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Recent eLetters

Displaying 1-10 letters out of 223 published

  1. Re-Freud's unconscious mind and the "EBM World"

    I would like to thank the author on a thoughtful reflection on the "unconscious mind" and would like to comment on its relevance in modern medicine especially psychiatry and allied fields.

    Understandably concepts like the "drive theory" or "defence mechanisms" do not lend themselves to critical appraisal in "Evidence- based Medicine" terms easily but that in it should not detract from their usefulness in everyday clinical practice. "Unconscious mind", "drive theory" and other classic Freudian concepts belong to the set of hypotheses whose validity might be difficult to prove, but nevertheless whose utility is unquestionable. Such concepts provide an extremely useful conceptual framework for clinicians to make sense of hugely complex and nuanced human behaviour- both "healthy" and "pathological".

    While helpful to all medical specialities, they are especially relevant to mental health clinicians working with patients who do not easily fit into established diagnostic categories or have significant personality dysfunction.

    Like with other medical theories, with greater knowledge and technological advancements they can be suitably modified and refined to the benefit of our patients. Just like any other hypothesis, Freudian concept of "Unconscious mind" has its strength and limitations and by its judicious use in the right context we would maximise its clinical utility.

    I feel we as clinicians would be doing us and our patients a dis- service if we remain totally ignorant about it or rigidly dismiss it outright for not being easily compatible with classic "Evidence-based Medicine".

    Conflict of Interest:

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  2. Re:Avoiding Burnout

    Dear Editor Our editorial was triggered by a PMJ paper showing that in a study carried out in the US, 76% of first year doctors exhibited burnout. We quoted other evidence that burnout may occur surprisingly early in careers and is not necessarily related to seniority. We know that jobs which require daily face to face interaction with people who are distressed or challenging lead to high levels of burnout. Sadly it is those who are most empathetic who become emotionally exhausted most quickly. We also know that isolation, overwork, lack of sleep and lack of expertise all add to the risk of burnout. New doctors should not have to cope with all of those at once. There is evidence from the GMC's annual National Trainee Survey (and before that the London-wide Point of View Survey) that over the past 16 years the proportion of new doctors who feel stressed, bullied or sleep-deprived has steadily reduced. We are not aware of any evidence suggesting it has got worse, though stresses may well have been transferred to those higher up the career ladder. Big problem is dependence on doctors in training to deliver service. Not a problem as such, but it is when service demands mean working under stress and without colleagues and supervision. Unsupervised work provides experience but cannot be considered as training. Working in teams, even if the membership of the teams changes, mitigates against isolation and provides supervision for the junior members. Diana Hamilton-Fairley. Elisabeth Paice

    Conflict of Interest:

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  3. Re:Informant based questionnaire I-AGeD tool to improve poor recognition of delirium in emergency room.

    We agree that delirium is serious, and more structured instruments are needed for providers of multiple specialties to detect delirium in multiple health care settings. While we have no experience on the I-AGeD in our emergency departments, we note that caregivers often are not available at the time of emergency presentation. Also, we find veracity of caregiver reports highly dependent on relationship and time spent with the patient. Ideally, providers should have access to tools that use only patient-level information in addition to tools that use caregiver information for diagnosing delirium.

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  4. Informant based questionnaire I-AGeD tool to improve poor recognition of delirium in emergency room.

    Dear Madame, Sir,

    In their interesting study Suffoletto et al [1] examined delirium recognition by emergency physicians. Trained researchers identified delirium in 24/259 (9%) of emergency room older patients. Diagnosis was based on CAM -ICU criteria, Richmond Agitation and Sedation scale and an interview with the surrogate. By contrast, emergency physicians recognised delirium in only 8/24 cases and misidentified delirium in seven cases. Delirium is a serious condition, and it is associated with poor outcome. Recognition of delirium is important and might improve patient outcomes. Study findings are in line with previous studies that showed there is room for improving delirium recognition,

    We have looked at this problem recently and developed and validated a new screening instrument, the Informant Assessment of Geriatric Delirium scale (I-AGeD) [2]. It is a 10 items caregiver baser questionnaire. The I- AGeD was validated in elderly patients admitted to a geriatric wards of two general hospitals. Average age in the construction cohort was 86,4 yr, 51/88 suffered from dementia and delirium was found in 31/88. In two validation cohorts, sensitivity and specificity ranged from 70-88.9% and 66.7 -100%.

    Given the present demographics, the incidence of delirium will rise, and recognition of delirium may be difficult, especially in patients with dementia. Training physicians outside the field of geriatrics on this issue is important. We think that an caregiver based screening instrument might be an efficient way to improve early and fast recognition of delirium in geriatric patients.

    With kind regards,

    JPCM van Campen1, HFM Rhodius Meester1, JFM de Jonghe2

    1 Slotervaart hospital, department of geriatric medicine, Amsterdam, the Netherlands 2 Medical Center Alkmaar, department of geriatric medicine, Alkmaar, the Netherlands

    References

    1 Brian Suffoletto, Thomas Miller, Adam Frisch, Clifton Callaway, Emergency physician recognition of delirium, Postgrad Med J 2013 June, ahead of Print

    2 Rhodius- Meester HFM, van Campen JPCM, Wung W, Meagher DM et al, Development and validation of the Informant Assessment of Geriatric Delirium Scale (I-AGeD). Recognition of delirium in geriatric patients. EGM , 2013; 4(2):73-7

    Conflict of Interest:

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  5. Avoiding Burnout

    Avoiding burnout in new doctors: sleep, supervision and teams Elisabeth Paice, Diana Hamilton-Fairley 2013;89:493-494 doi:10.1136/postgradmedj-2013-132214

    I applaud Paice and Hamilton-Fairley's call for better work schedules and supervision, but burnout seems to increase with seniority and probably reflects more fundamental problems. Achieving even the aims mentioned may be more difficult than the authors suggest.

    They note that instant teams function well in the airline industry but link this statement to a paper which referenced stability as one defining factor for well-structured teams1. The questionnaire to identify team membership in that study across all types of hospital employees didn't ask about (or exclude) stability in the 'well-structured' teams correlated with weaker stressor-strain relationships. One criterion defining membership of a well-structured team was 'regular team meetings', which surely implies at least moderate stability. 'Ensuring that there is a leader, shared goals, well-defined roles, and mutual respect' are indeed important but stability is also necessary for most medical teams. Instant teams might function on airline flights but such teams in Medicine present serious problems for care of patients as well as for clinical supervision and appraisal of new doctors.

    If it 'really isn't that hard' to avoid damaging work schedules, we might ask why they are still so common and why Deaneries and other bodies haven't been able to stop them. One answer is, presumably, that the profession has progressively lost influence in many Trusts. The experience of 'hospital-at-night' in many Trusts is very different from the original concept. Too often, a few doctors (without the other help provided in exemplar sites) are responsible for large numbers of patients. There is evidence of unacceptable demands on many medical registrars for whom effective supervision of newer doctors is not possible2

    It's interesting that stress and dissatisfaction appear to be increasing despite overall reduction in working hours. Preparing new doctors to cope with clinical reorganisations, NHS instability and employers' attitudes to medical staff is a significant problem. In truth, fewer doctors in both hospital and general practice seem to want to work at night and the NHS doesn't yet know how to cope with that. I wonder if current levels of burnout and dissatisfaction reflect a deeper malaise for which we might need a different type of conversation?

    References

    1. Buttigieg SC, West MA, Dawson JF. Well-structured teams and the buffering of hospital employees from stress. Health Serv Manage Res 2011;24:203-12. 2. Royal College of Physicians. The medical registrar: Empowering the unsung heroes of patient care. London: RCP, 2013

    Conflict of Interest:

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  6. relevance of time frame and left circumflex as the culprit artery

    The occurrence of coronary occlusion in patients without protocol positive ST segment elevation(1) might be attributable either to early catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter also being significantly(p < 0.001) commoner in non ST segment elevation(NSTEMI) patients catheterised within 6 hours of arrival in hospital than in STEMI counterparts also catheterised within that time frame(4). According to one study, there is a "higher rate of thrombotic coronary occlusion in the first NSTEMI patients with early catheterization than in those catheterized later"(2). That conclusion was based on an analysis of 878 patients in whom an evaluation was made of the prevalence of thrombotic occlusion with in time frames of 0-6 hrs, 7-24 hrs, 25-48 hrs, and 49-96 hrs encompassing time elapsed from admission with chest pain to angiography. A multivariate logistic regression analysis showed that the time frame of 0-6 hours was the most significant(p < 0.001) independent marker of coronary occlusion(with reference to the 48-96 hour interval)(Odds Ratio 3.01, 95% Confidence Interval: 1.94-4.66; p< 0.001), whereas, for anterior ST depression corresponding data for those parameters amounted to 2.09, 1.36-3.21, p=0.001, respectively, and, for inferolateral ST depression, corresponding data amounted to 1.83, 1.08- 3.11, and p=0.025, respectively. Total(ie 100%) thrombotic occlusion was documented in 55% of 141 patients who fell within the 0-6 hr time frame, and this represented a significant(p < 0.001) trend in comparison with other time frames. The left circumflex artery was identified as the culprit artery(in association with the marginal branch and the intermediate branch) in 50% of patients who fell within that time frame(2). Conversely, in a study which exclusively enrolled 27,711 patients with myocardial infarction attributable to left circumflex artery occlusion, the prevalence of NSTEMI was as high as 33%(3). What is more, in a study where 93% of 125 patients with suspected NSTEMI had coronary angiography within 6 hours of arrival in hospital the left circumflex artery was the culprit artery in 26%(as opposed to its involvement in 11% of 279 STEMI patients), the difference in prevalence being highly significant(p < 0.001)(4). Accordingly, the greater the delay in cardiac catheterisation the greater the likelihood that the opportunity will be missed to identify thrombotic coronary artery occlusion, especially in patients with left circumflex artery involvement. References (1)Apps A., Malhotra A., Tarkin J et al High incidence of acute coronary occlusion in patients without protocol positive ST segment elevation referred to an open access primary angioplasty programme Postgraduate Medical Journal 2013;89:376-381 (2)Fugueras J., Barrabes JA., Andres M et al Angiographic findings at different time intervals from hospital admission in first non-ST elevation myocardial infarction International Journal of Cardiologydoi.org/10.1016/j.ijcard.2012.09.168 (3)Stribling WK., Kontos MC., Abbate A et al Left circumflex occlusion in acute myocardial infarction(from the National Cardiovascular Data Registry) Am J Cardiol 2011;108:959-963 (4)Koyama Y., Hansen PS., Hanratty CG., Nelson GIC., Rasmussen HH Prevalence of coronary occlusion and outcome of an immediate invasive strategy in suspected acut myocardial infarction with and without ST- segement elevation Am J Cardiol 2002;90:579-584

    Conflict of Interest:

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  7. Transthoracic ultrasonography to differentiate bullous emphysema from pneumothorax: a bright future in black and white.

    Respected Editor, The case report by Lai et al. [1] was both interesting and informative. We agree with the usefulness of CT thorax to differentiate pneumothorax from giant bulla with double wall sign. Though CT offers the most accurate diagnostic information, it is difficult to transport unstable patient to a CT suite which is in a remote area from a resuscitative area or to wait for a specialized technician to perform it and a radiologist to interpret it. Traditionally, the presence of bullae and their advancement are recognized by chest radiography. At times, even forced expiratory films are used to demonstrate the existence of bullae [2]. However, limitation is difficult to differentiate the hairline shadows produced by avascular bullae from irregular walls of a cavity or cysts in the lung parenchyma in an emergency setting and may easily be mistaken for a pneumothorax [3] sometimes. In this scenario, the bedside transthoracic ultrasonography has emerged as a reliable technique to detect and exclude pneumothorax which is now well accepted by the medical community. The effectiveness of ultrasound in detection of bullae and differentiate it from pneumothorax [4] is well documented. The lung sliding may be minimal because there may be little movement of the visceral pleura that covers the bulla. As there is no free air in the pleural space, the reverberation artifact that produces the 'comet tail artifacts' may be noticed in bullous disease. However, it is absent when the lung is collapsed as in pneumothorax and thereby helps to arrive at the diagnosis [5]. Speedy and precise diagnosis of bullous emphysema from pneumothorax will assist in treatment, as the management of these two entities varies significantly. Many times patients presenting to the emergency departments were in extremis and call for an immediate decision making and delaying can be life threatening. In an emerging culture of protocol and guidelines regarding effectiveness of treatment, transthoracic ultrasonography may be considered in the emergency department to assure the high quality of health care given to patients.

    References:

    1. Lai CC, Huang SH, Wu TT, Lin SH. Vanishing lung syndrome mimicking pneumothorax. Postgrad Med J. 2013.

    2. Shah N N, Bhargava R, Ahmed Z, Pandey D K, Shameem M, Bachh A A, Akhtar S, Dar K A, Mohsina M. Unilateral bullous emphysema of lung. Lung India 2007;24:30-2.

    3. Waseem M, Jones J, Brutus S, Munyak J, Kapoor R, Gernsheimer J. Giant bulla mimicking pneumothorax. J EmergMed 2005;29:155?-8.

    4. Chan SS. Emergency bedside ultrasound to detect pneumothorax. Acad Emerg Med 2003;10: 91-4.

    5. Simon BC, Paolinetti L. Two cases where bedside ultrasound was able to distinguish pulmonary bleb fzom pneumothorax. J Emerg Med. 2005.29:201-5

    Conflict of Interest:

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  8. Cost-effective prescribing: Medical schools must take responsibility

    Nwulu and colleagues present a highly relevant analysis of the financial implications of prescribing by F1 doctors in a UK teaching hospital1.

    It seems that the most important of the recommendations they discuss are for undergraduate medical education. Whilst they mention that most of the 79 doctors they investigated graduated from the same medical school, they do not categorise this further. As their data indicate, the large majority of doctors performed to a very similar level to the reference doctor, with a minority on either end of the spectrum proving to be the most cost-effective and lavish prescribers. This raises the possibility that the doctors at the extremes of this range may have been the minority that trained at alternative medical schools.

    As they highlight, further studies are needed across the country, although they may prove to be more of a challenge in trusts that do not have electronic prescribing systems. Future work into this area may benefit from investigating the medical schools at which doctors trained. As these doctors are in their first year after graduating, conclusions may be drawn about the extent to which medical schools are covering the financial aspects of prescribing in their clinical pharmacology curricula. With the increasing importance of cost-effectiveness in the NHS, this important topic should be on the agenda of medical educators across the UK in order to breed a new generation of financially astute prescribers.

    1. Nwulu U, Hodson J, Thomas SK, et al. Variation in cost of newly qualified doctors' prescriptions: a review of data from a hospital electronic prescribing system. Postgrad Med J Published Online First: [30 March 2013] doi:10.1136/postgradmedj- 2012-131334

    Conflict of Interest:

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  9. Lewy Body Dementia in the Emergency Department

    Sir,

    We applaud the timely study by Kennelly et al and agree fully that ED physicians generally lack proficiency for recognizing and managing behavioral complications of dementia. As they succinctly state, "Failure of physicians to identify and highlight cognitive impairment can lead to disastrous consequences".[1] We venture that ED physicians are even less aware of the unique and potentially lethal emergency management aspects of Lewy Body Dementia (LBD). LBD is a degenerative neurological disease manifested by cognitive impairment, variable Parkinsonism, and marked psychosis exhibiting both auditory and visual hallucinations. LBD is now considered the second most common cause of dementia following only Alzheimer's comprising up to 20-30% of all dementia based on autopsy studies.[2] Differentiating LBD from other dementias can be difficult but the key features are daily fluctuation in cognition and the prominent hallucinations (paradoxically they are not distressful to the patient). DLB strikes its victims from late middle age up and respects no boundaries as to gender or race.[3]

    ED patients with LBD require careful and distinctive pharmacologic management of their agitation and psychotic symptoms. Administering typical neuroleptics will precipitate serious complications ranging from extrapyramidal symptoms to severe sedation to the often lethal neuroleptic malignant syndrome (NMS). Up to 50% percent of individuals with LBD are at an increased risk of these acute reactions to neuroleptics.[2].

    The pathophysiology of this phenomenon is based on the finding that neurons of the basal nucleus of Meynert and substantia nigra are reduced in LBD thus preferentially depleting acetylcholine and dopamine neurotransmitters. The typical antipsychotics, such as haloperidol (Haldol), fluphenazine (Prolixin), and chlorpromazine (Thorazine), block postsynaptic mesolimbic dopaminergic D1 and D2 receptors which can typically be helpful for reducing delirium and hallucinations in most patients with Alzheimer's. The specific neurotransmitter deficits in LBD however prevent up-regulation of D2 receptors in the affected brain centers thus uniquely sensitizing these patients to the EPS adverse effects of antipsychotics.[2] Not only can this exacerbate acute problems but it may worsen cognitive ability of these patients over the long term. LBD experts recommend the use of newer and more selective atypical antipsychotic agents. Importantly, however, case reports show that even these newer agents are not immune to inducing NMS in LBD, so small and carefully titrated doses are advised.[4] Employing non- pharmacologic modalities and the judicious of short acting benzodiazepines is also advised. Because the Emergency Medicine community is largely unaware of these unique hazards, the Lewy Body Dementia Association provides helpful guidelines for ED staff to safely treat these unique patients at http://www.lbda.org.

    1. Kennelly SP, Morley D, Coughlan T, et al. Knowledge, skills and attitudes of doctors towards assessing cognition in older patients in the emergency department. Postgraduate medical journal 2012 doi: 10.1136/postgradmedj-2012-131226.

    2. Baskys A. Lewy body dementia: the litmus test for neuroleptic sensitivity and extrapyramidal symptoms. J Clin Psychiatry 2004;65 Suppl 11:16-22

    3. Latto J, Jan F. Dementia with Lewy Bodies: Clinical Review. British Journal of Medical Practitioners 2008;1(1):10 - 14

    4. Weintraub D, Hurtig HI. Presentation and management of psychosis in Parkinson's disease and dementia with Lewy bodies. Am J Psychiatry 2007;164(10):1491-8

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  10. the current world record for giant left atrium

    The 76 year old patient recently reported in this journal with left atrial diameter of 10 cm(1), has been superseded, in the record books, by a 40 year old man with left atrial diameter of 21.5 cm attributable to severe mitral stenosis(2). The latter patient presented with dysphagia, hoarseness, and exertional dyspnoea. References (1)Shah BN., Rubens M Giant left atrium: a forgotten cause of cardiomegaly Postgrad Med J 2012;88:673-4 (2) Puri A., Vijay SK., Chaudhary G et al A rare cause of cardiomegaly Journal of the American College of Cardiology dx.doi.org/10.1016/j.jacc.2012.04.061

    Conflict of Interest:

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