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The WISDOM of ICS

12 Nov, 14 | by tomfardon

I was speaking at a local educational meeting in Perth last night, the topic being COPD, as it usually is at the moment. Every month another inhaler is released, another device, another pharma company courting our prescribing pens, another combination of drugs. So when I’m asked to go out to speak to our primary cary colleagues, it’s usually about this ever expanding world of therapeutic options. The biggest current controversy has to be the apparent contradiction that ICD/LABA has been shown to reduce all cause mortality (p=0.052), reduce exacerbation rates, slow the rate of FEV1 decline, and improve quality of life, but also been shown to increase pneumonia rates in large meta-analyses, as well as individually in large studies. At the end of my little show, I’m aways asked “Double, or Triple therapy?” LABA/LAMA or LABA/LAMA/ICS?

The recent WISDOM study announced at the recent ERS, and published simultaneously in the NEJM, attempted to answer that specific question. Over 2000 patients run in on triple therapy, were randomised to stepwise withdrawal of the ICS, or continuation of triple therapy. Over a 12 month study period, the primary outcome was time to first moderate or severe exacerbation of COPD. There was no difference between either arm – withdrawal of the ICS made no difference.

Great study. But not perfect. I’d like to see a ‘real world’ study that covers the same withdrawal of steroids protocol. In this study patients were run in on triple therapy whether they needed it or not. Stopping the ICS in those patients who didn’t need it would predictably not lead to much… I’d like to take patients with COPD in the real world who have been escalated to triple therapy, and withdraw their ICS, see what happens. This was done in asthma about 10 years ago, in a primary care environment – ICS was halved in a real world population, and nothing happened. I should dig out that reference. And the study still accepted all-comers with COPD, with no attempt to separate the phenotypic groups within the heterogeny of COPD. I’d like to see the individual patient data – some patients must have deteriorated on withdrawal of ICS, because we see that it real life. Don’t we?

The inhaler landscape gets more colourful, and of varied shapes in the next few months – we’ve been waiting for the first LABA/LAMA to market, and we’ll see what is it soon enough. In my doctor-lifetime the evidence based medicine guidance has gone from LABA then LABA/ICS then LABA/LAMA/ICS; to LAMA then LAMA/LABA/ICS and no LABA/LANMA option at all; to what will soon be (I’m sure) LAMA then LAMA/LABA, then LAMA/LABA/ICS for a very select few.

Interesting times.

#ers2014

7 Sep, 14 | by tomfardon

I’m not at the ERS, I’m in sunny Dundee, but due to the wonder of social media, we can all follow the goings on in Munich on the Twitter hashtag #ers2014. If you want to see what’s happened on this first day click here

Of great interest – those COPD patients with an increased Eosinophil count respond best to inhaled corticosteroids. More to follow on this topic, I’m sure. On my acute medical ward round yesterday I was bemoaning the lack of a space on the clerking pro-forma for eosinophil count; it seems chest physicians are the only people interested in eosinophils.

Conference Time

6 Sep, 14 | by tomfardon

There’s a thread over on on the Doc2Doc website about the ERS over in Munich. A couple of trainees asked about what to do and where to go – one of the more senior members over there thinks that conferences have become bloated, oversized, and are now so big that they have become too large to function effectively.

The ERS is a massive meeting – 24,000 delegates at Barcelona last year, and probably as many this year. But such a large meeting will draw big name speakers, and thus quality of presentations. There’s too much to see, of course – not possible to be in every place at once – and some of the sessions are so big that it’s very daunting to get involved in the discussions.

I fondly remember going to CHEST in 2004, in Seattle. Seattle is a great city – well worth the flight across to the West coast, I think- but the meeting was organised in a very different way to the giant ERS/ATS norm of today. Each session was very small, often only 12 or 15 people, of which 6 would be presenting. It lead to a very lively discussion in every session, between the people who were either really interested in the topic, or the real experts in the field. In some ways it’s like the spoken poster sessions at the Winter BTS.

There’s still the question of whether 20,000 people should get onto planes, and fly all the way to Munich for a conference that could be broadcast over the internet. The TED talks very successfully broadcast all through the year – we even had a TED-Med broadcast from Dundee recently, and we’re thinking of having a TED-Ed session later in 2015. The cargo footprint of the ERS must be astronomical – but the boost to the local economy of Munich, and Barcelona last year, Amsterdam next year, cannot be ignored.

I have a Maltese colleague who works in Dundee with me, but trained in the North East of Enlgand; he arranges one night out with his Maltese colleagues, one with his Liverpool colleagues and one with the Dundonians – hard to get together with so many people without meeting up at a conference.

I’m not going to the ERS this year – I was at the ATS this year, and the ERS last year, not to mention the excellent Summer BTS in York. But if you are in Munich, remember to visit the Thorax stand – there’ll be plenty of chat from our Editors, and a free copy of Thorax, probably.

Finally – do you want to be the next Editor in Chief of Thorax? We’re looking for one, or two – see the Journal Website for more info. If you don’t fancy the big seat, do you want to write a Thorax blog? Drop me a line – we’re looking for guest bloggers!

Should we have a Dr House?

5 Sep, 14 | by tomfardon

You’ve seen House, right? Prince George from Blackadder III plays a misanthropic “diagnostician” in a fancy Boston Hospital, taking on the hardest cases, those without a diagnosis, and works out what’s wrong through a range of tests carried out by his underlings, a whiteboard that *always* has sarcoid on it, and by being quite rude to the patient, relatives, and anyone else within earshot. He’s addicted to narcotics too, seemingly.

It strikes me that Gregory House is all well and good, reaching diagnoses that no-one else can make, devoting hours and hours to cogitation and diagnostician-ing, but he only has 1 patient at a time. The Royal College tells us we should have 25 in-patients each, and we have a variable out-patient workload. Greg has an out patient clinic to do, once an episode, but I don’t think he follows people up much. If I had only 1 patient at a time, I’d like to think that I’d be able to bury myself in the case, and come to a diagnosis, whether it’s Sarcoid or not.

Do the general public watch House and have the expectation that their doctors should be like him? I don’t mean grumpy, walking with a limp, and doped up on Vikodin – do they expect that we have as much time to dedicate to a single patient? Not to mention that the underlings seem to do all the tests, from gram stains to brain biopsies, via bronchoscopies and interventional radiology. I can do one of those tests, and ask experts for their opinions on the rest.

TV drama silliness aside, it makes me think – how many of my patients do I know really really well? How many do I see in clinic and know in depth the tests they’ve had, not had, the results, trends, discrepancies? Some. But not all – that’s unrealistic. But what if we had a special team of doctors, a ‘special ops’ unit, headed by a ‘House’? The team has a small number of the the most complex patients, and they know everything about that small number of patients, in depth. But that’s ICU, isn’t it? So House-UK is an intesivist? But intensivists are there for the intubated patients, in most places I’ve worked – although outreach ICU is more and more commonplace. So perhaps House-UK is an HDU doctor? HDU patient are awake, sick, complex – ideal House-fodder.

I’m on call for our HDU tomorrow, all weekend, in fact. Maximum of 6 patients, 2 to 1 nursing, and me. Not so many gram staining, colonoscopy-ing, brain biopsy-ing underlings, though. So I can play House-UK tomorrow? Consider sarcoid for every patient? Perhaps. But I’ll have all of the chest ward to see afterwards!

We chest physicians get a lot of ‘grey cases’ through out in patient, and out patient books, many with multi system disease that just happens to involve the chest, or, often, they come in with a co-incidental chest infection, or ‘breathlessness’ due to their unrecognised metabolic acidosis. We’re all Dr House to some degree, facing challenging cases in our clinic rooms, an on our weekend ward rounds. I rely heavily on second, and third opinions – formal, and informal multi-disciplinary discussions, sometimes in organised meetings, other times over a caffeinated beverage in the Drs’ Mess. None of us are Dr House, and none of us want to be – I hope our patients don’t expect us to be. A difficult case takes multiple brains, and takes time to get through.

My HDU ward round tomorrow will be the start of a weekend of ‘diagnostician-ing’. Perhaps I should get a white board, and write sarcoid on it?

Summer BTS, Insidious Advertising, Le Grand Dèpart, The benefits of time off.

13 Jul, 14 | by tomfardon

I’m just back home from 2 weeks of annual leave. 2 whole weeks, with my whole family, without having to go to work. I think the last time my wife and I had 2 weeks off, together, back to back, was our honeymoon. In September 2000.

After one week off my e-mail inbox usually has about 600 unanswered messages, so it’s no surprise to find 1153 in there just now. But, despite me now answering them, and me not being at work, the hospital, and the medical school seem not to have fallen down, burnt down, ground to a halt, disappeared and reappeared on the moon. I suspect no-one has really noticed.

Two weeks off has allowed me to actually have a holiday – something I have to admit, I rarely manage. I think we underestimate the importance of taking a decent chunk of time off, as a single block, to unwind, chill out, and have a bit of fun with the family. I even took the kids to Alton Towers.

It looks like I have another few days of annual leave to take before the end of July, but I’ll have to spread them out, piecemeal throughout the next couple of weeks – I have a sneaking suspicion that I’ll spend at least one of those ‘days off’ catching up with e-mails, going into the office to do a bit of dictation, having a quick meeting over lunch. Perhaps I should just go back to Alton Towers.

The Summer BTS was in York in the middle of my two weeks off. So yes, I did do some work in the middle of my ‘2 week uninterrupted block’, but the Summer BTS, as previously discussed, is a highlight of the year for me, so I don’t consider it too arduous – and the racecourse is only one stop round the A64 from the designer outlet village, which is always worth a punt. A real highlight for me was Jon Britton’s hugely engaging presentation on smoking cessation. I was only one of the audience who posted a number of tweets during his presentation – you can follow the twitter discussion on #BTSSummer (Incidentally, BT Sport were using the #BTSSummer and #BTSWinter hashtags to hold a poll on whether the World Cup should be in Summer or Winter – our Summer BTS tweets provided an unexpected bias to the vote).

Something I’d really not thought about was the insidious advertising that is seemingly endemic on our TV programs in the UK. Coronation Street was used as an example: the beer served in the Rovers Return is fictional; when the residents want to search on the internet, they use Poogle (or some such), but all the cigarettes displayed in the corner shop are real, likewise any cigarette boxes on tables, or just lying around. The cigarette display counter in the corner shop is at 90 degrees to where it would naturally sit in a real shop, otherwise it wouldn’t be in camera shot.

The recent film Rush, based on the real life events of the F1 stars James Hunt and Nikki Lauder shows the era-accurate F1 McLaren cars, sponsored by Marlborough. Fair enough, you might say. SKY movies made the effort to remove the branding from the cars on a shot by shot basis, so avoid any inference of advertising. Not something I ever thought about.

The question of eCigarettes was obviously high on the agenda for Prof Britton. He showed evidence that the uptake of smoking has not increased in under 18 year olds since the introduction of eCigarettes, going against the suggestion that they ‘normalise’ smoking. The availability of smoking alternatives, such as Snüss in Sweden, have reduced smoking rates, and, Prof Britton suggests, eCigarettes are no different. He accepts that they are probably dangerous in their unlicensed form, but the next moving is licensing, not banning them. He makes a compelling argument. Great lecture.

Then I was a TourMaker at the Tour de France Grand Dèpart in Yorkshire. I’m a keen cyclist, and I’m from Yorkshire, so this was a dream come true. I marshalled in a sleepy village outside Aysgarth, which involved very little actual marshalling, but the sense of excitement in the whole of Yorkshire was something amazing to be part of. The real joy, though, was seeing so many people out on their bikes, all through Yorkshire. The roads were closed in front of the tour, but the cyclists of Yorkshire didn’t get the memo – on the bus to get to the marshalling point, we must have seen 2,000 people cycling up the road. People of all ages, sizes, seriousness, all cycling up the road to see the tour. We’re constantly being told how we’re an obese nation, who we’re a sedentary nation; the nation I saw that weekend were neither. It’s easy for me to be a cycling evangelist – I love being out on the bike – but it looks like I’m not alone. I was a standard spectator on Stage 3 in Cambridge; it wasn’t just Yorkshire folk totally enthralled with the Tour. There’s thousands of bikes in Cambridge every day of the year, but the excitement of the tour was palpable. I do hope the enthusiasm carries on through the post-tour excitement, the cardiovascular health of the country can only be positively affected.

My 2 weeks of actual holiday are over. Back to those 1000+ emails, and who knows what remains on my desk. I’m glad I went away, though.

How many beans make 5?

13 Jul, 14 | by tomfardon

More importantly, how many consultants make a department?

We interviewed for two new colleagues recently. 2 posts, 2 applicants, 2 shortlisted, 2 interviewed, 2 appointed. All smiles down at the DCA that night.

This brings us up to 6 consultants, but 5 Whole Time Equivalents, for our teaching hospital service. The Royal College of Physicians has a document to guide how many respiratory physicians are required for a typical DGH with a catchment of 250,000. It makes interesting reading.

Inpatient work
2 ward rounds a week, with the extra responsibilities of discharge planning, family meetings, etc, makes 3 PAs for inpatient work. Daily review of patients in MAU, add another 0.5PA. If the respiratory physician does some GiM – add another PA. And add in 0.5PA for each MDT.

Outpatient Work
For a population of 250,000 people, 900 new referrals will be generated per year, requiring 11 – 12 PAs per week to cover the clinics – not including the cancer workload. And there will be general medicine follow up appointments added to this, in some centres. 30 mins per New, and 15 mins per Return mean in 4 hours we should see 4 New and 8 Returns – this ignores the need for CXRs and PFTs, of course.

Bronchoscopy
Everyone likes to keep their skills up – so most physicians undertake one PA of bronchoscopy a week, with no more than 6 patents per list.

Thoracoscopy
More excitement for the chest physician, but it is demanding, so requires a PA for every 2 patients per session.

Sleep Disordered Breathing
2-4 PAs of consultant staff, 2 WTE nurses, 0.5 WTE secretarial staff.

NIV
Ideally one consultant should supervise the service, requiring 1 or 2 PAs.

Lung Cancer
0.5 PAs for everyone who goes to MDT, and 0.5 PA for the the local clinical lead. A DGH of 250,000 population generally requires 10 PAs of consultant time to run the lung cancer service.

TB
Generally requires 2 consultant, with a lead taking 0.5 PAs for each 25 annual cases.

Specialist Clinics
Difficult asthma, bronchiectasis, ILD, transition clinic – all require another PA for the consultant carrying out the work.

CF
0.75 PAs for every 50 patients

And there’s some more, less common, more esoteric things that we might like to do too.

This adds up to a lot of clinicians. I don’t think we’re any different in respiratory medicine; I’m sure every speciality feels they are under-staffed, overworked, etc, and they’re probably right. I’ve written previously on the increasing number of junior doctor roles we have to cover when on call, and the lonely figure of the on call consultant, writing in notes, rewriting drug charts, fluid charts et al at the weekend – it’s not just the chest physicians.

But, reading through the list of things chest physicians get to play with, I’m sure we should be inundated with applications for ST3 numbers in our speciality. We’ve filled all our permanent, and LAT posts here in Sunny Dundee, but the national picture is not as rosy – many centres have unfilled LAT positions, meaning consultants will be ‘acting down’ more and more.

How many consultants does a respiratory service need? How many registrars? If you had the choice, would you want a consultant, or 2 registrars?

How many beans make 5? 2 consultants, 2 ST3s and 2 LATs, seemingly.

Summer BTS – Day 1 in the BTS House

3 Jul, 14 | by tomfardon

I like the Summer BTS. It’s not as well attended as the Winter meeting in London, there’s a smaller choice of talks, it’s doesn’t have a pub right opposite into which to retire post conference, there’s a far smaller number of posters, talks, and it’s shorter, out there’s something relaxed about the Summer meeting that I like. It’s certainly nice to run into old friends and colleagues at these meetings.

The program is necessarily limited, as there’s not many rooms, but the organisers have sorted out a very interesting and diverse meeting.

I skipped this morning’s year in review, instead going to “Sarcoid”. It’s pleasing to hear that essentially everyone has the same problematic patients labelled with “Sarcoid”, who continue to have symptoms, deteriorating lung function, and more, despite having this seemingly straightforward, steroid responsive disease. Evidence not in abundance, but opinion valuable. PET scanning, gadolinium enhancing cardiac MRI, leflunomide, methotrexate at rheumatologically laughable doses. A great session.

I stayed in the exact same seat for the PE session, chaired by my old classmate Rachel Davies, now one of the pulmonary hypertension consultants at the Hammersmith – she’ll not thank me for mentioning that she was in the year above me at med schl, but she did teach me how to do ophthalmoscopy in the medical school bar.

What is a massive PE, what is a submissive PE? Who should we thrombolyse, who should we sit tight and watch? Luke Howard: “[vs tPA] placebo wins hands down”. How to set up a PE follow up service, but no clear decision on who to give life-long anticoagulation to – Patient preference was proposed as the first step… If we can’t decide, how can we expect the patients to decide??? A whistlestop tour of the novel oral anticoagulants wrapped up the morning session.

There might not be a pub round the corner at the Knavesmire, but the food onsite is always pretty good. Menu (with local Yorkshire translation from my step father): Tagine Lamb (lamb stew with an apricot in it); Salmon Mornay (fish in white sauce); mushroom risotto (something veggie).

Non-Tuberculous Mycobacterial Infection in the afternoon. Charles Howarth, Andreas Floto, Michael Loebinger, Rob Wilson – the usual top notch presentations, with gems of wisdom from Rob Wilson. The interactive voting system was out in force – nice to see the experts in the room and the audience completely disagree on management of complex NTM infection…

The Tour de France starts on Saturday in Leeds, stage 2 starts on Sunday in York city centre. The whole of Yorkshire has gone cycling crazy – it’s great to see. Usually when I visit God’s Own County I see a couple of folk out on their bikes; this year I’ve seen hundreds. Every shop has a bike in the window. Every village has a yellow bike on the village green. I cycled up Buttertubs pass on Monday – it’s pretty brutal, 1 in 4 for long stretches, and 1 in 3 for a short stretch. It might not be as long a climb as the Col de la Croix de Fer, but it’s steep enough!

Tomorrow, day 2 in the BTS house. Bronchiectasis, Lung Cancer Survivorship, Occupational Lung Disease, Interventional Procedures, Quandries in TB, and commissioning (not for the Scots and the Welsh). And what will be for lunch?

IVOST-ing, and Mycoplasma

29 Jun, 14 | by tomfardon

The verbalising of nouns is an insidious threat to modern civilisation, some would have us believe. Things are ‘actioned’, when the already existing verb, ‘to do’, would seem perfectly suitable. Adjectives seem to be replacing adverbs: the triathlon magazines I read each month promise to tell me how to ‘run fast’, or how to descend on the bike “fast”, rather than quickly.

Medicine is the biggest culprit, though. We ‘warfarinise’, and even ‘fragmentise’, our poor unsuspecting patients, unaware that our grammar teachers of old are turning in their graves. To warfarin: I warfarin, you warfarin, he warfarinises, one warfarinises, I have warfarinised, I will warfarinise, I will have had have warfarinised…

The most recent, though, is IVOST. It crept into the “Plan” section of ward rounds notes:

Plan
Wean O2
Stop IV fluids
IVOST

Then it became a question “Can I IVOST them today?”. And now we’re all IVOSTing all over the place. Some more than others. I “IVOST” all the time. I think it’s the main input I have on a daily basis. Modern antibiotics have such high oral bioavailability, if the oral route is available, and an oral preparation exists, there’s little benefit in going down the IV route.

At a ‘board round’ this week, I encouraged the trainees to do some more IVOSTing, but they were reluctant. The acute medicine guidelines on sepsis so clearly say IV antibiotics for suspected sepsis that they are wary of making any changes down the line. One of them piped up: “Makes no difference, though, does it?”. Cue a 5 minute, massively informative, ad hoc ‘teaching session’ on the expense of IV antibiotics, the risks of soft tissue injury from unnecessary cannulas, and the difference in nursing dependency required to make up, check and administer the IV antibiotics, compared with the oral variety. Yes, I know, I must be a marvel at parties.

The protocolisation (there, I can verbalise a noun with the best of them) of everything means that far less thought goes into antibiotic prescribing than I’d like to think we did years ago, when I was a House-man. Or maybe we just missed cases of sepsis, and under treated.

In other news, I’ve seen 3 cases of confirmed mycoplasma pneumonia this past fortnight – reassuringly all in young people, two with a background of asthma, and all with a typical history of dry cough, fever, and not dramatic systemic upset. It continues to perplex me slightly that we give ‘atypical’ cover to older patients (who have a CURB65 score of 1 even when they’re well) when it’s very unlikely hey have an atypical pathogen; yet the younger, fitter, low CURB65 score patients who are more likely to have an atypical pathogen who just get the amoxicillin. It’s all in the history, of course, as always.

I have to admit that I don’t know whether it’s an ‘epidemic’ year for mycoplasma, or a ‘mini-epidemic’ year, but in Dundee, 3 in a fortnight is at least something.

I have 2 weeks off work: the Tour de France starts in only 6 days, in Yorkshire, and I’m marshalling (an actual verb), on stage 1, somewhere a bit north of Skipton. The Summer BTS is in York before that though – I’ll be sending Tweets from the conference, and might fit in a blog at some point. Hopefully I’ll be maximising my VO2Max, and AT in the run-up to both, with some time out on the bike.

If IVOST is now a recognised verb now, how can we get a verb for putting people back on their usual inhalers, and stopping their nebulisers. I’ve proposed NIST – Nebuliser Inhaler Switch Therapy. I NIST, you NIST, I am NISTING, I have NISTED, I was NISTING… It’ll catch on. Or perhaps I’m delerium-ing.

What’s Pneumonia Anyway?

18 Jun, 14 | by tomfardon

This afternoon a patient on the ward asked me “So do I have pneumonia then?”.

Not a straightforward answer.

She has a productive cough, crackles in her left base, a WCC of 24, CRP of 140, and presented with a lactate of 3.4, and a bicarbonate of 14. And a normal CXR.

SIRS? Yes. Sepsis? Yes? Chest infection? Almost certainly. Pneumonia? Depends.

The BTS Pneumonia Guideline says that the diagnosis of pneumonia depends on where the patient is: CXR is required in secondary care, but in primary care the diagnosis is made on clinical grounds only.

The ATS/IDSA consensus statement on community acquired pneumonia tells us: “In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for the diagnosis of pneumonia.”

So in the UK my patient has pneumonia if she’s seen in primary care, but not in secondary care because of her normal CXR.

In the US she doesn’t have pneumonia based on her CXR, but if she went on to have a CT, she might do.

In Australia she would need CXR evidence of new consolidation, so she doesn’t have CAP.

Assessment of the severity of said pneumonia gets more interesting, depending on the longitude of your residence. The BTS suggest using the CURB-65 score. The ATS suggest the PSI. The Australians suggest either the CORB score, or SMART-COP.

I told her that she has an LRTI, with systemic upset, and a normal CXR on admission, but I’ll be treating her as though she does have pneumonia, as repeating her CXR until it become positive seems a bit of a waste of time, and a tad excessive.

We’ve been looking at COPD treatment options in our MCN. The current discussion is the risk of pneumonia in COPD patients on inhaled corticosteroids, particularly in reference to the newest, and most recently licensed ICS/LABA therapies. Sami Suissa’s paper in Thorax has made all of us think twice about our treatment algorithms. But it begs the question – how was pneumonia defined in this (and other) clinical trials? Primary care definition? Secondary care definition? CXR? CT? The seeming paradox of ICS/LABA reducing exacerbations in COPD, yet increasing pneumonia risk, but reducing (not quite statistically) mortality is a puzzle to all of us, I think. I’ve been asked “Should we take all out COPD patients off Seretide?” a number of times. I don’t think its all that simple. To be continued, I suspect.

My patient has a significant pulmonary infection resulting in systemic upset, and sepsis. But the variation in guidelines across the globe means whether she has pneumonia or not depends on where she lives, which must be an issue for international multi-centre trials, and treatment guidelines.

Incidentally, she had a CURB-65 of 1 when she came in. I’m keeping her in the ward until the weekend.

10,105

18 May, 14 | by tomfardon

10,105 runners and walkers lined up this morning for the Navy Bridge Run. Fantastic event, great course, albeit tough.

Results are here – a reasonable 46th position for me, and 3rd Lady…

Off to conference proper now.

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