Sports Energy Drinks

Bradley Wiggins - Amazing Achievement!!

It was great on Sunday watching Bradley Wiggins cross the finish line of the 99th Tour de France as overall winner. What made the day even better for Team Sky was that Mark Cavendish won the sprint on the day, his 23rd stage win. While Bradley Wiggins took much of the attention, Team Sky showed that it really was a team effort in the end. Wiggins could have just let up in the last few laps of the Champs-Elysees, savouring the moment, waving to the crowd - but instead he was leading the peloton into the final sprint to help tee up Mark Cavendish to sprint to the finish for the win. It was an amazing achievement for British cycling and with Chris Froome finishing second overall, I don't think we'll ever see such a dominant performance from a British team in the Tour de France. It's incredible to think that some of these guys will be getting up, dusting themselves off and starting training for the Olympics, which starts in just four days time.

Keeping on the subject of sport, the BBC's Panorama ran an episode last week in conjunction with the BMJ about "The Truth Behind Sports Drinks" (it'll still be available on BBC iPlayer for a week or so). Sports marketing is big business, praying on the needs of sportsmen and women seeking to improve their performance, or just as a "fashion accessory" to be seen using whilst taking part in sport. Energy drinks such as Lucozade and Powerade make claims on the adverts and packaging about "boosting performance" and are becoming an "essential piece of sporting equipment". They advise people to drink before they feel thirsty. This is all a new concept. In the 1970s, runners were discouraged from drinking too much for the fear that it would slow them down. When the evidence is carefully scrutinised, it doesn't hold up. A lot of the studies cited are sponsored by the companies wishing to promote their products and the evidence is weak. What the promotion of these products has achieved is to undermine the importance of thirst. This is the basis that the only symptom of dehydration is thirst. Drinking too much can lead to exercise associated hyponatraemia, with 16 marathon deaths recorded due to a drop in sodium levels. The most effective way to prevent hyponatraemia during marathin running is said to be to prevent having a positive fluid balance. When the BMJ asked the major manufacturers of sports drinks to supply evidence, only GSK (who make Lucozade), supplied evidence. Other problems arising from sports drinks are the risks of obesity (people drinking too much - one in four American parents believe sports drinks are healthy for their children), and increasing numbers of patients with diabetes. So in conclusion, the evidence is not all there - sports drinks are not all that they are cracked up to be, and only drink water when you're thirsty. Plus it'll save you a lot of money!

The Challenges Facing New Doctors

Only one more week until the changeover and the new FY1s step up and take over. The media seem to take of advantage of this, by coming up with 'shocking' headlines and describing August as "the killing season" in NHS hospitals. This doesn't really help the confidence of the new doctors who will already be nervous at the prospect of taking on massive responsibility. A column in the BMJ this week written by an inter-calating medical student talks about exactly this. What people often seem to forget is that we've been at medical school for 5, 6 even 7 years sometimes working up to this point, and the new FY1s will be much more prepared than they realise. Studies have shown that the care given by new doctors in training is comparable with that of their senior colleagues. I'm giving a talk to the new FY1s next week to give some advice on how to work as a save, effective FY1 doctor and I'll try and remember how I felt when I was in their shoes only a year ago. I'll be moving on to a new hospital on the 1st August and no doubt I'll have plenty of new challenges to get my head around. 

I presented the gentamicin audit which I talked about in the last post before the wedding to the department in June and it seems as if it was good timing to do an audit on gentamicin because the new prescribing form is being rolled out across NHS Greater Glasgow and Clyde next week. No doubt there will be a few speed-bumps initially as doctors and nurses get used to it but hopefully it'll lead to safer prescribing and closer monitoring of IV gentamicin in the long run. I'll try and recruit some of the new doctors in the hospital next year to repeat the audit next January to see if there really is an improvement with the new prescribing form.

The president of the Royal College of General Practitioners (Dr Iona Heath) this week spoke out in praise of young doctors. In a letter to the BMJ she wrote that too much emphasis from an early stage of training new doctors is on science and understanding. However science is never enough in a profession which seeks to try to alleviate human suffering. Students and doctors are not being encourgaed enough to think and question assumptions about the nature of science and medicine. She continues in the letter to talk about the erosion of continuity of care, and the lack of a 'team based' attitude to practicing medicine (only this week we had to our FY1 end of year ball due to a lack of interest from our senior colleagues). She highlights that with shift patterns and the European Working Time Directive, it is difficult to learn from our actions (I used to see patients on night shift and then wonder what had happened to them the following day - I would sometimes go and check out patients at the start of my next shift to see what had happened but often time wouldn't allow). 

She also argues that there is a rapidly changing culture in medicine of 'protocol and guideline medicine'. Many doctors are now afraid not to follow the guidelines and although I've only had one years experience, I am already starting to feel that there is a great deal of "over-treatment" and "over-diagnosis" in the NHS at times such as end-of-life care which can be dangerous and un-necessary. According to Dr Heath this is "destroying the confidence of many young doctors, so that they no longer feel able to make the courageous professional judgements necessary to tailor treatment to the needs, aspirations, value and context of individual patients". Finally she says "as I grow old and frail, I want a doctor who thinks and questions, not one who feels obliged to blindly follow protocols".

Wedding and Honeymoon Photos!

It came and went in a flash - the wedding was an amazing day. Great to see so many family and friends on the day, it seemed like all of the guests enjoyed themselves as much as we did!
 

Brig O'Doon, Ayr, Scotland - Saturday 23rd June 2012

Reethi Beach Resort - The Maldives

Gentamicin Pescribing Audit Project

 Last week I presented the results of the audit project I've been working on in the hospital where I work as part of the monthly medical division clinical governance meeting. Audit is an important process whereby everyday practice is compared to the ideal standards and practice. I wanted to audit prescribing of gentamicin in the hospital. It is an antibiotic which has nephrotoxic and ototoxic effects if given in high concentrations. Monitoring of blood levels is very important to ensure safe prescribing and levels should ideally be documented on a monitoring chart, with the dose calculated based on the patient's weight and renal function. Duration of treatment should not exceed 72 hours except in exceptional circumstances. I audited this process and found that in more than half of cases at least one of my outcome measures were not being completed correctly. In these patients, it was more likely that renal function would be affected, leading to my suggestion that patients will directly benefit form improved compliance with these monitoring protocols. The plan is for a new gentamicin prescribing and monitoring chart to be introduced in the hospital in August 2012 which will hopefully improve compliance. There's a lot coming up over the next couple of months (the wedding, portfolio hand-in etc) so I'd imagine that posts on here are going to be a bit more sparse over the next while. More to follow...

Notes From On-line Modules - Monday 16th April

Notes From On-line Modules - Monday 16th April

1. Diabetes Management + Insulin Types

Novorapid, Actrapid, Humulin S and Humalog are fast acting, short duration. Humulin M3 is fast acting, long lasting. Humulin I and Insulatard peak slowly and are long lasting. Insulin Detemir and Insulin Glargine are very long acting. In patients in DKA requiring insulin for infusion - short acting insulin eg. Actrapid should be used.

2. Diabetes Management: Prescribing Insulin Safely

If unsure about the correct type of insulin which a patient normally receives - clarify with the GP. If discharging a patient on Insulin in whom steroids have been stopped - advise the patient to increase the frequeny of blood glucose monitoring (risk of hypoglycaemia increases). If discharging a patient on a new insulin regime they should ideally be seen by the diabetes team as an outpatient in 1-3 days.

3. Information Governance

Next of kin does not have a 'right to know' information about a patient. In a "serious offence" situation the doctor can disclose information about a patient to the police as acting in the "public interest". Inadequate clinical records are cited as a factor in approximately 80% of indefensible medico-legal cases. Ward round notes should include: summary of the case, discussion with the patient, examination findings, relevant investigations, impression/diagnosis and management plan.

4. Palliative Management of Nausea

Chemotherapy induced nausea involves the neurotransmitted 5HT3 - large amounts are released when the gut is irradiated. Ondanstron is a powerful 5HT3 antagonist. Opioids can stimulate the chemoreceptor trigger zone (CTZ) - this is best treated with either haloperidol or metoclopramide. Cyclizine has no effect on the CTZ. Cyclizine acts upon the vomiting centre in the brain. Side effects of ondansetron and cyclizine include constipation. For nausea caused by constipation metoclopramide would be the drug of choice. For nausea induced by hypercalcaemia, this should be treated with haloperidol.

5. Pharmacy: Adverse Drug Reactions (ADR)

These are surprisingly common! And can be fatal! Most commonly they are caused by NSAIDS, diuretics (renal impairment, hypotension and electrolyte disturbance) and anti-coagulants. The main way to report adverse drug reactions is via the "Yellow-Card Scheme". In the BNF new medicines are marked with a small black triangle (these often have a higher rate of ADRs. All health care professionals can report adverse drug reactions using this scheme.

6. Pharmacy: Prescribing in Pregnancy

A teratogen is an agent or factor which can cause congenital malformations. Nearly all drugs cross the placenta. The most susceptible period is 3-8 weeks post-conception. Ideally best practice is to rationalise and alter medication prior to pregnancy through planning (eg. stopping certain anti-epileptic drugs such as sodium valprotae). Sources for doctors if they are concerned about the effects of drugs in pregnancy include: the BNF, Toxbase and EMC (http://emc.medicines.org.uk/emc). Trimethorim, for example, is not recommended in pregnancy. Cyclizine is a widely used anti-emetic in pregnancy for the treatment of nausea.

Filaggrin and Medical Eponyms

Moness Country Club, Aberfeldy

Had a great weekend away over Easter with the family staying up in Aberfeldy for the JK orienteering held over the Saturday and Sunday. Finished 10th on my course but still took over 2 hours both days so lots of space for improvement!

In 2008 for my BMSc in Genetics I carried out some research on the role of genes coding for skin barrier protiens, specifically the keratins. At the time the lab was involved in some break-through research regarding the role of the protein, filaggrin. It is now estimated that as many as one in ten European people have a mutation in the filaggrin gene which results in a dysfunctional skin barrier. This can manifest itself as painful skin fissures in the heels, lips and ears. It is recommended that moisturisers are applied liberously during times of low humidity (such as winter), to help maintain skin hydration. The results of this recent study are summaries in the BMJ this week in the 'Minerva' section.

Medical eponyms are commonplace in medical school or clinical examinations but rarely heard in everyday clinical practice. Des Spence (Glasgow GP who writes a weekly column in the BMJ) visits this topic this week. He argues a time may have come to evaluate the evidence of the usefulness of clinical eponyms and to move on that the 'classic' medical examination taught systematically to all medical students. Of course, all students must learn how to examine patients effectively - this is a key skill for every new doctor, but is it time we updated the clinical examination. Could the increasing use and availabilty of bedside imaging (eg. portable ultrasound) be used to improve clinical practice? Dr Spence thinks we should teach all medical students how to ultrasound patients. Imagine a world with portable ultrasounds in A&E to examine the abdomens of surgical patients, or in the coronary care unit to examine the heart function of new cardiology patients? So much time could be saved! Which would be more sensitive at picking up a physical sign eg. hepatomegaly - the scanner, or the doctor's palm, or both combined?

 

Craig a Barns - JK Day 3