In October a group of intrepid trainees left the lights of central London and headed for the coast, for a training day in sunny Southend.
Interesting facts about Southend:
- Southend has the world’s longest Pleasure Pier (1.34 miles)
- Notable people from Southend include: Phill Jupitus, comedian; Helen Mirren, actress; and Simon Sharma, historian and TV presenter
- People living in Essex are 38% more lightly to be hit by falling aeroplane parts than anywhere else in Britain (Ok, this is not specifically about Southend, but it’s an interesting fact)
The day began with a Radiology quiz from Dr Perera. We were reminded of some key concepts in respiratory imaging:
- Patterns of chest xray appearances with lobar collapse
- Differential diagnosis for mediastinal masses
- The importance of checking the review areas of a chest xray as they may reveal bony mets and other relevant pathology
- The appearances on chest xray of diaphragmatic hernias, and their causes: both congenital (posterolateral Bochdalek, anterior Morgagni) and acquired causes (blunt or penetrating trauma and labour)
- The differential diagnosis of multiple nodules on CT (VZV pneumonia, miliary TB, Histoplasmosis, fungal infection, and metastases), and the importance of clinical information on determining which is most likely
And some key facts on radiation doses of common tests (a CT chest around 7mSv – 400 chest xrays – which is 3.6years of background radiation): think twice about the frequency and interval of repeating CT chests, and the increased cancer risk that may result.
After a caffeine injection, we hoped our ESSs were low enough to concentrate on some sleep case studies, introduced by Dr Ali. He highlighted some useful papers on the cardiovascular complications of OSA:
- Terán Santos, Joaquín, M Luz Alonso Álvarez, José Cordero Guevara, José María Ayuela Azcárate, and José María Monserrat Canal. “Sleep Apnea-Hypopnea Syndrome and the Heart” Rev EspCardiol 2006;59(7) 718–724.
Ryan, S, C T Taylor, and W T McNicholas. 2009. “Systemic Inflammation: a Key Factor in the Pathogenesis of Cardiovascular Complications in Obstructive Sleep Apnoea Syndrome?” Thorax 64 (7) (July 1): 631–636.
He also explored tools for objectively assessing excessive sleepiness, including Multiple Sleep Latency Test (MSLT), Maintenance of Wakefulness Test (MWT) and the Oxford Sleep Resistance test (OSLER). A number of sleep disorders were covered:
- OSAS was contrasted with upper airway resistance syndrome (AHI <5 but consistent history and high ESS, treated similarly with CPAP); there was some debate in the room as to whether this was a distinct entity or part of a spectrum from simple snoring to OSA.
Central sleep disorders were touched on with the important distinction between REM and non-REM sleep disorders highlighted. As is so often the case, the history (including witness accounts, and accurate timings of symptoms) is key to diagnosis.
- REM sleep normally occurs around 90mins after sleep onset. The key feature of narcolepsy is that patients have sleep-onset REM. Although cataplexy is often associated it can be very subtle eg jaw dropping, rather that total loss of muscle tone.
- In REM sleep behaviour disorder (REMBD) patients do not have the usual muscle atonia during sleep and therefore physically act out dreams, often waking and injuring their partners. There are some important associated medical conditions, many of which are neurological, which should be explored in those presenting with REMBD : Parkinson’s disease, Lewy Body dementia, MSA, Alzheimer’s disease, PSP, narcolepsy; in addition to drugs such as venlafaxine. The only antidepressant drug that is not associated with REMBD is buproprion.
In the afternoon we were challenged with some interesting cases from Dr Ansari and Dr Powrie.
- Platypnoea orthodeoxia syndrome – rare, but interesting physiology, indicating a shunt and an additional functional defect. A bubble ECHO can be very useful
- Organising pneumonia can have many causes, one of which includes polymyositis. Include anti-Jo1 and CK as part of the autoimmune screen in unexplained COP. Perhaps 30% of patients with polymyositis have an interstitial lung disease, in particular those who are anti-Jo1 positive.
- PCP remains a condition requiring a high index of suspicion. BAL can detect P. jerovicii for a period of time after treatment has been initiated, so it remains a useful test to confirm the diagnosis.
The less that is said about the talk on Medical Record Keeping the better. But it is important to consider the importance of accurate written communication. There are numerous examples of when things go wrong, and it is worth learning from the mistakes of others (such as those quoted in the MPS casebook). The RCP has published guidance on a number of aspects of medical record keeping, including handover documentation. In fact the importance of clear written communication, both on paper and on electronic records, was the subject of a recent blog in the Postgraduate Medical Journal by newly appointed Consultant at UCLH, Dr Toby Hillman .
Lisa Ward, lead sleep nurse, reminded us of the BTS emergency oxygen guidelines and the importance of prescribing oxygen. We are all aware of the dangers of hyperoxia, both for our CO2 retaining patients, and for those with MIs and strokes. Some of our non-Respiratory colleagues however, still need convincing that oxygen is a drug and can be both life-saving and harmful. We hope your departments are taking part in the BTS audit and look forward to seeing the results. It offers a good opportunity for educational intervention, especially on A&E and in acute care units.
We finished with a talk from Dr Lingham with the intriguing title “what is it?” and were encouraged to think about ACOS, the asthma-COPD overlap syndrome (anew acronym to add to the arsenal…), since these patients have worse outcomes than those with asthma or COPD alone.
The next training day will be the Pan London Training Day at Hammersmith Hospital on Tuesday November 12th.
The programme for the next year is currently being constructed. If you have suggestions for titles/topics or activities you would like to see or that your centre could offer please get in touch.