This is a re-written version of a blogpost that I put up on northerndoctor.com back in 2008. The death of Jack Klugman seems an appropriate time to post a small tribute.

Kick back and enjoy the classic opening theme for a minute. It’s a proper little earworm – I’ll be humming it for days now. Doo doo-doodoo doo dooo!

One of my resolutions when teaching medical students is to stop making cultural references that are likely to be met with blank looks.  Partly because it baffles the students – most of them were not born when Quincy was in his pomp – but mainly because it is mildly depressing for me.

Quincy, M.E. is the reason I am a doctor.

With no doctors in my family, and in the pre-internet universe (how did we cope?), my view of the medical profession was limited to 1980s television. That really didn’t extend much beyond Quincy, early Casualty and that programme, Doctors to Be, that followed some St Mary’s medical students through their course. That really was it. Exposure to Quincy at such an impressionable age meant that I initially assumed I would go on to be a forensic pathologist. The postmortem scenes may look tepid by today’s maggot-ridden standards but at the time they were thrillingly morbid. However, when I arrived at medical school in 1992 I was very quickly disillusioned after about 5 minutes into our first histology lesson. Squinting down microscopes at pinkish-purplish blobs with my defective colour vision meant pathology quickly lost any glamorous associations with Quincy.

Klugman was magnificent as the character and Quincy remains a great, albeit fictional, role model. He was phenomenally tenacious with exemplary clinical skills. Most importantly, he had a moral compass second to none. All of this was allied to an ability to sniff out a corporate murder from the other side of the county. He was also a bit of a one for the ladies and he enjoyed a good rant at stifling bureaucracy. What a legend.

This is my 20th Clinical Update – you can access them all here. Or jump to the bottom to learn about SMMGP.

The papers covered this time are:

A record-linkage study of drug-related death and suicide after hospital discharge among drug-treatment clients in Scotland, 1996-2006. Merrall ELC, Bird SM, Hutchinson SJ. Addiction 2012. Published online ahead of print. 

This study showed that there is an increased risk of death in folk who have recently been in hospital and are also registered with substance misuse services in Scotland. Even those who hadn’t stayed overnight showed an increased risk of death.

Opioid dependence during pregnancy: relationships of anxiety and depression symptoms to treatment outcomes. Benningfield MM, Dietrich MS, Jones HE, et al. Addiction 2012;107 Suppl 1:74–82

This was a secondary analysis from the excellent MOTHER study. Women who had just anxiety were more likely to drop out. Women who were just depressed were less likely to leave treatment.

Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review. Addiction 2012;107 Suppl 1:5–27.

This was a huge review that lays out all the most recent evidence for buprenorphine treatment.

‘Subutex is safe’: Perceptions of risk in using illicit drugs during pregnancy. Leppo A. Int J Drug Policy 2012;23:365–73.

This qualitative study highlights some of the wider issues in women who use during pregnancy: far too often health care professionals get stuck in the ‘biomedical discourse’ without considering other areas.

Heroin users’ experiences of depression: a qualitative study. Cornford CS, Umeh K, Manshani N. Fam Pract 2012;29:586–92.

Another qualitative study from the remarkable Fulcrum Medical Practice in Middlesborough.

Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Grattan A, Sullivan MD, Saunders KW, et al. Ann Fam Med 2012;10:304–11.

Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Minozzi S, Amato L, Davoli M. Addiction 2012. Published online ahead of print. 

These two papers look at different aspects around the problems of prescription opioid misuse.

The challenges of reducing tobacco use among prisoners. Richmond RL, Butler TG, Indig D, et al. Drug Alcohol Rev 2012;31:625–30.

‘Do more, smoke less!’ Harm reduction in action for smokers with mental health/substance use problems who cannot or will not quit. Baker AL, Callister R, Kelly PJ, et al. Drug Alcohol Rev 2012;31:714–7.

These two papers draw together papers on smoking cessation in some very challenging groups who have high rates of smoking.

Widening access to treatment for alcohol misuse: description and formative evaluation of an innovative web-based service in one primary care trust. Murray E, Linke S, Harwood E, et al. Alcohol Alcohol 2012;47:697–701.

A web-based service that helps address alcohol may seem like a good wheeze but, in practice, there are many problems and barriers to overcome.

Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. MacArthur GJ, Minozzi S, Martin N, et al. BMJ 2012;345:e5945–5.

A solid BMJ systematic review that makes it clear that opiate substitution therapy remains a key intervention to prevent HIV transmission. Yet, globally, only around 6-12% of people who inject drugs will receive it.

Benzodiazepine use and risk of dementia: evidence from the Caerphilly Prospective Study (CaPS). Gallacher J, Elwood P, Pickering J, et al. J Epidemiol Community Health 2012;66:869–73

A UK based cohort that shows that there is a clear association between benzos and dementia. Some aspects of the paper seem to rule out reverse causation but there wasn’t a dose-dependent relationship – so whether benzos are causal is not yet clear.

Would it be appropriate for the Royal College of General Practitioners to run an alcohol-based event as a fundraiser for the new building at Euston Square? Apparently so.

Unfortunately, the RCGP website has rather highlighted the tension here. On one hand, it is perfectly reasonable to enjoy alcohol in a social context. On the other hand, alcohol is a massive public health problem with significant costs and harms to individuals and society. It seems the RCGP can cater for all viewpoints.

William Pickles

This month in the BJGP, the editor, Roger Jones, reviews open access publishing. There are lots of issue around open access and these are well summarised in the article. In general, open access is regarded as A Good Thing. I wouldn’t disagree.

Organisations such as the Wellcome Trust, the Research Councils UK, and National Institute for Health Research all have plans, or at least aspirations, to make the research that they fund open access. However, there are clear financial implications for some journals with the risk they could go to the wall if they don’t manage their income. Personally, I’m not sure that’s necessarily a disaster – arguably, there are far too many journals publishing too many papers of dubious quality.

The BJGP have analysed their papers from the past 2½ years. They reckon around 50% would have had APCs (article-processing charges) in their research grants. However, 50% wouldn’t and 38% were from outside the UK. Clearly, there is a risk that this research wouldn’t have made it into publication.

The current range for APCs in medical publishing is around £1000-2500 per article; not a large fraction of a major research grant, but a very significant sum for research that is not externally funded or which has been conducted with no funding at all.

I’ve been recently involved in a piece of ad-hoc research. It’s been through peer review and accepted by an open-access journal and we are now trawling around various departments in the university in a bid to find some funding. It’s a problem.

General practice has a rather proud tradition of research in the community. William Pickles, the first president of the College, came to light for his epidemiological work in Wensleydale. And I admire the work of Doug Jenkinson – a now retired GP who studied hundreds of cases of pertussis in his own practice over a long career. Perhaps there is no room for the amateur (not that I would classify the quality of work as amateur in those cases) in research these days but it would be a shame if an unintended consequence of open access was to close off these avenues. It isn’t necessarily desirable that community and primary care research becomes confined to academic silos.

So, I wonder if some kind of hybrid model may be most appropriate for the BJGP. I’ll watch with interest.

Roger Jones (2012). Open access publishing: a new direction for medical journals BJGP, 62 (603), 514-515 DOI: 10.3399/bjgp12X654830

The MPS continue with their excellent twice yearly edition of Sessional GP. I’m still writing the back page article for them – this time it’s The irony of complaints where I get to muse on the various aspects of complaining and moaning that we all do in the NHS.

Sessional GP is a good idea. There is a very real risk that sessional and locum GPs can feel excluded from many publications that emphasise practice-specific systems and risks. Of course, it’s not like we do radically different jobs to GP principals but there are some subtle and meaningful differences.

It’s all available for free online. If you want to delve into the individual articles you can follow these links:

• In the dark: Risks of telephone consultations

  Dr Tony Males looks at the skill-set required for consulting on the telephone in order to safeguard patients

• Revalidation watch

  Dr Rachel Birch is in the first wave of GPs going through revalidation; she shares her experiences

• Home visits

  Dr Zaid Al-Najjar explains the art of telephone triage

• Don’t miss the signs

  Charlotte Hudson explores all guidance surrounding child protection

• How to create a patient safety culture

  Julie Wilson discusses how to build a patient safety culture in primary care

• From the outside looking in

  Terri Bonnici highlights the locum’s role in the complaints investigation process

• In the hot seat: Dr Susan Stone

  Dr Susan Stone shares her battle plans for getting commissioners to engage with sessional GPs

• Final thought: The irony of complaints

  Blogger and locum GP Dr Euan Lawson [er, that's me] says that when it comes to complaints we should be grateful that thorns have roses

Or you can read an interactive version of the PDF at the link below:

http://www.medicalprotection.org/Default.aspx?DN=e636d167-4a53-4197-b63c-9222315e2c68

I’m continuing to write the SMMGP Clinical Update on a bi-monthly basis. It’s a summary of some of the key clinical papers on substance misuse relevant to primary care. Generally, it’s around 3000 words long and I might cover anything from seven to ten papers in that. There is a summary of the methodology and findings of the paper and I make an attempt to put it all into some sort of appropriate context. The team at SMMGP read it through, make helpful comments, and try to filter out any blatant libels. It’s available at www.smmgp.org.uk under the ‘Resource Library’ heading. If you’ve an interest in substance misuse in primary care then you should join SMMGP – it’s free.

I’ve been writing this every couple of months since August 2009 so I’ve now racked up quite a few of these – my next one will be my 20th Clinical Update.

The last one was the Aug-Sep 2012 version and covered the following papers:

Prevalence of common chronic respiratory diseases in drug misusers: a cohort study. Palmer F, Jaffray M, Moffat MA, et al. Primary Care Respiratory Journal. Published online: 8 August 2012.

An interesting retrospective study from Scotland looking at this sorely neglected area. And there are few surprises in the findings – even without smoking (and smoking is pretty terrible in this group) respiratory diseases are much more likely.

Persistent cannabis users show neuropsychological decline from childhood to midlife. Meier MH, Caspi A, Ambler A, et al. Proc Natl Acad Sci USA Published online: 27 August 2012.

This is a deeply impressive study based on the New Zealand Dunedin cohort. It goes a long way to settling a fair few questions around harms from cannabis – and adolescents looks particularly vulnerable.

Substance misuse of gabapentin. Smith BH, Higgins C, Baldacchino A, et al. Br J Gen Pract 2012;62:406–7.

A brief report/letter in the BJGP highlights an issue that won’t come as a surprise to many folk working in substance misuse (or particularly prisons). Gabapentin is highly abusable and this report points out some of the issues.

Retrospective accounts of injection initiation in intimate partnerships. Simmons J, Rajan S, McMahon JM. Int J Drug Policy 2012;23:303–11.

This qualitative study does what a good qualitative study should – it’ll really make you step back and consider some of your attitudes. Recommended.

Brief case finding tools for anxiety disorders: Validation of GAD-7 and GAD-2 in addictions treatment. Delgadillo J, Payne S, Gilbody S, et al. Drug Alcohol Depend 2012;125:37–42.

This UK study studied whether or now GAD-7 is actually of any value in an addiction setting.

Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme. van Beurden I, Anderson P, Akkermans RP, et al. Addiction 2012;107:1601–11.

This Dutch study had a bit of a torrid time as they struggled with poor recruitment and not very impressive participation. Some good lessons on how we might go about improving the management of alcohol problems in general practice.

Buprenorphine/naloxone and dental caries: a case report. Suzuki J, Park EM. Am J Addict 2012;21:494–5.

This was just a short case that reported on a woman who developed marked dental caries while on buprenorphine/naloxone. It’s a good opportunity to reflect on the dire state of oral health in many of those with substance misuse issues.

I’ve had a couple of articles in the BJGP in recent months.

I wrote a piece on tobacco and the role of harm reduction. I’ve written on this before (here is one of my old Northern Doctor posts on the subject) and it seems to stir up some good discussion. I know NICE are consulting on this – I think it could become a hot topic in the next year or two. So, I thought it might provoke a little controversy but I’ve not heard a peep. Interestingly, I did get an email from Big Tobacco asking me if I would meet them to discuss my work. I haven’t followed up on that.

I also wrote a book review for Margaret McCartney’s The Patient Paradox. I’m sure you’ve read it already. You can buy it from Pinter & Martin here. I’ve just noticed that P&M are using a quote from my review.

The arguments are measured and well-referenced; the conclusions are distressing… Read this book. But don’t expect to be able to practice medicine in the same way again.

I haven’t had my blood pressure checked for a couple of years. I think the last time was for a life insurance medical so I wasn’t given much option. As with all investigations, it’s always worth having in mind what you plan to do with the result, and I’m pretty sure I wouldn’t be in any hurry to take blood pressure medication. We use QRISK in general practice (it is embedded in some of the GP computer systems) and I’ve been playing around with QRISK online. Here’s my QRISK score based on my current risk factors:

So, over the next 10 years that’s a risk of 0.8% (1 in 125) of a heart attack or stroke. Most of my risk is related to my age and my gender. Can’t do much about them.

Risk calculators can be a bit weird. You’ve got to be careful how you use them. Let’s assume that in fact I’ve got a slightly elevated BP – perhaps a systolic of 160mmHg, which according to NICE guidelines should be treated at that level. According to QRISK-2 (2011), my risk of a heart attack or stroke over the next 10 years is now 1.3%. That is, in my opinion, remains a fairly low risk (and just a 0.5% increase in absolute terms from having a normal blood pressure).

But, say I have a change of heart, my family insist, and I start on medication. I may then revisit the QRISK calculator a couple of months later. I pop in the same details but also check the box ‘on blood pressure treatment’. Even with a systolic BP of 120mmHg my risk is now 2% over 10 years.

It has gone up! That’s not very encouraging and is a good reminder of the limitations of these tools.

The QRISK information page does suggest the calculator can be used this way:

 Where patients are on antihypertensive treatment, should a pre-treatment blood pressure be used when calculating their risk?

No. QRISK®2 has been designed such that if a patient is taking antihypertensive medication then their current blood pressure on treatment can be used rather than a pre-treatment value.

I don’t have details of the algorithm used in QRISK. Presumably what is happening here is that either there is more harm than benefit from anti-hypertensives, or more likely, the sub-group ‘on blood pressure treatment’ has a lot of confounders which haven’t all been teased out. That means that being on blood pressure treatment is simply a marker of other medical issues that worsen risk when looked at on a population basis.

Risk calculators like this don’t offer some magical glimpse of the future for individuals – they are just playing with statistics and, as QRISK are at pains to point out, are best used with careful real world interpretation.

OK, something a little different for a blogpost this time. I thought I’d put down a few words on the writing software Scrivener and I’ve added a screencast too.

Scrivener is fairly well known amongst fiction writers. It has enormous functionality and it can be used just as easily for writing non-fiction. It was originally written for Mac (and was one of the reasons I came back to Macs after a few dispiriting years of being distracted and frustrated by Windows) but there is a Windows version now available. Scrivener is particularly useful for longer projects but it can be easily adapted for all kinds of writing. I have a number of different Scrivener files that I use for different non-fiction writing projects and ideas. These include a non-fiction book and my blog but I also use a Scrivener file for any freelance writing where I can record market research, pitches, article research, drafts and finally PDFs of the published articles.

It is easy to create new text documents in any folder in Scrivener. You can then write each small section and move them around to get the order correct. In fiction this lends itself well to the natural breakdown of a novel into books, chapters, sections and scenes. The book can be written one scene at a time and then scenes can be easily moved around. The ‘scrivenings’ mode allows any combination of scenes to be viewed and read together. Non-fiction can, of course, also be split down and each section written independently. It works just as well. Rather than managing a big unwieldy Word document (or multiple Word documents in a folder) bigger projects are logically split into their individual elements. It is also very easy to import all kinds of media and other documents (such as PDFs of research papers) into Scrivener where they are easily available for reference.

But Scrivener is not just for books, dissertations or other long works. Any writing that tends to hang together can be collected together in one place.

For instance, I write the regular Clinical Update for SMMGP. Check out this screencast for a quick tour of how I use Scrivener to help with that.

Scrivener can be used to write your blog. It gives me an easy way to take a look back at previous posts (mainly to check I’m not recycling my usual tics and cliches) and it is the perfect place to jot down ideas, collate research, write drafts and refine posts. As I show in the screencast I’ve found the splitscreen option particularly useful. The thing about Scrivener is that it is a bit of a beast – the features and functionality are stunning. But you don’t need to know much about it to get cracking and the introduction videos and support at www.literatureandlatte.com are excellent.

This was a meta-analysis of data on light alcohol drinking and breast cancer. The authors reported that they looked at 113 papers which reported breast cancer risk estimates for light drinkers. Only 36% of the reported estimates were adjusted for the main risk factors (age, family history, parity, menopausal status, oral contraceptive/hormonal replacement therapy use). The findings reported in the abstract were:

 A significant increase of the order of 4% in the risk of breast cancer is already present at intakes of up to one alcoholic drink/day.

This fits with the random-effect summary relative risk (RR) of 1.04 (95% CI, 1.02 to 1.07) for the overall analysis. However, when pooling for the 36% of studies that had adjusted for the main risk factors the RR was 1.03 (95% CI, 1.00 to 1.07). Hmm, a 95% confidence interval that includes 1.0 – I’m starting to feel a little anxious about the numbers here.

These epidemiological studies can only show an association. However, alcohol as a causative agent in breast cancer doesn’t seem that unlikely. There is secure evidence that higher consumption of alcohol is associated with an increased risk of breast cancer. There is a plausible mechanism with alcohol affecting oestrogen levels and given that breasts are a highly oestrogen-sensitive tissue. The studies also seem to suggest a dose-response relationship – a further piece of evidence suggesting alcohol is causative.

So, seeing a small effect (and it is small) with light drinking is hardly surprising. On population terms the epidemiologists may be impressed but your average person may wonder at their real risk. It is notable that at no point in this paper, or the press release, or the Daily Telegraph article does anyone attempt to put it in absolute risk terms.

Telling people who drink heavily that they need to cut down isn’t controversial but how much can a woman who cuts down on her light drinking expect to benefit? Well, firstly, there is no guarantee that stopping or reducing drinking will reduce risk anyway- no one has ever done that study and they’re not likely too either. But we can do a very rough and ready calculation with the absolute numbers.

How about if we do something as simple as reduce the current age-related risks by 4%?

Of course, these numbers wouldn’t make quite such impressive headlines. But it’s a pity that the authors, the journal, or the newspaper haven’t made any referral to absolute risk at all.

Seitz, H., Pelucchi, C., Bagnardi, V., & Vecchia, C. (2012). Epidemiology and Pathophysiology of Alcohol and Breast Cancer: Update 2012 Alcohol and Alcoholism DOI: 10.1093/alcalc/ags011