We are proud to announce that we have been successful in our application for funding from Tenovus-Scotland to start our first clinical trial of 2013. Richard Stretton, James Chalmers, and Tom Fardon will be leading on the study, looking into the effects of pulmonary rehabilitation in bronchiectatic patients.
The Japan earthquake and Tsunami has lead to critical incidents at nuclear power stations, and, understandably, concern over radiation levels throughout Japan. At the site of the incident, radiation levels soared to 400mSv per hour, but quickly fell to 0.6mSv per hour at the front gate of the plant hours later. Levels throughout Japan have been reported as 6uSv per hour this morning.
But what does these figures actually mean? And how do they relate to the doses of radiation we expose our patients to in clinical practice?
A CXR is about 0.02 mSv
Background radiation for a year in Dundee is 2.5 mSv
A helical CT scan of the Chest, Abdomen and Pelvis is about 12 mSv
Radiation sickness usually occurs at 1 Sv
Louis Slotin received 5.1 Sv during the criticality accident in 1946 that lead to his death
Radical radiotherapy is usually of the order of 50 Sv, in a number of fractions
If you want to learn more about the risks of ionising radiation associated with common radiological investigations, you can visit the Radiation Tutorial that Smithy devised last year.
That headline has nowt to do with this post but I feel an obligation to myself, and to all those who hold the pure art of the pun in high regard, to use it. Mind you, there is plenty of scope for pun-age with the article from Chest that caught my eye – “Fighting Vampires and Ventilator-Associated pneumonia: Is Silver the magic bullet?“. Aside from briefly thinking that Buffy had widened her slayer repertoir to include pathogenic bacteria (a much more sedate spin off series methinks), this piece is an editorial on the publication of the NASCENT study in the same edition. It looks at the antibacterial effect of silver coated endotracheal tubes on the mortality rate of ventilator associated pneumonia in ICU. The study authors are fairly upbeat in their message suggesting that it “was associated with reduced mortality in patients who developed VAP in the NASCENT study”. The editorial is less convinced, and gives a good overview of the state of play for this difficult condition, ending with the upbeat message that rates are already in decline with the introduction of good old fashioned hygiene in the form of ventilator bundles, so you may not need your fancy pimped up ET tubes anyway. So there.
User El has asked a question over on the AskDundeeChest page of the site
DC : in asthma, can you explain the order of drugs used, I don’t really understand the circumstances for using ACh antagonists, is it just in acute asthma these are given?thanks
As ever, the information is easily at hand on the BTS website, under the asthma guidelines section. But here’s the relevant page for you (Click it to make it bigger):
In answer to the last part of the question – Anti Cholinergics have no evidence base in asthma, despite there being a valid theoretical place for them in a bronchoconstrictive syndrome.
It’s web 2.0, then? What happened to web 1.1.4, and web 1.3.8? What about web “Snow Cheetah”? Well, it’s web 2.0 until we get to web 4.0, I’m told. So about time we got with the program, and brought the Dundee Medical Course into the “teen-ies” (after the nought-ies….). The Dundee Blogging Network aims to do just that, and spearheading the attack is DundeePRN. I don’t know of any other medical school who is running the same thing: a student led; student written; student delivered; student edited, moderated and administrated web based resource of the same scope as DundeePRN.
A couple of the students have put in literally hundreds of hours over the past 4 months putting this together, and the fruits of their labours are starting to be evident now.
We launched the site during lectures today (DundeeChest braving the outside world despite his precarious post operative condition), and already we have over 60 users registered with the site. We start the analytics from today, to see how the site is utilised – we hope to get the other years involved in this as soon as possible.
The site is available to everyone and anyone – some pages are only visible to registered users, but there’s nothing stopping anyone registering.
A recent paper in Chest has suggested that the staple treatment for COPD may not be the knees of the bees after all. Inhaled corticosteroids (ICS) have been the cornerstone of COPD management for some time, with the aim of reducing inflammation and (hopefully) cutting exacerbation rate. The TORCH study successfully did away with thoughts of ICS improving survival (ahh, the agony of p=0.052) but at least we have the principle of symptom control to cling to don’t we? Well, don’t we?
The clever bods from Chandigarh, India have taken 11 large prospective, double-blind, randomized, placebo-controlled trials and passed it through their Metaregression-ometer and come up with the conclusion that “The benefits of ICS in preventing COPD exacerbations seems to be overstated”. The collected statistics from the 8,164 patients pooled from seminal papers including ISOLDE, TRISTAN and TORCH showed that “we did observe a modest benefit of ICS in preventing COPD exacerbations in patients with FEV 1 < 50%. However, this finding was not further substantiated on a metaregression analysis wherein we did not observe a significant effect of baseline values of FEV 1 (percentage predicted) on the benefits from ICS compared with placebo. Thus, ICS is likely to have only modest benefits in preventing COPD exacerbations, if at all, and should be judiciously used in patients with COPD keeping in mind the risk-benefit ratio.”
I’ll admit my utter ignorance of the nuances of metaregression analysis and its potential flaws when used like this, but I would hope that the use of words such as “likely” and “modest” would hint that the analysis has scope to be challenged by people with more statistical savvy than my good self. Mind you, it doesn’t really matter does it, what with the veritable panacea of COPD drugs at our disposal…………(right, anyone got shares in Roflumilast?).
While the main headline grabber from the Tobacco and Primary Medical Services bill passed in Holyrood last week was the banning of the display of cigarettes, there was another hugely important aspect of the bill that passed with barely a ruffle in the feathers of the great media Chicken. In fact I couldn’t even find mention of it on the BBC website. They voted unanimously to keep private companies out of running General Practice services. “Why of course, that runs against the very fabric of the NHS” says you, but commercialisation of the Primary sector is very much alive and kicking south of the border. I would like to use superlatives to stress just how widespread it is but in fact it is difficult to know. What I can stress however is just how radically different the NHS is south of the border both in Primary and Secondary care, having just moved up from the Newcastle area.
For those in the dark, essentially the primary care trusts (PCTs) now hold all the cash and they essentially “buy” services for their patients (also called “Practice Based Commissioning” – my, how I love management speak). This means that they will pay the hospital respiratory outpatient department, say £40 for a new appointment, £20 for a review. For their cash they would expect a good service. If they don’t feel they are getting it, and there happens to be a nice bunch of specialists who have set up their own service and undercut the hospital by £10, then the Primary care trusts can dictate that all their chest patients go to “Stretton inc. Respirology”. The PCTs also know that follow-up of chronic disease can easily be done at the practice, saving them money, and so are reluctant for the old fashioned 6 monthly clinic review. The PCTs therefore hold the power and keep the money not spent as profit to invest in other services (or dare I say it – wages). This is where the private companies come in, if they see a profitable GP practice they can swoop in, buy up the practice and take over all the administration (the bit most GPs hate) while offering the doctors a guaranteed steady healthy wage. These companies are however duty bound to put the financial health of their shareholders at the top of their agenda. Some large American health insurance companies are starting to do this in England as the NHS is seen very much as the most lucrative untapped market in Europe. Is that the sound of doom I hear?
Services farmed out to private ventures (Polyclinics ring a bell?) means that the hospitals stop getting their cash and an outpatient service can be stopped altogether. This is already happening in certain areas of England. For an excellent treatise on this parlous state of affairs the book “NHS plc” is spot on.
So what does this mean for the respiratory outpatient clinic? Well, despite my revulsion at the financial driving force, I found that clinics had to up their game in the service they were providing. Less long term reviews meant more new patients which meant more money for the hospital and shorter waiting times. Clinics were set up to provide a vast array of services on the day. I could see a patient and have a 6 min walk, skin patch testing, ABG, ambulatory Oxygen assessment and inhaler technique all done before the patient went home. The financial pressures meant meticulous records of patient numbers, diseases and waiting times were recorded, and regularly reviewed, not only providing a valuable audit resource but could also prove how much money the department was bringing to the hospital, and therefore be used as a very effective method of leverage when pressing for investment into further services. The inpatient sector was no different, although there was no alternative service provider for the PCT they would expect a certain value for money depending on the reason for admission. A “menu” of diseases and the cost of admission meant that PCTs were billed for what they sent in. The onus however is on the hospital doctors to record the problems because it is actually clerical staff who flick through the notes and state ‘COPD’ or ‘Heart failure’. Given that the hospital would receive about £1000 more for COPD and Type II resp failure than COPD alone, then the problem list for the admission had to be meticulous (or certainly we were roundly thrashed if it wasn’t – it’s hard down south), which again provided another valuable audit trail.
The financial incentives to raise or maintain the standard of services is all pervasive in the English NHS. The fear in hospitals of losing services to a private venture, beholden to its shareholders, is actually creating some change for the better. Let me be completely clear that I abhor the infiltration of the NHS by the private sector but from what I witnessed market forces were moulding a more efficient service, it’s just a pity there has to be a market behind it.