the Unexplainable

Random orienteering photo

Big news this week is that I have a job lined up for later this year! If all goes to plan I'll be starting work at the Victoria Infirmary, Glasgow in July.

Several interesting articles in the BMJ this month and alot to talk about. Here's a brief overview of some of the features which caught my eye:

Six months of exclusive breast feeding: how good is the evidence? - Back in January this year, Fewtrell et al published a review article which questions the advice to mothers to breast-feed exclusively for the first 6 months of life. This has unsurprisingly led to some uncertainty among mothers, medics and families internationally. A letter to the BMJ this week however criticises the article and some of the references cited. Public health groups have spent years promoting the benefits of breast feeding and it seems to me that before releasing an article such as this which throws all of the advice info doubt, more scrutiny should have been placed on the original evidence.

Is the NHS failing elderly patients? - This story hit the news in a big way this week with reports of poor standards of care of elderly patients (in England). Pain control, discharge arrangements, communication with patients and their relatives and nutrition are areas which are not being done well. Indeed just recently whilst on my medical shadowing block a complaint was made because a patient had been sent home on the wrong medications. It is improtant to know areas where we need to improve and what this helps to do is to highlight the simple things which can be done much better. Several of these measures are in areas where the FY1 is directly involved eg. discharge scripts for patients therefore its good to know areas where mistakes are more likely to be made.

Islet transplantation in type 1 diabetes - Is this the answer to finding a cure for type 1 diabetes? Back in 2001 this was the prediction however 10 years on it is only suitbale for a small number of patients who have severe glycaemic lability, recurrent hypoglycaemia and hypoglycaemia unawareness. Most patients do not in fact fit the criteria for islet cell translplantation and it is not a possible treatment for type 2 diabetes. Interestingly although insulin independence can be achieved in some cases, many patients will need to resort back to insulin treatment. Patients with islet cell transplantations must also be given long term immunosupressant agents whose long term dangers are somewhat unclear. The authors conclude that while progress in this field has not been as quick as was once anticipated, more is now known about the technique and advances in transplantaiton and patient management are likely to further improve clinical outcome of islet cell transplantation procedures in the future.

Type 1 Diabetes in Children - Is it easily missed? - The incidence of childhood type 1 diabetes in Europe is increasing and the diagnosis is often delayed. Often teachers and parents may not be aware of noticing children who may be drinking alot or peeing frequently. A child may present with quite non-specific symptoms and the question of new onset diabetes should be raised. Children can develop dehydration and acidosis, deteriorating rapidly on first presentation.

Explaining the Unexplainable - A Glasgow GP writes in to say that doctors are not very good at understanding and explaining the unexplainable. He writes that when he started work, people would say things like "If the symptoms don't make sense then there is nothing wrong with them", "Frequency of attendance is inversely proportional to likelihood of pathology" and that "referring the anxious only makes them more anxious". I think that the difference between him and myself is that he writes with years of experience of medicine under his belt. With more practice I hope that it will be possible to sort the serious from the insignificant, however until that becomes the case, it will be important to stick to what I've been taught at medical school!

Liberation for Egypt

Friday 11th February was a momentous day in Egypt's history when, after 18 days of protest, President Hosni Mubarak stepped down from power after 30 years of rule over the country. The announcement was met with dramatic scenes of jubilation and celebration in Cairo, concentrated around Tahir square. I am relieved that my parents left Egypt having been living there for four years, before the riots began. During the protests, the reports sounded like the city of Cairo which I know fairly well had become dangerous and chaotic. After all of the destruction (and many dead/injured of which I am 100% sure the Egyptian authorities are under-reporting numbers), I hope that the country will become stable and improved in future. I think that the next 12 months will be a very difficult time for Egypt as it tries to recover from the events of the past few weeks but I hope that the people see the benefits in the near future.

The theme of this month in uni is very much on how to improve patient safety in healthcare. I'm working with two other students on a project on improving venous-thromboembolism patients in hospitalised patients. We have found that there is a significant amount of evidence to show that prescribing mechanical or chemo-prophylaxis can improve patient outcomes to prevent deep vein thrombosis or pulmonary embolism. Worryingly though we have also found evidence from a worldwide study to show that prophylaxis is commonly either underprescribed or poorly prescribed. What we want to do is to find out if this is the case in Ninewells Hospital and if so, what can we do about it.

Continuing with the theme of patient safety, there are two articles in the BMJ this month on the same subject. The first: Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation, Benning et al, asks what the impact of this intervention was from the Institute of Health Improvement (IHI). The answer was that the quality of monitoring sick patients on medical wards participating in the project was better than hospitals not taking part. The study shows that quality improvement interventions tackling specific issues such as hospital acquired infection are easier to demonstrate change that massive systemic change in large organisations. The next article: Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase, Benning et al, asks whether the NHS has become safer as a result of the Safer Patients Initiative. They found that while the NHS in England has become safer, hospitals taking part in the initiative were not necessarily safer than those not taking part.

Finally, there was a very interesting article in the BMJ News this week in the "See One, Do One - Working and Surviving as a Junior Doctor" section, written by Dr Freda McEwan, a CT1 trainee in psychiatry. She writes about an instance as a surgical FY1 when she had to break bad news to a patient. Despite evidence of a diagnosis of disseminated malignancy with metestases, she had not been told of the news. Despite the doctor's recommendations that the discussion with her be had with a more senior member of staff and not during the night (she had been asked to see the patient at 1am), the patient was terribly upset saying "why won't anyone tell me" and asking the doctor "do you know what is wrong?". Not wanting to lie, the doctor told the patient the diagnosis, and she was pleased because she said that "finally she would be able to plan for the future". I think that the doctor was correct not lie and was correct by telling the truth. However I do not know if she should have given the diagnosis that night, so late on. She ends the article by saying "as a junior doctor, you often feel that the public has higher expectations of you than you merit. But as any doctor, all you can ever do is your best."

Now on that note I can enjoy my Valentines Day tea which Amy is cooking for me tonight (lucky me!).

Predicting Risk in Atrial Fibrillation

During my medical shadowing block in January, a decision was made for a patient I was looking after to be started on warfarin for anticoagulation. She had been admitted to the hospital with congestive cardiac failure secondary to atrial fibrillation. Patients who have AF are at increased risk of developing a systemic embolism and an ischamic stroke. On admission, this patient was on a low dose of daily aspirin (75mg once daily) however she had several risk factors which put her at increased risk of stroke. The question is which patients with AF should be anticoagulated, if not all of them. Warfarin is a dangerous drug, associated with an increased risk of haemorrhage, particularly if dosing is poorly controlled. In order to justify starting a patient on warfarin, it must be judged that the benefits of reducing risk of stroke outweigh the disadvantage of increased risk of harm.

In the BMJ this week, an editorial was sent on this topical subject titled 'Anticoagulation in people with atrial fibrillation'. The author argued that anticoagulants are underprescribed. In the past, the CHADS2 classification scale has been used to predict patients with AF at risk of stroke. The patient gains a point for each of: Congestive Heart Failure, Hypertension, Age >75, Diabetes and 2 points for stroke. Patients with a score of 2 or more are recommended to be started on warfarin. Now, a new index has been developed called the CHA2DS2VASc score which takes more relevant risk factors into consideration. This new score takes into account sex of the patient and history of vascular disease. The results of the new index is that more patients are recommended to be anticoagulated. In fact, only 8.6% of patients with AF in general practice would be considered low risk. An advantage of the new CHA2DS2VASc score is that it is better than CHADS2 at predicting patients at low risk of developing a stroke.

There has been much discussion recently about developing new anticoagulants to replace vitamin K antagonists. It will be interesting to see whether development of new, safer anticoagulants will result in doctors lowering the threshold for prescribing anticoagulants. Dabigratan is a direct thrombin inhibitor which may result in fewer intracranial haemorrhages than warfarin. It remains unclear whether prescribing trends with anticoagulants will change in the forthcoming years as they become safer.