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