Too many still do not yet Get it!

Lessons from patients’ journeys | BMJ
This is a fascinating article marking the 10 years since the series of patients' journeys was first published in the British Medical Journal. I have read most of them and find them extremely useful.  After what has happened in the National Health Service over the past 12 months (Midstaffs, Francis report etc etc), I think that this kind of account must be required reading for all clinical staff however junior or senior and for all managers - well anybody anywhere who works in the health service.
My experience of being a patient over the past 2 years has certainly been eyeopening .
In this account of the 10 years experience by the BMJ's patient editor, I am struck but probably not surprised by his conclusions that doctors still do not really understand or empathise sufficiently with patients. The rise of the internet as an increasingly important source of information has not come quick enough for many. The accounts also suggest that the traditional nihilistic approach doctors in the UK take when dealing with cancer are not in keeping with most patients' expectations.

The Perfect Human Valve Substitute ?

The quest for the perfect heart valve substitute goes on. This article in recent edition of the Circulation journal shows how little has changed in the 50 years we have been implanting prostheses to replace diseased human aortic valves. Patients who have mechanical heart valves still require anticoagulants and are at greater risk of strokes or anticoagulant related haemorrhages. The new anticoagulants have not and will not change that reality. Patients who receive biological valves are at higher risk of requiring reoperations due to degeneration of the prosthesis. The cut off age for the use of mechanical prosthesis used to be 70 years. (Below 70 mechanical, above biological). Over the past decade, it has drifted downwards first to 65 then to 60. Although the rate of bioprosthetic degeneration does slow with age (possibly related to calcium turnover) the main determinant of whether degenerative changes become clinically significant is years of life with the prosthesis in situ I.e. longevity or prognosis. As life span of both women and men has increased rapidly over the past 20 years, the cut off age should in my opinion, be going up and not down. This downward drift in cut off age has not occurred because of new evidence or because of dramatic new developments in the design or manufacture of biological valve prosthesis. What has driven this change is marketing and the advent of TAVI (Transcutaneous Aortic Valve Implantation) or valve on a catheter. This device ( which is essentially a biological prosthesis that is collapsed around a catheter ) can be used to treat a stenosed native aortic valve or a degenerating surgically implanted prosthesis without the need for open surgery. A TAVI device inside a degenerating biological prosthesis is a very imperfect solution for many people who might still have 10 or more years of like ahead of them. What is needed and what has not yet been invented is a biological valve that does not degenerate over time or a mechanical valve that is completely non-thrombogenic. The advent of stem cell technology and the emerging concept of using acellular valves that get seeded by autologous cells suggest that the former I.e. a perfect biological valve is more likely to be invented than the latter. I won't however be holding my breath.

 

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It just seems so Logical Now.

 

A few years ago, I would have thought that this idea was nuts. Now it just seems a logical thing to do. Anyone on Facebook and Twitter are life loggers.

why does every Vimeo or YouTube video that accompanies a piece of tech or a new app always has an American speaking? This is a European (Swedish) product, and it should have a European doing the voice over - someone like Stephen Fry or Harry Hill !

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An Entertaining Viewpoint

 

STOOPIDTALL - CICLAVIA 2013 - LA BIKE CULT from Richie Trimble on Vimeo.

Amazing how a slightly different viewpoint of an otherwise normal scene becomes so entertaining

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NHS England and Mitraclip - Room for Improvement

MitraClip passes FDA hurdle | theheart.org
Mitraclip is a device that can be used to treat a leaking mitral valve, which is one of the valves in the heart..  The main advantage of this device is that it  can be inserted percutaneously without the need for open surgery. The gold standard treatment for mitral regurgitation is surgery. However not all patients are suitable or fit for open surgery. Mitral regurgitation is also an epiphenomenon of heart failure and when present is associated with repeated need for hospitalisation. This type of mitral regurgitation is very rarely dealt with surgically.  Use of the mitraclip therefore has the potential to decrease many admissions to hospital due to heart failure.  More than 4000 of these devices have been inserted into patients in Europe since 2008 when the CE mark was awarded. The American FDA, who traditionally are very conservative when it comes to approving devices has finally given a stamp of approval through one of its expert advisory panels. These panels consist of cardiologists and cardiac surgeons who are recognised experts in the field of mitral valve disease and related heart failure.  The proceedings of these panels are open and transparent. 
In the UK, there is no equivalent of the FDA. Devices are approved as being safe with a CE mark granted by the European Union. There is no requirement for them to be effective. As one can imagine, the bar for CE marking is set pretty low. Mitraclip has had a CE mark for several years.  The NHS commissioning board or as it is now known NHS England are responsible for commissioning of specialised procedures and devices.   In recent weeks it has published guidelines on the commissioning of specialised procedures. It has decided that the NHS will not routinely commission Mitraclip. It will however  'Commission through Evaluation". This process is described on NHS England's website  - ‘Commissioning through Evaluation’ enables treatments or procedures to be commissioned initially on a limited basis whilst further evaluation is carried out to determine whether a substantive commissioning policy should be developed for future use'.
I am not sure that this position NHS England have decided to adopt is logical. It certainly is vague. There is no doubt that the Mitraclip reduces mitral regurgitation in a safe fashion and there is no doubt that it does so in a less traumatic & less invasive fashion when compared to surgery. That surely is the only evidence one requires before commissioning. The decision as to whether the patient is treated percutaneously, surgically or medically should be taken by the patient's physician or Heart Team. It is this decision that will be determined by emerging evidence.

Robert Francis Has a Point

Two points in this article resonate with me, and I am sure with many of my peers - the first is the one that makes it to the title of the piece - every patient needs ONE hospital doctor who is responsible for their care.
My instinctive response to this is 'absolutely. It's the way it used to be before the wretched European Union stuck their oar in'. The contrary argument is that doctors need to go home or go on leave sometimes, but patients still need looking after. although the system clearly failed at Mid staffs it did not in countless other hospitals in England. The broader point is that the current norm, i.e. the involvement of many junior doctors and consultants in the care of a patient, carries risks. It is also clear to me where the risks originate from - inadequate handover. Sort handovers out (and technology has an important part to play here), and the risks will diminish. The increased use of MDT working in the management of patients may also be associated with a dilution of accountability and responsibility - here Robert Francis has a point.
The other part of the article that really resonated with me was Robert Francis's observation that 'in the NHS, nothing gets done because nobody has been told to do it' - or words to that effect. This must surely be the greatest weakness of the current model that has been chosen for the NHS - the top down, central control model. The QC is absolutely right - nothing gets done, unless there is a carrot or a large stick dangled in front of managers. It seems to me sometimes that NHS organisations have lost the power of independent thought. They only look upwards for guidance, and yet it is patients and their own staff that probably hold the key to the future. This way of working also makes a mockery of all the efforts of the NHS to develop leaders. Progressive patient empowerment will mean the current model is doomed to fail, eventually.

The Difficult Problem that is Aortic Dissection.

There is no other cardiothoracic procedure that is as challenging as the management of a patient with type A aortic dissection.
Untreated, the immediate mortality rate is 1% per hour.   The surgery to repair a type A dissection is extremely challenging, patients are very sick, and coagulopathic and the dissected vascular tissues are incredibly friable and difficult to work with. To make matters worse, the average on call surgeon dealing the majority of these cases will only operate on a very small number of aortovascular cases per year.  The operative mortality in most countries of the world for this procedure is around 25-30%.
I have come across this excellent video presented recently by the American Society of Thoracic Surgeons on some of the very difficult issues surrounding the operative management of these patients.
It is worth a share!