Archive for November, 2009



Don’t worry about a thing

I got this through the post this morning:

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A flyer on screening for cardiovascular disease, where you can turn up and have scans done for “peace of mind” and all that bollocks.

I’ve no idea where they got my name from or why they think a 28 year old is at significant risk of stroke (must be all that cocaine use…)

It got me in a bit of a rage. These things do.

They use unproven, emotional driven language to make money out of people’s anxiety. Surely the fact that they “can see inside your arteries” impresses you?

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Yes it is true that being over 55 increases you risk of stroke – as does obesity, smoking and lack of exercise. But wait they’re all entirely modifiable risk factors, something you don’t have to pay 140 pound for the privilege of.

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My favourite bit of that photo is the fact that i don’t have to remove my clothes. Phew…

These tests are not accurate. Let me emphasise that. All tests have limitations. Some more significant than others. Lots of these tests find false positives. In other words they tell you have the disease when you don’t. When you screen a population with no symptoms (which is what screening does) then by nature you screen a population with a very low prevalence of the disease you are looking for. If you screen the whole population for pneumonia with a chest x-ray only a very small number will have the disease. If you only take a chest x-ray on people with symptoms of pneumonia then you will pick up far more.

When you screen asymptomatic patients then often the number of false positives outweighs the people actually found to have disease.

Which is why screening in the NHS is so controversial.

Some are now well-established – like breast screening for ladies of a certain age and cervical cancer screening for presumed sexually active women (incidentally they presume everyone is sexually active and therefore screen all women over 18, they just don’t phrase it that way).

Screening for prostate cancer has been less successful – all the men complained that just because they don’t have cervices and boobs that they shouldn’t be left out…

The problem with the PSA test for prostate cancer is that it leads to far too many false positives – it leads people to have prostate biopsies that confirm either no cancer or such low-grade cancer that it’s not actually going to be significant (ie you often die with prostate cancer, not because of prostate cancer).

Ask all the people who get false positive PSA tests if it gave them peace of mind.

Tests are not benign things – one trial (and i can’t find the damn reference) looked at the use of x-rays to assess low back pain. People were randomised (ie both groups were the same) to receive either x-ray or nothing. Those who received the x-ray had worse symptoms at 6 weeks. And of course the x-ray revealed nothing useful to help them. Simply by doing the x-ray these patients were worse.

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That is a plain old fib. Most tests are only worth ordering if you have symptoms but there are other tests that are often ordered in populations at risk – for example the screening programmes already mentioned or simple blood pressure measurement.

The goal to identify patients with significant disease before a problem occurs is very noble (even though their real goal is of course to make money) but unfortunately not possible with what they offer. Every now and again a patient or two will benefit – but over all people will not benefit and some even come to harm.

This one was my favourite – it’s not entirely clear if the Will had carotid dopplers done or not but at least they’re happy together…

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And just to finish: Read this if you’re interested and see what you think about peace of mind for the people found to have aneurysms in their brain.

Vernooij, M.W., et al, N Engl J Med 357(18):1821, November 1, 2007

BACKGROUND: Increasing use of MRI of the brain in clinical practice may be associated with increased detection of incidental cerebral findings of uncertain clinical significance.

METHODS: This Dutch study reports on incidental findings on high-resolution noncontrast- enhanced MRI studies of the brain performed in 2000 asymptomatic subjects aged 45-97 (mean, 63.3 years) (52.4% female) participating in a population-based cohort study.

RESULTS: Incidental findings were common, and most often included asymptomatic cerebral infarcts (7.2%), aneurysms (1.8%), and benign primary tumors (1.6%). The most urgent finding was a large chronic but asymptomatic subdural hematoma in a patient with a history of minor head trauma one month prior to participation. A possibly malignant primary tumor was identified in one subject and cerebral metastases in another. Of the 35 aneurysms, 33 were located in the anterior circulation and 32 were smaller than 7mm in diameter (believed to have a low likelihood of rupture). Operative intervention was considered to be indicated in two patients (the patient with the subdural hematoma and a patient with a 12mm aneurysm). Increasing age was associated with an increasing incidence of asymptomatic cerebral infarcts and meningiomas, and a greater median volume of white matter lesions, but not an increasing prevalence of cerebral aneurysms.

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Don’t make me laugh

[Yes this is another medical related blog but you’ll all love it. All 3 of you]

This one‘s for all the people I amuse at dinner parties (like I go to dinner parties… really I mean just dinner) with rude x-rays.

This one is written by a guy I pulled a shoulder with once

Hat-tip to Vinny for the website.

Put the book back on the shelf

I read a lot of books. At least I try to read a lot of books. I like the pretentiousness mainly. Sometimes I even like the books.

I read War and Peace – it took me 4 months and I didn’t enjoy it and I’m not entirely sure what happened, apart from a lot of stuff about Russian farming.

I read Crime & Punishment – it rocked.

When I start these things I tend to finish the. A bit like Magnus Magnusson on Mastermind.

I tried Kirkegaard’s Fear and Trembling on the basis of the cover line

if there were no eternal consciousness in a man, if at the bottom of everything there were only a wild ferment, a power that twisting in dark passions produced everything great or inconsequential, if an unfathomable, insatiable, emptiness lay hid beneath everything, what would life be but despair.

I get that. I gave up two thirds of the way through the book. I’m sure he said great things. They were just over my head.

How you can mend a broken heart

Roughly 4 years ago I started to blog (on a different site) and this was one of my very first.

long time no blog people, my apologies. Busy with lots of different  stuff. I was on a course with work last week. Interesting experience.  You get thrown in a room together with all these random punters who  become your “group”, we were group E, we rocked. It was a life  support course so it was lots of role playing and pretending that the  dummy in front of you is having a heart attack, and then shouting  CLEAR and shocking them with the defibrillator thingy. But it’s not  hard not to get into it, and all of a sudden the whole group is  pretending to treat this plastic dummy and saying calming reassuring  things to it.

You also get all that wonderful small talk, trying to engage in  conversation with this random punter. “so.. where do you work then?”  My job becomes that much of my identity that i find it hard to engage  in conversation with people on any other level. I always had this bit of a thing against small talk and superficiality. How we have a  complete inability to say what we actually mean and instead stick to Coronation St and the footy, nice safe topics.

So by the end of our two day course, we’d bonded to a certain extent,  we knew each others jobs well and a brief insight into our  personalities. And i suppose they knew i was a decent enough guy,  that i was involved in “church stuff”. But none of them came in  contact with the JESUS of the gospels. I made sure he was hidden deep  under layers of banal superficiality.

By the way the dummy had an extended period in ICU but recovered to  walk out of hospital and to full recovery only to be killed testing  air bags 2 months later.

After 4 years of resuscitating actual people I’m not sure I’ve learnt that much more about. We do it infrequently and it is almost universally a failure. If you’re sick enough to need CPR then you’re almost definitely stuffed. Except if you’re a newborn baby when a vigorous towelling and a bit of a squeeze on the chest seem to do wonders.

So 4 years on I’m back on an APLS (Advanced Paediatric Life Support) course (apparently someone started a mock course called Advanced Faecal Life Support – in honour of Mr Hankey the Christmas Poo) in Newry.

And I realise that I kind of know all this stuff already. Shouting at a manequin and pretending to intubate dummies is not so realistic once you’re actually done the real thing. Alas it’s a little piece of paper I’m meant to have so I can’t moan too much.

This type of thing breeds arrogance in me – “won’t you all just shut up with your nonsense protocols and realise that I am the king of all things…” Something like that.

Started at 8am and finished at 7pm. And it’s meant to be a wee dossy day away from actual work…


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