Showing papers in "Clinical Medicine in 2002"

An organisation with a memory.

Abstract: Patient safety has been an under-recognised and under-researched concept until recently. It is now high on the healthcare quality agenda in many countries of the world including the UK. The recognition that human error is inevitable in a highly complex and technical field like medicine is a first step in promoting greater awareness of the importance of systems failure in the causation of accidents. Plane crashes are not usually caused by pilot error per se but by an amalgam of technical, environmental, organisational, social and communication factors which predispose to human error or worsen its consequences. In healthcare, the systematic investigation of error in the administration of medication will often reveal similarly complex causation. Experience and research from other sectors, in particular the airline industry, show that the impact of human error can be reduced if the necessary work is put in to detect and then remove weaknesses and vulnerabilties in the system. The NHS is putting in place a comprehensive programme to learn more effectively from adverse events and near misses. This aims to reduce the burden of the estimated 850,000 adverse events which occur in hospitals each year as well as targeting high risk areas such as medication error.

Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen

Abstract: Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were first published by the British Committee for Standards in Haematology in 1996. Key aspects of these guidelines related to anti-infective prophylaxis, immunisation schedules and treatment of proven or suspected infection. A recent review of the guidelines was undertaken, with a view to updating the recommendations where necessary The guideline review process did not reveal any major change in patient groups considered at risk. Occupational exposure to certain pathogens may, however, be a new risk factor for some infections. The recommendations for anti-infective prophylaxis remain unchanged. New recommendations for vaccination include the use of meningococcal group C vaccine in previously non-immunised hyposplenic patients and a need to consider the use of seven-valent pneumococcal vaccine. Recommendations for treatment of suspected or proven infection have not been significantly amended, but a local protocol should take into account relevant resistance patterns. There is an identified urgent need for further research into the effectiveness of varying vaccination strategies in the hyposplenic patient, and audit of infective episodes in this patient group should continue long term. Key guidelines are summarised below, together with grades of recommendation.

The expert patient: a new approach to chronic disease management for the twenty-first century

Abstract: The expert patient: a new approach to chronic disease management for the twenty-first century, produced by the Department of Health, recommends the introduction of 'user-led self management' for chronic diseases to all areas of the NHS by 2007. The premise is that many patients are expert in managing their disease, and this could be used to encourage others to become 'key decision makers in the treatment process'. Furthermore, these expert patients could 'contribute their skills and insights for the further improvement of services'. It is hypothesised that self-management programmes could reduce the severity of symptoms and improve confidence, resourcefulness and self-efficacy. It is stressed that this is more than just patient education to improve compliance. Instead there should be 'a cultural change...so that user-led self management can be fully valued and understood by healthcare professionals'. I point out that these ideas, while welcome, are not particularly new. Achieving the desired culture change will not be easy.

Helicobacter pylori: 20 years on

Abstract: Helicobacters are a new genus of bacteria, inhabiting the interface between mucosa and lumen of the gut. Microaerophilic, spiral, flagellated and urease positive, they possess features necessary for colonisation of the juxtamucosal mucus environment. Helicobacter pylori is the major pathogenic species. Once attached to the gastric epithelial cells, it incites an immune response characterised histologically by the development of active gastritis and immunologically by the presence of specific IgG. Persistence of infection is ensured by attachment to tissue antigens (eg Lewis B), a vacuolating toxin (VacA) which assists the free passage of urea through epithelial cells, and a cytotoxin (CagA) which is actually injected into the epithelial cells via a Type IV secretion system. Finally, during the typical lifelong chronic infection, two important diseases occur. H. pylori alters gastric physiology to cause acid hypersecretion and peptic ulcer. Secondly, it damages the acid secreting mucosa leading to atrophic gastritis and gastric cancer risk.

Potential therapeutic targets in the rapidly expanding field of purinergic signalling

Abstract: The concept of a purinergic signalling system, using purine nucleotides and nucleosides as extracellular messengers, was first proposed over 30 years ago. After a brief historical review and update of purinoceptor subtypes, this article focuses on the diverse physiological roles of adenosine triphosphate, adenosine diphosphate, uridine triphosphate and adenosine. These molecules mediate short-term (acute) signalling functions in neurotransmission, secretion and vasodilation, and long-term (chronic) signalling functions in development, regeneration, proliferation and cell death. Plasticity of purinoceptor expression in pathological conditions is frequently observed, including an increase in the purinergic component of parasympathetic nervous control of the human bladder in interstitial cystitis and outflow obstruction, and in sympathetic cotransmitter control of blood vessels in hypertensive rats. The antithrombotic action of clopidogrel (Plavix), a P2Y12 receptor antagonist, has been shown to be particularly promising in the prevention of recurrent strokes and heart attacks in recent clinical trials (CAPRIE and CURE). The role of P2X3 receptors in nociception and a new hypothesis concerning purinergic mechanosensory transduction in visceral pain will be considered, as will the therapeutic potential of purinergic agonists or antagonists for the treatment of supraventricular tachycardia, cancer, dry eye, bladder hyperactivity, erectile dysfunction, osteoporosis, diabetes, gut motility and vascular disorders.

Are preventive drugs preventive enough? A study of patients' expectation of benefit from preventive drugs.

Abstract: Objectives ‐ The study aimed to find the threshold of benefit for a hypothetical cholesterol-lowering drug below which the subject would not be prepared to take the drug. We also looked at whether proximity to the target event (myocardial infarction) and the subjects’ views on drug taking affected this threshold. Design ‐ We studied 307 subjects using a written questionnaire and interview. Group 1 (102 subjects) had just been discharged from the coronary care unit. Group 2 (105 subjects) were taking cardio-protective drugs but had no recent history of myocardial infarction. Group 3 (100 subjects) had no history of myocardial infarction and were taking no cardio-protective drugs. Results ‐ Median values for the threshold of benefit below which the subject would not take the preventive drug were 20%, 20%, and 30% absolute risk reduction for Groups 1, 2 and 3 respectively. Median values for expectation of average prolongation of life were 12, 12 and 18 months respectively. Only 27% of subjects would take a drug offering 5% or less absolute risk reduction over five years. Subjects’ views on medicinal drug taking in general and proximity to the target event were predictors of the acceptance of preventive drugs. Eighty percent of subjects wished to be told the numerical benefit of a preventive drug before starting on it. Conclusion ‐ For the majority, the expectation of benefit from a preventive drug is higher than the actual benefit provided by current drug strategies. There is a tension between the patient’s right to know about the chance of benefiting from a preventive drug and the likely reduction in uptake if they are so informed.

Hospital episode statistics: time for clinicians to get involved?

Abstract: Hospital episode statistics contain clinical data. They are used for many purposes, including monitoring activity in the NHS and the allocation of funds. More recently they have been applied to monitoring performance, and it is intended that they will inform consultant appraisal and revalidation. The validity of hospital episode statistics was questioned by Korner in 1982. Recent publications have shown that problems persist in England and Wales, and that the quality of the data is inadequate for the task. The lack of involvement of clinicians in the process of data collection and validation is no longer acceptable. To rectify the situation there should be a change of process and culture, supported by education and investment. NHS data definitions of terms such as 'spells', 'episodes' and 'diagnoses' need to be reviewed. The development of separate data processes to monitor national service frameworks is regrettable.

The report of the Chief Medical Officer's CFS/ME working group: what does it say and will it help?

Abstract: Chronic fatigue syndrome (CFS) sometimes known as myalgic encephalomyelitis or encephalopathy (ME) has long been a controversial topic. This year has seen the publication of a report from an independent working party set up by the UK Chief Medical Officer (CMO) to make recommendations for the management of the condition. The report makes a number of general recommendations about the provision of appropriate care and services. The more controversial issues of what to call the illness, the nature of the illness and what treatment should be recommended are all addressed, but in the form of compromise rather than resolution. To the extent that this report is a step towards highlighting the needs not only of patients with CFS but the larger group of patients with symptom-defined conditions, it is to be welcomed. As a guide to management it raises as many questions as it answers. Much remains to be resolved before guidance that is both evidence based and acceptable to all parties is achieved.

The use of oxygen in acute exacerbations of chronic obstructive pulmonary disease: a prospective audit of pre-hospital and hospital emergency management

Abstract: Treatment with high-flow oxygen in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) can cause or aggravate acute hypercapnic respiratory failure and adversely affect prognosis. National guidelines for the management of COPD recommend an initial fractional inspired oxygen concentration (FiO2) of no more than 0.28. However, a prospective audit of 101 consecutive episodes of AECOPD demonstrated that oxygen therapy with an FiO2 in excess of 0.28 is common, potentially deleterious and predominantly initiated in the ambulance. Patient awareness, aids to disease identification and ambulance protocols are likely to hold the key to improvement in the acute care of these patients.

Believing is seeing.

Abstract: Deborah Padfield worked on ideas for images which Deborah photographed, either solely or with their assistance. The resultant images were reviewed in further sessions. The images that best expressed their experience were chosen by the subjects and the process reiterated until they were happy that the image ‘said something’ to them in terms of expressing what their pain felt like. They then had the opportunity of showing me the final images and discussing the result. I had at some point in the planning stage thought that the process may open diagnostic avenues, but I rapidly came to realise that this was a minor and temporary atavistic aberration of Cartesian thinking: Virchow has little place in chronic pain management. Here diagnosis is not the only end point. Listening and acknowledgement are fundamental. To paraphrase John Major: perhaps there are times when we need to understand less and accept more. The resultant images are extraordinary, moving and provocative. One fundamental question – could an artist develop images that had a meaning for the sufferer – was answered early on: some subjects still report a quickening of the pulse when they see ‘their’ images. The resultant exhibition, shown at St Thomas’ and Guy’s throughout May and June and followed by a stretch at the Royal College of Physicians, reaffirmed the effect that these remarkable images have on the interested bystander. The feedback has been uniformly positive, not in terms of the beauty of the images, although many do have a strange aesthetic quality; but in their impact. We will long remember the medical student who wrote ‘Thank you. I will now see chronic pain in a different light.’ For me the crucial aspect is the transference of the reality of experience. The sufferer stands brazen in front of an image of their disquiet one metre high. We cannot ignore it or walk away, it has gained a reality that has to be faced. Our confusion may remain but it is the subject who now has the strength and certainty. It is the physician who has to accept the premise, process the implications and respond. We have to take the representation as we find it; we can no longer disbelieve. It is humbling.

Healthy limb amputation: ethical and legal aspects.

Abstract: A surgeon in Scotland has amputated the legs of two consenting, physically healthy patients. Although a handful of medical professionals believe that the desire for healthy limb amputation is symptomatic of a mental disorder that can be treated only by amputation, there is currently no consensus on what causes a person to desire such a disabling intervention. As long as there is no established body of medical opinion as to the diagnosis and treatment of such a condition, performing the surgery may be a criminal act. Given the ethically problematic history of surgery for psychiatric conditions, as well as the absence of sound medical data on this condition, surgeons should exercise great caution before complying with a request to amputate a healthy limb.

To PEG or not to PEG.

Abstract: Patients with adequate intestinal function who are unable to eat may benefit from enteral tube feeding. Percutaneous endoscopic gastrostomy (PEG) is preferred when prolonged treatment is envisaged. PEG feeding will reduce morbidity and mortality in many such patients by reversing malnutrition. The increasing numbers of elderly patients with chronic diseases have resulted in an increased demand for PEG placement that has stretched resources. Many patients who are referred for PEGs are frail and the procedure is associated with complications. Careful management and support for the carers in the community are essential. Not all patients benefit from PEG feeding. The aim must be an improvement in the quality of life, not a prolongation of terminal disease.

Epidemiology of end-stage renal disease.

Abstract: Chronic renal failure (CRF) is not uncommon in the population. The incidence of CRF rises with age and is commoner in men and in Indo-Asians and African Caribbeans. End-stage renal disease (ESRD) is treated by renal replacement therapy (RRT), dialysis and transplantation. Acceptance rates have risen fivefold in the last two decades, but population need is still not being met. The main cause of ESRD is diabetic nephropathy, though many patients present late with small kidneys of uncertain cause Cardiovascular disease is a major cause of morbidity and mortality in patients with CRF and ESRD.

Professional attitudes: can they be taught and assessed in medical education?

Abstract: The medical profession is under increasing scrutiny with regard to the undesirable attitudes and behaviours of some of its members. Despite the setting of objectives for professional attitudes, it remains unclear how these can be taught and assessed. Having defined 'attitudes', we consider some of the influences upon the development of professional attitudes within medicine. We then review possible ways of encouraging desirable attitudes and behaviours. Finally, we review and critique the main types of attitude assessment. We conclude that attitudes are complex, that the influence of medical culture is crucial, and that feasible assessment tools have yet to be developed.

To stand on one's own legs

Abstract: A fundamental human expectation is to stand upright. This exposes the cardiovascular system to gravitational forces, with a fall in pressure above heart level exposing organs such as the brain to impaired perfusion if adequate adaptive mechanisms are not activated. The autonomic nervous system plays an important role in the initial response to standing upright, and can be affected by several disorders, some rare, some common. Autonomic failure can result in orthostatic hypotension with hypoperfusion of vital organs, causing a variety of symptoms including syncope. Thus, it is important to recognise orthostatic hypotension, determine its aetiology, evaluate and treat it. Intermittent autonomic dysfunction (such as neurally mediated syncope without chronic neurogenic failure) also results in falls and syncope; various forms include the 'common faint' (vasovagal syncope) and carotid sinus hypersensitivity (especially in the elderly). Orthostatic intolerance without orthostatic hypotension is increasingly recognised as due to an autonomic disturbance. New techniques are helping to unravel the functional anatomy of cerebral autonomic centres and their pathways in the causation of orthostatic intolerance.

Self-poisoning and self-injury in adults

Abstract: There are currently no national registers in England, Scotland and Wales and the national monitoring system in Ireland is in the early stages of development. Epidemiological studies have historically relied on monitoring systems in accident and emergency (A&E) departments or in psychiatric services, but gathering accurate data from either source is difficult. These methods fail to account for people who present only to their general practitioner (GP)1 or who do not present to health services at all. Rates of self-harm rose dramatically from the late 1960s to the early 1970s, then decreased in the early 1980s only to rise again by the end of the decade. In most cities the annual rate is about 400/100,0002. This rise has been particularly noticeable in men aged 15–24 years and women aged 25–34 years, with recent UK studies showing a female to male ratio of 1.6:1. UK statistics indicate one of the highest rates of self-harm in Europe3.

Management of lower leg cellulitis

Abstract: Cellulitis is deeply situated inflammation of the skin and subcutaneous tissue, usually due to an infection. The distinction from erysipelas, which is more superficial and thus has more sharply demarcated margins, is somewhat artificial on the leg. Typical lower leg cellulitis is characterised by progressive painful swelling and erythema (Fig 1) with pyrexia and general malaise which are often present before the localising signs. Blistering and ulceration may occur, usually if oedema is marked.

A consultant physician in acute medicine: The Bournemouth Model for managing increasing numbers of medical emergency admissions

Abstract: Consultant-led medical admission units have been developed as one method of managing the increasing number of acute medical emergencies. The need to document such innovations and to evaluate and analyse the role of an acute care physician in meeting the problems of acute care has been emphasised. We therefore report our experience of an acute admissions unit led by a consultant physician in acute medicine in a district general hospital.

How to respond to abnormal liver function tests.

Abstract: Des indications cliniques ou des marqueurs biologiques peuvent aider au diagnostic de maladies hepatiques

Botulinum toxin in the management of spasticity in adults

Abstract: Botulinum toxin (BTX) is a powerful neurotoxin which blocks cholinergic transmission at the neuromuscular junction. Judiciously applied, it can reduce local muscle overactivity while maintaining the strength in other muscles. To date BTX has not been licensed for use in spasticity in the UK and the literature pertaining to clinical practice is still relatively scant. However, controlled trials have provided evidence of the effectiveness of BTX both in reducing spasticity itself and in achieving functional gain. The guidance given here to clinicians involved in the management of spasticity covers the types of patient suitable for treatment using BTX, the appropriate dosage, and the necessary follow-up procedures and documentation.

Intensive care monitoring: past, present and future.

Abstract: Monitoring is the serial evaluation of time-stamped data, and the volume of such data in an intensive care unit is huge. Clinical and biochemical data may be available at hourly or more frequent intervals but physiological data are 'continuous'. Although sophisticated monitors display the physiological data in multiple and varied combinations, staff are challenged by the frequency of the false alarms and lack of knowledge of the patterns from which they could predict problems. All these data, together with large amounts of clinical data, lead to information overload. In this paper, the case is made for the development of automatic decision-support system based on statistical and probabilistic analysis of data patterns appropriate for the level of cognition of the user (nurses and juniors at the bedside rather than consultants). Such decision support could both reduce the false-positive alarms that frustrate clinical staff, and improve the early detection of pathophysiological events. We have used the development of a pneumothorax as our paradigm. Our data indicate that the clinical diagnosis of pneumothorax takes a median of 127 minutes, but using short decision algorithms based on routinely available monitoring data, most can be detected within 10-15 minutes of occurrence.

The management of thyroid cancer in adults: a review of new guidelines.

Abstract: The management of thyroid cancer has been facilitated by the recent publication of the Guidelines for the management of thyroid cancer in adults under the auspices of the British Thyroid Association and the Royal College of Physicians. This is a consensus document that has been developed by a number of key investigators in the field. The central tenet of the guidelines is that thyroid cancer is a disease which requires specialist care from a multidisciplinary team, including an endocrinologist, nuclear medicine physician, thyroid surgeon and endocrine pathologist. The guidelines are comprehensive and detailed, covering differentiated (papillary and follicular) and medullary cancer of the thyroid. They have been written in sections aimed at thyroid cancer specialists, primary care physicians, patients and their families. The guidelines are greatly welcomed and represent a major step forwards in the co-ordination of specialist care for thyroid cancer in the UK.

Brain attack: a new approach to stroke

Abstract: 'Brain' attack' is a new term to describe the acute presentation of stroke which emphasises the need for urgent action. The article describes the basis for this new approach to acute stroke treatment. Rational treatment requires individual causes of stroke to be identified early and treatment targeted at the mechanism. Acute stroke treatment aims to preserve the ischaemic penumbra, protect neurons against further ischaemia and enhance brain plasticity to maximise recovery. There is a strong evidence base supporting the routine use of aspirin, but not heparin, in acute ischaemic stroke. There is also convincing evidence supporting intravenous thrombolysis using recombinant tissue plasminogen activator in selected patients within 3 hours of stroke onset. Surprisingly, as many as 33% of suspected-stroke patients arrive in Accident & Emergency departments in the UK within 3 hours of onset. New techniques in MR imaging, particularly diffusion weighted imaging, are transforming the approach to diagnosis of acute stroke. Although neuroprotective drugs have proved disappointing, active neuroprotection in acute stroke should include control of blood pressure within certain limits, antipyretic therapy, maintenance of blood glucose, and early feeding and fluid replacement. Surgical hemicraniectomy should be considered in patients with malignant cerebral oedema. There is good evidence that the best way to enhance recovery from stroke is to admit the patient to a stroke unit. To enable patients to benefit from the early active approach outlined in the article, the following are needed: the development of acute stroke units; imaging protocols; and education of patients, general practitioners and the ambulance services. Stroke care has become a specialised field, requiring input from stroke physicians, as well as the multidisciplinary rehabilitation team. The British Association of Stroke Physicians (BASP) has therefore developed a curriculum which is designed to lead to the development of a new sub-specialty of stroke medicine.

The evolving pathogenesis of systemic vasculitis

Abstract: The primary small vessel systemic vasculitides are disorders that target small blood vessels, inducing vessel wall inflammation and associated with development of antineutrophil cytoplasmic antibodies. Multiple organs are attacked including the lungs and kidneys. Increasing knowledge of pathogenesis suggests that the antibodies activate neutrophils inappropriately, leading to endothelial and vascular damage. Cytokines such as tumour necrosis factor (TNF) can facilitate the damage by priming neutrophils and activating endothelial cells. Understanding pathogenesis can help to rationalise existing therapies and indicate new approaches to therapy such as the use of agents that inhibit the effects of TNF.

The impact of future technology on cancer care

Abstract: Globally cancer will increase greatly over the next 20 years because of ageing populations. Minimally invasive surgery will reduce the need for routine organ resection. The application of sophisticated computer systems to radiotherapy planning will allow the precise shaping of beam delivery conforming exactly to the shape of the tumour. The most promising advances will come from the rapidly increasing understanding of the molecular genetics of cancer. This will have considerable impact on prevention, screening, diagnosis and treatment and lead to a golden age of drug discovery. Individual cancer risk assessment will provide messages tailored for individual prevention and have far-reaching public health consequences. Increased consumerism in medicine will produce increasingly informed and assertive patients seeking out novel therapies, bypassing traditional referral pathways through global information networks. This will bring new ethical and moral dilemmas. The cancer future will be created by the interaction of four complex factors: technological success, society's willingness to pay, future healthcare delivery systems and the financial mechanisms that underpin them.

Medical professionalism in the new millennium: a physicians’ charter

Abstract: The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges centre on increasing disparities between the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform healthcare systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the healthcare system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.

Chronic lower limb oedema

Abstract: Contrary to popular belief, little fluid is reabsorbed by the capillary and most of it is returned to the circulation via the lymphatic. Lymph drainage begins in thin-walled, superficial initial lymphatics with wide (14 nm) oblique intercellular junctions that function as flap valves. They freely allow passage of fluid and protein into the lymphatic but prevent back flow. The initial lymphatics unite to form collecting vessels which feed into afferent lymph trunks alongside major vascular bundles. These have muscular contractile walls and semilunar valves to direct lymph flow centrally. Approximately eight litres of fluid a day pass through the afferent lymphatics. The afferent lymphatics drain into lymph nodes, where approximately four litres of fluid are absorbed daily by the nodal microcirculation, the remainder passing on to the thoracic duct via efferent lymphatics1. The duct empties into the left subclavian vein at its junction with the jugular vein.

The evolution of the hospitalist movement in the USA.

Abstract: The hospitalist movement represents a novel paradigm of health care delivery in the USA, its evolution hastened by a variety of financial, clinical, and time pressures. Hospitalists are site-defined specialists who spend the majority of their professional time practising in the hospital, and in this respect are similar to emergency medicine or critical care specialists. Community hospitals were the sites of early growth in hospitalist systems, and academic medical centres quickly followed suit. The field has grown rapidly, and now has its own textbook, professional society, training programme, and research and educational agenda. Published research to date has upheld the promise of the hospitalist model: improving efficiency of care by reducing length of stay and hospital costs without compromising quality or patient satisfaction. Future hospitalist research will aim to elucidate the role of hospitalists in the care of critically ill and surgical patients, identify the competencies that will ultimately define this specialty, and expand our understanding of key inpatient issues, such as prevention of nosocomial infections, end-of-life care, and hospital quality measurement.

Teaching the humanities to medical students

Abstract: The decoding of the human genome offers great promise for the understanding and treatment of chronic human diseases at the last frontier. There is a widely recognised hazard that an exaggerated emphasis on molecular reductionism may lead to the loss of the essential humanitarian instincts of young doctors. To counteract this danger it is now accepted by many leading figures of the medical establishment that the undergraduate curriculum must evolve to incorporate a variety of subjects conventionally taught in the faculty of humanities at our great universities. In this article, the case is argued that the study of 'medical humanities' will enhance the empathy, communication skills, ethical standing and, paradoxically, the scientific literacy of the next generation of young doctors. As a clinical scientist, I cannot prove these assertions with an evidence base, but offer up arguments as qualitative or hypothesis generation.