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.