Taking a Break...

<--- The beach in Barbados. (elective countdown - 5 weeks to go!)





Going to take a break from the blog for a month or so to concentrate on revision for finals, thanks for reading though!

May Review

Here are the most interesting articles / stories I've heard about from the BMJ in May:
- New consensus on screening has recommended that all patients over the age of 55 years should have a flexible sigmoidoscopy as part of the national bowel cancer screening programme. This could be done by doctors or specialist nurses. This test has been shown to catch two thirds of colorectal cancers.
- In Spain, surgeons worked for 24 hours to carry out the first 'full' face transplant.
- Regarding viewing the body after a traumatic death, relatives should be informed of the choice and given the option. The decision should rest with the relative.
- The national patient safety agency reports more than one incident in the past year where leaving a tourniquet on has led to people losing digits - beware!
- The Australuian government has decided to remove branding from all cigarette packaging as of 2012 to reduce marketing advertising of cigarette brands.
- A new way of labelling and packaging foods known as the 'traffic light system' is in the process of being passed through the European courts. Some supermarkets in the UK have already adopted the scheme but it is being held up at present by arguments that some foods which should be included from time to time as part of a balanced diet eg margerine / cooking oils.
- Screening again, a study was carried out recently to find out whether sending 'informed choice' letters inviting people to screening would lead to less uptake than the 'standard invitation' for screening. Informed choice tells people about some of the disadvantages of screening. The result was that there was no difference in the number of people who attended (approx 60%). What was apparent however was that the most significant marker of a person's likelihood to attend for screening was their socio-economic status.
- What will the legacy of the 2012 Olympic games be (and other major sporting events). New research shows that politician's promises of long term health benefits for the host nation / city are largely unfounded. Quality of evidence of health improvement is low, most measures are of economic improvements. With the 2012 games around the corner, perhaps more work should be done to evaluate the effects of the games.

Smoking in Pregnancy, Improving Outcomes from Surgery and Medico-Legal Cases

Last post from sunny Oban then its back to Dundee - only 4 more weeks of 4th year to go! The next two articles were sent from The Obstetrician & Gynaecologist - a publication from the Royal College of Obstetricians and Gynaecologists.

1) Smoking During Pregnancy
there is still a high incidence of smokers in pregnancy. Effects on the unborn child can be devastating. Smoking is still the single largest preventable cause of fetal and infant morbidity in the UK. Potential problems include placental abruption/praevia (3x greater risk), prematuire rupture of membranes, fetal growth restriction, ectopic pregnancy, intra-uterine infection, fetal growth restriction, sudden infant death syndrome etc. Motivational assessment, 'talking' therapy and one to one councelling are ways of helping mothers quit. The aim really is to empower the individual. Carbon monoxide tests can be used to assess maintenanct. Nicotine replacement therapy is best avoided in pregnancy because nicotine crosses the placenta. One way of helping people quit is to dispel any untrue theories mothers ay have eg. that a small baby is good because it won't hurt so much when its born. Perhaps eduction is the best way forward...

2) Improving Outcomes from Gynaecological Surgery
A cancer 'survivor' is someone who has 'completed the initial cancer treatment, is living with progressive disease before the terminal stages of illness or who has had cancer treatment in the past. Most gynae cancers are curable IF THEY PRESENT EARLY. In the majority of cases treatment-related morbidity IS PREDICTABLE. Major morbidities include: GI adhesions, bowel obstruction, chronic diarrhoea after radiotherapy, radiation cystitis, ureterovaginal fistulae, infertility, decreased sexual function, peripheral neuropathy and lymphoedema which can become severe. It is important to be aware of all of the potential sequelae of treatment but the majority of survivors can look forward to a good quality of life, supportive relationships and the many positive aspects of a continued life.

Also every 3 months the MPS sends its 'Casebook' magazine for members which at the back contains a series of medico-legal cases of recent interest. Here is one interesting case - a 30 year old man attends A&E after noticing a widespread skin rash. He has rheumatoid arthritis and is taking Methotrexate, however the junior doctor on call forgets to ask him what medications he is on and the patient doesn't reveal this info. The doctor correctly recognises that the man has chickenpox (varicella zoster viral infection) and sends him home. He feels worse and both out-patient phone services and the GP agree with the provisional diagnosis and tell him his symptoms will improve with treatment. He goes on to collapse at home, is taken to hospital and diagnosed with disseminated meningoencephalitis. Despite therapy with IV acyclovir, he dies due to multi-organ failure secondary to sepsis. The family made a claim against all aprties involved and the case was settled for a high sum.

Should the UK go for the "opt-out" of organ transplantation policy?

This topic seems to come up again and agina and was brought to my attention this week on a TV debate on BBCone. Although I've always been for the "opt-out" scheme which has been adopted in some coutries eg Spain, I started to see the ethical points raised by arguments AGAINST the proposals:

FOR the opt-out schmeme:
Saves lives, reduces waiting times for organ transplantations, beneficence (doing what's best for the patient needing the transplant) and justice (benefiting the greater good of the population) are just some of the points for.

AGAINST the opt-out scheme:
Loss of patient autonomy on deciding what is to be done with their organs following death, the danger of harvesting organs against family members of the deceased's wishes leading to distress, possibility of leading to an increase in mistrust in doctors about how organs are handled (I don't believe this) and also the loss of that sense of 'giving someone the gift of life' if organ donation becomes automatic.

The opt-out organ donation scheme was most recently reviewed in 2010 and will be reviewed again in the near future. Any scheme would need to come with aggressive advertising to allow people to opt-out of the scheme, however I beleive that before jumping to this more should be done to get people registered to opt-in. I'd like to see GPs asking patients, schools requiring all leavers to register their wishes or people passing their driving tests to register (although I think this may already be being done).

Should we sterilise drug addicts?

Things I'm reading at the moment:
Should we pay drug addicts to become sterilised? - Doc2Doc Discussion. The idea is a financial incentive to encourage drug addicts to either become sterilised, or to take up long term methods of contraception. An ethical dilemma.
For - Babies born to drug dependent mother's have a very difficult start to life.
Against - Depriving someone of their human rights. Not ethical to offer sterilisation when more short term alternatives are avaliable. Does including a financial incentive impede the user's ability to consent? Sterilisation of drug addicts, then where do you stop? Patients with heritable diseases?

A Career in Dermatology - Student BMJ
An article in the journal gives a further insight into dermatology as a potential future speciality. To become a consultant dermatologist the typical route is to finish foundation years, then enter either core medical training or acute care common stem (take MRCP part 1 exam minimum), then apply for a specialist training post in dermatology (ST3 level). These posts are highly competitive and often candidates have a PhD or MD. Specialist training lasts for 4 years. Things that can be done right now: get undergraduate experience, enter essay competitions and get involved in research.

Also...
Is Modern Genetics a Blind Alley? - BMJ
The Academic Foundation Programme - Student BMJ
Is ADHD a valid diagnosis in adults? - Student BMJ

Diagnosing Death, Thyroid Disease and Medical Eponyms

<---Sunrise, Mt Sinai, Egypt. June 2009

Diagnosing Death - from the BMJ Podcast (16/04/10)

Dealing with death is probably one of the hardest things to cope with as a junior doctor, particularly if you are being faced with it for the first time. Here are a few tips on how to manage the situation:

Verify the death - check patient identity, observe patient appearance and note absence of any respiratory movements (over a 5 minute period). Auscultate over the chest and listen for heart/breath sounds. If any activity at all, reassess for a further 5 minutes. Check corneal reflexes, pupil response (reflexes) - pupils will be dilated and non-responsive. Check motor response (apply supra-orbital pressure) Check for pulses - carotid (both sides), radial and femoral. Wash hands. Make an entry in the patient's notes - date and time of death, findings on examination.

Breaking Bad News - Step back, take a deep breath, don't rush into the situation, think about your management plan. Communicate with family members, next of kin, what has happened. Do this in a private, quiet place eg. relatives room (clean and representable). Don't keep people waiting, turn off phone, pager etc and ensure NO interruptions. Use lines eg. "I'm sorry to say we have some very bad news". Use terms dead / died, as opposed to 'passed away', 'deceased' etc. Avoid common euphemisms. Discuss practical issues eg what will be done with the body, how the body is laid out. Inform the GP of the death.

Consider need for a post-mortem / referral to the procurator fiscal eg cause of death is uncertain, suspicious, accidental, violent, due to surgery/anaesthesia. If there is any cause for concern / suspicion, do not complete the death certificate - instead, discuss with a senior colleage.

Complete a death certificate. Ask yourself, am I the best person to complete this certificate? Legally someone can only complete a death certificate if they have seen the patient in the past 14 days. You MUST see the body after death. Once it is completed, it should be taken to the registrar of births and deaths (usually by the patient's next of kin). If there is any doubt, discuss with senior colleagues before proceeding.

Some OnExamination question corrections:
Differential Diagnosis - Thyroid Disease:
deQuervain's Thyroiditis - most frequently seen in young females. Often follows a flu-like illness. The patient commonly reports pain and a tender thyroid gland. It is usually a self-limiting illness.
Follicular Carcinoma - spreads haematogenously to the lungs. Treatment is with a total thyroidectomy. It presents with a firm neck nodule.
Anaplastic Carcinoma - rapid onset growth of a hard, woody thyroid lump which eventually progresses to acute dyspnoea. Abysmal prognosis.
Hashimotos's Disease - the commonest cause of primary hypothyroidism. Usually presents with signs of myxoedema. On examination there is a diffusely enlared non-tender thyroid gland.
Multinodular Goitre - may be asymptomatic or may present with pressure symptoms eg. dysphagia, dyspnoea or hoarseness. Particularly endemic in areas with iodine deficiency.

Medical Eponyms:
Rovsing's Sign - RIF pain exacerbated by pressing in the left iliac fossa (bowel is pushed onto the inflamed appendix) - classic in appendicitis.
Courvoisier's Sign - Law that states that in the presence of painless obstructive jaundice if there is a palpable bladder then the cause is unlikely to be gallstones.
Grey-Turner's Sign - Bruising of the flanks seen in retro-peritoneal haemorrhage.

Tumour Markers:
Carcinoembryonic antigen (CEA) is a commonly used tumour marker in colon cancer.
alpha FP and bHCG are markers raised in testicular cancer.