Do you really need that x-ray ?

A man sees his doctor after fainting — does he need a brain imaging scan when there is no evidence of seizures or other neurological signs and symptoms?

According to 9 US medical society’s :– NO 

(because in patients who  have a witnessed faint or syncope but with no suggestion of seizure and no report of other neurologic symptoms and signs, the likelihood of a central nervous system cause of the event is extremely low 

This is just one questionable test or investigation out of a compendium of 45 clinical "don't do’s" drawn together by the American Board of Internal Medicine as  part of a campaign called Choosing Wisely :  The campaign is an an attempt to reduce the number of common but often unnecessary tests and procedures which have no evidence to support their use.  Such tests contribute to the high cost of healthcare and may even harm someone’s  health, for example if they are exposed to excessive radiation through diagnostic imaging or suffer complications of surgery that they didn’t need but had because of a false-positive test result.

The lists of questionable tests includes :   

•   Patients with no symptoms and at low risk for coronary heart disease : Do not order an exercise stress test

•   Patients with non-specific low back pain : Do not do imaging studies (MRI  of spine etc) within the first 6 weeks unless there are “red flag symptoms” such as  severe or progressive neurological deficits – most patients will have no significant changes on the scan and will settle down.

•   Patients who might have a deep vein thrombosis but according to pretest probability charts have a low risk ; Do not order imaging studies as an initial test instead, but first obtain a high-sensitive D-dimer measurement (this is a blood test).

•   If a patient is going for surgery but has no clinical suspicion for intrathoracic pathology : Do not do a preoperative chest X-ray.

•   Patients in early stages of prostate cancer with a low risk for metastatic spread : do not do scans such as positron emission tomography (PET), CT or radionuclide bone scans, as there is no evidence to suggest that such scans improve the detection of metastatic cancer or survival.

•   If a patient has no symptoms of heart disease and are at low risk, don’t do an annual ECG

•   Patients with acute mild-to-moderate sinusitis:  Don’t routinely prescribe antibiotics for unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement

If this has left you worried about being exposed to radiation during diagnostic imaging such as a chest x-ray, you might want to read what    

the British Medical Journal recently published on the topic


This summarised that : 

•   The demand for imaging, especially computed tomography, has increased vastly over the past 20 years

•   An estimated 30% of computed tomography tests (CT scans) may be unnecessary

•   Ionising radiation (as in x-rays and other radiological investigations) may be associated with cancer and other non-cancer sequelae

•   The risks of iatrogenic radiation exposure (i.e. from medical tests) are often overlooked and patients are seldom made aware of these risks

•   The requesting doctor must balance the risks and benefits of any high radiation dose imaging test, adhering to guideline recommendations if possible

•   Difficult cases should be discussed with a radiologist, ideally at a clinico-radiological or multidisciplinary team meeting

Memories of mornings on the old Radio 5

Really enjoying the ramblings of Andy's blog (worth a read !!) which has brought back memories of medical contributions I used to make to Johnnie Walker's morning programme The AM Alternative on the old BBC Radio5 (before all that Sports nonsense got in the way!)

Funny how he doesn't mention his stint on the programme (which ran for several years) in his autobiography. And the BBC don't even mention it in his profile page

There used to be bands (old and new) on the programme most days and as it was a fairly small studio that often meant that after doing my piece I had to stay hidden in a corner of the studio while the musicians played. This was an amazing treat - and far more interesting than whatever I had to say about hernias or vitamins or other medical stuff.  One of the highlights (i.e. one of the things I can remember clearly !!) was when Everything But The Girl played this :

Another memory was the day I took these into studio for a discussion.  Johnnie had to guess what they were for and tactfully started talking about fishing....

(if you need a clue its here - could be very useful for some of my elderly female patients... and some of the younger ones too.. )

Off air we also talked about music a lot and he would pass on recommendations for things to listen to - lots of gems among them including this one - still a favourite..

MARY COUGHLAN, 'A LEAF FROM A TREE' 

Another highlight was meeting Paul Young - such a gentleman and now fronting these guys (Los Pacaminos) who are HUGE fun - in fact they are playing just up the road in Guildford on December 1st 2012  so recommend yy'all get along there !!  

 Here's a taster.. 

The slog

Can't believe its been 5 months since I managed to post here.  Well, maybe I can.. here's a little reminder of part of my world...

and here's this weeks favourite toon ...   More very soon

The Black Keys Tighten Up !!

When your heart goes Boom Diddy Boom Diddy Boom Boom Boom !

The old songs are the best !!

Oh Doctor I'm in trouble ..

Chairing a meeting tomorrow on anticoagulant drugs in Atrial Fibrillation (or AF) - the most common abnormal heart rhythm. 
  
A few facts :

• More than 1 in 200 people over 50 have it - and 1 in 10 over-80's. 
• AF increases your risk of having a stroke 5 fold  
• The reason why people who have AF suffer with strokes is because the top chambers or atria of the heart are beating irregularly and clots form in them, in particular in the left atrial appendage (LAA), a small blind ending pouch off the main left atrial chamber. The clots then break away and travel up through the blood vessels to the brain where they interrupt the blood supply to cause a stroke.  (This ‘appendix’ of the heart is not necessary for normal heart function and is routinely removed during certain types of heart surgery. With the LAA removed the chances of having a stroke are greatly reduced and patients do not need to take warfarin.)
• AF-related strokes are particularly nasty ones, doing more damage or being more likely to prove fatal than strokes not caused by AF. 
• If someone has AF, and another major risk factor for stroke (such as heart failure) they are usually advised to take treatments which thin the blood. 
• This has, until know, meant treatment with warfarin - or rat poison to the man in the street.  
• Warfarin is not easy to control, many other things can interfere with its action, and it involves regular blood tests to monitor - many patients aren't taking enough of the drug  - at least 50% are under treated and so not protected, while over treatment leading to nasty haemorrhages is also fairly common.   
• New drugs have just got their licences - they give  a much more regular control than warfarin - but at about £2.50 a day they work out at twice the cost of warfarin (which is cheap as chips) + the monitoring costs involved with warfarin (total £1.18).  There are hundreds of thousands of people on warfarin, so the NHS will only fund the new drugs for a few. 

On the wards in our hospital (which has a specialised Stroke rehab unit) we help lots of people juggle their warfarin dose. But we will have to wait to hear what our Pharmacy Protocol says before we    prescribe the new drugs (Rivaroxaban or Dabigatran). Given the endless financial strains/overspends/cutbacks, warfarin may remain the only treatment on the menu for now. 


If you don't fancy rat poison, here's a different option - looks like a jellyfish but the Watchman Device is like a tiny fishing net inserted into the major blood to catch clots before they hurtle up to the brain.  

Trials suggest the Watchman device may be as effective as warfarin

Of course, there are many other important aspects of AF that need consideration - 

For more on AF, here's a wonderful poster by the manufacturers of dabigatran. 

or hook in to The Atrial Fibrillation Association  

The only Heavy Metal I need has the atomic number 79..

Especially for those of the Heavy Metal persuasion....

A Swedish report in an journal published by the The Neurological Society of India warns that headbanging can be dangerous..

(is headbanging big in India ?  To the sitar ???)

The risks, it seems, are mostly about damage to the arteries in the brain. The violent movement of the head and neck can shred the delicate blood vessels, causing them to split open or clot up, leading to a potentially fatal stroke

In other words there may be sudden damage to the brain rather than just a gradual loss of brain cells - although we also know that repeated minor trauma to the head such as in boxing, increases the risk of dementia later in life, so when the generation who invented headbanging grow old we may discover a higher rate of dementia among them. 

To quote the article :  

"Head banging is a type of dance which involves violently shaking head in time with music, most commonly heavy metal music. Head banging can be up-down, circular swing, full body, or side-to-side. It is considered that head banging to loud music, while "making you more metal," has associated risks other than acquired hearing loss. Several case reports have indicated the inherent risk in this activity, especially of head and neck injury. We describe a patient with a history of intensive head banging and basilar artery thrombosis (BAT).

A 20-year-old man presented with neck and head pain and vertigo of three weeks duration. His medical history was otherwise normal including drug exposure or abuse. He was a musician and had a history of intensive head banging. He had sought medical help for these symptoms at other facility, but was not worked up to establish the diagnosis. The symptoms progressed in severity and he had intermittent loss of consciousness. On physical examination, vitals were normal and neurological examination revealed left hemiplegia with dysarthria. Computer tomography of brain, electrocardiogram, electroencephalogram, complete blood picture, and blood biochemistry were essentially normal. Magnetic resonance imaging including angiography could not be performed as he was very anxious. Possible diagnosis of basilar artery thrombosis was suspected and he underwent cerebral digital subtraction angiography under general anesthesia, which revealed basilar artery thrombosis. No underlying dissection or vascular malformation could be detected. He was treated with intra-arterial fibrinolytic agents. However, the outcome was complicated by a locked-in state and no obvious improvement has been observed during the follow-up."

Sadly the 20-year old in this case was left  "locked in" - aware but unable to move a muscle, with a very bleak future  ...  

The article explains that there have been reports linking headbanging to all sorts of unpleasant head and neck trauma, with  neurological complications of intensive head banging including subdural hematoma, vertebral artery aneurysm, carotid artery dissection, whiplash injury,  odontoid fracture, and vertebral artery dissection with vertebrobasilar ischemia or infarction.

Terry Balsamo

Terry Balsamo, guitarist from the heavy metal band Evanescence, had a stroke thought to have resulted from head banging.  

The Swedish report warns :

"A high index of suspicion of vascular injury in young persons presenting with persistent unilateral head or neck pain even after a minor trauma should be maintained. This index of suspicion should be even higher in patients with posterior circulation symptoms with antecedent trauma."

The report also lists the following as examples where trivial blunt trauma to the head and neck resulted in vertebral artery dissection (splitting of arteries at the back of the neck which are an important supply to the brain) :

• chiropractic manipulation (beware chiropractic !)
• tennis
• seat belt use
• yoga (gentle, huh ?)
• head banging...

Vertebrobasilar ischemia or infarction (stroke to the part of the brain supplied by the vertebral arteries) as a result of extremes of movement of the cervical spine is probably due to the fact that the vertebral arteries are fixed in the transverse foramina (a hole in the skull where the arteries enter to get to the brain) rendering them susceptible to occlusion or shearing from extremes of neck motion.

Rotation occurs first at the atlantoaxial joint before any rotation occurs in the cervical spine, leading to stretching and compression of the vertebral artery. Occlusion and spasm of the artery has been documented. An tear in the intima (the lining of the artery) can occur with formation of a clot or thromubs blocking the lumen or central space of the artery, which may result in embolization (clotting) in the posterior circulation (the posterior part of the brain's blood supply).

So, if I didn't have enough reasons already, there's another to explain why the only Heavy Metal I need is one that doesn't have headbanging habits..

Now..doesn't a gentle bit of folk music sound nice ?