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McCulloch case

Communication, Ethics, Generic, Patients

Clarifies an aspect of the Montgomery decision in a way that supports healthcare professionals getting consent. The decision can be found here.

In Montgomery, the Supreme Court said that a doctor ‘is under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments’. In the McCulloch case, the Supreme Court was asked to decide what legal test was applicable when assessing whether an alternative treatment was ‘reasonable’. Was it the Montgomery test or was it the Hunter –v- Hanley test? Put another way, was the decision about whether to discuss an alternative treatment with a patient one of clinical judgement, or was it one for the Court to assess and determine?

The decision was that a doctor (or other healthcare professional) who has decided that a treatment is not a ‘reasonable alternative treatment’ for a particular patient will not be negligent in failing to inform the patient of that alternative treatment if the doctor’s view is supported by a responsible body of medical opinion. In other words, this decision involves an exercise of clinical judgement and any challenge to that decision by a patient is therefore to be determined by the Hunter –v- Hanley test. In the circumstances of the McCulloch case, the application of that legal test resulted in the claim being rejected by the Court.

The court said this:

“Taking a hypothetical example – say that there are ten possible treatment options; the doctor, exercising his or her clinical judgment, decides that only four of them are reasonable and that decision to rule out six is supported by a responsible body of medical opinion. The doctor is not negligent by failing to inform the patient about the other six even though they are possible alternative treatments.

“The narrowing down from possible alternative treatments to reasonable alternative treatments is an exercise of clinical judgment to which the professional practice test should be applied. The duty of reasonable care would then require the doctor to inform the patient not only of the treatment option that the doctor is recommending but also of the other three reasonable alternative treatment options (plus no treatment if that is a reasonable alternative option) indicating their respective advantages and disadvantages and the material risks involved in each treatment option.”

[Michael Stewart, Central Legal Office]

Monkeypox

General paediatrics, Infectious disease

=mpox (considered less stigmatising?).

Emerging infection particularly in men who have sex with men. Reached the UK in 2022.

New variant (Clade I) has high mortality, started in Central Africa (Congo, Central African Republic, Burundi, Uganda), now in Kenya, first case now reported in Europe (Sweden, 2024). Grade 3 human pathogen (along with Yersinia pestis, O157, TB, anthrax…).

Viral haemorrhagic fever found in these areas too, of course…

Incubation period is 5-21 days. High risk would be household contact, mucosal (with bodily fluids) or broken skin, inhalation without PPE if cleaning room or changing bedding. Medium risk would be intact skin with bodily fluids or face to face within 1m considered medium risk – do not need to isolate but should be offered post-exposure prophylaxis. See PHS matrix.

Besides blistering rash, can cause fever, sore throat, lymphadenopathy, myalgia.

Swab blistering lesion, or if none then throat. MSS (molecular sampling solution, as used for flu etc) ideally otherwise extra transport precautions required. Mark sample “suspected HCID”, notify lab in advance – needs to arrive for 9am!!!

Cases are asked to self isolate at home.

PPE – as for viral haemorrhagic fever. https://learn.nes.nhs.scot/58193/high-consequence-infectious-diseases-hcid

Post-exposure prophylaxis with MVA-BN vaccine (Imvanex®) offered within 14 days. Pregnant and children under 5 considered at risk.

Smallpox vaccine was considered effective.

Mental health emergency

Child protection, Common, Emergency medicine, General paediatrics, Mental health

Firstly, is there a suicide risk?

Then, consider mental health needs. Is there an alcohol or drug issue?

Are they known to social work? Are there any child protection issues for the young person? Their siblings or other family members? If young person is over 16 then consider Adult Protection measures (Scotland Act 2007).

A proper mental health assessment requires that they are physically well enough (consider intoxication, sedation, pain etc). Consider competency (which can be impaired temporarily by physical illness).

Consider:

  • Violent/aggressive behaviour – needs risk assessment and management
  • Evidence of learning disability
  • Any existing care plans or coping mechanisms?
  • Psychosis? ie delusions, hallucinations
  • Unusually withdrawn/quiet is a red flag.

Chronic Variable Immunodeficiency

General paediatrics, Immunology

=CVID. Another terribly named condition.

Usually presents in adulthood but about 20% in childhood. Typically recurrent infections of ears, sinuses, lungs – usual bugs, not funny ones.

Bronchiectasis may develop. In some cases granulomas develop.

Lymphadenopathy +/- splenomegaly is sometimes a feature.

Autoimmunity is an important feature – low red cells or platelets, thyroid disease.

Enteropathy and arthritis can be seen.

Diagnosis

Low IgG, usually IgA, sometimes IgM. Functional antibodies (to pneumococcus, tetanus, Hib) low.

Treatment

Immunoglobulin replacement – IVIG or subcut immunoglobulin, regularly.

Prophylactic antibiotics in some cases. Screen for infections esp chronic GI.

Bias

Ethics, Generic

In research, many studies are non-randomized, so risk of bias.

Newcastle-Ottawa scale is one attempt to assess bias formally – judged on:

  • the selection of the study groups;
  • the comparability of the groups;
  • the ascertainment of either the exposure or outcome of interest for case-control or cohort studies respectively. 

So things like cohort not being representative; control group coming from different population; measurement being rather subjective; duration of follow up – all increase risk of bias.

Publication bias

Suspicious if small study with big effect!

Vasovagal syncope

Common, General paediatrics, OPD

=Faints, “whitey”.  Insufficient blood to the brain, due to immature or hyporesponsive autonomic nervous system control of cardiac output and peripheral vascular tone.

Similar symptoms with POTS but with obvious drop in blood pressure.

Symptoms of light headedness, feeling hot/clammy, dizziness, black spots in vision or tunnel vision (pre-syncopal), potentially followed by collapse, which can be remembered in most cases. Can be brief posturing or clonus due to hypoxia, but only for a few seconds, which freaks everyone out as it looks like an epileptic seizure.

Recovery is fast, within seconds or a minute, once circulation to brain improves – requires that person is left lying on ground and not propped up!

They look pale, feel hot, but once on ground go clammy/sweaty. Heart rate and blood pressure typically low.

Typically fast growing teenagers, but can be anyone.  In some, lifelong tendency.  You can suffer significant facial trauma from syncope so it’s not trivial, if recurrent can also be disabling with significant psychological co-morbidity. Usually prolonged standing, or standing up after sitting/lying for a while (especially boys going to the toilet for a pee).  Other common triggers are physical stimuli (reflex syncope) eg painful procedures, esp immunisation (distinguish from anaphylaxis), cannulation.  Some unusual triggers eg hair brushing/combing.

Mostly trivial but potential for injury (eg facial fractures) and can be disabling.

Useful to become aware of triggers, so countermeasures can be tried.  But sometimes no warning, which is difficult.  Worth asking directly how often symptoms happen, as child might not tell anyone.

Other differentials are epilepsy, arrhythmia. Syncope with exercise is a red flag.

Abortive manoeuvres

  • Lower body muscle tensing – abdomen, buttocks, thighs
  • Same, but with leg crossing
  • Whole body tensing!
  • Squatting
  • “Brace” position – sit with head between knees

These should all work, probably worth practicing though.  And should work within seconds.  You hopefully only need to keep doing it for 30-60 seconds. [Krediet, J Appl Physiology 2005 Vol. 99 no. 5, 1697-1703 DOI: 10.1152/japplphysiol.01250.2004]  All of the evidence seems to come from the Netherlands!  Some evidence for isometric arm/hand exercises, but might be incidental abdominal tensing at same time!

Preventive measures

Regular meals/snacks. Avoid big carbohydrate meals though – low GI foods (ie wholegrain/wholemeal) best to avoid big swings in sugar levels. Avoid sugary drinks for the same reason.

Getting hungry is probably bad – have emergency snacks available (oat cakes, nuts, malt loaf, dark chocolate – not high sugar).

Drink plenty – consider increasing to 2-3 litres. Try to drink 1L in the first 2 hours of the day.

Caffeine?

Salt intake may need to be boosted, especially if a “healthy” eater, or losing a lot in sport. Slow salt tablets?

Good cardiovascular fitness.

Could try putting blocks under the foot of the bed to raise it up 2-3 inches! Retrains baroreceptors.

Medication

Desmopressin, to increase circulating blood volume?

Beta blockers? Fludrocortisone? See POTS.

Patient/family info at www.stars.org.uk.

Graphic stories

Communication, Generic

A creative way of learning/teaching about illness. But biases around being for kids, or frivolous, or simplistic.

But actually the ability to use images, fonts or other text effects means you can express things in ways both delicate and brutal that might require a lot of reading. Visual understanding is often more intuitive. By combining the two you are involving the different parts of the brain that handle language and image processing, and research shows understanding is enhanced.

They teach observational skills – you read but you must also interpret what is implied.

See MediKidz and GraphicMedicine.org.

POTS

Cardiology, General paediatrics

POTS (Postural orthostatic tachycardia syndrome) – more common in females. 

Orthostatic tachycardia (NOT hypotension, which suggests vasovagal syncope), dizziness, chest pain, palpitations, headaches, dyspnoea.  Sometimes bluish red discolouration in lower limbs. 

No known cause, can have sudden onset in previously fit individuals.  Associated with Ehlers Danlos (venous return problem?). 

Can be debilitating, associated with chronic pain, sleep problems, GI symptoms.  Can improve over time.  Diagnosis – heart rate increases by 30 beats per minute (bpm) or more (40bpm in those aged 12-19) within 10 minutes of standing, or if it increases to more than 120bpm. “Hyperadrenergic” POTS is where BP actually goes up, rather than down.

Monitor during valsalva manoeuvre to look for autonomic dysfunction.

Increase fluid intake to 2-3L daily. Increase salt intake?

Waist high compression stockings?

Consider treatment with beta blocker, fludrocortisone, desmopressin, clonidine, modafinil, SSRI.

Food allergy diagnosis

Allergy, General paediatrics

Getting it right is important because otherwise people (child but also the rest of the family) end up anxious and scared of foods, cut out different foods, spend out on expensive alternatives, and risk nutritional/growth problems as well as aversion in the child.

In young infants, avoiding foods unnecessarily makes it more likely that you will become allergic in the future (“iatrogenic food allergy”). This is especially true with atopy and sensitisation – one series of 11 patients sensitized to cow milk found that all developed true cow milk allergy after a median time of avoidance of 2.3 years (with no significant improvement in their atopic dermatitis, which was the initial reason for avoidance). Pronuts study confirmed that multiple nut/sesame allergies was a factor of age – “secondary spread”. Similarly, in the Learning Early About Peanut (LEAP) study, it was precisely the infants sensitized to peanuts who were more likely to benefit from early introduction.

Having unproven food allergies also causes huge problems for schools and nurseries, and may lead to the public becoming sceptical of true allergy, with potentially disastrous consequences.

Getting it right can identify other potential allergies; it can help estimate risk of anaphylaxis; it can help with predicting whether the allergy is going to go away or not.

Allergy focused history

EATERS method –

  • Exposure – did they actually eat it!? Or was there clear skin contact? Perhaps from surface contamination?
  • Allergen (suspected) – one of the common ones? Although you can be allergic to pretty much anything, it is really rare to have an isolated rare food allergy.
  • Timing – type 1 is immediate (within 15 minutes, rarely up to 1hr after) and then settles even without treatment within 24 hours. Rare to fluctuate.
  • Environment – home (usually during weaning)? Outside home? Co-factors (infection, medicines, exercise, sleep deprivation) come in here.
  • Reproducible – consistent reactions with exposure? May have had before with type 1 allergy but often on trying for the first time, and won’t have had recently. Milk/egg different, of course…
  • Symptoms – type 1 vs non type 1. Some overlap of course.
[Mich Erlewyn-Lajeunesse, ADC 2019]

Other issues are age (adolescents with hay fever more likely to develop secondary pollen food syndrome type allergies), alpha-gal allergy can be delayed up to 3 hours; raw vs cooked food sometimes makes a difference; usually you already have eczema and family history of atopy.

Testing

At the end of history taking, you should have be able to assess probability of type 1 allergy. If low, you may wish to proceed straight to challenge (unless reactions sound severe). Otherwise testing may help confirm or refute.

If negative/equivocal on initial skin prick or specific IgE testing, do another test! Skin prick if negative/equivocal IgE, and vice versa.

IgE Component testing may give added information, esp where potential pollen co-sensitisation – best evidence (mostly in US population, however) for Peanut, Hazelnut, Cashew (respectively Ara h 2, Cor a 14, Ana o 3 – other components may give extra information in some cases). Jug r 1 v specific (walnut) but not v sensitive.

Challenge

Challenge will be useful where results still equivocal – viz

  • Results positive but never eaten or history inconsistent
  • Results positive but possibly co-sensitivity without allergy
  • Food in alternative form might be OK eg baked