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  • Another sorry melanoma story

    Searching on melanoma and Covid/Lockdown for some background to a research paper I am working on, I found this sad story in The Scottish Sun. The …

    Another sorry melanoma story

  • New, changing mole is cancer

    This is an archive case. I’m planning to post more cases this year-this blog was originally aimed at medical professionals, but my ongoing clinical …

    New, changing mole is cancer

  • Peri-menopause and menopause resources

    Just added to the resources drop down menu…more to follow…

  • Updated Mental Health Resources

    I have updated these after being sent a very useful list by a colleague. There may be some duplication but it is growing into a comprehensive list. This is at a time when we are certainly seeing more mental health problems in primary care.

  • Multidisciplinary Chronic Pain PBSGL

    Despite studying for a foundation module in pain management, I learnt an awful lot. It was great other members found the biopsychosocial model of chronic pain so useful. It reinforced what I have been learning. I shared some of the resources which are available for general access which I think is essential as we all want to improve patient care. Right at the end, the physiotherapist who attended this session mentioned establishing a chronic pain clinic with education and paced activities at its heart. I am very keen to get involved so volunteered to help. I hope to include neuropathy patients (non-freezing cold injury). My own hypothesis is if we can normalise what these individuals are complaining of, give them a label of chronic pain (albeit of neuropathic origin) and get them to engage with other chronic pain sufferers, I think they will do better. They will feel engaged and empowered.

    Interestingly and once again, we had a physiotherapist attend as an observer but who also played an active part.  He is about to undertake a dissertation as part of an MSc in pain management.  In the end, he was one of the group, contributing and discussing like the rest of us.  Having a healthcare professional from other disciplines in a small group learning environment represents a wonderful opportunity.  There is the possibility of funding for a more widespread study into PBSGL within Defence Primary Healthcare and I hope we can extend it to our physiotherapy and nursing colleagues.

    In the end, we summarised what we had learned and shared the resources.  Here are a few & I hope you find them useful:

    Palouse mindfulness – I shared this after I discovered about it at a psychiatry course.  Well worth a look.

    Head Space as the go-to app (based on evidence, albeit one study, small & undertaken by the app authors!).  Also, highest rated mindfulness app according to another paper using the MARS scale.  I should add, there doesn’t appear to be hard evidence that Mindfulness improves chronic pain.  It enhances acceptability but not intensity, probably by enhancing affective elements.

    ‘Struggling to be me‘ video (plus the healthcare professional opinions – a real eye-opener).  Based on a BJGP paper exploring patients experiences of living with chronic pain.

    www.paincommunitycentre.org – requires registration but a fantastic resource for chronic pain presentations and educational material. UPDATE Unfortunately this website was discontinued on Feb 19.  However, a lot of the talks are available at the Vimeo site.

    pain-ed.com – not thoroughly evaluated but looks good.

    The pain team page at the University College Hospital London – some good videos for patients who want to learn more.

    Understanding pain in less than 5 minutes – YouTube video

    Lower Back Pain by DocMikeEvans – YouTube video

    Am I safe to move – Audio lecture by Prof Lorimer Moseley on pain

  • Chronic non-freezing cold injury results in neuropathic pain due to a sensory neuropathy

    Perhaps not a hot topic for NHS General Practice but as we approach another winter, this journal article is relevant for any healthcare professionals involved in the care of soldiers.

    The original article is here  (I want to highlight the use of a DN4 neuropathic pain scoring chart if you are assessing a patient with suspected neuropathic pain).

    My own experience with managing this very difficult condition is that it is frustrating for both the patient and doctor. Soldiers of Afro-Caribbean origin are far more likely to suffer from NFCI (30x by some estimates) and they are more prone to the side effects of neuropathic drugs, especially amitriptyline (totally anecdotal evidence).

    In summary the article confirms this is a neuropathy confirmed by skin biopsy.  Quantitative sensory testing is also helpful.  Because the nerves are small sensory fibres, detection by nerve conduction studies is not always accurate.  It goes into quite some detail about the process (it is a PhD project).

    For me the main message is this is a real phenomenon with physical changes.  In the study, 35% were medically discharged from the Forces and of these, over 50% were unemployed.  This is pretty horrendous and re-iterates that NFCI can be a chronic & disabling condition.

    My own management involves adequate protection (motorcycling warmed gloves are useful as are silk liners), neuropathic agents, simple pain relief (opiates are occasionally helpful funnily enough) and a cognitive approach to pain.  The latter is especially important given that employment may be difficult if working outdoors is impossible for 4 months of the year.

  • Chronic Pain

    After our 2 sessions on chronic pain, we have performed a couple of audits at Bulford.  My own is here: 20150121-Opiate audit . Tony (D) has also done one.

    I found both sessions incredibly useful.  I am finding I am being more pragmatic with patients and being realistic with outcomes.  I think the main learning points for me have been

    a. what is feeding the chronic pain cycle?  Catastrophising I think is an excellent term.

    b. recording follow up thoroughly in follow up using the 6A’s.  In particular affect, adverse effects and analgesic effect.

    I think there is probably some more work to do on the occupational aspects of strong analgesia.

  • PBSGL Oct 14 – Post Menopausal Symptoms

    An excellent discussion. Lots of areas where there was learning and confirmation of practice. There was also discussion about our role as patient advocate in 2 of the cases. Should we stop the HRT in the 74 yr old lady suddenly? What about if it was contra-indicated. Also the role of alternative medicine – if we advise it as an option & the patient is harmed, where do we stand?

    Unaswered questions were:

    1. Circulate a Menopause Rating Scale (ASW to do)
    2. Should we ask opportunistcally about peri-menopausal symptoms?
    3. When using topical E3 gel as a systemic therapy (as opposed to vaginal gel), what are the options for providing progesterone? The IUS was discussed as an excellent option but what about if it was contra-indicated or if the patient declined? Are progesterones actually required if use of E3 gel is intermittent and on a PRN basis? (JCS to find out).
    4. Which is the best primary care tool for memory/dementia screening (TW to find out).
    5. What are the absolute contra-indications for HRT and smoking? (ASW will investigate).

    Two new members (both young males) expressed concern about the limitations of their knowledge in this area. Whilst we all expressed this (we do not have many patients with peri-menopausal symptoms), it is something that needs to be raised on the PQO/PGMO course. The curriculum should cover common urogenital problems in middle aged women at least so GDMOs are confident in raising the subject. Women are known not to volunteer conditions such as loss of libido and stress incontinence.

    Areas of learning we discussed:

    1. The use of a topical E3 gel as a systemic therapy.
    2. Use of self help web sites – Amarant Menopause Trust.
    3. One of the scenarios involved a concern about dementia. We moved on to scoring systems in primary care – 6 question CIT, MMS.
    4. We all agreed the time constraints in a single consultation would rule out a comprehensive history, examination and investigation. Another option was to spread over 2-3 consults with the patient doing some research in the interim.

    There shouldn’t be too many barriers to change. ASW will raise the issue of the curriculum change with the GP Dean next week on the Tri-Service Trainers Course.

    Most of what we discussed had mutual agreement. Some guidelines were discussed and we agreed that a single sheet of pros/cons of the long term risks & benefits might be a useful tool in the surgery.

  • Tweeting For Learning

    Tweeting for learning: A critical analysis of research on microblogging in education published in 2008–2011

    F Gao, T Luo, K Zhang – British Journal of Educational Technology 43.5 (2012): 783-801.

    I came across this article when searching for microblogging papers. It is a useful article in that it summarises the research done between 2008 and 2011 on microblogging, or more succinctly, microblogging in education (MIE). It is worth a read due to the design of the study. What the authors did was to try and look specifically at evidence for the benefit of MIE whilst excluding opinion pieces and review articles. During my various searches, I have come across a lot of opinion pieces which although relevant, do not always provide the evidence for benefit. This paper is essentially a systematic review. Due to the variety of the included studies, it isn’t a meta analysis but it does provide a nice summary. One can delve further into the individual studies if one wants to and I hope the title above links to a free text version of the paper.

    The article attempted to answer 4 research questions:

    1. What types of research were conducted on MIE?
    2. How was microblogging used for teaching and learning in these studies?
    3. What educational benefits did MIE have on teaching and learning as identified in these studies?
    4. What are the suggestions and implications for future MIE research?

    The method involved is one of the clearer descriptions I have read in a paper for a while and I would recommend reading this part of the paper. Four rounds of searches identified a total of 21 papers which met the criteria for inclusion. They were then analysed. Reassuringly some of the papers I have already reviewed plus ones which are pending were included in the datasets so I did feel a bit smug. It rated the paper by Ebner et Al as having greater validity (sample size, duration etc). Another rated highly is by Kop et Al available here which I haven’t read yet. The submission date in October is getting closer and every time I scratch the surface, another paper pops up.

    RESULTS

    The article described the papers included. These varied in several ways. For example a couple explored microblogging in the context of a conference and the positive effect of real time feedback and questions to the lecturer/presenter. Most were set in higher education. The sample size varied greatly. My own view is that this is less important as these tend not to be quantitative studies. The duration varied as well. A conference or lecture may only last a few hours yet some of the interventions extended to 2 semesters. Ebner’s study lasted 6 weeks yet was very labour intensive & meticulous. It also drew some very balanced conclusions.

    The areas further identified and explored by the authors are: Who is participating? When to learn? What to learn? How to learn? Participation and Engagement; Reflective thinking; Collaborative learning.

    The ‘who’ and ‘when’ are fairly straightforward. Examples of who given include delegates at conferences and the when is essentially at anytime. The concept of education when & where you want it. MIE has been used for informal communication outside of the classroom sustaining engagement by posting updates and relevant links.

    A lot of the positive benefits of MIE have already been described when looking at collaboration and these are all positive effects in the studies looked at. The remaining ‘how’ is a bit more interesting. ‘Fostering interactive activities’ and ‘encouraging informal learning’ are known strengths of MIE. The main educational effect from the review was the development of learning communities, promoting interaction between conversations between students as well as students and teachers. MIE is not meant to be a conversation tool but using the @ prefix achieved this. My own experience is that this is not the case but by flagging with a #, response and conversations are more likely. Apart from all these, there was no objective evidence on the educational impact of MIE. For example better scores in assessments. This is discussed in their future research suggestions. Only one of the studies was experimental, the rest being descriptive. This is what I am finding. Whilst these studies are important, it would be good to find an experimental study which perhaps compared marks with & without a Web 2.0 tool. This would be dependant on students being without their smartphones for a period or not using SNS, something which may prove more challenging.

  • Wikis, blogs and podcasts: a new generation of Web-based tools for virtual collaborative clinical practice and education

    Maged N Kamel Boulos*, Inocencio Maramba and Steve Wheeler

    BMC Medical Education 2006, 6:41  doi:10.1186/1472-6920-6-41

    Free text here

    I found this article whilst doing a search trying to find evidence of the educational impact of SNS and Web 2.0 tools. Unfortunately it is a slightly older article so some of the concepts and ideas are a bit outdated but it is useful summary. It looks specifically at three types of Web 2.0 tools – Wikis, Blogs and Podcasts. It was written in 2006 and its age is shown slightly when it talks about the lack of evidence of the effect/impact of Web 2.0 tools in the context of medical education (although the research base is still expanding). However what I found most useful is it lists the advantages and disadvantages of the three tools. The article mentions the tools and resources to create a Blog or Wiki are freely available and easy to use. Since 2006 of course there has been an explosion of apps, programme & online resources which have made things even easier. I could not believe how easy it was to construct a blog from a freely accessible website. Since 2006 mobile platforms have expanded and become more powerful. I was still using a Palm 650 then. I compare this to my latest smart phone and the number of apps I can get for it, the expansion has been exponential. However, the article is not about this. It is about the impact on education.

    There are a couple of useful additional PowerPoint annexes to the article which I would recommend reading.

    Wikis

    I didn’t realise a Wiki is from the Hawaiian term wiki, to hurry, swift. I still don’t know why this term was used. Essentially it is an on-line resource which has open editing. Most people are aware of Wikipedia. This concept can also be used to make an educational or medical Wiki. It is clear for anyone who has used Wikipedia that this would be a useful too for increasing collaboration and indeed some examples are cited. Ganfyd is one which can be edited by any registered medical professional.

    A term I hadn’t heard before is Darwikinism. This refers to the evolution of Wiki pages as authors & collaborators edit and update the page. Indeed unlike evolution, this process is rapid. The authors mention a comparison with the Encyclopaedia Britannica and the fact both had similar numbers of errors. Unlike a printed publication, Wikipedia is corrected far more quickly. There is a downside to this, namely vandalism. A famous case was that of the American journalist John Seigenthaler. This downside is outweighed by the benefits of openness and the ability to restore a quality page using tools such as rolling back.

    Sharing a digital tool such as a Wiki (and to a lesser degree a Blog) enables participants to become a stakeholder in the outcome. This outcome could be part of a project or developing a reference resource. It also encourages a deeper understanding of the subject matter by encouraging online collaboration. This is a key concept underpinning the pedagogical impact of a Wiki and its main advantage.

    Ensuring accuracy is a concern but having a group of peer reviewers plus the ability to change an incorrect entry at the click of a mouse provides some assurance. Obviously for a large Wiki this may mean a large number of reviewers with subsequent time constraints but for smaller educational projects should be manageable.

    Blogs

    Of interest to me, blogs have obviously exploded in their popularity since 2006. It took me until June 2014 to start my first. As mentioned previously, it was a simple thing to set up and the tools are free. Unlike Wikis, it is the author (or co-author) that moderates the entries so this can make the moderation more consistent and refined. However this could skew the information posted given the lack of a group consensus. I would argue this is more advantageous as article meta-information is known. Wikis can lack this due to the anonymity of the contributors. I own my blog and have a sense of authorship.

    Both Blogs and Wikis run the risk of inadvertently posting copyright material as I found out. In my case it wasn’t malicious, just accidental (it was rectified easily by editing the post). As a single author this does protect me whereas the collaborative Wiki could be vulnerable. This lack of collaboration may reduce the educational impact of a blog – it could be perceived as an opinion piece which it essentially is. This article for example is my interpretation & critical evaluation of a journal article.

    Another downside of blogs as I have found out is that whilst people may like to read them, encouraging active participation is a different matter. What one does get is other bloggers following you so this is in itself, a Network of Practitioners. It is a diverse network however, not just medical. The educational impact is therefore about blogging (I have enjoyed reading followers own blogs), not about medical education. I am learning from an informal curriculum and its great fun.

    Podcasts

    Despite my best efforts I have never got into Podcasting and I worried that this might mean I never had anything interesting to say. I actually think the reason is it involves having either headphones on your head or listening in a car/at home and therefore requires more concentration. I started downloading BMJ & NEJM Podcasts but never actually got around to listening to them. The ones I listened to tended to be a background noise, rather like a nice piece of music, whilst I did something else. I did not learn from them. On this background of negativity, I was interested to see what the authors thought.

    Both audio & video Podcasts are used extensively. From recordings of lectures to audio recordings of text books, it is a tool which nicely encapsulates what m-learning is. One of the advantages described is the superior support for auditory learners (primary learning style in at least 30% of learners). The same applies to visual learners. On this basis, and not commented on by the authors, I would suggest this is their main disadvantage. I could not attend a Hot Topics course once so opted to do the ‘Webinar’ instead. This was essentially a video Podcast of the lectures with PowerPoint. I duly completed the exercise, answered a fairly straightforward quiz & was awarded my PGE credits. I reflected that I learnt very little but had a big thick textbook of Hot Topics & 6 hours accredited. It is clear that Podcasts do not work for me but I have always found Problem Based Learning & Small Group Work more effective. I like to be hands on. So whilst there is a pedagogical basis for some learners, it is not for everyone.

    To summarise, this is a nice review article which provides an interesting snapshot of Web 2.0 tools and their potential educational impact in 2006. It recognises the lack of an evidence base for this and encourages readers to get involved in research. And therein lies the rub. I am already out of date according to some teenagers I know (Facebook is sooo middle aged). I should be using WhatsApp and Instagram, until the next great thing comes along. Trying to research the educational impact of Social Networking tools when those tools are continuously changing is a challenge.