DundeeChest 3.0

Archive for the ‘Featured’ Category

As ever the Scottish Parliament do their best to nose ahead of Westminster in their implementation of forward thinking policies. The recent vote at Holyrood in favour of banning cigarette displays is now closely followed by the Department of Health publication “A Smokefree Future” outlining strategies to control tobacco in England.  Little nuggets like banning smoking in doorways would be welcome, although would probably be as effective as the mournful ghostly voices from the tannoys outside Ninewells telling a legion of deaf smokers to put out their fags. “Fresh air garden” indeed (how exactly do you grow fresh air??).  The Guardian has a good piece on how far the proposals go eg. stopping short of banning smoking in cars, but also give voice to the pro-smoking campaign.  There is little to comment about their position as I think most intelligent free thinkers can come to their own conclusions about their arguments. “Got to die of something” and “free will” are crackers and always makes me think we should encourage unsheathed Stanley knives in primary schools to prove a point.

The opportunities to attend post mortems are not what they were – when I was at medical school back in Addenbrookes in the mid 90’s, we went to PM every day, apart from Grand Round day, to see the specimens from the morning. We were grilled, but we saw so much, and learnt so much.

I doubt many current medical students ever go to PM. So here’s a great Flikr stream of pathological specimens taken from patients who succumbed to lung cancer. The photos are remarkable, and cover a wide spectrum of disease. Well worth a look.

Donald MacGregor, consultant paediatrician in Perth, told me about 18 months ago that he had noticed a dramatic increase in empyema cases in children over the preceding year. The reasons for this rise were not clear to him, or me, at the time.

Today, Paediatrics reports the same increase in empyema, and notes that this comes in spite of increased pneumococcal vaccination rates in recent years.

When patients come to clinic and tell me that they gave up smoking 4 weeks ago, my doom-ometer starts swinging wildly. When patients stop smoking “Out of the blue”, we know there’s a high chance that they have lung cancer. Whether patients consciously decide to stop, because they know they have something seriously wrong, or there’s an unconscious push to stop, it’s a recurring theme. But is stopping smoking at the point of lung cancer diagnosis worth it?

One of my more cynical colleagues says “Why stop now? The outlook is terrible, it’s their only pleasure in life, the damage is done”. Our oncological colleagues are adamant that chemotherapy is more effective if the patient stops smoking, and “reduces the risk of second primary”.

So what should we be telling our patients? What this needs is a bit of evidence base, I suspect.

This week’s BMJ has an editorial, and a meta-analysis on smoking cessation in early lung cancer. They conclude that it’s never too late to stop, even in early lung cancer.

The difficulty putting this data into clinical practice in Dundee, though, is that we don’t see very much limited stage lung cancer. Well over 80 % of our presenting lung cancer is Stage IIIb or above (In the old system – it’ll be a higher with the new system, I’m sure). What do we tell someone with stage IV NSCLC, with a life expectancy of 2 months?

I think the message here, kids, is: don’t smoke in the first place.

Cigarettes on display in a Canadian duty free store

The Scottish Government voted 108 vs 15 to ban the open display of cigarettes in Scottish stores, the BBC News website reports

The Tobacco and Primary Medical Services Bill will also ban cigarette vending machines and introduce a registration scheme for retailers.
BBC News Website

Large stores have until 2011, smaller stores until 2013, to remove all displays of cigarettes and vending machines.

Opposition leader John Drummond of the Scottish Grocers’ Federation is quoted as saying:

The evidence that this will actually stop young people smoking just isn’t there
John Drummond, Scottish Grocers’ Federation

Good grief, man. When did we start to need evidence about such obvious measures? Out of sight, out of mind, anyone? I think it’s a fantastic piece of legislation, but I hope just the start. In some parts of America, where smoking has been banned in public places for some time, smokers are looked on with disdain, and perhaps a bit of pity; in the UK we’re still making jokes about smokers standing out in the rain…

Dropping smoking rates might put me out of a job, but it’ll take 20 years, so my pension is safe. I jest – I would be overjoyed if every smoker in the country stopped today, and lung cancer all but disappeared from routine medical practice. I’m sure the cardiologists feel the same about ischaemic heart disease.

Scotland certainly leads the rest of the UK in this, I’m not sure about the rest of Europe…..

Life In The Fast Lane‘s Latest Pulmonary Puzzle is a very nice example – take a look here. If you don’t have Life In The Fast Lane bookmarked yet, I strongly encourage you to do so – it’s one of the best all round medical blogs I’ve found, and it keeps a wry sense of humour to boot. It’s particularly useful if you want to be an A&E doc, but helpful to all.

And the Pulmonary Puzzles are spot on!

I just need a second post to test the system!

Another year, another go at making the website more functional and more appealing to you, the reader.

This means a new hosting service; a dedicated lifelone URL; a switch to WordPress self hosting; and trying out new themes. This one is attractive, for sure, but it doesn’t handle drop down menus. It does have this lovely featured post bar at the top though. The theme is called Nofelia.

We’ll see.

I graduated in December 1999, and finally finished doing night shifts on 1st May 2009. That’s a lot of time up at night wandering around the hospital in varying degrees of excitement and panic.

A group from Innsbruck have now show that working night shifts is bad for our cardiovascular systems. Not a great shock – I remember in Falkirk, years ago as an SHO I took part in a study where we measured ambulatory blood pressures whilst on day shifts and night shifts. It clearly showed elevated diastolic pressures throughout the night, even if asleep…

So will I end up doing nights again? Probably. The reduction in junior doctor numbers, and hours, means we will doubtless have to fill the gaps with consultant hours. This creates a big issue – who will do my clinic in the morning, if I’m up at night in HDU putting in central lines, and managing unwell patients?

And do we ask my more ‘senior’ colleagues to do nights shifts after not doing them for 15 – 20 years?

Edit 31/01/10: BMJ Careers this week has an article written by a new consultant who has taken on a post as a “Hybrid Consultant”. She seems very happy with the role, it sounds like a terrible idea to me…

The mainstay of COPD management is bronchodilatation – the local, and national guidelines rely on beta-2 agonists, and anti-cholinergics. Recent(ish) data from the TORCH study suggested that inhaled corticosteroids increase the risk of fatal and non-fatal pneumonias.

Unopposed long acting beta agonists have been linked with increased cardiovascular death in asthmatics, although not in COPD. The most recent ’scare’ has been whether Spiriva increases cardiovascular death in COPD patients. Today the FDA rule that there is no compelling evidence to that effect.

To learn more about COPD visit the COPD GOLD guidelines pages, or the NICE guidelines on COPD.  We’ll be updating our local guidance on COPD soon, so keep checking the Knowledge Base section for updates.

To see some patients with COPD, come to ward 3, any day of any week!