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Roaming

18 May, 14 | by tomfardon

It turns out that roaming charges in the States are ridiculous. £8 a MB means only a few tweets, FB updates, and attempts at writing up a blog post leas to an astronomical phone bill…

The ATS starts proper tomorrow. San Diego is it’s usual mix of great places to eat, deceptive heat, and a big aircraft carrier in the bay. The program looks interesting, and so long as I get free wifi somewhere (roaming charges being prohibitive), there should be a stream of tweets and FB updates to keep everyone up to speed.

Before that, though, is the Navy Bridge Run/Walk. I cycled the 20km out to the registration point this afternoon – one application of factor 30 seemingly not enough to prevent 1st degree burns on my arms… The race starts at 08:00, so hopefully the sun won’t be at full strength as we run over the Coronado bridge – usually it’s closed to pedestrians.

The most intriguing session tomorrow has to be “Great Cases: Clinical, Radiologic, and Pathologic Correlations by Master Physicians”. The descriptions of the cases include: the case of the vanishing lungs; connecting the dots; breathing through Swiss cheese; a very unfortunate player; hear me roar. I have to go, really.

Although “There’s nothing latent about latent TB” has a certain ring to it.

Time to put my arms in some more cold water, and venture out to an evening symposium.

Stay Classy San Diego

12 May, 14 | by tomfardon

In 4 days I’ll be flying out to San Diego to the American Thoracic Society Conference. I’ve not been to the ATS since 2006. I’ve not been to American since then either. The ATS used to be the big meeting. It used to be THE meeting to go to, to be seen at, and to learn at. But the tide seems to have turned – the ATS continues to get smaller and smaller, compact and bijou, perhaps, but certainly smaller. The ERS, however, gets bigger, and bigger: it was too big to get around in Barcelona, certainly too big for @ThoraxBMJ to find a reliable wi-fi signal to keep posting updates.

I’m intrigued to find out what the ATS has become. I’m told by others that the meeting has a more basic science focus, but it also continues to include more intensive care medicine, as well as respiratory medicine, such is the remit of the US pulmonologist. The ATS charges for poster submissions, which leads to an interesting mix of posters – I’ll keep an open mind!

Should we still be going to conferences in wildly different time zones? To get to San Diego I have to drive 60 miles to Edinburgh Airport, fly to Birmingham (Leadership Conference), train to London, fly to LA, car to San Diego. If there’s 10,000 people at this conference, how many air miles are earned, or used? @DundeePublicHealth told me the other day that the carbon footprint of Addenbrookes Hospital is the same as Kings Lynn. What’s the carbon footprint of the ATS, including getting there, in the new SI unit, The Addenbrookes Day?

There’s the usual evening symposia going on – I’m even chairing one of them. I know there’s going to be news about new licences for old drugs, phase 2 data on new drugs, and some ‘promising data’ on new indications for old drugs. There’ll be competition for my bum on a seat throughout the week, I’m sure. Asthma and COPD seem to tee’d up to dominate the symposia – I’m hoping there’ll be a little more on the infection side, but I’m not holding my breath.

“Conferences are more about networking” people say. I hope to meet up with some old friends and colleagues, and the Thorax Editorial Board will be a feast of statistics batted between colleagues, and a highlight of the week.

The ATS, though, is all about the Annual 5K race, held at daft o’clock on Sunday morning, so it’s not too hot when we all set off. If memory serves the course in 2006 was around the marina behind the conference centre, and I was a laughable mess having just cycled from LA to San Diego two days previously. This year I doubt I’ll trouble the podium, but look out on Strava for my run data…

<Edit – it turns out there's a 4 mile run this year, the 28th Annual Navy Bridge Run>

4 days to go – look on Facebook and Twitter for updates live from the conference. There’s no official hashtag that I can find on the site, so I’ll stick with #ATS2014 if you want to keep up with things – I’ll try to encourage others to use the same.

And once we’re all back from the ATS, we’ll be thinking about the Summer BTS, which surely must have a smaller Addenbrookes number?

Confidence, the demise of the SHO, and lung cancer screening.

20 Apr, 14 | by tomfardon

I have been on call this weekend. Recently in an RCPE survey the consultant body was asked specifically “Do you frequently carry out duties previous carried out by more junior roles”, or words to that effect. Many a time do I hear my colleagues saying “I do the same job today as I did xx years ago as a house officer”. I certainly saw plenty of patients today, rewrote a number of treatment charts, prescribed analgesia, night sedation, and the like, looked up blood results, and requested radiology tests. So perhaps not much has changed since 2000.

One of the tasks today was the removal of a chest drain that was not working, mainly because it wasn’t actually in the thoracic cavity any more. I asked the house officer to do it, which seemed reasonable enough to me (and the registrar trudging around after me). 2 hours later I got a call from the FY1 telling me that they didn’t feel confident to pull the drain; could I come and do it?

We used to have a sea of SHOs in hospitals – I remember being one. The SHOs ran the show – they knew the patients, they did the ward rounds, they did the jobs, saw the relatives, and kept the hospital running. We don’t seem to have SHOs any more. FY2 – ST2 should be the group of Doctors who run everything. But there’s been a change. I’m not sure when registrars started doing all the work, no that’s not right, I don’t think FY2 – ST2 doctors don’t do any work, they do seem very busy, but they don’t seem to make decisions any more, that’s what the registrars and consultants do. Perhaps our hospital is different from everywhere else, but I suspect not. Consultants do what the registrars did, registrars do what the SHOs did, so perhaps the SHOs are doing what the house officers used to do? House officers seem to have an awful lot of paperwork to do these days.

I’m sure everyone across the land has had similar conversations. Our juniors seem to lack the confidence to make decisions – perhaps that’s appropriate, perhaps the every increasing senior cover is the correct way to go, but I do worry about how the future consultant body will get to the point of making decisions, or at least being confident in the decisions they make.

The most recent edition of Thorax runs an editorial on being confident about our diagnosis of ‘meaningful’ lung cancer in screening programs. Overdiagnosis is reported as common most screening programs, lung cancer included. But we ‘know’ that some patients have a lung cancer that doesn’t progress, at least not dramatically, so they die “with” lung cancer, not “from” lung cancer. But identification of these patients is difficult. Dr Frank C Detterbeck, Division of Thoracic Surgery, Yale, muses that overdiagnosis can only be defined in retrospect, looking back in a population after a long period, yet the clinician has to make decisions prospectively about an individual patient, not a population. He concludes that the article by Patz in JAMA doesn’t help to determine the benefits of screening, but does suggest how to minimise harm, stating that intervention in non-Broncho-Alveolar-Carcinoma NSCLC is very rately unnecessary, but for BAC we should be more circumspect, and wait for the right time to intervene. Of course our biggest dilemmas come for patients who have isolated lung cancers, early stage, with no pathological confirmation of malignancy, never mind a sub-type. Perhaps these cases are more straightforward – excision biopsy is indicated. But how confident can we be that these lesions are malignant? How much functional loss will occur due to the lobectomies carried out to find out? I don’t think we’re looking at the same situation found in breast and prostate cancer screening, with many unnecessary procedures, but with more widespread use of CT screening, we might get close.

The ECLS lung cancer screening study is underway in East and West Scotland – too early to see what the screening will lead to, in terms of surgical procedures, but we’ve already seen a lot of people with advanced disease who only presented as they answered the call for volunteers for the study: same patients, a bit earlier, but not early enough. Time will tell if lung cancer screening does save lives.

COPD, Me and the GMC

12 Apr, 14 | by tomfardon

This blog has been fallow for some time, for which I can only apologise, and push on. The main reason behind the paucity of musing has been that I’ve been investigated by the GMC.

That may cause a slight intake of breath from you, but it caused a lot more when I found out 5 months ago. The letter from the GMC came on a Friday evening. I’d had a particularly good Friday: bronch list with an EBUS and a couple of tran-bronchials, and an entertainingly enthusiastic trainee; an educational meeting with some actual education in it; an afternoon of paperwork, but a satisfyingly empty in-tray at 5pm. A weekend of parkrun, bike riding, and family fun lay ahead, and lest we forget that Friday night is Pizza night. When a letter comes from the GMC it’s usually a pamphlet about the duties of a doctor, or an invoice for the annual fee, but the tell-tale markings on the envelope raise the heart rate a little. This letter caused more sympathetic drive than a direct debit notification.

The GMC, the austere body we pay hundreds of pounds to each year and hope to never hear from. The letter was a pretty stock thing: someone has made a complaint about you, and we need to investigate it; the investigation will take 6 months; we’ll be investigation all of your practice, not just the issues surrounding the complaint. This focuses the mind somewhat. The recent GMC guidance on digital professionalism, likewise. So on advice from my chums at the MPS, I’ve been digitally silent.

Last month I was cleared of all wrong-doings, and declared to have practiced in the manner of a “reasonably competent doctor”. I’ve not framed the letter for hanging in my study, but I can now get back to the business of musing on the world of respiratory medicine.

The new issue of Thorax is about to hit your doormat. Paul Enright (Arizona) writes in his editorial on the COPDGene Study: “There is no evidence that the cost/benefit ratio of daily COPD inhalers is favourable for patients with CAO unless their FEV1 is below 60% predicted. No inhaler will help those with HRCT-defined emphysema and mild CAO. Therefore, the only imperative that I see to detect COPD early is to ‘sell sickness’ and thus enhance the billion dollar (pound or Euro) annual profits of companies that sell COPD inhalers”. Perhaps this explains why our patients with large bullae secondary to coannabis abuse seem to be so symptom free.

All this does leave an important question – what do you do with a patient who has significant symptoms, but doesn’t reach these criteria for an inhaler? It’s very difficult to do nothing. Patients will ask about ‘those inhalers that my friend has’. Patients do tend to feel better on a bronchodilator – I completely accept the ICS argument, and I’m sure all my colleagues around the country are in the process of stopping ICS in a large proportion of their COPD patients this week. Enright also highlights the importance of COPD phenotyping – a subject I think is key to our understanding of how to treat our COPD patients in the future.

It’s nearly conference time – I’m heading to the ATS this year, my first visit to the ‘big’ American meeting since 2006. The ERS attracted over 22,000 visitors in 2013, the ATS fewer than 10,000. Does this mean the meeting is no longer relevant? No longer worth the huge trip across a continent and an ocean to reach? I’ll admit that the meeting being in San Diego is an attraction: the sun is usually out in May; I can take my cycling shoes and pedals out there and hire a bike to ride the PCH for an afternoon; it has a lovely zoo; and I can’t remember having a bad meal in any part of California. My real motivation for going is to see what has become of the meeting – is it still relevant in 2014?

I’ll be going to the Summer BTS too. Again, it being in York is an attraction: the county of my youth; the chance to spend a few days cycling before the conference; and the Grand Depart of the Tour De France is the day after! (I’ve been selected as a ‘Tour Maker’) But the real reason for the trip to Yorkshire is to meet up with colleagues, and attend what I think is a greatly under-appreciated meeting.

I’ll be Tweeting and updating Facebook from both venues, so keep a lookout for the new from California, and Yorkshire.

Tomorrow is the London Marathon. A number of virtual friends and FIRL are running; some for charity, some for personal bests, and some for fun. Good luck to them all – remember than water is all you need, despite what the manufacturers of Lucozade might tell you – it’s GSK, and we’re back to inhaler cost effectiveness again.

More digital musings should follow, now I’m “reasonably competent” again.

Reflective Practice, Comfort Zones, And Mistakes.

2 Feb, 14 | by tomfardon

Doc2Doc user OmarhBore posted a blog this week on the futility of the current reflective practice system for junior doctors, suggesting alternative media for reflection, including poetry, amusing musings on NHS computer screens, and interpretive dance. He felt that the enforced reflections were too contrived, and there was more to be gained from reflection than the current system allows. Reflective practice wasn’t ‘invented’ when I was a lad, or at least, it wasn’t particularly encouraged. Not that I remember, that is.

But I agree with our Doc2Doc FY-Blogger. There’s a lot to be learnt from our experiences, particularly our mistakes. And it’s easy to make mistakes – I made a mistake today – but it’s harder to talk about it, learn something from it, and move forward.

A common complaint from consultant colleagues is the feeling that we do more and more tasks that were previously carried out by more junior doctors. I’m sure I’ve ticked that box on surveys at some point. So today when I needed to write out a prescription for a patient to collect opiate based drugs from pharmacy I was in that position – doing something that is usually done by the junior doctors, and something that I’ve not done for a few years. The patient was complex, the prescription was complex, I was already thinking about the next job for the day, perhaps even the next after that, so I finished the prescription, handed it over to the nurse, and wandered off to the next task of the day.

The prescription had mistakes in it, and fortunately the nurse I gave it to realised very quickly. She caught up with me and I had the opportunity to correct the prescription. No-one likes making mistakes, least of all me, but I was relieved that she took the time to read it, and call me back.

So, I’ve reflected on it. Why didn’t I get it right? Couldn’t I be bothered? No – I want to get things right. Did I know what to do? I *thought* I remembered what to do, but I was clearly out of my comfort zone, having not written out an opiate prescription for some time. At that point, I should have asked for help, shouldn’t I? Of course I should. I spend my days teaching medical students that there’s really only one rule – Know when you don’t know what you’re doing, and know to ask for help. So why didn’t I? Why did I just scribble the prescription, and move onto the next thing in my busy day? Too many things going on? Too busy? Too proud to ask for help from someone more junior? Preoccupied, I think, with many many other tasks to do in the rest of the day, and not enough focus on the job in hand.

I had the opportunity to rewrite the prescription, and certainly the pharmacists would have called me up about it, but I was saved those blushes. When I was rewriting it, I felt suddenly very stressed. Stressed about getting it wrong again? Stressed that I got it wrong in the first place? Not sure – but stressed, for ceratin. I wonder if the juniors feel similar levels of stress when they are asked to do things outwith their comfort zone – surely they do, and surely we ask them to do this on almost a daily basis.

Come October it’ll be 20 years since I started medical school: 6 years later I was a house officer. So today, faced with something out of my comfort zone, and not stopping to ask for help, blundering on and making a mistake, only to be rescued by a nurse – I remembered very clearly what it was like to be a PRHO in 2000.

So what have I learned in those 14 years? Perhaps not enough, as I still made the mistake today, but I’ve certainly learnt that getting worked up about it, or trying to forget it, or brush it under the metaphorical rug, is not the way to move on – reflective practice makes us all better doctors. I have the opportunity to share my mistake, and my reflection on it, with a reader, perhaps an FY1 who feels stressed, or perhaps another consultant who made a mistake when rushed, and didn’t take the time required. Or perhaps it only helps me, to realise that sometimes the best thing to do is ask for help, and get it right first time.

So thanks to the nurse for picking me up on my mistake, and to OmahrBore for his poetry, and interpretive dance*. I encourage him to continue to reflect on his experiences, and particularly his mistakes, and to share them, as if only one person reads, or hears, and avoids the same pitfall in the future, it will have been worth the time and the effort – even if the person who reads it, is the person who wrote it.

I’ve kept a copy of my hastily penned prescription, and I’ll be using to teach the medical students – an example of what not to do. I’ve kept a copy of the second version, to remind me what I should have done in the first place.

*Citation needed

Uncertainty, Acceptance and Trans-Atlantic COPD

17 Jan, 14 | by tomfardon

I taught some 4th year medical students last week, in my bronchiectasis. We saw a variety of patients, mostly chronic infection, but some IPF, some difficult asthma, and some lung cancer, such is the way in a small department, such as ours. The students were most interested in the lung cancer patients. We, like many centres, run an accelerated investigation process for our patients, whipping them through the CT scanner, and up to clinic very quickly. One of the students asked if the patients get scared, getting tests before they see us. The other asked what happens to the patients who go through the scanner, and don’t have a tumour: “Do they get a non-urgent appointment instead”?

Everyone gets an urgent appointment if they’re in the ‘urgent, suspected cancer’ stream. The student looked puzzled – but if the scan is normal, why would you see them urgently, she asked, increasingly puzzled.

It led to a discussion about what leads patients, people, all of us to stress and anxiety. I think the worst thing for anyone is uncertainty. You see your GP, they say that you might have cancer, and you spend every waking hour from that point worrying, stressing, panicking, even, about the possibility you might have cancer. The uncertainty is the stressor. The patients come in wanting an answer, a release from the uncertainty – being told there’s nothing wrong is the best release, but being told that the do, indeed, have cancer, leads to a release also. Once you know, you can start to cope. It’s very hard to cope with uncertainty.

Later in the clinic the students asked me about eCigarettes; are they safe? I’m not certain. And that’s the problem – uncertainty again. We simply just don’t know enough about the effects of eCigarettes on the lung, and their standing as a medical instrument, rather than a medicine, means we’re not likely to see any evidence for a while. This case discussion in this Month’s Thoraxreports on a patient with marked deterioration in pulmonary function, cough, sputum production and breathlessness, which abated once the patient stopped vaping. The first of many? Or an idiosyncratic reaction that’s unlikely to be repeated? Certainly I see more and more people vaping around Dundee. It seems to be slowly gaining acceptance.

We’d like everyone to stop smoking, holistically speaking – everyone can exert their free will to smoke or not, of course. How can we stop people smoking? A manager in the department asked me for advice a couple of years ago, as her 14 year old daughter had started smoking. I shared the link to a Flickr photostream of post mortem lung cancer specimens – she showed them to her daughter, who immediately quit, or so she said. So the spectre of lung cancer was sufficient to induce smoking cessation on this occasion, but this study in Thorax shows that, in Denmark at least, being screened for lung cancer doesn’t increase smoking cessation.

Last week COPD made the news in the US, and the UK. The news in the US was the FDA’s decision to approve umeclidinium/vilaterol, and the publication of more safety data for the same combination. Over on this side of ‘the pond’, COPD made the news when Phil Everly succumbed to COPD, but the reporting didn’t focus much on the disease, rather focussing on the music. When Kylie Minogue had breast cancer, the profile of breast cancer increased significantly. Perhaps Phil Everly wasn’t big enough news.

Remember to check out the Thorax Weekly Scoop.it to see the snippets I find through the week, the Thorax Facebook page, and the Thorax Twitter feed.

And next week, more musings.

Eat, Drink, Smoke, Vape, Run.

11 Jan, 14 | by tomfardon

It’s been an interesting week. The floods down South didn’t appear up here, but there was enough wind to blow the Tay half way across the city. And this weekend we’ve had the first proper frost of the year: -2.5 when I started to defrost the car this morning to go and set up parkrun. Brass Monkeys.

The telebox has been inundated by programs about obesity this week, at least this is the week I’ve noticed it most. The new show is Weight Loss Ward, where the massively obese people in and around Sunderland go to lose weight, prep for gastric banding, and ultimately have their ‘life saving operation’. Images of Terry, 300+ kg were followed by his gastric balloon insertion, and subsequent weight loss of 15 stones, leaving him only double his ideal weight. There’s a lot of chat in the show about him being able to get up the stairs, into the bath, and out of the house, but not a lot of discussion about the respiratory efforts of such a degree of morbid obesity. A couple of students recently asked me about the effects of obesity, and the benefits of gastric banding/balloon surgery on respiratory function, and breathlessness – here’s a very nice review of just that from Thorax back in 2000. A colleague has said for many years that patients at our ‘breathlessness query cause’ clinic should simply be redirected to the obesity clinic – a slight over exaggeration , but an analysis of the BMI of the patients in that clinic would make an interesting student project.

The obesity epidemic can be ‘halted or reversed’ say ‘doctors’ in this piece in the Independent this week.The Mail tells us that 58% of the UK population are overweight. Not new news, but not a lot has changed since this paper 11 years ago showed very clearly the cardiovascular risks of obesity.

If ‘sugar is the new tobacco’, ‘weed is the new weed’ and it’s legal in Colorado, and the purveyors of the finest weed are charging a premium, yet the first 10 days of legal sales has already generated 5 million US$ of sales. Prices are inflated by 100 – 150 %, comparing the legal shop price to last year’s ‘underground’ prices, but much of that is Colorado state tax. Legalisation of marijuana can be seen as ‘normalising’ casual drug usage, or perhaps it is just a money generation exercise. A more detailed investigation of the economics of legal marijuana can be found here. For a review of the potential harmful effects of marijuana smoking (written by my boss) look here. If you’re thinking of a ski-ing holiday to Colorado to get a legal high, they’ve sold out.

If sugar is the new tobacco, and over a third of US states are moving to legalised marijuana, what of the humble cigarette? I think smoking is still a bad thing.

One of our registrars gave a nice presentation at our department education meeting this week on the rise of the eCigarette. eCigarettes, not regulated by anyone in particular in the UK, provide the ‘vaper’ with nicotine in an aerosol of propylene glycol, which is essentially antifreeze – though ethylene glycol is the really nasty one in the glycol family. There’s no set amount of nicotine in any brand, or design, and there’s no regulation of whatever else can go into an eCigarette. The sales pitch is that they are for current smokers who wish to continue with the pleasurable parts of smoking, but avoid the harmful aspects. There’s some evidence that they aren’t harmful (despite the antifreeze). They haven’t been advertised as nicotine replacement therapy, or a means to quit, in the UK at least, because that would mean they were a drug, and therefore subject to stringent testing. As one of my colleagues pointed out, coffee contains nicotine in reasonably high quantities, and we don’t get worked up about his Nesspresso machine in his office – I do wonder if there should be *some* limitation on coffee availability… I digress. If vaping is a safe, reliable alternative to smoking, and reduces, even removes, the risks to health associated with smoking, surely there is no argument? We should be telling all our smoking patients to switch to vaping forthwith. Can’t get long term oxygen therapy because you’re still smoking? Switch to vaping, and you can have your concentrator in 5 working days. Love the taste, but don’t want the risk? There’s an eCigarette for you. Tried NRT and Champix, and nothing works? Vaping is the answer. But there is some evidence, such as the seemingly controversial study in 60 Million Consumers, a French Consumer magazine, that reported Les cigarettes electroniques ne sont pas sans danger!. The Daily Mail’s usual journalistic rigour can be seen here.

But perhaps there’s something a little bit more sinister going on. ‘Big tobacco’ has been very quick to scoop up the eCigarette manufacturers, not to immediately close the factories, and essentially put an end to their competition, but to support and promote their use. If big tobacco can keep the nicotine doses low enough, and the price just about affordable, but more than a pack of 20, then what does the nicotine craving, thrifty vaper do?

One of our SpRs told us about a new craze at his son’s school: shisha sticks. Very easily available online, these are eCigarettes without any nicotine, just a fruit flavour in an antifreeze propylene glycol aerosol. They look like an eCigarette, come in a variety of colours, and flavours, and using one looks a lot like smoking, French inhale and all. They cost £3 for 500 inhalations, and the kids are ‘all doing it’. Will they progress to vaping eCigarettes, or smoking tobacco? If there’s a cheaper one..? Looking ridiculous is obviously not a concern of kids in school, so long as they all look the same ridiculous, but “smoking looks cool”.

A quick walk the length of Dundee’s main shopping street this afternoon, on the way to the library (via the video game store), I saw 3 ‘bus stop’ of adverts, and 2 ‘rotating poster’ adverts for differing eCigarettes, on top of 3 stalls in the shopping centres selling the brands at discount to anyone and everyone. At the one in the Wellgate, a woman was helping her early-teenage daughter pick out a shisha stick, whilst at the one in the Overgate, a group of mid-teenage boys were buying their first nicotine-included eCigarette. They didn’t look 18 to me, and no-one bats an eyelid. But they’re safe, as far as we know.

John Britton, in his excellent Thorax editorial, concludes:

In short, these products represent a huge opportun- ity to improve the health prospects of millions of smokers in the UK and world- wide. They will present challenges and problems, but are an opportunity not to be missed.

Back to parkrun.

At time of writing over 56,000 people did a free, timed, 5k run in a park at a parkrun event this morning, either at 9, or 9:30 am. As a comparator 37,500 people did the London Marathon in 2013. This weekend our local parkrun saw a record attendance for 4 runs in a row. 154 Dundonians, out running through the ice and freezing winds, through a park, at 9:30 in the morning, reducing their cardiovascular risk, and enjoying the fresh air. But, running in sub zero temperatures does put one at risk of cold air induced bronchospasm. Scottish Ironman Triathlon Record Holder Graeme Stewart was in just that position today after tough run through the park, and he was not alone. The physiology required to Swim 3.8k, Cycle 120 miles, and then run a marathon, all in eight and a quarter hours, undone by the cold air in Camperdown.

There’s a clear sense of health and wellbeing at all the parkruns I’ve been to, and certainly it is a rarity to see any runner smoking before or after the run, and I presume not during – I wonder how long until people vape after parkrun? I’ll stick to the Mars Bar cheesecake in the Camperdown wildlife centre cafe after my park running.

Remember to check out the Scoop.it feed Thorax Weekly to find things I scoop up from the internets during the week (Eg. Are eCigarettes Safe, YouTube asks)

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5 Things and a Scoop

3 Jan, 14 | by tomfardon

It’s New Year – Happy New Year, by the way – and the internet is full of last year’s greatest, top 10s of everything from 2013, some top 16s, worst 5 things too, not to mention the all important top 40 countdown (Does anyone else miss Top Of The Pops…), and the even more important 20 words I should avoid in this blog. So, rather than recap 12 months of highs in Thorax, or in respiratory medicine, I’ll try to look forward at the 5 things I’d like answered in 2014. In no particular order…

1. What to do for patients with COPD.
This has to be on everyone’s agenda somewhere, doesn’t it? Sammy Suisa gave us the preview in 2013, but it wasn’t until the end of 2013 that he dropped the full bomb – Canadian COPD patients on Symbicort, and more so Seretide, get more pneumonia, and they die. “But the data is retrospective” (although from an enviably large database, but retrospective non the less) “so is it valid”, say my colleagues. “Where’s the prospective data?”. It’s in TORCH, of course. So job done. “But why do ICS/LABA reduce exacerbations, and” (nearly statistically) “significantly reduce all cause mortality?”, my specialist nursing colleagues ask. And at the ERS in Barcelona, data spewed forth on the “Dual Bronchodilator” approach, novel only because no pharma company has up to this point been able to produce a LABA and a LAMA, but known since 2002 to the jobbing chest physician (Spiriva + Serevent was a common enough prescription in the mid and late naughties, certainly in our practice). There’s even some triple therapy data out there, but it has the big ugly shadow of “the steroid data” looming over it. Ultibro (Which is too close to Ultimo if you ask me) is the first to licence, and the first to market, in the UK at least, yet it will not be promoted, due to cut backs in the primary care division of Novartis. We wait for new molecule, or put our hopes into Roflumilast, or perhaps a resurgence of theophylline. In an area of respiratory medicine that has such a huge evidence base, we are still looking out through a fog of misunderstanding. My take on this is that the big studies done up to this point have not stratified out the patients in any meaningful way; there’s been divisions by FEV1 (Shown nicely by ECLIPSE to have little bearing on exacerbation rate, or anything else, really), or by treatment burden, but no consideration of separating out the “drier” emphysema patients from those will a more productive, “wetter” variants in chronic bronchitis, and what of COPD patients with bronchiectasis. I don’t think we need bigger studies, I think we need smarter studies, with real life phenotypes, putting into studies those patients we actually recognise as being patients we see.

2. What to do with macrolides?
Always on the agenda at bronchiectasis meetings, splitting the audience variably, is the use of long term, low dose, macrolides. Bronchiectasis continues to be the slightly ignored, slightly odd cousin of CF; we get the CF ‘cast offs’. Azithromycin works really well in CF, so why not try it in NCFB?”. The problem is when it really doesn’t work so well – DNA’ase works wonders in CF, works dark magic and mischief in NCFB. So we try, and we dabble, and we see successes, and failures, and try to find our way in a research vacuum that many centres in the UK are desperately trying to fill. Back to macrolides. We’ve all seen them work, I’m sure. We can all recall an unfortunate patient, often young, with recurrent infections, to whom, as a punt, we gave long term clari, only to see them at 3 month review, with a na’er a cough, spit or tickle. And yet, the advice on who should receive it, and indeed which moiety, and what the criteria should be for initiating, and stopping, are wooly, and not well adhered to. At a recent meeting of chest physicians in Scotland, there was no consensus at all on how long a trial of macrolide should be given to a patient with NCFB, with opinions ranging from 6 weeks to a year; some physicians wouldn’t give it at all. So we need a trial, a big trial, a well designed and well co-ordinated trial A multi-centre, UK wide trial perhaps? Certainly there’s a need for it in NCFB, but what of the other diseases? There’s been “macrolide creep” in recent years, creep into asthma, COPD, and anything else that produces exacerbations, infective or inflammatory. The COPD trials show some improvements, but the trials didn’t differentiate between phenotypes, which makes it difficult to know if Mrs Miggins with emphysema, or Mr Melchit with chronic bronchitis are going to react in the same “magic” way. So we give them both a trial, but of which? And what dose? And for how long? And if it works, how long do we continue it? If 2014 provides me nothing else but a clear guideline to follow, backed up by some really good evidence, telling me who and what and how much and for how long, I’ll be a happy blogger.

3. What to do in UIP in the Post-Pather World?
Sounds like a great title for a BTS symposium. I am not an ILD enthusiast. We have an ILD lead, and it’s not me. But I do a remote/rural clinic once a week, and see plenty of ILD, mixed up with everything else. Pre-Panther, it was straightforward enough – have a open and honest discussion with the patient about the risks associated with steroids/azathioprine, and the near impossibility of predicting their prognosis, and the patient chooses, and usually chooses to sit it out. But at least they had a choice. Now, Post-Panther, we have no obvious option. We have pirfenidone – and a handy booklet courtesy of Thorax on the indications for it – but it’s expensive. Massively expensive is something I’m used to, after all I have 3 patients on ivacaftor, and 3 on posaconazole, but I feel I standing on firm ground giving these, and it’s small numbers. A quick calculation on the back of a beermat suggests we probably have hundreds of patients who qualify for the pirfenidone treatment. At an ATS many moons ago, Talmadge King stood up in an ILD symposium (I’m not an enthusiast, but I do try to keep up my CPD). He proposed that the only ‘ethically sound’ management plan for a patient with UIP was to enrol them into a study. There was much wailing, and gnashing of teeth, but in the end, no-one had a better plan. I don’t see we’re much further on. So I’ll keep up my current practice, which is to refer to our enthusiast those who meet the pirfenidone criteria, and keep a list of everyone else…

4. Can someone work out what Sarcoid is?
I see a lot of sarcoid, and I’m not sure anyone really knows what it is, do they? My good friend Wikipedia says it’s probably a lingering reaction to an infection. Patient.co.uk agrees that it’s probably triggered by an infection, in genetically susceptible people, but can’t specify the causative organism. I really like the Royal Brompton’s patient information page on sarcoid; it’s charmingly honest about our lack of understanding of the disease, leaving the patient with “bad luck” as their causative organism. What confuses me, and others I chat to about such matters, is the massive variation in disease severity. Remember at medical school when you were taught that BHL and EN in young people would resolves spontaneously? Remember when revising for MRCP the stats about percentage of patients disease free at 9 years without relapse? I recall the steadily increasing numbers of patients who come up to my clinic on ever rising doses of immunosuppressants, with little in the way of improvement. Patients with complications of steroids that start to outweigh the underlying disorder, and patients who crumble in front of me, as I look on, helpless and slightly embarrassed that we don’t have anything else to offer. It must be more than one disease, right? Surely it’s a spectrum of granulomatous disorders, some of which are exquisitely steroid sensitive, and others that are rampant even in the face of aggressive immunosuppression. Or is it simply that these patients do have an infection. An infection that causes granulomata, that we just simply can’t detect, grow, let alone treat, that immunosuppression is providing jet propelled assistance to, and we’re ‘first doing harm’. Again, I’m not an enthusiast, but I try to keep up – there wasn’t a lot at the ERS about sarcoid, but a quick Google Scholar search (0.05 seconds, if you must know) gives me: CD4 subset dysfunction; pulmonary function tests are more useful than HRCT, or KCO; and early data on exhaled breath condensates in pulmonary sarcoid. The work is going on, but I’d like Santa to let me know what causes Sarcoid in time for Christmas.

5. A Reliable Indicator of Infection…
The Holy Grail? A marker to distinguish between an infective exacerbation, and a non-infective exacerbation of COPD would be very nice, thank you. My next-office-neighbour at work is the professor of infectious diseases, and national lead for antimicrobial stewardship: a way to cut needless antibiotics would be high on his wish list for 2014, I’m sure. I’d like to take it one step further, and ask for something we’re very near to: a practical way to take 16S analysis of sputum/bronchial washings to the clinical environment so we can quantify the microbiological load in the bronchiectatic/CF/COPD lung. We know there’s bugs down there, but are they really the cause of Mrs Miggins’ current admission? IV antibiotics over a 2 week stay in hospital do seem to make our patients feel better, but the physio, hydration and rest they get must have something to do with it, my registrars keep telling me. We’ve started 16S analysis on a research basis, but the information we get from the test needs to reach a clinical audience. I heard a very interesting talk last semester by Prof Colin Palmer, on the GoShare project. the ‘automisation’ of full genome sequencing over the past decade means a sample of blood can be turned into a full genome sequence in a couple of hours, and all for a couple of hundred quid. Understanding the information that’s been handed to you might take a while, but the system delivers information that was beyond our dreams 30 years ago. Back to infective markers, and we’ve had, and continue to use, Pro-Calcitonin, although only in our ICU environment as we’re yet to be convinced. As the theory of the lung being a sterile environment withers on the vine, and we start to understand that infections are a disruption of the balance of microorganisms within the lungs, we need technology like the 16S analysis closer to the bedside. As my neighbour tells me with a face of thunder: “We’re going to run out of antibiotics at the rate you give out Tazocin”

My look forward to 2014 has become more of a review of things I don’t understand, and a wish list for the things I can’t control. But I spared you the Top 10 of Everything.

One final note is to take a look at the Thorax Weekly Scoop.it. “Props” to @DundeePublicH (It’s not just about water) for pointing me to Scoop.it, a site that allows me to grab anything I think is interesting over the week, and put it in “one digital place”. I’ll drag some of it over to here on the Blog, and discuss at variable lengths, and wait for the torrent of discussion to appear in the comments section.

My pick of the Scoops from this week? Will Big Lungs Make You a Better Cyclist?.

Stay classy, internet.

Winter Pressures

27 Dec, 13 | by tomfardon

Merry Christmas to all Thorax readers, and everyone else as well.

Having been mentioned in dispatches by Ian and Andy, it only seems fitting that I actually write something on this blog. I could write down here a litany of excuses for not having written missive #2, but as the majority of potential readers here are respiratory physicians, nurses, physiotherapists and pulmonary function techs, you will all know how over the Winter months deadlines do tend to slide, and our attention is caught by many other pressing matters.

When I was a trainee (and all this was fields as far as the eye could see), we had something called “Winter Pressure”. This was the general term applied to the massive increase in admissions through the medical take, notably pushing the respiratory service particularly hard during the “Winter Months”. I know enough about medicine now to know that my Granny wasn’t quite right when she told me “You’ll catch pneumonia by being ‘out in the cold'” (although I do still avoid sitting on radiators, and cold stone floors…), but there’s no doubt the chest ward swells in the winter.

These days the Winter seems to go on for most of the year. I accept that up here in “The Frozen North” it’s winter for longer than down in Professor Pavord’s tropical paradise, but our “Winter Pressure” seems to extend well into June, and starts in October. This year we have been given a few more beds, but with no nurses to staff these beds we wait for the influx of our COPD patients, and the seasonal increase in pneumonia numbers with baited breath.

But Winter brings with it the Winter BTS, and the opportunity to fly down to London for a bit of extra christmas shopping. Alas this year colleagues all had more worthy reasons to go to the BTS than I: One was presenting his research; one was presenting his MD; and one had foregone the delights of Barcelona and the ERS, so had ‘first dibs’ on the BTS; leaving me to stay at home at man the fort. But the twitter sphere kept me in the loop. I proposed #BTS2013 over on our Facebook page, but a matter of hours later BTS CEO Sheila Edwards launched #BTS13 as the ‘official’ hashtag of the conference – we really should co-ordinate efforts next year. This gave me two has tags to follow, but twice the opportunity to cross-fertilise.

I think #BTS13, just sneaks the win...

I think #BTS13, just sneaks the win…

Over 500 Tweets on the first day shows how in tune with Social Media the delegates were this year. In total, 1,304 tweets to #BTS13, and 296 to #BTS2013 showed a massive interest from everyone out there. I don’t have comparable data for 2012, but it’s clearly a growth area. I received a constant stream of updates from delegates on a wide range of topics, not just @copddoc‘s area of interest. A highlight was the Storify-ification of the palliative care session – worth a look.

One Winter pressure I don’t mind too much is the pressure to scoff all the Chocolates left on the wards. Over on sister-site Doc2Doc the discussion turned to which chocolates last the longest in a medical ward, following this article in the festive BMJ. I was on call Christmas Eve, Christmas Day, and Boxing Day: I favour the Chocolate Orange, but the Twisted Creme Egg miniature Hero will do for me.

A couple of interesting snippets for your consideration:

This is a lovely review of the nomenclature of airways disease, which on the face of it doesn’t sound *too* exciting, but asks a very important question: Where is the evidence base for all the asthma/COPD crossover patients who get excluded from clinical trials? As Nigel Tufnell would say… “Nowhere”.

In a bit of shameless promotion for a colleague here in Dundee – here’s a soon-to-be published article on a proposed bronchiectasis severity index, and the online tool to calculate the BSI score on your own patients.

In my spare time, I’m one of the run directors for our local parkrun here in Dundee. We’ve been running for 18 months, and have over 100 folk regularly pitching up on a Saturday. On Xmas day this year, whilst I was at work, we had 93 hardy souls completing 5k, for fun. The parkrun initiative has taken off to such a huge degree that there are parkruns everywhere throughout the UK. I’m a bit of a parkrun evangelist now, but the difference it’s made to the cardiovascular health of people throughout the UK, and beyond, is worth a mention here. It’s entirely run by volunteers, yet more and more runs start every week. If you’re looking for something to do on a Saturday morning…

New Year brings with it resolutions, so I resolve to keep this blog up to date. Check back for more musings on respiratory medicine, life in the chest unit, the twitter-sphere and more. Other resolutions include more exercise, fewer chocolate oranges, and finally getting round to submitting that case report to Thorax…

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Find your nearest parkrun

A new beginning, or the beginning of the end?

20 Oct, 13 | by tomfardon

The Thorax Blog – an opportunity to muse on respiratory medicine beyond the confines of the print journal, and an opportunity for the readership to provide quick fire responses and feedback, and an opportunity for something a bit different.  So we’ll see how this goes – post 1.

The paper issue of Thorax landed on my doorstep two days ago. It’s a great issue:  Respiratory infection, COPD, Epidemiology, Smoking Cessation, Tuberculosis, and a bit more Pneumonia, not to mention the usual high quality smatterings of Chest Clinic.  But how many people read the issue?  I don’t mean what’s the readership of the journal, but how many people read the paper version, compared with the online version I linked to just 2 sentences, and one hyperlink, above?

10 years ago I started my MD, researching anti-inflammatory treatments in atopic asthma patients.  My first task was to do a thorough literature review of the topic, to get up to speed with the research already done in the area, particularly by my own unit, and to present something that might be acceptable as an introduction to a thesis.  I trudged off to the departmental library to start to read journals.  I read the paper versions.  Mainly because the department had copies of the big journals in the area all the way back to 19 hundred and oat-cake.  Thorax; The “Blue Journal” (including copies of the American Review of Respiratory Disease, but not so far back as to encompass the American Journal of Tuberculosis, with, or without “A Journal of Respiratory Disease); CHEST; Allergy; JACI; and more.  I blew dust off the jackets, and started to read.  A colleague, now retired, was convinced he developed occupational asthma due to the dust from patient notes – I don’t think I had an allergy to the old journals, dusty as they were, but it was hard going, until a fellow research fellow, a cardiologist, asked me why I didn’t just read the digital copies, and save myself the legwork?

And, of course, this is how we work now.

“Have you seen the latest review of Hantavirus Pulmonary Syndrome?”
“No… is it good?”
“Yes, you should read it”
“I’ll find it online, I can read it on my iPad”

So what place is there for the print version of a journal these days? I asked my registrars if they read the print version any more. The answer was that they put the paper version in the smallest room, and read it whilst ‘on a break’. They read the online version at work. Reading during ‘a break’ isn’t exclusive to paper and print.

The juniors certainly like to get their names in print – original articles, letters in response to articles, chest clinic articles. But it’s easier, quicker, and more convenient to post a rapid response on a article on an online forum, or reply to a blog post, or even write one.

So if we can read the online version everywhere, carry it around in the cloud, wherever we go, and respond to it almost immediately, what need do we have of the printed version? Is this beginning of the end of the printed journal? Who prints out their photos anymore? So how long does the print version of any journal have..?

Thorax comes through my door every month, and I read it, every month, in its paper, real life, pages, glue and a spine reality. I like reading from paper, and I suspect I’m not alone. I have digital subscriptions to magazines that I don’t read, yet I will buy the paper version from TESCO, thereby paying twice; the Thorax digital subscription comes for free!

So I doubt this is the end of printed versions of journals: it’s easier to read the paper version, I think; it’s accessible without the cloud to power you along; it never runs out of batteries; and there’s something particularly special about flicking backwards through the paper journal, as there is flicking backwards through Cycling Plus (other magazines are available).

Who reads the paper version? Who reads the online version “cover to cover”? How long will it be before we can’t blow the dust of back issues? Or do we need the print versions, forever more?

Let me know what you think in the comments below.
 

 

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