Tuesday, May 08, 2018

Barts MedSoc end of year reflections

Last week saw the end of my first experience as a GP tutor to Barts Malta first year medical students. The MedSoc programme, as it is called, is a series of twelve themed days from October till May dealing with a range of topics from the GP perspective. Topics dealt with included chronic pain, diabetes and pregnancy amongst others.

I was on a learning curve. Organising visits to associations, agencies, old people's homes and patients' residences as well as preparing tutorials and practical sessions....the work was intensive. Seeing my students motivated and eager to learn made it all worthwhile.


So this week it was with a bit of a heavy heart that I met Upe, Hish, Lexie and Casey for the last time. Knowing however that the experiences shared will stay with us for a long time...

Friday, April 20, 2018

Hair Apposition Technique for scalp lacerations

In urgent care we often come across injuries to the head which result in lacerations to the scalp.  Often dramatic due to the profuse blood supply of this region causing copious bleeding, they however rarely require more than simple suturing. An exception is small children, who we know are often accident prone and tend to get agitated very easily when at the doctor. An agitated child makes the procedure of suturing immensely more complicated, increasing the risk of failure of the procedure and injury to the operator. For this reason a technique for treating scalp lacerations known as hair apposition technique  (HAT) is a very valid alternative. Made public in 2002 this method involves using the patient’s own hair as the suture material and obviates the need for anaesthetic infiltration and use of needles. Furthermore the patient is spared having to return to the clinic for removal of sutures. As always patient selection is important, thus HAT is not advised for patients with  persistent profusely bleeding wounds and those with extensive contamination. For obvious reasons HAT is not suitable for bald patients or those with sparse or short hair. More information can be obtained in the video below. 

Saturday, April 07, 2018

Overeating



What makes us overeat? What drives us to take in all those extra calories? Former Food and Drug Administration Commissioner Dr David Kessler explores these issues in this interesting interview.

Saturday, January 27, 2018

When to give the meningitis B vaccine

Meningitis is a term used to refer to inflammation of the meninges, the tissue covering the brain. This is often caused by infection. One type of microbe that causes meningitis is Neisseria meningitidis and this leads to a disease called Invasive Meningeal Disease (IMD). IMD is an aggressive form of infection that quickly spreads to the blood and nervous system causing high fever, severe headache, a rash and can deteriorate to loss of arms or legs, coma and death.

Neisseria meningitidis is a very common microbe, mostly residing in the throat of carriers without causing any harm. It is estimated that around 10% of people have it. Transmission is by droplets of saliva as when breathing into another person's face, sharing of eating utensils, sneezing without covering the face and poor hand hygiene.

Problems arise when Neisseria starts to multiply uncontrollably such as in people with weakened immune systems. There are 5 subtypes of this meningitis microbe, namely ABCWY. Up till recently there was a vaccine available for subtypes ACW and Y. Subtype B was not covered. This situation changed when a shot targeted at the B subtype became commercially available and the demand for it was (and still is) huge. This in part was aided by news stories of deaths in children having been stricken by meningitis B and the consequent emotional outpour duly amplified on social media platforms such as Facebook and Twitter. In Malta you had people going over to Sicily with cooler bags to buy the vaccine and bring it over.

A close look at the facts reveals that IMD is a rare disease with two major peaks of incidence. The first occurs in the first year of life and the second peak towards teenage. The first peak is much more significant than the second. Furthermore the currently available vaccine covers against around 80% of type B Neisseria meningitidis and the duration of immunity beyond 48 months is unknown. This means that widespread use of this vaccine will presumably cause natural selection for the uncovered 20% of strains, thus rendering the vaccine useless in the long term.

Two respected internationally recognised organisations have issued different recommendations with regards immunisation with meningitis B vaccine in healthy individuals. These are the British NHS and the Center for Disease Control (CDC) of the United States. The NHS recommends that the meningitis B vaccine is given to all children in the first year of life together with the other routine vaccines. This approach assures protection during the age wheninfection with the meningitis B bacterium is most likely. However there is no assurance that the child will remain covered through life. CDC on the other hand recommends giving the vaccine to children as they reach teenage.

One should note that the vaccine is considered safe to all effects but it does carry the risk of side effects such as pain at injection site, fever, loss of appetite and nausea.

So in conclusion I have to say that the development of this vaccine has been a welcome development, but more research is needed to increase the range of protective cover it provides and to elucidate the length of immunity it affords.

Wednesday, February 01, 2017

Screening for Diabetes...does it make sense?

In order for a disease to be a candidate for screening it has to satisfy the following seven criteria1: 

  1. it has to be an important health problem 
  1. the natural history of the disease is well known 
  1. it has to have a recognizable preclinical asymptomatic stage 
  1. tests that can detect the preclinical stage are available 
  1. offering treatment after early detection is of proven benefit 
  1. the process has to be cost effective 
  1. screening has to be an ongoing process 

Diabetes Mellitus can be broadly classified into type 1, type 2, and diabetes due to other causes (including gestational diabetes). Whereas  screening for diabetes type 1 is not advised because there is no treatment recommendable for the asymtomatic phase2, diabetes type 2 meets conditions 1 to 4 (conditions 5 to 7 are not met entirely)1. Furthermore diabetes type 2 accounts for 95% of diabetes patients in the United States and its global prevalence is increasing2. 

Nonetheless there are differing expert opinions on whether to screen for diabetes. For example the UK National Screening Committee recommends against screening for diabetes type 23. On the other hand in the United States and Canada screening is recommended for patients at risk of diabetes type 2 or its complications2. 

Screening for diabetes type 2 may take the form of a questionnaire, formal laboratory investigations or a combination of the two4.  Fasting plasma glucose (FPG) is the preferred test1 for the following reasons: 

  1. easier to perform1 
  1. faster to perform1 
  1. patients find it more convenient and acceptable1 
  1. relatively inexpensive1 
  1. has relatively high sensitivity and specificity4 

The screening programme may take one of the following approaches4 

  1. target an entire population 
  1. target only those at risk of a disease 
  1. screen opportunistically 
  1. screen haphazardly 

Opportunistic screening is testing done for a particular disease or condition during patient encounters for unrelated problems. Haphazard screening is done on subjects chosen at random, for example testing customers at a supermarket. 

In the maltese context screening for diabetes type 2 occurs to a greater or lesser extent at primary care level5. The type of screening is opportunistic. Patients either request routine blood investigations (including, but not limited to FPG), or these are offered by the physician during a consultation for another reason. Patients testing positive are then offered one or a combination of the following: 

  1. lifestyle and dietary advice 
  1. pharmacological treatment 
  1. referral to secondary care 

My suggestion is, in line with WHO recommendations4, to adopt the following improvements to the screening already being done in Malta: 

  1. formulation of a clear policy on screening including all the stakeholders which should be reviewed periodically as new evidence materializes 
  1. carrying out randomized controlled trials(RCT) on the efficacy of screening, or if this is not feasible logistically and economically, participating in any which may be currently running 
  1. carrying out a feasibility study comparing early detection versus other preventive and therapeutic options 
  1. haphazard screening should be discouraged 
  1. those being screened should be given an explanation as to why they are being tested 
  1. testing should be done with investigations of adequate sensitivity and specificity 
  1. addressing the psycho-social needs of those testing positive and negative 
  1. the screening should take into consideration the epidemiology of diabetes type 2 and related cardiovascular complications 
  1. screening should take into account competing health priorities 
  1. the screening being carried out should be formally evaluated


References 
  1. Diabetes Care January 2002 vol. 25 no. suppl 1 s21-s24  
  1. Am Fam Physician. 2010 Apr 1;81(7):863-870.    
  1. http://www.who.int/diabetes/publications/en/screening_mnc03.pdf  
  1. Personal professional experience in Primary Health Care