DundeeChest 3.0

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Like those who sit outside Apple shops waiting for the latest flat shiny “Jabscreen”, respiratory physicians have long awaited the publication of the BTS Bronchiectasis Guideline. I would venture however that the online rumour mill was less frenetic, few will pose to be photographed unwrapping it from the cellophane, and as far as I am aware it will work if you hold it in your left hand. I’ll admit I haven’t read it yet, but I know from previous seminar sessions that it is likely to highlight the weight of evidence that is lacking as much as give sound guidelines. Now that is all a bit dry, and, you know – clinical. So here is an animation based on the medical illustrator Fritz Kahn which is much more entertaining….

Death in a bun. Tasty, tasty death....

No I’m not a militant vegetarian, I wouldn’t be able to cope with all the hemp and Tofu. I just love the eye-catching nature of this piece from a consumer health blog about choking hazards – “About 17 percent of food-related asphyxiations were caused by hot dogs.” Despite the original press release from the American Academy of Pediatrics mentioning nary a word about processed pig snouts being the biggest killer since smallpox, there has apparently been a move to redesign the hotdog. As one statement author Gary Smith put it, “If you were to take the best engineers in the world and try to design the perfect plug for a child’s airway, it would be a hot dog,” One could only assume they would be working for Dr. Evil in this task.

Perhaps we simply need to encourage increased use of condiment lubrication and practice  our skills at removing these pig fingers from the right main bronchus? If nothing else, I’m sure our great british press will be able to torture this information into assuring us that Cumberland rings are better for your health.

“If meat is murder, is Quorn just wasting police time?” Armando Iannucci

Teaching the 5th years in the final gasp of their medical school career, the APART course last week ran them through some scenarios of acutely unwell patients. This was quite literally their last two hours of medical school before starting work in August and I was surprised at the sea of blank faces when they were faced with a COPD patient in type two respiratory failure.  The progressive (simulated) decline of the patient (accompanied by my now legendary impressions of “elderly confused woman” and “obstructed airway”) did little to trigger the request for non invasive ventilation. Comments like “ask ITU to keep an eye on them” did little to quell the rising panic in my little respiratory educationalist heart.  Once the topic of NIV was broached there remained an air of mild confusion and the whiff of misunderstood acronyms in the air. What is BiPAP, CPAP, NIPPV? Can’t you just tube them all?  I find myself relieved that the new and improved respiratory teaching for the second years will go some way to exposing our students to this most oft used and useful of therapies, but what of the students in the more senior years? DundeeChest 3.0 to the rescue….? When I find some useful web resources in this area I will post them, but I have to admit I’ve come up short so far.

Carlsberg don't do anaesthetists....

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.

Calm down dear, its only your 210th admission.

The more the merrier. Or if not merry, at least alive. That is the message from a recent paper in the New England Journal looking at the survival rates for common conditions depending on the patient load of the admitting hospital.  It would appear that having to admit yet another pneumonia is actually good for the health of the other four you already admitted this week. Looking at all the admissions through Medicare to US hospitals for MI, CCF and Pneumonia the authors found that the hospitals with the larger patient volume of each condition had improved 30 day survival for that particular illness. The improvement in mortality wasn’t relentless though, (otherwise we should have a giant überhospital for all UK pneumonia patients where no-one dies) given that they found once your hospital topped 210 pneumonia patients there was no further survival benefit. Mind you, EWTD means they are all probably clerked by the same lonely registrar…..

Alternatively, it will tell you what the weather is like out at the smoking shelter...

The Department of Health is trying to prove that although it can spend more money than the GNP of a small African nation on a dysfunctional patient database, it is up to speed with the world of mobile technology.  They have produced an iPhone app to help patients quit smoking and surprisingly it, well, actually works (as an App I mean, I couldn’t attest to its impact). There are prominent hints and tips about kicking the habit and a few nice scary facts (in red, no less) to try and keep the underlying fear factor above the “can’t be arsed” threshold.  By far the best feature however is the timer that starts from the second you quit and then tracks how much money you have saved. If nothing else I recommend non-smokers to download it and start the counter for that nice warm smug feeling you get when you see how much of your cash hasn’t gone up in smoke.  I will have to restrain myself from shoving it in the faces of smokers and laughing though….

Doh!, indeed.

As ever, the best piece of writing (in my humble opinion) from over the weekend comes from the “Bad Science” blog.  Ben Goldacre’s mind is hardwired for statistics, and this week he has turned it to the oft touted health benefits of smoking, and in particular, protection against Alzheimers.  He discusses a recently published systematic review which – surprise surprise (and I’m sure I’m not spoiling it for anyone here – hey? what? smokings bad! You don’t say) – shows that the risk of alzheimers is increased in smokers.  The really interesting part however, if you are into this sort of thing, is the analysis of papers where the researchers were associated with the Tobacco industry. Now that is a surprise I won’t spoil.

Hands up if you want a chest drain....

Well, probably not.  Is bigger better? That is the question (with apologies to Billy Shakespeare) that wafts around the room when discussing the chest drain options for an Empyema.  Long has it been argued that drains of a wider bore ensure complete drainage of tenacious pus from the chest cavity, and sidestep the problem of getting repeatedly blocked.  The pros and cons of both wide bore surgical drains using blunt dissection, and their smaller counterparts inserted with the seldinger technique, are batted back and forth among chest physicians and cardiothoracic surgeons alike.  This recent paper in Chest looks to clarify the issue by looking afresh at the MIST1 trial data and determines that the smaller drains did not lead to increased rate of death, or need for surgery, but were associated with less pain. Their conclusion is that the small drains seem to be doing the job just fine thank you very much, but needless to say a properly designed study looking specifically at this issue is needed. Don’t they always say that?  For a good discussion around the topic I would check out the editorial in the same issue.

Strained metaphor to get amusing picture into blog...

We know that asthma often goes hand in hand with other atopic conditions such as eczema and hayfever but it appears it may be holding hands with a few other diseases too.  German researchers have taken a sneaky peek at the Swedish Hospital Discharge Register for the years 1964–2007 on 148,295 hospitalized asthma patients.  They found that the rate of hospitalisation for an autoimmune disease was higher amongst the Asthmatic population than the general population, the most common being Polyarteritis Nodosa and Addisons disease.  There is a healthy amount of speculation about Lymphocytes, cytokines and HLA systems, but that makes my brain hurt and its Friday so I wouldn’t dare to comment……

Yes, that is a crystal studded MDI....

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?).