Archives for August 2013

Travel medicine with Marc Shaw part 1 #GPCMEsouth

Marc Shaw is a travel doctor based in Auckland (we wont hold this against him)  professor of public health at James Cook University, Australia (We might hold this against him) Worldwise Travellers Health & Vaccination Centres NZ  medical director and consultant for New Zealand academy of sport.

marc_shaw

 Marc Shaw DrPH, FRGS, FRNZCGP, FACTM, FFTM (ACTM), FFTM RCPS (Glas), DipTravMed.

Prof Shaw gave 3 talks at the GPCME south conference on travel medicine. I will try to convey the essence of the talks some key points and his sense of humour which I’m told is very important in travel medicine.

The first was preparing the last minute traveller. A common general practice presentation.

The talk started with a quote by Billy Crystal   ‘By the time a man is wise enough to watch his step, he’s too old to go anywhere’

Marc was clear that the major role of a travel health professional is to convert a pre-contemplator into a contemplator. You need to balance what the patient wants and the level of risk.

As a big fan of any aid memoire when he suggested his T.R.A.V.E.L. Acronym I was very interested.

T TRANSMISSION of Infections and Dis-ease, discussion around insect avoidance use of repellents, other forms of transmission and ways to avoid “Dis-ease” whilst travelling.

 R REMEDIES Prescriptions x 2 CACHES Usual medications, a card with them on it in case of lost meds and a smaller collection in separate location if possible.

Med. Kits + first aid advice.

G.P. letter re meds & med. conditions can be needed for a number of medications. Antipsychotics are a major one for this most countries need some documentation for these to be carried across boarders. Medic Alert Bracelet may be needed for some.

Antimalarial Medication + SEs Treatments: self-treatment. Preference for malarone over doxycycline but understanding the cost issue.

 A ACCIDENTS Accidents/Injury Prevention Simple measures the best, good footwear, seatbelt use, helmets. Accidents and injuries make up a majority of the overseas illness but often seen as not significant risks in the settling. I understand the feeling as whilst travelling you do get a “hot frog” type situation when before you know it your riding a motorbike without a helmet and not worried in the slightest.

AIR TRAVEL Jet Lag suggested travelling east-to-west as much as possible, getting out in the sunshine and taking time to recover. expect half a day for each time zone crossed.

ADVENTURE As the numbers of people going heli-snorkeling or para-fishing  are rapidly increasing you will be seeing more of these through your door. A pragmatic approach needs to be taken, you may not think base jumping with a speargun is a great idea but do what you can to reduce their risks whilst doing so. Scuba Diving is a special note, check dive tables ect.

ANIMALS Bites, the importance of rabies vaccination and explaining the place of immunoglobulin which can be very difficult to access in some areas.

V VIOLENCE Avoiding areas: this covers both the high risk locations and areas of higher risk within regions. The risks to travellers have changed greatly in the last few years and as conditions are so volatile it is worth checking travel advisories from government and travel agencies.

VACCINATIONS and adverse reactions I really liked the table which balances the impact and incidence giving you the degree of preventable risk.

Risk vaccination  

ref: http://www.ncbi.nlm.nih.gov/pubmed/15996464

E EATING / DRINKING Ingestion. High risk foods, how to reduce your risk. the classic example being Roadside>Buffet>Restaurant

EXAMINATION Pre- and Post- travel. All travellers should have a good physical check up before leaving for their journey and also on returning.

ENVIRONMENT Expedition Medicine/Altitude. If on an expedition check the itinerary are they going high, low, high ect. Do they have a expedition doctor?

EMERGENCIES Insurance/evacuation: Insurance is widely available, people in complex situations may need a broker but most can and should be covered in someway(eg: exceptions of existing conditions)

“If a patient cannot afford to have travel insurance of some form they cannot afford to travel”

L LIFESTYLE ‘Sex Drugs Rock and Roll’ This one explains itself really. Harm prevention.

So that’s a pretty beefy way of remembering things but hopefully will help remember what should be covered. As always if concerns or unsure there are many resources for travel advice online and via the various govt. agencies. Onto a couple of other thoughts from the talk.

 Travel related illness: the gender differences.

59000 travellers in 57 world wide travel medicine clinics.

Women more likely to have diarrhoea, GI problems, Colds, UTIs and adverse reactions to drugs esp: antimalarials. But much less likely to develop STIs.

Men much more likely to get a febrile illness, malaria, dengue, rickettsia. Men are known to be less compliant with mosquito repellant ect.  Acute mountain sickness or frostbite this may reduce in future years but currently men have a strong majority when it comes to “extreme illness”.  STIs which is thought to be related to the common travel observation that majority of men sleep with locals and women with other travellers.

“You should advise your patients to keep it in their pants it is a Holy-day after all”

Ref: http://cid.oxfordjournals.org/content/50/6/826.full.pdf

Prof Shaw also talked about his pharmaceutical medical kit which is extensive! Some medications are more appropriate for some patients than others and the balance needs to be upheld between the safety of disease and treatment/Side effects.

Pharmaceutical Medical Kit – suggestions:
•Medication for: allergies, insect bites, colds and ‘flu, and diarrhoea
•Antibiotics for: ear, eye, respiratory, stomach and skin infections
•Fever therapy (aspirin / paracetamol), and water treatments
•Medication for anti-fungal infections
•Medication for motion sickness, nausea and vomiting
•Anti-malaria medicines (where appropriate)
•A sufficient supply of any regular medication (with spares!)
•Diarrhoeal Pack: Immodium, Noroxin/Azithro, Tinidazole, ORS

If only the travellers who often end up in ED were this prepared.

As this has ended up pretty large will split this into part one and two. In part two i’ll cover the talks on mass travel events and the South Americas!

GP CME South 2013 #GPCMEsouth

This week I shot down to Dunedin for the NZ medical associations CME conference.

top_banner2013

It was a great event and had a huge variety of talks and informal Q+A sessions.

See programme here:

http://www.gpcme.co.nz/south/programme.php

It was a little lonely on the twittersphere (#GPCMEsouth) but the teams from Canterbury health laboratories and New Zealand Doctor magazine keep me company.

The social media talks were well attended and in the plenary sessions others spoke about the need for doctors to have more information in the public realm. I did have the slight embarrassment of being called out at the #SoMe talk as a “serious tweep” and “blogger” (Thanks Barbara!)

Our wee kiwi GP conference managed to generate 224,403 Impressions! which was quite cool and It was really nice to get lots of messages from those who enjoyed the info flowing onto their timelines. Symplur here

Many of the presenters have been kind enough to let me write about their talks and include a few pearls in a longer format than 140 characters.

So over the next few weeks I should have a few interesting talks to cover and hope to share a few learning points and help solidify my thoughts as well.

The great PSA debate #pcwc13

This week in Melbourne the prostate cancer world conference was held.

The consensus statement this produced/publicised is linked below.

 http://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-statement-on-prostate-cancer-testing/

I think we can all agree the PSA cat is out of the bag and has had kittens. There is no going back to Pre-PSA testing but the harms of testing/treatment are very real. What follows are a few thoughts on the statements, responses and few interesting links. Some thoughts from GP peer review.

 Consensus Statement 1: For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer.

This statement is really a push back against the US Preventive Services Task Force recommendation. The evidence base is mixed but that screen reduces the mortality and risk of metastases  at diagnosis is fairly clear . What is unclear is how much harm this screening and treatment causes. Interestingly within the statements there is no mention of harms which leads to Statement 2.

 Consensus Statement 2: Prostate cancer diagnosis must be uncoupled from prostate cancer intervention.

 This is an attempt to reduce the harms that over diagnosis and treatment cause currently. The GPs at peer review thought this aspirational statement was excellent but still remained cynical about how much this was currently occurring.

The reality that PSA testing drives a large portion of private urology work/referrals does make some uncomfortable.

 I would point you in the direction of Dr Rajiv Singal who wrote an excellent piece on this in June. (@DrRKSingal)

“In my view PSA itself is a blood test. It is harmless. It is the treatment machinery that it often initiates that potentially gives it a bite and needs careful reflection.”

http://www.bjuinternational.com/bjui-blog/early-prostate-cancer-detection-one-canadian-urologists-perspective/

Consensus Statement 3: PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection.

There are currently multiple risk assessment tools but little consensus around their use. This also reflects the benefit of DRE in addition to PSA testing. 

 Consensus Statement 4: Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer.

I understand the reasons for this statement but the application of it which I have seen discussed confuses me. If someone is very low risk for prostate Ca in their 40s and make up less than 10% of prostate cancer diagnoses when followed up why would you continue to screen them in 5-7 years or again at all?

 Consensus Statement 5: Older men in good health with over ten year life expectancy should not be denied PSA testing on the basis of their age.

I found this interestingly nonspecific which I guess is the point. The risks of overdiagosis do need to be stressed more than with younger patients. Also the benefit is unclear as patients age beyond 70.

“Dr. Patrick Walsh, the noted Johns Hopkins urologist and forceful advocate for prostate cancer screening, famously (and humorously) said that he would not do a PSA test on a man older than 75 unless he was brought to the office by both his parents.”

 

 Media discussion:

The media uptake of the consensus statement has been pretty impressive. All the major networks picking up the story and print media have also followed suit. Unfortunately the stories have been one sided and this may be a “necessary evil” but the reality is this document will be seen as the prostate cancer experts giving their opinion on screening even if that is not the stated intention.

“ONE of the world’s greatest medical debates has come to an end with experts  agreeing that men should start testing for prostate cancer in their 40s.”

Read more:  http://www.news.com.au/lifestyle/health-fitness/prostate-cancer-test-should-be-taken-by-men-in-their-40s/story-fneuzlbd-1226692750214#ixzz2be5K2une

 You tube video of the media response:

http://www.youtube.com/watch?v=a1qUGG1-68g

From some of the comments from the BJUI website:

Associate Professor Ian Haines clearly not convinced of the merits of the document:

“This appears to be a pointless, self-serving, unbalanced, unhelpful piece of ‘propaganda’ by a self-selected group of like-minded urologists with huge financial conflicts of interest. It seems no more useful than a group of 10 pig-farmers telling us that we should eat more bacon.”

I am comforted by the comments of Mike Leveridge

“We have doubtless all had patients developing cynical approaches to PSA testing based on what they have seem and read recently, and it is nice to see this side of the debate register some air time (one caveat might be the promulgation of sensational headlines: The Australian: “Prostate experts end PSA test confusion”; I think Bloomberg’s “Prostate Test Warrants Rational Use” is much more becoming of the discipline, but I suppose we can indulge some rabble-rousing if it draws attention to the message).”

 A final thought will be left to Minh le Cong who left a comment which I think reflects the thoughts of myself and the other GPs at my peer review:
“Like other commenters, I don’t totally agree with some of the claims in the statement. However the spirit of the statement is on moving forward and changing our strategic thinking on prostate cancer/health. We should all be supporting that spirit.”

 

A common Kiwi presentation.

 I recently saw a patient for an off work certificate who was somewhat unusual for New Zealand.

He worked on a mine in Queensland and had been having a holiday before returning to NZ. Whilst wandering in the shallows he stood on something sharp and had severe pain in his foot. Lifting his foot he had four puncture marks and assumed he had stood on some coral.

He then describes ascending pain,  spreading erythema and severe oedema and pre-syncopal symptoms.

His mates loaded him into the Ute and rushed him to the local hospital.

On arrival he was mildly hypotensive BP 100/60 with a relative bradycardia of 50bpm for a patient in severe pain.

He was treated with a combination of oral, IV analgesia and hot water immersion (which he reports no effect from) and was kept for observation. Discharged with oral antibiotics and returned to NZ.

Discharge diagnosis of “Fish envenomation NOS”

He was kind enough to share his photos from the “holiday from hell”

 

foot 1

24 hours post injury.

foot 3

 Impressive oedema.

foot 4

 72 hours post injury.

When seen in clinic (2 weeks post injury) the patients oedema was resolving but he couldn’t get his boot on yet. The blistered areas had sloughed off and good granulation tissue in the bases. As he was working for a rich Aussie mining company I put him off for another week 😉

So I went looking for some info on fish envenomation’s. The Team at LITFL did a great review in 2009 so I chased about to see what the literature has come up with since then.

http://lifeinthefastlane.com/2009/04/scorpionfish-stonefish-lionfish/ (LITFL discussion of management)

Published at the exact same time as the LITFL review was a case series from Singapore hospital of 30 patients, showing most did very well and antivenom was not used very often.

http://www.ncbi.nlm.nih.gov/pubmed/19495521

 An article in French which discusses a case leading to cardiovascular collapse:

 http://www.ncbi.nlm.nih.gov/pubmed/20099677

My hand’s a bit munted.

Bloke arrived in ED holding  his “Munted hand!”

Patient was clearly in pain with a deformed hand:

image

Mechanism of injury was fall from BMX wedging hand between a large rock and tree.

image

Analgesia and off to x-ray:

metacarpal disolcation 3

 

Metacarpal dislocation 2

The films show Carpometacarpal dislocations of 3rd 4th and 5th (and possibly 2nd according to radiology) But no associated fractures on any views.

Titrated fentanyl was given for analgesia and midazolam was added for the reduction.
The reduction only required minor force applied to base of metacarpals and longitudinal traction.

Post reduction films showed:

metacarpal dislocation reduced

Patient was taken to theatre later that day for K-wire fixation.

The patient was planning to be back on the bike after removal but couldn’t help himself and was out riding 4 days post cast removal (day 11 post reduction)

So the Munter with the munted hand is doing well. K-wires removed at clinic increasing strength and not too much stiffness. (the benefit of early mobilisation?)

I was going to write more about Carpometacarpal Dislocations but Chris Partyka has covered it so well over at The blunt dissection I thought pointing you there would be better.

http://thebluntdissection.org/2013/04/quick-case-01/