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.