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Archive for May, 2015

Nivolumab Data Presented

30 May, 15 | by tomfardon

More to follow, no doubt. And there might *just* be a bit of journalistic hyperbole in there, but might this be some hope for lung cancer patients?

Guessing Tubes

26 May, 15 | by tomfardon

I broke my stethoscope this week. I was listening to a chest, on a ward round, as you do, and the ear-pieces just went all wonky. The metal spring hidden in the rubber tubing had snapped.

My stethoscope is like Trigger’s broom – I’ve had the same stethoscope since 4th year of medical school; I’ve only replaced the diaphragm twice, the bell rubber three times, and the tubing once. The metal bit – the business end – is the original, shonkily engraved with my name.

I borrowed my registrar’s guessing tubes for the rest of the ward round. I think I used them once.

I’ve found a place that will sell me a replacement tube/earpiece thing. Last time it broke, in 2001, I think, I went to a medical supply store, and picked out the replacements. This time it’s the internet to the rescue, of course.

I was very excited about getting my first stethoscope. 1997, 4th year of medical school, and the Littmann reps came to the students’ mess with a range of excitingly coloured stethoscopes, and boxes of complimentary fish and chips, I recall. The decision of colour was simple – hunter green, obviously – but the mode of transport was perhaps more important: over the shoulders, round the neck, in a pocket?

Fast forward 5 years and I was using (mostly) the same stethoscope sitting my PACES exams. No longer guessing with my tubes, I was dedicated to the fine art of differentiating a murmur of aortic stenosis from that of mitral regurgitation. Fortunately the murmur in my exam was aortic regurgitation, and I didn’t have too much trouble.

I was regaling my registrar with this tale of exam pressure in 2002, when she asked me “But what’s the point, though? You’re going to get an echo regardless, aren’t you?” Yes, that’s as maybe, but they’re really important for listening to lungs, say I. “But aren’t you going to get a CT?” Sigh.

She makes an interesting point though.

10 years ago, when I started my respiratory registrar post, we had access to an ultrasound machine. It was the size of a top-loading washing machine (remember those?), and weight about 20 metric tons. We didn’t use it very much. Now we have a number of portable USS machines, all the size of a chunky laptops, and every chest SpR has to be trained to ‘level 1’ before they can get their CCT. Is there a pleural effusion, is it consolidation, is it an elevated diaphragm? We don’t listen, we don’t percuss any more, we get the ultrasound machine out and we know.

Should we be training up all our doctors to use the same ultrasound machines to look for valve abnormalities? I’m no cardiologist, so I have no idea how long it must take to train up to be able to look at valves, but the cardiology trainees manage.

In days of yore the fine details of murmur analysis were critically important. When to refer for an aortic valve replacement? When the second heart sound disappears, of course. Who would refer for an AVR without a valve area, or pressure gradient? W don’t put in a chest drain without doing an ultrasound of the thorax immediately beforehand, would we?

So should I get those replacement parts for my stethoscope? It’s going to cost me over £100 after all. Or would I be better off putting that money towards an echo course?

Are you asleep yet?

12 May, 15 | by tomfardon

I don’t do a lot of sleep medicine. It’s never appealed to me. But I work in a relatively small department, so it’s inevitable that I will see people with sleep apnoea, and have to deal with it. In all senses.

We have a relatively small population to serve – about 450,000 across the whole of Tayside, but a prevalence of 4% means a lot of patients with sleep apnoea. The prevalence of ‘tiredness’ must trend towards 100%, so referrals into the system are numerous. Myriad. Legion. Over 100 a week, so I’ll go with legion.

Everyone gets limited polysomnography now. Overnight oximetry seems to diagnose the problem in a small few, but essentially everyone went on to get limited PSG anyway, so we just do that now. The test takes a long time to report. The computer does a lot of the work, but the technicians have to go through it, and highlight apnoeas. A long, tedious process, I’m sure.

Anyone with a normal study is dispatched at a virtual clinic review. Everyone else comes up to clinic, is seen by a consultant, and gets another appointment to come back and get a CPAP machine, and off they go.

Surely there’s a more straightforward way to deal with this large burden of investigation, reporting, clinic appointments? As a ‘non-enthusiast’, I wonder why we don’t just give everyone a trial of treatment? The outcome we’re chasing is decrease in daytime somnolence, so rather than go through the laborious process of limited PSG, reporting, and clinic review, why don’t we just give everyone who’s somnolent a CPAP machine to trial for a week? My sleep interested colleagues tell me that the response to CPAP is dramatic, so patients would know very quickly if it works. I also see how uncomfortable it must be, so anyone in whom it doesn’t work, would quickly hand it back, I think.

That shortens the pathway, doesn’t it? Patient falls asleep in the daytime. Gets CPAP machine in the post. It either works and they keep the machine, or it doesn’t and they hand it back.

I’m sure I’m over-simplifying a very complex and fascinating sub-speciality area. But it does seem to occupy a lot of our time, and anything that speeds up the process has to be worth a thought?

The other problem I don’t have an answer for is what to do with people who have sleep disordered breathing, but no daytime somnolence. Stopping breathing overnight is clearly a common occurrence, and we can obliterate that, but are we only treating the partner’s anxiety, rather than an actual disease? I floated this on sister site Doc2Doc a year or so ago – it was a very polarising question. There were sleep enthusiasts who told me very firmly that anyone with a raised AHI should, nay MUST, get a CPAP machine, and be treated aggressively. They couldn’t tell me why, as the outcome measure of somnolence is hard to monitor when the patient it not sleepy in the first place. Others asked the question of why bother to do the test, a view with which I clearly hold much sympathy.

As I write this, a colleague is poring over limited PSG reports, many of which are normal, but the majority will get a review appointment, and a trial of treatment for their equivocal limited PSG. I look over and my heart sinks. But I suspect he feels the same when he sees me leave to go to adolescent asthma clinic…

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