The Great Cardiologist Dr Shah

Dr Shah has recently returned to Japan for the 13th consecutive year and is once again teaching our junior doctor about the importance of ECGs and echocardiography. Dr Shah's ECG lectures commenced with a refresher presentation about limb and chest leads, heart axis and vectors to name but a few items, which then progressed on to a more detailed ECG session in the afternoon, which was enlightening.

By the end of the session, the junior residents were buzzing with new knowledge on how to interpret the finer points and the intricacies of ECGs. This was a very worthwhile teaching session. The following day, Dr Shah taught the junior and senior residents about the basics of echocardiography. He then demonstrated echo such as 2D, M-mode, Doppler and Tissue echocardiography.

All in all, it was a great two-day teaching session and despite this, Dr Shah was only able to cover a fraction of his course, and he has much to be able to offer the residents in this hospital and throughout Japan today and in the future. It is hoped that Dr Shah will continue coming back to Japan for many years yet!! :)

Fever and Cancer

It is well established that the presence of malignancy itself can cause fever. Classical malignancy causing fever include lymphoma, leukaemia, renal carcinoma and so on. However, on occasion infection and hence the resulting fever, can occur because of the presence of cancer and the investigation of fever can lead to finding a sometimes unexpected malignancy.

In the following case supplied from another hospital and fully anonymised, it shows how history and physical examination gave a bedside diagnosis.

A 70 year old female was admitted with fever. The fever had started 2 days previously and was associated with appetite loss and headache. There was no associated chills, mylagia, nausea or vomiting. The headache was frontal in nature and there were no other associated symptoms of meningitis and no visual disturbance. She complained of no chest problems i.e. no dyspnoea, no cough or sputum. She had no skin or joint problems. She had no urinary symptoms. However, on direct questioning, she admitted to a long history of diarrhoea that was not painful. She denied night sweats and weight loss.

Previous medical history included hypertension and ovarian cancer that had been operated 6 years ago with chemotherapy as additional treatment, although the patient was no longer under active follow up.

She was taking no regular medication.

There was no family history of note and she lived alone and was independent.

On physical examination, she appeared relatively well. Hydration state seemed adequate although she felt hot to touch. Dentition was extremely poor.

CVS: There were no peripheral stigmata of endocarditis. Pulse 80/min and regular. BP 140/70. JVP not raised. Heart Sounds were normal with no murmurs. No peripheral oedema or evidence of DVT.

RESP: Respiratory rate 20/min. Expansion was normal and percussion was resonant. Chest sounds were normal.

ABDO: Slightly obese abdomen and soft. However, in the Right Iliac Fossa there was a smooth, tender mass arising from the pelvis. Percussion revealed dullness, but not stony dullness, making this consistent with a solid or at least a semi-solid structure. Auscultation of the mass revealed no bowel sounds. The mass was at least the size of a grapefruit from what could be elucidated from the surface examination. There was no hepatosplenomegally or ascites and bowel sounds were otherwise normal.

CNS: No evidence of meningeal signs. Neurological examination was otherwise unremarkable.

CLINICAL IMPRESSION

In view of the previous history of ovarian cancer and no regular follow up, a new fever and a tender, smooth abdominal mass, recurrent ovarian cancer had to be high on the list. However, this could have also been sepsis related to formation of an abscess although it was considered too large to be an abscess especially as the history of fever was only 2 days. In view of the poor dentition and despite the absence of a cardiac murmur and peripheral stigmata, endocarditis was also considered although this would not have accounted for the pelvic mass.

INVESTIGATIONS

Bloods revealed a raised white cell count of 20, and high CRP of almost 30, haemoglobin was normal. Renal blood result revealed mild renal failure with normal sodium and potassium. Liver tests were normal. Urine revealed blood, a high white cell count, protein 2+, bacteria 2+ and casts. Chest Xray and ECG were unremarkable. Echocardiogram revealed no vegetation.

Abdominal CT scan was grossly abnormal. The Left kidney was almost completely destroyed due to hydronephrosis and the right kidney was mildly hydronephrotic. The pelvic region revealed a very large, well circumscribed mass with internal septations and dense fluid. The mass was compressing the sigmoid colon and displacing it to the right.

DIAGNOSIS

The diagnosis was likely to be recurrent ovarian cancer and compression of pelvic structures had resulted in renal failure from hydronephrosis and as a result, bacterial infection had occurred due to urine stagnation, and probable overflow diarrhoea from colonic compression and / or invasion.

DISCUSSION

Once again, from taking a thorough and detailed history by asking questions in respect of causes of fever, it was possible to work out the likely diagnosis. In this case, the patient only had fever and few other symptoms. In such a case, the physician has to consider infective and non infective causes of fever. Direct questioning involves asking about symptoms from ALL of the body regions e.g. cardiovascular, respiratory, abdominal, genitourinary, musculoskeletal, skin, central nervous system. This is in fact part of the Review of Systems that is normally done at the end of a history taking session but when few symptoms are evident, the Review of Systems is the safety net for the physician to try and squeeze out innocuous symptoms from the patient which in this case was the diarrhoea and which the patient had not initially offered up as a worrisome symptom. Hence, the Review of Systems came in to use at the beginning of the history taking !

The shorter the history of fever, the more likely it is to be infective and yes, infection was indeed found. However, the presence of the infection led to the diagnosis of a recurrent tumour which seems to have by itself, not caused a fever at all, and only few symptoms such as diarrhoea and mild abdominal discomfort on examination. When there is a situation when one finds an obstructed and hydronephrotic kidney with fever and evidence of infection, the infection could well exist in the kidney itself and in such situations, it is necessary to insert a nephrostomy tube to try and save the kidney and drain the infection. Sometimes, a double J stent can also be inserted to drain the kidney.

In this case, the history made the physician concentrate the physical examination on the pelvic region and indeed the recurrent tumour was identified. Hence, history and examination can provide a bedside diagnosis and in this case, CT scan CONFIRMED the diagnosis rather than making the diagnosis.

Please consider.... :)

Never Ignore Chest Pain

I would like to start todays discussion with a case vignette. The case is from a colleague in another hospital and all details have been anonymised.

The patient was a 75 year old male who presented with dypsnoea and wheeze.

The patient was normally only able to walk 10 metres before becoming short of breath and needing to rest. On the day of admission, the breathlessness had got worse and wheezing had also commenced.
He had not offered up any other history and only when the doctor directly asked the patient if he had chest pain did he actually say YES!

In fact, the patient had chest pain when he was being seen by the doctor! It was described as 'heavy' and in the centre of his chest and with no radiation to jaw /neck /arms. However, the patient was breathless at rest and he had a 'cold' sweat and he was wiping his forehead with a towel. The pain was described as being similar to that as when he had a myocardial infarction several years before, although it was less painful.

He had also been apparently suffering with asthma for the last 50 years although he had never been hospitalised. Despite this, he was apparently able to lie flat in bed at night.

Previous medical history included: Old MI, Congestive Heart Failure, 'Asthma', Atrial Fibrillation (AF) and Gout.


Medications: Spironolactone, verapamil, anti-histamine, low dose steroid

On examination

The patient looked unwell. Pulse 120/min, RR= 30/min, sats 94% on room air, BP 130/82.

Skin looked atrophic due to long term steroid use. Patient used accessory respiratory muscles. Chest was hyperinflated and bilateral gynaecomastia was evident. JVP was not seen as patient was sitting at 90 degrees. Heart sounds were normal.
Chest percussion revealed a large area of dullness, reduced air entry and reduced vocal resonance consistent with an effusion.
Legs revealed bilateral pitting oedema 1/3 up the lower limbs.

Abdominal examination: Distended, no tender. No organomegally. Bowel sounds present.

An emergency ECG was performed that revealed Right Bundle Branch Block, ST depression in the septal leads and AF.

CXR revealed a large pleural effusion on the right, a large heart, upper lobe diversion and fluid in the horizontal fissure consistent with heart failure. Comparing the CXRs to a previous one taken 1 month earlier, there was evidence of worsening CHF with an enlarging right pleural effusion.

ABG revealed a Compensated Respiratory Alkalosis with hypoxaemia.

Bloods revealed mild renal impairment and slight neutrophilia. CK was normal although this was taken before the chest pain occurred.

The clinical impression was

• Worsening CHF
• COPD
• Unstable Angina

Discussion:

In this case, the physicians were able to diagnose the worsening CHF and COPD. However, it was with direct questioning about chest pain that the patient admitted to having chest pain. In fact, the patient had become so used to experiencing daily chest pain, he had considered it to be a normal occurrence and had not considered telling the doctor !!

Therefore, doctors need to ask the questions of exclusion rather than just asking questions around the area of what the patient describes. In this case, the patient had worsening CHF, but why was it getting worse???
Note that the patient has AF. The commonest cause is ischaemic heart disease and this patient has had an MI previously. Also, hyperthyroidism can worsen heart failure and cause worsening angina in patients with underlying ischaemic heart disease. Moreover, was the patient having small recurrent ischaemic events????

Despite this classic history, the patient was not using a nitrate spray, no anti-platelet agent was being used, no furosemide or ACE/ARB was being used for heart failure or any statin therapy.

This patient was clearly a high cardiovascular risk with a previous MI, hypertension, an ex-smoker and hyperuricaemia.

Moreover, his AF treatment, that being Verapamil, despite it being very effective at rate control, it can also worsen heart failure.

Treatment of Acute Coronary Syndrome

• Sit the patient up unless hypotensive
• Give oxygen by mask
• Give 300mg Aspirin immediately and then 75 mg daily thereafter or ADD Clopidogrel 300mg immediately and then 75mg daily thereafter if the patient is already taking aspirin. If patient has allergy to aspirin, then load with clopidogrel.
• Give sublingual nitrate spray / tablet
• If pain continues give morphine and anti-emetic
• Commence intravenous unfractionated heparin or low molecular weight heparin for ACS dosing until cardiac markers are found to be negative. If positive, continue the heparin until 48 hours after last episode of chest pain.
• If pain continues give intravenous nitrate infusion
• Patient should have a 12 lead ECG and placed on a cardiac monitor
• CK and Troponin T should be examined
• If pain continues then cardiologist should be contacted with the aim of emergency PCI.
• Patients should also be commenced on long term anti-anginal therapy if conservative therapy is to be continued including

- Isosorbide Monoitrate / Nitrate dermal patch
- Beta Blocker (not in severe CHF)
- Nicorandil
- Calcium channel blocker e.g. nifedipine / amlodipine

Patients should also be commenced on statin therapy even if the cholesterol level is normal as the benefits of having low cholesterol reduce cardiovascular events.

In this case, asking about chest pain revealed a major cardiovascular history and altered the emphasis on the patient's care.

Please consider....

Broad Spectrum Antibiotics and Confusion

Dear Bloggers

There seems to be some confusion on how to manage seriously ill patients will the right cover of antibiotics.

From my experience in Japan, I often hear that the patient with sepsis and no definite focus of infection is given a carbapenem antibiotic because of the various routes of coverage e.g. gram positive / negative and anaerobic.

My response is usually less than favourable because it is the last antibiotic that should be used and not the first !

I recently wrote another article on antibiotics but I feel it is necessary to reiterate the point.

Broad spectrum cover can be achieved in many ways with different combinations of antibiotics rather than with the carbapenems. For example, a second / third generation cephalosporin plus metronidazole / clindamycin has good coverage of gram +/- and anaerobes. Another good combination is the amoxicillin-clavulanate or ampicillin-sulbactam combinations which again have good broad spectrum cover. Broad spectrum cover can be enhanced by using gentamicin especially in patients with an undefined cause of sepsis and it is especially good against infections including e.g. endocarditis, pyelonephritis....

The reason I continue to push for other combinations of antibiotics for broad spectrum use is because of RESISTANCE.

From the USA, there have already been reports of bacteria producing Carbepenemases which destroy the carbapenems and if this occurs then these bacteria are resistant to all beta lactam antibiotics including penicillins and cephalosporins.

Just imagine a situation where bacteria cannot be killed by third or fourth generation cephalosporins !!! That does not leave a great choice of antimicrobials to choose from.

The UK and American physicians strongly advocate not to use the carbapenem antibiotics unless other therapies have failed. It is a hidden weapon to coin a phrase. However, if we reach a situation where the carbapenems are being used in place of other antibiotics, the latter which in combination provide a similar coverage, then resistance to this antibiotic will soon occur and then Japan will have major infectious disease problems.

Use of carbapenems should not be first line. Yes, they may be simple to give and reduce the work of the nursing staff, but that should not be the reason for their use. Resistance should always be considered and the use of such antibiotics should normally be restricted to ICU patients where all other treatments have failed.

The source /focus of infection should always be considered on initial presentation and the type of organism considered that could cause the problem. Then, a combination of antimicrobials can be chosen to cover the considered organism(s). Empiric therapy, as it is actually called, is an educated guess, but using combination drugs for broad spectrum cover will treat the vast majority of likely causes. Then as results become available, and narrow spectrum antibiotics can be used, the other antibiotics in the combination which are not necessary can simply be stopped :)

In all fields of medicine, there is always uncertainty whether the treatment is going to be the right one and especially when considering antibiotic coverage. However, uncertainty is something that we as doctors all need to accept and live with. Our medical practices should not be driven by defensive protocols but by clinical need considering history, physical, radiological and laboratory data and the likely differentials diagnoses.

If we reach a situation when all treatments are provided because the medical profession is being defensive, then we cease to be free thinking physicians.

Please consider......

Sicko and State run Healthcare Systems

Dear Bloggers

I recently saw the new film Sicko which is a real-life compilation of different peoples stories about how the American health system has failed them because of the insurance run practices that exist in the United States.

Some of the stories are shocking and reveal how some insurance companies refuse to pay out on the medical bills because of their own corporate decisions, rather than the advice of the treating physicians, that the treatment is not necessary or considered experimental.

Despite the first world American leading in medical advancements, or at least that is what we are led to believe, still some 50 million Americans have no healthcare insurance and as such, if they get sick, then they have a problem ! Sick-O-No!

Then there is a comparison to state run health care systems that are described as 'Socialist' run systems, which are in fact, State runs and which exist in Canada, France, UK and Cuba !

These State run health care systems are funded by Taxation from the working population that is then FREE at source for ALL members of the society. These systems work very effectively by cutting down on unnecessary costs, inpatient stays, increased outpatients procedures, scrutinisation and implementation of evidence based practices and cost to benefit for particular treatments and use of generic drugs to keep down the costs of overall expenditure. This is at least the way it carried out in the UK system.

The Author of the film was amazed when speaking to the various doctors in the four different countries with State run systems that the Health care systems actually do WORK. He was also amazed that there was no payment desk in ANY UK hospital as patients DO NOT pay anything for their hospital stay as it is paid totally through the high taxation.

I am sure the Film was certainly an 'eye opener' for most Americans who have seen it, but for me, who has come from the UK where health care is free at source, I feel saddened that people without insurance will not benefit from the best medical intervention.

Does this have implications for Japan?

Well, the Japanese system sits somewhere between the British and American systems. There is an insurance system plus state cover for expenses. Despite the large part of the expenses being covered by the Government, there is still some 30% or so that will need to be paid by the patient or the patient's family unless, this is covered by the particular insurance programme.

Of course, if the patient has no family to foot the bill and no personal insurance, then it leaves a financial problem for the patient, who should not be worried about health costs when they are sick and moreover, a financial problem for the hospital.

How can this problem be solved??

Could a Government run medical system funded by taxation alone work here in Japan? This would mean a higher taxation on the working population to support an ever growing elderly population.

However, in doing so, the Government would have the ability introduce legislation to cut costs on medical expenditure such as having effective antibiotic and drug protocols to provide effective medical therapy but at a cost to benefit sliding scale. No one would ever be worried about accessing medical treatment and all medical expenses would be free in the time of need....sounds good !

However, from my experience of the UK medical system, there are delays in treatment directly as a result of this State run service.

In the UK, hospitals are provided with their annual money and they then need to manage their finances effectively by juggling services to try and stay within their financial provision. However, some treatments which are expensive, e.g. new cancer drugs with limited evidence, may be refused to patient (see UK National Institute of Clinical Excellence [NICE] Guidelines ). Moreover, some planned surgical lists may be postponed because the funds are not available to pay for the surgery. Waiting lists for outpatient surgery can be several months although emergency surgery and cancer surgery tend to be very fast.

Patient awaiting a new hip, of which there are many in the UK, sometimes have to wait for a year before they are operated on. It has been known, that some patients have travelled to France or Germany for their operation and the National Health Service (NHS) reimburses those foreign hospitals. The system clearly has some problems.

To get an outpatient appointment at a hospital to see a specialist in the UK is not like in Japan. You cannot just walk into a hospital and see who you want. You must first see your General Practitioner (GP) in the local community who then has to refer you by letter to the hospital in the locality. The GP practice usually will use only one hospital as it is that hospital from which it purchases the services for their patients. Hence, there is no choice of where you can be referred. The wait to actually be seen can be several months for non-urgent conditions and from my experience, the same day or the same week for more urgent conditions e.g. deterioration in diabetes control.

So, there is no ability to choose the hospital of choice....the UK are trying to now change this, which seems logical. The Canadian system is also paid by taxes, but you have the ability to choose whichever hospital you want to receive a consultation or treatment. Again, it is free! :)

As with any system, there are good and bad perspectives. There is a trade off for having a free system such as reduction in expenditure, generic drug usage, evidence based practice which drives down expenditure, more use of clinical skills such as history and examination with less reliance on radiological services unless deemed necessary BUT longer waits to see doctors in outpatients and longer waits for non-urgent surgery.

However, the Emergency treatment is rapid e.g. stroke, AMI. Even ER waiting times are not too long. Non urgent conditions can be seen within a few hours and more urgent conditions more rapidly. In the UK system, new legislation means that no patients wait more than 4 hours in the ER department before being moved to a ward. Hence, this means that the patient are seen within 4 hours, treatment is commenced and they are moved to a ward where therapy can be continued.

From my experience, the Japanese medical system works well but in my opinion, it could be enhanced in many ways.

I would hope that in the future, Japan can learn many things from these State run medical systems in order to help Japan reduce expenditure its health care system, provide cover for all which is free to utilise at source and so to therefore avoid what has happened to the American medical system so that 'Sicko' does not occur here.

DISCLAIMER: These comments are my own personal perspective on the health care systems within which I have worked and are not in any way endorsed by my hospital or anyone else.