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Recent eLetters

Displaying 1-10 letters out of 228 published

  1. Old Age: Medicine is activity

    Sir,

    This article points out the well documented fact that increased physical activity has clear-cut protective effect from all cause mortality(1). Developing countries like India are also acknowledging such facts and are issuing guidelines for the same so as to promote health care of elderly even at primary health care level(2).

    With development and prosperity the average individual age is increasing which is attracting focus of governments and policy makers towards growing need to cater to such population. The root cause of major physical impairment in old age is physical inactivity and its consequences, this fact need to be projected in a clear and concrete way in the midst of general population specially the elderly and their families.

    The physician, individual concerned and community all should work in synchronization towards promoting health and vitality to the elderly. There needs to be greater involvement of elderly into accepting increasing bodily movements as a part of life. Another area of concern will be ways to protract such activity and devote greater manpower and political will towards this often neglected but inevitable phase of life.

    References :

    1. Ueshima K, Ishikawa-Takata K, Yorifuji T, et al Physical activity and mortality risk in the Japanese elderly. A cohort study. Am J Prev Med 2010;38:410-18.

    2. www.mohfw.nic.in/WriteReadData/l892s/NPHCE.pdf Ministery of Health and Family Welfare, Government Of India, New Delhi, India. 11/11/2013.

    Conflict of Interest:

    None declared

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  2. Holistic care needs to be met with holistic education

    The increasing numbers of frail elderly patients certainly poses a challenge for all parts of the healthcare landscape within the UK and beyond. Whilst organisational change and modifications to where, when and how we deliver care is important this must be underpinned by appropriate education for doctors and allied healthcare professionals.

    Much of this needs to be aimed at more junior staff, especially medical students and junior doctors. Elderly care medicine has been undervalued for too long and the complexities of older people have been underestimated. Education therefore needs to be focussed on two main areas:

    1. An ability to understand complex medical conditions, the interactions that these conditions have with each other and the medications that can improve and worsen these problems. This must be learnt in the context of the multi-disciplinary team and understand the complex psycho-social dimensions that exist within the ageing community.

    2. An understanding that over medicalisation of the health needs of older people can be detrimental to both physical and psychological care, in particular the understanding that just because we can investigate and treat problems doesn't mean that we should. These decisions are complex and should be made in conjunction with patients, their families and independant advocates if patients lack capacity and family.

    Changes to the care of older people must be made in a sustainable and holistic way which have education as the foundation to ensure modifications are successful.

    Conflict of Interest:

    Academic Clinical Fellow in Medical Education at Plymouth University

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  3. Less health care might be fair in the older patient.

    Predicting prognosis in this older group of patients is complex due to their highly variable health status, driven by their fundamentally different prognosis to younger patients. We have published two recent pieces on this theme, showing that firstly though there was an incremental reduction in the use of evidence-based therapies for ACS (acute coronary syndrome) with older age and that better survival was associated with intensive management at all ages, this benefit was attenuated the older the patient.(1) Secondly, higher troponin levels are associated with increasing risk of mortality, but we found very high mortality rates in older patients even at the lowest troponin values. There was an attenuation of the prognostic value of troponins in older age and thus, the prognostic value of troponins depends on patient age in ACS - essentially, age is the biggest prognostic marker, and arguably markers we use in younger patients are not as relevant in older patients.(2) Current risk scores to guide aggressive management of coronary disease in the older person perform poorly, over-estimating mortality and ignoring morbidity, perhaps of more relevance to this age group.(3) In a population of older adults, adjustment for 27 biological risk factors including co- morbidity, social status, lifestyle and disease factors, cognition and frailty substantially reduced the association between chronological age and 5-year mortality (ages 80-84 years: unadjusted relative risk, 4.1; adjusted relative risk, 1.7).(4)

    As outcomes are influenced by both age and co-morbidity, is the under -treatment of older people with ACS relative to younger patients thus 'appropriate'? Evidence suggests that risks associated with more intensive management in older people may be related more to their greater co- morbidity than age alone(5) and thus chronological age alone may not be the best measure by which to plan clinical management in older people. Trials also tend to focus on hard outcomes and also rarely take into account wider prognostic measures such as disability, repeated hospitalisation and return to independent living that are more relevant in older people. Others have also written that sometimes following exacting clincial guidelines that lead to more treatment may not be in the best interests of the older patient.(6)

    The ideal pathway in the older patient for example with an ACS should not assume early intervention with revascularisation is the optimum strategy (as is usually the case in the younger patient) but should be a more holistic management strategy based upon thorough comprehensive geriatric assessment. Frailty,(7) functional status, and social aspects of care in the elderly are rarely included as clinical parameters (read wider prognostic markers) in decisions pertaining to future care. Furthermore, outcomes beyond survival need assessing, and ones of particular relevance to the older patient.

    1. Zaman MJ, Stirling S, Shepstone L, Ryding A, Flather M, Bachmann M, et al. The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP). European Heart Journal. 2014 March 18, 2014.

    2. Myint PK, Kwok CS, Bachmann MO, Stirling S, Shepstone L, Zaman MJS. Prognostic value of troponins in acute coronary syndrome depends upon patient age. Heart. 2014 June 26, 2014.

    3. Zingone B, Gatti G, Rauber E, Tiziani P, Dreas L, Pappalardo A, et al. Early and late outcomes of cardiac surgery in octogenarians. Ann Thorac Surg. 2009 Jan;87(1):71-8.

    4. Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF, et al. Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study. JAMA. 1998 Feb 25;279(8):585-92.

    5. Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A, et al. Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey. Eur Heart J. 2006 Apr;27(7):789-95.

    6. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA. [doi: 10.1001/jama.294.6.716]. 2005;294(6):716-24.

    7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2001 March 1, 2001;56(3):M146-M57.

    Conflict of Interest:

    None declared

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  4. Evaluating the 5Fs mnemonic for cholelithiasis in a peruvian population

    Dear editor: We read with great interest the paper by Bass et al[1] on the mnemonics of cholelithiatis in the november 2013 issue of PMJ. The authors conclude that Family History should be considered as a predictive factor. We would like to share our own experience on this matter. We collected 173 consecutive patients diagnosed of cholelithiasis, inpatients and ambulatory care patients, during January and February, 2014. In all cases the diagnosis of biliary stones was established by an abdominal ultrasound or surgical confirmation. Patients were interviewed on sex, age, parity, family history of cholelitiasis. Skin fair and the body mass index were determined by our team. Parity was considered positive when there was at least one born child. Fat was considered as such with a BMI of 25 or more. A family history was considered positive if a first degree relative had been diagnosed or had surgery for cholelithiasis. A total of 173 patients were included; with an age average of 50,16 +- 14 years and 79.8 % female. The frequency of each of the 6 Fs studied are a)Fertility:95.7% ; b)Female: 97.8% ; c)Forty: 75.1% ; d)Fat: 69.9% ; e)Family History: 46.2%, f) Fair: 4% (*Fertility: only females ; fat: excluded 69 patients with surgical confirmation) According to our results, fertility, female gender, age above 40 years and an increased BMI were the 4 Fs that best predicted cholelithiasis. In Peru, and particularly in Callao, where predominant skin phototypes are III, IV and V and fair skin is very rarely found, the F of fair, should be disregarded[2]. Therefore, we agree with the authors that Family History should also be considered as a predictive factor. Conflict of Interest: None declared REFERENCES 1. Bass G, Gilani SNS,Walsh TN.Validating the 5Fs mnemonic for cholelithiasis: time to include family history. Postgrad Med J 2013;89:638-641. 2. Ramos C, Ramos M. Conocimientos, actitudes y practicas en fotoproteccion y fototipo cutaneo en asistentes a una campana preventiva del cancer de piel. Callao-Peru. Febrero 2010.Dermatol Peru 2010;20(3):169-173

    Conflict of Interest:

    None declared

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  5. The patient, too must be on the same page as the team

    When Professor Weller and her colleagues speak of members of the team being "on the same page"(1) no mention is made of the patient(or the patient's advocate)(2) being also on the identical page. To facilitate the inclusion of the patient in the team I have proposed the use of an abbreviated patient-held health record which essentially documents the problem list and the corresponding drug list, and this should be updated each time the patient attends a healthcare facility(3). So as to mitigate the risk of inadvertent adverse drug interactions, the community pharmacist, too, needs to be on the same page as the patient. Accordingly, each time new medication is prescribed, the patient should be advised to take his abbreviated patient-held record with him so that he can spell out to the pharmacist what his current medications are(4). Finally, in recognition of the potential for the hierarchical structure to generate "disastrous consequences"(1), patient-related correspondence from secondary care to primary care must include a copy to the patient so that the patient can compile his own medical file, which he can then carry with him to complement the abbreviated patient-held record in the event of an admission(here or overseas) to a hospital other than his usual hospital. The patient can also refer to that medical file if he wants to correct factual inaccuracies which sometimes creep into the correspondence. At a stroke such measures would create a level playing field between the patient and the healthcare team, thereby mitigating the risk of disastrous consequences attributable to the hierarchical system. References (1)Weller J., Boyd M., Cumin D Teams, tribes, and patient safety: overcoming the barriers to effective teamwork in healthcare Postgrad Med J 2014;90:1490154 (2)Jolobe OMP Bridging the communication gap between healthcare providers and patients' advocates Brit J Hosp Med 2012;73:654 (3)Jolobe OMP The abbreviated patient-held health record: bridging the communication gap Brit J Hosp Med 2012;73:234 (4) Jolobe OMP Can phrmacists help prevent adverse drug ineractions from newly prescribed drugd Br J Hosp Med 2009;70:360

    Conflict of Interest:

    None declared

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  6. 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:

    None declared

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  7. 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:

    None declared

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  8. 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.

    Conflict of Interest:

    None declared

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  9. 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:

    None declared

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  10. 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:

    None declared

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