Headache

Peter Goadsby recently reviewed headache in the BMJ, see "Recent advances in the diagnosis and management of migraine BMJ, Jan 2006; 332: 25 - 29".

There was lots of information in their for the GP and as it's a review and summary I took away some messages.

Migraine - worth diagnosing because there are some effective treatments. Diagnosis relies on:
Repeated headache lasting 4-72 hours, normal physical examination, no other reasonable cause for the headache, at least two of

• Unilateral pain
• Throbbing pain
• Aggravation of pain by movement
• Moderate or severe intensity of pain with at least one of
• Nausea or vomiting
• Photophobia and phonophobia

Secondary Headache is the one that worries us GP's. Are we missing a sinister cause? Warning signs for secondary headache include:

• Pain of sudden onset
• Fever
• Marked change in pain character or timing
• Neck stiffness
• Pain associated with higher centre complaints
• Pain associatedwith neurological disturbance, such as clumsiness or weakness
• Pain associated with local tenderness, such as of the temporal artery

The article also considers the pathophysiology of migraine, treatments and differentiating different sorts of headache.

Resuscitation training

Last week saw me access my annual cardio-pulmonary resuscitation training. At the start of the session one member of the group expressed anxiety that the guidance is continually changing. "For the better" said our trainer - reminding us that the guidance is based on evidence. Studies of survival after CPR have influenced the guidance.
As of April this year, but not before, he is allowed to teach the latest methods! This was odd to say the least, but I was pleased to learn that he was happy to fill us in on what the new guidance entailed. In essence, it's all the same BUT instead of 15 chest compressions to 2 breaths we need to do a ratio of 30:2. If we are concerned that as resuscitators we are at high risk of HIV/Hepatitis from resuscitating, then it is acceptable to just do chest compressions (100 per minute) providing the airway can be maintained! Apparently this has been done in the US and survival is as good or better than chest compressions + respirations. Providing the airway is open, chest compressions allow some air in and out of the chest.

See BMJ 2005;331:1281-1282 for "A new international consensus on cardiopulmonary resuscitation"

A New Year

Well, we are 10 days into January and I am yet to make a post. I confess that not much learning went on over Christmas and the early New Year has been blighted by my handing my notice in at work - I am returning to mainstream general medical practice in April.

Perhaps it's time to reflect on the blog so far. Why am I bothering to do it?

Well - I have access to the internet at all the places where I work and at home. It's easy to use the blog to collect my thoughts and learning experiences all in one place. I can access it from anywhere. I could use paper but by now a notebook would be either very tatty or lost (or more likely - both). Additionally, a paper based system would be less easily searchable. I could just keep a big text file on one PC at home and this would certainly be more personal but would lack the "write it up anywhere" feature that makes the blog so appealing. So at least for now I aim to continue with 1-3 posts per month concentrating on learning experiences.

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.