Statistical Process Control

Statistical Process Control

I am always keen to learn about new ways to enable me to examine how effective the processes I am part of are at achieving end results. When a process changes, does it change the outcome for the better, or for the worse?

Today saw me attend a basic 1 day course on “Statistical Process Control” (SPC) and I confess that I was very nearly put off by the title. I’m glad I went on to do the course as I think I learnt something new and useful.

What is it about?
SPC (at this level) described a simple method to examine common types of information available in a healthcare setting. By applying SPC to the information, it should be possible to understand:

• Why data varies – is it due to a special case, or are we describing “normal” variability?


• What does the information say about our performance against a given target?


• If we make a change to our processes, how does this influence our outcomes?

I used it to look at the last 25 people who attended for a “tier 2” assessment and were allocated a clinic appointment with a clinician to access opiate substitute treatment. The control chart (see below) shows the number of days between tier 2 assessment and clinic appointment on the “y” axis, with patient id number for consecutive patients on the “x” axis. The green arrow is a target of 21 days. The mean wait (green line) falls below this at 13 days and the 2 dotted red lines show the upper and lower confidence intervals.

Confidence intervals are calculated at 3 standard deviations from the mean. I understand that the consensus in SPC circles is that 3 standard deviations should be used so that it is very unlikely that special cases, those outside the red lines, are part of the normal population. In this example the confidence intervals extend below zero – clearly it’s impossible to see someone in the clinic before they have presented requesting treatment, so we ignore this.
Special Cases
Special cases are examples of variation that could require special explanation. The rules are as follows:

1. Any point which lies outside one of the confidence intervals.


2. A run of 7 points all above or all below the centre line, or all increasing/all decreasing.


3. Any unusual patterns or trends within the control limits – this one is a bit hard, but essentially if there is change from a little variability around the mean to a lot of variability around the mean, or vice versa there is something funny going on!


4. The proportion of points within the middle third of the region between the control limits differs excessively from the other two thirds.

In my data I did not have any special cases. If I had a point for patient 6 that was at 40 days, this would be a special case and would require explanation – for example the patient might have failed to attend the first clinic appointment they had been offered, perhaps they had been in hospital when they had had a triage assessment and their hospital stay had been for some considerable time.

How do we calculate the confidence intervals?
Find the mean for the values that you have collected.
Calculate the moving range values. This is the difference between a value and its preceding value.
Calculate the mean of the moving range values.
1 standard deviation = the mean of the moving range/d2 (where d2 = 1.128)
The confidence intervals are +/- 3 standard deviations from the mean.

Capability Index
This tells you how capable your current process is in relation to a target.
Capability index (Cpk) = (Target – Mean Value)/3 x standard deviation.

• A Cpk >/=1 indicates that there will be at least 99.865% inside the specified target.


• For a Cpk <1 you need to read off a % figure from a table.


• For a negative Cpk, less than 50% will be inside the target.

Some quick applications for this technique

• Examine waiting times for treatment using this approach and when nurse prescribers come into the system, see what difference it makes.


• Do the same and see what difference it makes when test on arrest starts up.


• Use it to look at numbers of referrals – does test on arrest make a difference?


• Look at hepatitis immunisations. What percentage of prescribed clients were immunised at least once in May, June, July, August etc.? Keep going, what happens when we have 4 trained nurses complementing the doctors in immunising people?

Amphetamine

Just a brief note that the Advisory Committee on the Misuse of Drugs has published a document reviewing amphetamines and particularly methylamphetamine. The document is long and very detailed, looking at history, manufacture, adverse effects and treatment amongst other things. The document is perhaps the most useful thing I have read on this subject for a long time.

SSAD

The Society for the Study of Addiction held it's annual meeting yesterday and today - the title "If we did have evidence based policy and practice, what would they look like?"
I'm afraid that there weren't too many clear answers to the question - largely because policy is in the hands of the policy makers.

Alcohol was a case in point - there is now a large body of evidence (UKATT and Project Match) to support brief interventions in people with hazardous or problematic drinking, but policy is slow to support with funding for these brief interventions, perhaps because the alcohol industry is at the table when it comes to formulating alcohol policy. Anyway, one thing that came out of Jane Marshall's excellent talk was that I bought a book she has co written about alcohol treatments. Perhaps I will report back on this in the future.

Robert West spoke admirably on the evidence for effective quit smoking strategies. He reminded me that in people with low seizure risk bupropion is an option and that although unlicenced, in the person not at risk of OD, nortriptyline 75-150mg has been shown to be effective. Nicotine replacement therapy is effective, and although it is not licenced, he suggested that an acute delivery system could be co-prescribed with a chronic delivery system, eg gum and patches together! Telephone councelling of the proactive sort has some benefit but reactively is not useful. The best results are achieved with combining either NRT or bupropion/nortriptyline with behavioural support and can achieve a 15% cessation rate at 6 months. He added the titbit that there is some evidence that those who suddenly decide to quit mid pack seem to do better than those who decide and set a date, so that our smoking cessation clinics need to be able to respond to such an individual who is suddenly in need of support. Finally he mentioned 2 new drugs that might be heading our way - Varenicline - a "false tobacco" and Rimobant.

In the short papers section Duncan Raistrick presented on a comparison of lofexidine vs buprenorphine detoxification. There was little to chose between the two but the service users voted with the feet and those who refused randomisation elected for buprenorphine. Nicky Metrobian and Nick Lintzeris presented information on injecting rooms in London. These are just being established and a trial of effectiveness in process. Intriguingly they claimed that in toxicological screens they could distinguish between street and prescribed heroin, but gave no further details on this.

An overdose of training

Several useful training courses arose together in the last 2-3 weeks, hence my postings have gone down because I have been too busy. Here is a digest of what went on.
4th of November - the RCGP launched its' methadone guidance in London. The meeting and guidance confirmed that my practice is within the new guidance, rather than adding much in the way of the new information, so was useful for that.
3rd of November - this was the twice yearly meeting of my local RCGP Action Learning Set. We networked and discussed recent changes in policy direction. Non medical prescribing was touched on - I think that there were differences of opinion about how appropriate this was in the field of drug dependence and in the wider field of medicine. Interestingly, I think the most negative views came from the one non medic in the room! We discussed the way that the criminal justice system has developed drug treatment schemes and how various different patient groups might access services through these schemes. A colleague produced a flow chart which really filled in my understanding of this area. Finally we had an interesting case presentation about a young person with an alcohol problem. We discussed how difficult it was to access formal inpatient alcohol treatment services for young people and the risks of mixing them up with inpatient drug treatment services.
October 17th (RCGP) and November 5th (NKPCT) saw me attend 2 seperate events on "GP Appraisal". I really felt the need to "up my game" with appraisals after a recent appraisal just felt flat, so that was my motivation for attending the training. The RCGP event was an advanced appraisal training event and the NKPCT event was aimed at improving Personal Development Plans. The RCGP event went reasonably well, although there was a mix of experience appraisers, some who had never appraised and some like myself with a few appraisals under my belt. What I learnt was that it was important for me to review my appraisal technique before each appraisal, as it was easy to forget the process especially if there was a month or two passed since my last appraisal. To this end I have produced a simple 2 page reminder document to enable me to quickly revise before I appraise. The NKPCT event was much more focussed on Form 4 and the PDP. It reminded me of the value of looking at Form 4 in the light of the evidence that the appraisee has submitted in his/her written material and in the interview. I think I will be able to use this to develop more focussed PDP's in the future.

Paediatric Cardiology and Atrial Fibrillation

This week has seen me attend 2 x 2 hour evening post graduate meetings. I am a bit overdone with lecture based learning at the moment, but best to get what I learnt down in writing, so that hopefully I can remember it.

Wednesday evening’s lecture was the first in the Huddersfield Medical Society’s annual lecture season. We heard an eminent Paediatric Cardiologist from Great Ormond Street Hospital speaking about his work.

He performs percutaneous surgical procedures that fall into 2 groups – opening operations and closing operations. For example he “opens” pulmonary artery stenosis and closes patent ductus arteriosus. His procedures require cardiac catheterisation and he is guided by XR control and trans-oesophageal ultrasound.

Congenital heart disease was described as quite common, affecting as many as 8/1000 newborns. Common lesions include ventricular septal defects and patent ductus arteriosus. He was delighted to remind us that very often these lesions do not require intervention and will often settle on their own. In the case of VSD, the majority are inconsequential.

After these introductory remarks he followed on with a sequence of beautiful video loops of echocardiograms and video X rays. He demonstrated the blocking off a PDA with a device he described as being like a bed spring, the opening up of a coarctation of the aorta, closing an atrial septal defect etc. etc.

Particularly challenging was the coarctation of the aorta that had been dilated but despite being dilated up the aorta wall was “floppy” and had developed a kink. Here he demonstrated stenting of the kink and reminded us that stents needed to be able to grow with the patient – they therefore required expansion over time! He also showed the use of radio frequency ablation to first bore a hole in a completely closed pulmonary atresia, before he passed a wire through the hole and performed a balloon dilatation – extraordinary. Towards the end he discussed a recent development. He reminded us that the cardiothoracic surgeons have been using treated porcine or bovine valves in heart valve replacement operations for some time. A colleague of his has adapted this technique to produce a bovine jugular vein valve wrapped in stent. The valve can then be passed into the right side of the heart and used to replace a pulmonary valve.

Thursday evening (last night) I attend the Calderdale and Huddersfield Diabetes and CHD Network meeting. Our local cardiologist spoke about management of atrial fibrillation. His recommendation was:

• Treat the symptom


• Find the cause and treat that


• Decide a plan either to try to control rate or control rhythm


• Consider anticoagulation

Treating the symptoms was about the acute presentation. Digoxin alone in the elderly was commonly used, but if the patient was going to exert themselves then digoxin alone was unlikely to be effective. He recommended the addition of a beta blocker or diltiazem or verapamil. Amiodarone could be used but should be initiated by a specialist.
Common causes were ischaemic heart disease (remember to treat these with 75mg of aspirin as well), hypertension, COPD and heart failure, less commonly – think of hyperthyroidism.

Recent data from the AFFIRM trial suggest little difference in mortality if you treat with cardioversion (rhythm control) compared to treatment of the rate. He made an argument for attempting to cardiovert those who were under 65 based on an analysis of subgroups from the AFFIRM study.

Finally he talked about anticoagulation. Remembering that there is a 1% a year risk of intra-cerebral bleed in those patients on warfarin he told us about the CHAD2 scoring system. Assign 1 point to each risk factor of congestive heart failure, hypertension, Age >75 or diabetes and 2 points to previous cerbrovascular ischaemia. Score more than 2 points and treat with anticoagulation, score less than 2 points and avoid treatment, score 2 points and think quite hard about what to do!

Scabies

How long does it take for the itch to stop after treatment?
Is permethrin the treatment of choice? How long should it be applied for? Are 2 applications required?
Should genital scabies trigger a sexual health screen?
Just another afternoon in primary care. Must be a bit rusty on scabies though.

UKATT

This recent article is a major publication from the UK alcohol treatment trial. This confirms the benefits of motivatinal enhancement therapy (MET) and marks as them as being as successful social behavioural network therapy (SBNT), which was a bit more expensive.
A BMJ leader discusses the uk government's approach and suggests that regulatory capture has occurred, where the regulators accept the diagnosis and proposed treatments of the drinks industry. Here in the uk we can look forward to longer drinking hours to encourage the development of a continental style of drinking. The big fear is that there will be more public drunkenness and more drinking overall. Sure, this would suit the alcohol industry but will do nothing for the nation's health.
Of course the government might have a vested interest in increasing the consumption of alcohol - it will raise more taxes. However, if financial considerations are being taken into account, in this paper, UKATT makes a fine case for SBNT or MET providing savings of about five times as much in expenditure on health, social, and criminal justice services as they cost. So far I have heard no news of HMG increasing resources for alcohol treatment services, perhaps they are waiting for the increased revenue from alcohol taxation to pump prime treatment services.

Oral Contraception

Oral Contraception pre treatment advice – what should I discuss with the patient? This is something I should look up I think.

The Medical Reading Has Piled Up

So here are some snippets and links:

“Delayed prescribing of antibiotics for upper respiratory tract infection” has once again reared its head in the pages of the BMJ. The use of delayed prescribing is advocated, so a script is printed off but not given to the patient, the patient is asked to return for a script if the symptoms don’t clear. Trials suggest that this approach has the same or lower rates of re-attendance for the same illness than not prescribing at all. Guidance should be given to parents and patients:

• Children with otitis media should wait for no longer than 72 hours after the first consultation when significant fever or otalgia persists, or for no longer than 10 days where there is persistent ear discharge.


• In sore throat the delay can be 5 days.


• In lower respiratory infection 10 – 14 days.

I feel uncomfortable with the lower respiratory tract advice. Perhaps this is appropriate for the patient with a non febrile cough, but it seems important to exclude asthma, patients with chronic lung disease and those with pneumonia!

The BMJ has sound advice on the impending influenza pandemic. I must remember to get my vaccination booked again this year, even though the predicted pandemic strain will not be covered.

Perhaps more controversially, the same edition of the BMJ has an article proposing that we rename heart failure as cardiac impairment. The rationale for the change is that heart failure is a confusing title for doctors and patients alike. I am reassured to learn that there is a test for cardiac impairment (HF), and if we take the time to measure the BNP (B-type natriuretic peptide) we have an indication of how much the heart is struggling which we can monitor over time to indicate response to treatment! I must remember to stop asking patients how breathless they are, how far they can walk and what things they would like to do that their breathlessness stops them doing as indicators of treatment response, I just need to measure the BNP instead.

A reminder to search for the splenectomised in our practice population was the final editorial in this most pertinent of BMJ’s. I should ensure that all such patients are vaccinated against pneumococcus, HIB, meningococcus type C, and on lifelong penicillin (or erythromycin in the penicillin allergic). Also I must remind them to wear a warning bracelet.

Finally for now, “The prescribing of methadone and other opioids to addicts: national survey of GPs in England and Wales” Author(s): John Strang; Janie Sheridan; Claire Hunt; Bethanne Kerr; Clare Gerada; Michael Pringle BJGP 2005; 55: 444-451 was a survey of GP’s to identify what role they were playing in the provision of prescribing services. The paper was based on a 2001 survey and concluded that although the number of GP’s providing a prescribing service was on the increase the quality of prescribing was not high. I found the paper depressing because I’m sure the authors are aware that since 2001 there has been a major initiative led by the RCGP to educate GP’s in the provision of high quality care, including prescribing initiatives. The authors are running the risk that the work of GP’s with substance users is not highly valued. Some follow up correspondence (Prescribing to substance misusers Stephen Willott, British Journal of General Practice Volume: 55 Number: 517 Page: 638) supports my view. I’m still disappointed that the authors published.

Blast Injury

The CDC document referred to previously makes for chilling reading. As a primary care physician what might I expect to have to deal with? The acute management of blast victims seems to be something most primary care physicians are unlikely to have encountered. Let's hope it stays that way.

Primary care physicians might be involved in the acute management of blast victims, but they are also likely to see people in the days and weeks following a blast. Whilst the psychological consequences can be serious and severe, there may also be developing physical causes for some symptoms.

The potential number of people seeking treatment in the first wave of casualties. It seems that roughly half present in the first hour but if buildings have collapsed it will take longer to get to the receiving centre and the injuries are likely to be more severe. Also, the walking wounded arrive first, the more serious casualties arrive later. Exposure to the blast produces predictable injuries. In particular the blast shockwave has a deleterious effect on gas filled structures.

Injuries to be expected:

• Up to 10% have eye injuries and these are not always symptomatic, so seek them out.
• Bradycardia, apnoea and hypotension are the cardinal signs of blast lung. Suspect it in the dyspnoeic, those coughing or those with haemoptysis after exposure to a blast. CXR and supportive management.
• Middle ear damage - always examine the auditory canal.
• Abdominal trauma including perforation, mesenteric shear injuries and haemorrhage. Sometimes these can present late, so proper examination, observation and re-examination are required.
• Brain injury from concussion to more severe damage to vessels and brain tissue. Consider brain injury in any victim complaining of headache, fatique, poor concentration, insomnia or lethargy, even days after the event this could represent brain injury.

I hope I never have to refer to the CDC document in a live situation, but for anyone receiving acutely injured blast victims it at least points the way.

London suicide bombs

Back from annual leave and I have started catch up reading on my journals. Just before I went away there were several simultaneous bombings in London. News reports showed footage of a partially destroyed London Bus just outside Tavistock Square - where the BMA has its HQ. The first journal I turned to was my BMJ and it had several moving accounts from those who were amongst the first medics present at that bombing. In addition there was a report from Eddie Chaloner (http://bmj.bmjjournals.com/cgi/content/full/331/7509/119) exhorting all doctors to be aware of what to do in case they are first on the scene at such a tragedy. He refers to a primer - Explosions and blast injuries: a primer for clinicians. May 2003. www.bt.cdc.gov/masstrauma/explosions.asp from the CDC which is something to refer to in coming weeks.

Diabetic network

I recently received an invite to attend a meeting organised by our local diabetes network. A local biochemist was discussing "Metabolic Syndrome". Well I have to say that I really did not know what to expect and was intrigued by what I heard. As a medical student I was well aware of the association between abdominal obesity and heart disease. What I hadn't kept up to date with was how biochemists and in particular North American biochemists seem to have significantly developed this idea.
Abdominal obesity associated with insulin resistance, raised BP (130/85 or more) and raised triglycerides is linked with an increased risk of type 2 diabetes and atheromatous vascular disease. The American criteria -

• Central obesity as measured by waist circumference:
  Men — Greater than 40 inches
  Women — Greater than 35 inches
• Fasting blood triglycerides greater than or equal to 150 mg/dL
• Blood HDL cholesterol:
  Men — Less than 40 mg/dL
  Women — Less than 50 mg/dL
• Blood pressure greater than or equal to 130/85 mmHg
• Fasting glucose greater than or equal to 110 mg/dL

are about to be replaced by European criteria which are even more stringent.

Why make the diagnosis? Well one good reason seems to be that it is possible to reduce adverse outcomes by increasing exercise (1 hour of moderate exercise daily) and dieting. Our local biochemist recommended starches with a low glycaemic index.

For more information the American Heart Association has a useful resource.

The most striking thing from the talk I attended was the prevalence data - it was suggested that 20% of adult males are affected! Now where is that exercise bike?

Heart Failure

Local guidelines now available and have been read.
Key points -
Consider doing Brain Natriuretic Peptide test when it is available, normal levels are negatively predictive for heart failure.
Everyone should have an ECG (normal is >90% predictive of not having Heart Failure) and if diagnosed with HF an echo.
Control arrhythmias.
Everyone should have a max tolerable dose of ACEI or A2RA (monitor creatine).
Diuretics do not improve exercise tolerance but can clear peripheral and pulmonary oedema, use at lowest dose to get improvement and monitor U+E's.

Establish aetiology and treat underlying causes - IHD and hypertension are commonest causes. Consider valvular heart disease, alcohol excess and familial causes.

Use the New York Heart Association classification of symptoms and consider referral to Class III and IV

General stuff - those on frusemide >80mg daily should be on a twice weekly weight chart and fluctuations of 2kg in 3 days should prompt review of diuretic Rx. Some patients can be taught to adjust this themselves. Aim for a healthy, low salt diet. Long haul flights are contraindicated in those who are so breathless that they need to stop after climbing a flight of stairs or who cannot hold a conversation without symptoms. Travel - hot climates might need adjustment of diuretic. Encourage aerobic exercise. Avoid soluble forms of tablets because of sodium content. Avoid NSAIDs.

Haemoglobinopathy

Whilst I am busy reflecting on my learning needs this morning I might as well recall that I don't really know much about haemoglobinopathy and it's time to review this as well.

New practices and a different population

Having previously practiced in an area with a static population I am now seeing many patients who are seeking asylum from African countries and the Middle East. TB is much more common in this population. Time to do some research I think.
In addition to the asylum seeking population, the indigenous population seen in this practice are usually homeless. This brings with it a higher proportion of people with mental health problems and in particular I have been struck by the high rates of depression and schizophrenia, so definitely these are areas to brush up on.

Sick notes

Last week I got asked for the usual sick notes, but then I had a request that filled me with uncertainty. Time to check out the rules - if I can find them.

Sick health professionals

Although the RCN does not have a service analagous to the "Sick Doctors" service, it does have the RCN Counselling service and Welfare Service. Unfortunately to fully explore the RCN website you have to be a member.

Sick Doctors and Sick Nurses

I know that there is a uk based service for "sick doctors" but what is available for sick nurses? The RCN website is unhelpful so I'll have to e-mail an enquiry I think.

Coeliac Disease

An excellent BMJ leader prompted me to reconsider this condition. Here are some take home messages:

• affects 0.3 to 1% of the population
• 1/4 of patients receive the diagnosis after the age of 60!
• conventional diagnosis rests on villous atrophy in the small bowel which recovers after a gluten free diet
• screening is possible - anti-endomysial and anti-transglutaminase antibodies are often used
• positive antibody tests are not diagnostic - sometimes they become negative again.
• sometimes positive Ab tests are followed by negative biopsies - it's worth reviewing the biopsy. Has the patient stopped gluten before the biopsy?
• Ab negative cases do occur, most commonly in IgA deficiency.

For me the key things are - don't forget to think of it as a possibility, even in the older patient.

Cervical cytology

This is a typical example - I knew I needed a cervical cytology update, I hadn't done a smear in 2 years, yet the population I work with seems best at responding to opportunistic interventions rather than appointment invitation based interventions. I hadn't formally noted it as a learning need.
I was pleased to find an invite to a cervical cytology update promoted by the PCT and also involving a local specialist discussing Chlamydia.
What was news? Well the whole local call/recall system has had an overhaul and practices do not need to get involved in sending out invitations. We are still using slides and Aylesbury spatulae but by next Autumn we are moving to wet preps and brushes! When the move comes each practice will get a teaching session, so need to worry about that just yet.
Chlamydia screening is coming but they were hoping to tie it to the smear programme, however since this has moved from starting at 21 year to starting at 25 years this is now considered inappropriate. There was no news on when it was going to start. Our local GU clinician preferred one dose of Azithromycin as treatment, rather than a week of doxycycline for obvious reasons of compliance. Whatever I do, I must not forget the contact tracing. Apparently the fallopian tube blockage is thought to have an immune basis and re-infection increases the risk of this occurring. Treating the woman and not following up with her partner is a sure road to infertility.

Learning Styles

What works for me? I thought I would blog to record learning needs and then use it to remind me what I needed to look up, then I'd go and look them up. This doesn't seem to be happening. Probably I'm not very good at spotting a learning need, but perhaps it's because my GP consultations are sufficiently infrequent, and occurring in an environment where the IT is very flaky that I just look things up in a book at the time - I know this happens.
At present, what does seem to work is using the blog to reflect on something I've read or picked up from a meeting or lecture. I'm not giving up on it as a "recording my learning needs tool" just yet though.

The 10th National Conference: Management of Drug Users in Primary Care

10 Years On: looking back; moving forward
28th and 29th of April, 2005-05-09

Why did I go?
The RCGP conference is a high quality national event which allows me the opportunity to get a better understanding of national trends in primary care management of people with problematic substance use. In addition I have the opportunity to meet people working in this field and have one to one discussions.

What new knowledge did I acquire?
I attended 4 group work sessions that were really useful.

1) Laura Sheard, Nat Wright and Charlotte Tompkins presented on their work with detoxification. Their pragmatic randomised controlled trial compared 2 week community based detoxification from a primary care setting using dihydrocodeine versus buprenorphine. 60 people were recruited. 8 people were negative for morphine at the end of the 2 weeks, 7 of them in the buprenorphine group – this was not statistically significant. 23% of the survey group were abstinent at 3 months post treatment.

2) Judith Yates led a session on “Managing the needs of older users”. This session echoed some of the content covered in the “Managing Pain….…” seminar. It drew attention to the need to consider older drug users in our plans for treatment services as their needs are distinctly different from younger people. In particular they are more likely to present with other medical problems in addition (or as a consequence of) their substance use. By the time they are in their 60’s many people on long term methadone maintenance have no intention of stopping their treatment. What are the implications of this? Should we have separate “older people’s” sessions? What plans do we need to make for residential care of elderly drug users? Admittedly there were more questions than answers generated by this group but it did open up a new area of thoughts for me on this subject as I have a small number of people in treatment aged >50 years.

3) In the same session Roy Robertson presented work from Edinburgh which looked at a trial of methadone versus dihydrocodeine for maintenance. As a pilot they examined whether patients could identify which treatment they were taking and demonstrated that they could! Their subsequent trial was therefore “open label”. There was no difference in any outcome measures at 36 months, dihydrocodeine was slightly better for retention in treatment at 6 months.

4) “Managing pain in opiate dependence” was lead by Mark Gabbay. Case studies were used to demonstrate a number of points. The summary information that I took away was:
a) Where patients are being admitted for treatment, consider negotiation with the pain team. Below the waist surgical interventions might be managed with spinal/epidural anaesthesia.
b) Methadone’s analgesic effects are relatively short lived – 4-8 hours, therefore consider co-prescribing short acting narcotic analgesics where necessary. Some delegates considered oxycodone to be a useful adjunct to methadone maintenance in the treatment of pain. Apparently it has an affinity for kappa receptors, whereas methadone is mainly a mu receptor agonist.
c) Use pain scales to tailor treatment to the patient.
d) In dihydrocodeine dependence consider the use of dihydrocodeine reduction programmes.

Full Hall Sessions

Bob Newman from “The International Center for Advancement of Addiction Treatment Baron Edmond de Rothschild Chemical Dependency Institute of Beth Israel Medical Center” spoke on the rights of drug dependent persons to treatment access and choice of provider, and the right to be cared for under the same conditions as apply to the management of all other chronic medical conditions. This much I took as a given, what surprised me was his comments about treatment facilities in the U.S. which seem to be punitive, secondary sector and inaccessible. Bob told us that the predominant philosophy on treatment remained a “Just Say No” legacy of the Reagan era.

Jez Thompson did some “blue sky thinking” leading to discussion of the future for drugs and drug services. Points of note include the developing role of the expert patient, the increase in coercive treatments, our expectations that all doctors in the future will be better educated about drug problems, we might have immunisations against some drug problems, injectable treatments – what does the future hold, we need to consider the children of drug users and what the future holds for them, we need to consider the long term future of our “die hard” opiate users.

Consensus Statement from the Conference

1. We recognise the importance of meaningful user engagement in the commissioning of drug treatment service, and call for secure funding and structures to fund this.
2. We welcome the large increase in funding for drug treatment services in recent years but there needs to be urgent review of the evidence base underpinning how services are accessed and delivered to ensure that they optimise health gain for drug users.
   
3. The primary care team needs to work in partnership with all other drug treatment services to assess and address the problems of individual drug users within a holistic framework.
   

Was this helpful to my working role? Was the information gained in line with my current practice? Do I need to change my practice? Do I need to disseminate this information to other members of my team?

Yes, as usual the conference was thought provoking. I need to consider the older drug users in our local services and look at their needs. People with ongoing needs such as chronic pain or an acute need for pain relief need better support – I hope that our hospital liaison nurse helps us meet these needs. I need to continue to scan the horizons for new developments in this field.

I was reassured that there was still no good evidence to support using dihydrocodeine in detoxification. Its use in maintenance is more promising but the systems, such as supervised consumption, that we have in place to safeguard our service users and their families do not currently lend themselves to dihydrocodeine prescribing.

My current practice will not change a great deal but I need to think about the differing needs of older people and those people who have acute or chronic pain in addition to their drug dependence needs.

To disseminate the information I will forward this to Lifeline team leaders and present some of this information to our local shared care forum.

ECG material

The web is a mine of useful information on the ECG. I found a very useful primer at http://www.fleshandbones.com/readingroom/pdf/505.pdf. After a quick read of this I found some more material at http://medstat.med.utah.edu/kw/ecg/ on pages dedicated to an old master of ECG teaching in the U.S. This site has lots of information and some really useful quizzes to test your knowledge. I was very impressed with the explanation of the cardiac axis - the first time I really understood this I think!
Anyway, useful thoughts are:

• Check there is a 1mV calibration 1cm high and that the paper speed is 25mm/s (that much I remembered from my student days.
• Report rate, rhythm, axis, the QRS and then the ST segment and T waves, again this seemed familiar.
  
• Normal ranges are - rate 60-90 beats per minute, P-R interval (start of P to end of QRS) - 0.12-1.2ms, QRS less than or equal to 0.12ms, axis -30 to +90 degrees
• Look for the P waves, are they a consistent distance from the QRS? Is the distance in the normal range?
• Look at the QRS, is it a normal duration? Are there Q waves where there shouldn't be Q waves?
• Is the ST segment depressed? Elevated?
• Are T waves inverted?
• Back to calculating rates and intervals - one little square = 0.04s, one big square = 0.20s. For rate, count the little squares between 2 complexes and divide into 1500, assuming sinus rhythm.
  

Enough - am not a cardiologist!

A busy few days

Last week I attended the RCGP 10th annual conference on drugs, "10 years on, looking back and moving forward" a silly title I think. Anyway, I hope to link and report from that in the next few days.
Today was my GP day and I felt rusty from the word go. It's a long time since I reported an ECG. When I arrived at the surgery I found an ECG I had requested a couple of weeks ago had actually been done - the patient had turned up for the investigation! Unfortunately our ECG machine generates a report and it seems as if any slight deviation from the norm has to be reported. I thought the ECG was normal, the machine disagreed. Thankfully my partner was on my side .... but I felt so rusty I decided a crash course in ECG reading had to be done. Watch out for a further report ASAP.

Action Learning Set

Yesterday was an all day Action Learning Set in Leeds, convened by Jez and attended by Jez, , Susi, Gillian, Matt, Belinda, Jacki, Ian, Helen and me. I discussed amphetamine and reviewed amphetamine prescribing for the group.
Gillian took us through assessing motivation and the "decision to change". Points to remember:

• Practical stuff - "do I know what to do to change my behaviour and how to do it?"
• Self efficacy - "do I believe I can do it?"
• "do I have feelings of self worth?"
• "do I believe life will be better for the change?"

Gillian gave a practical demonstration and an additional point was that it is possible to pick up on someones feelings about changing by assessing the tone of voice and I think this would apply to non-verbal cues. She suggested that in a busy practice setting using a 0-10 scale for the questions:

• How important is it to change
• How ready am I to change right now
• How confident am I that I can change right now
• How much better will my life be if I effect the change

Susi added that a question on self worth would be appropriate.

Helen presented on 360 degree appraisal. General points around readyness to receive the information were made and the need to ensure that you were asking the right people for their views. A collater was suggested for receiving reports. It was advised that feedback should be given from someone trained in giving feedback.

When requesting 360 degree appraisal from colleagues, service users etc the 3 suggested questions are:

What 3 things am I doing well that you would like me to do more of?

What 3 things do I do that you would like me to differently?

What 3 things that I am doing well that you would like me to continue to do?

Perhaps I'll give it a try for next year....

Finally, the other thing that stuck in my mind was Gillian's discussion of the management of pregnant drug users in her service. It prompted me to think, should we survey our own work in this area - to discuss with the workers I think.

The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community -- Milne et al. 330 (7491): 576 -

The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community -- Milne et al. 330 (7491): 576 -- BMJ
This paper in the BMJ along with a leader in the same issue challenged my understanding of antenatal care arrangements.
The advice on screening at initial appointment, along with early referral for specialist assessment in at risk groups should be easy to follow. One of previous pre-eclampsia, multiple pregnancy, underlying medical conditions (pre-existing hypertension, booking diastolic >90mmHg, pre-existing renal disease, booking proteinuria (>/= to + protein on more than one occasion), pre-existing diabetes or the presence of antiphospholipid antibodies should all trigger referral. More than one of first pregnancy, >/= to 10 yrs since last baby, age >/=40 years, BMI >/=35, or family history of pre-eclampsia should also trigger referral.
After 20 weeks, at every assessment I should be looking for new hypertension (hypertension at or after 20 weeks' gestation in women with a diastolic blood pressure < 90 mm Hg before 20 weeks), new proteinuria, headache, visual disturbance, epigastric pain, vomiting, reduced fetal movements or a small for dates baby. The guidance gives various thresholds for referral. In my practice if any of the criteria are present then the expectant mother requires hospital assessment - exceptwhere there is 1+ of proteinuria in the absence of other features I would review them within the week.

Post Traumatic Stress Disorder

A quick reference is available at http://www.nice.org.uk/pdf/CG026quickrefguide.pdf.

Summarising treatment:

• Don't do debriefing
• In mild symptoms less than 4 weeks after an event review in a month
• Trauma focussed CBT(individual outpatient basis) for individuals with severe symptoms in the first month after a traumatic event
• All individuals with PTSD should be offered (on an individual outpatient basis) trauma focussed CBT or eye movement desensitisation and reprocessing
• Children should be able to access treatment
• Drug treatments should not be first line treatments
• Paroxetine or mirtazepine can be used where psychological treatments are declined

PTSD can occur in any individual who has experienced or witnessed a severely traumatising event.
Consider the diagnosis in people experiencing depression, substance use, episodes of re-experience of an event (e.g. flashbacks, nightmares), hyperarousal, numbing (difficulty in experiencing feelings), avoidance (of situations or people), anger and unexplained physical symptoms. Clearly with some of these situations the trauma may not be part of the presentation and may be revealed by direct enquiry.

The above information is appropriate for me as a generic GP but the guidance goes on to dicuss screening after major disaster - let's hope I don't have to do that and screening asylum seekers (who I do come into contact with).

Post traumatic stress disorder

Ok, the NICE article seems to be here - http://www.nice.org.uk/pdf/CG026NICEguideline.pdf.

Post Traumatic Stress Disorder

A word in my ear from the PCT helpdesk has advised me that NICE (the National Institute for Clinical Excellence) has released advice on "post traumatic stress disorder". When I get the time I need to have a read and summarise this.

Cardiac electrophysiology and Methadone

"Torsade de pointes associated with very-high-dose methadone.
Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, et al. Annals of Internal Medicine [NLM - MEDLINE]. Sep 17 2002. Vol. 137, Iss. 6; p. 501 " In this paper the mean dose of methadone used was 397 +/- 283mg of methadone. This article strongly suggests an association between torsade de pointe and very high methadone dose. I will continue to avoid co-prescription of methadone and lofexidine.

Lofexidine - Summary of Product Characteristics 2/4

Lofexidine - Summary of Product Characteristics 2/4 suggests that lofexidine should not be co-prescribed with other drugs that prolong the QT interval.

Substance misuse and cardiology

What should I do? Lofexidine prolongs the QT interval. A client wants to use it to "smooth the transition from methadone to subutex". Methadone prolongs the QT as well. Is it safe to combine the two? Where will I find the answer to this one? I think I might try the lofexidine manufacturers in the first instance.

Getting Started

Well, this is a big step. The idea is that PGE4me should allow me to record my learning needs as they occur to me and then to use a resource, pointing to those resources that are internet based.
There are a few problems:

• I can't remember my Athens password - it's at home, so I need to sort that out.
• I have a whole load of critical reading stored in a Word document - I think it will have to stay there.
• I don't really understand how to use Blogger - so this is a learning process for me and I want to know that I can save my posts to disk from time to time - so I will have to have a look around for some instructions.

My learning sources are the usual for a UK based GP. The following sites are some of my regulars:

• The British Medical Journal Learning site
• The British Medical Journal itself
• Doctors on line
• The Royal College of GP's

I also have an interest in substance misuse and find the following sites useful:

• Substance Misuse Management in General Practice
• The National Treatment Agency

There are more links to be added in the future.