Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact
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About Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact

VTE Dublin 2015

VTE Dublin Header

This is a brief heads up about a new conference coming in Dublin, Friday 18th – Saturday 19th September 2015.

My current hospital as a venous thromboembolism working group (which I am nominally a part of) consisting of the whole gamut of specialties involved in the diagnosis and management of VTE. From the ED to the long term haematology follow up we have it all and everything in between.

We have some really smart and passionate people involved, so much so they’re planning the VTE Dublin 2015 conference.

The speakers come from a wide variety of backgrounds including the vascular medicine specialists who seem to “own” the disease in Europe. If you read the literature you’ll recognise a lot of the names on the programme, it’s a bit of a who’s who in VTE. Perhaps the most familiar name to an EM audience is that of Prof Wells, of the Wells score fame.

It’s looking like a great conference so check it out and the programme and book your place. We’re also on twitter so follow for all the updates

 

VTE Dublin Programme

[DOI: I am a tiny part on the planning committee and will receive some remunerating from developing the website (slowly…)]

Anatomy for Emergency Medicine 032: CFN Eye Anatomy Part 3

This is the third of a series of podcasts I’m doing on basic eye anatomy for the CEM FOAMed Network. This is a developing resource which aims to provide a fully mapped college curriculum with FOAMed resources. Be sure and check it out and get the podcast. This podcast went out a while ago on the CFN and I’m just providing it for everyone else who hasn’t got it already.

The single most important resource you need is Ophthobook.com

Part 1

Part 2

Tasty Morsels of EM 052 – Rheumatic Fever and the Jones Criteria

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

This is something you’re very unlikely to diagnose in Ireland. The real reason for including this is it seems to be a favourite exam question and I put it here in the hope that I’ll remember it. I did look after a couple of kids with ARF when I was in NZ in 2007 but that’s it.

As an acute illness you’re hoping to see

  • kid aged 5-15
  • Migratory Arthritis
    • usually the earliest manifestation
    • usually large joints
    • one joint just settling while another one flares up. Usually over a 2 week period or so
  • Carditis (a poker overuse syndrome?)
    • usually called a pancarditis cause it can affect everything from valves to myocardium
  • Sydenham chorea (nothing to do with the Sydenham bypass apparently…)
    • sometimes called St Vitus’s dance. See this video.
  • Rash
    • Erythema marginatum
    • serpinginous (what a word!) bright pink macules
    • apparently hot water (bath or shower) could make the rash worse
  • Subcutaneous nodules
    • small round and painless over the joints

These are summarised in the Jones criteria:

  • Major
    • Arthritis
    • Carditis
    • Chorea
    • Rash
    • Nodules
  • Minor
    • Fever >38
    • Arthralgia
    • ESR/CRP rise
    • Prolonged PR interval (without other carditis)

Two major criteria nails it or one major and two minor.

More FOAMed Resources:

Featured Image:

  • Painting by Pieter Brueghel the Younger on Wikipedia CC License. Of note it comes from a wonderful article called ‘dancing mania’.

Tasty Morsels of EM 051 – Spondyloarthropathy

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. This one from a recent training day with a rheumatologist. Some is literature based some his good old fashioned doctoring and experience.

  • can be axial (think ank spond) or peripheral (think psoriatic)
  • most important ones
    • ankylosing spondylitis
    • reactive arthritis (formerly Reiter’s)
    • arthritis of inflammatory bowel disease (enteropathic arthritis)
    • psoriatic
  • enthesitis (tendons or ligs into bone) and dactylitis are distinctive features
  • lots of systemic features/associations
    • uveitis
    • skin rash
  • For ank spond MRI will show the SI joint changes so much earlier than plain films and you’re likely wasting your time with plain films (my own opinion on that one)
  • NICE Guidelines suggest diagnosis of ank spond based on radiological and clinical evidence. Beware of unilateral sacroilitis as it’s often infective (esp IDU)
  • Psoriatic
    • nail disease v common
    • back pain, dactylitis and enthesitis all common
    • psoriatic skin changes prior to the arthritis in 60%

 

References:

  • Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
  • Rosen’s 8th Edition Chap 115

 

Featured image:

Tasty Morsels of EM 050 – Rheumatoid arthritis

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. Some of this morsel is straight advice from a local rheumatologist rather than strict EBM.

  • commonest presentation
    • middle aged female with multiple small joints
    • remember that if symptoms less than 6 weeks then it’s usually one of many viruses
  • there are formal diagnostic criteria
    • heavily weighted on number of joints involved and some of the tests
    • >6 weeks duration is on the criteria
  • 10% of healthy population has pos rheumatoid factor.
  • Swollen joint much more diagnostically useful than simple painful joint
  • anti CCP the big new test. Very specific test but not sensitive
  • Rheumatoid in general carries increased CV risk never mind the NSAID use

Treatment pearls

  • flare of known RA
    • steroids depomedrone 80mg IM or 40mg oral for a week
    • NSAIDs – remember naproxen is the only one with low CV risk
  • mouth ulcers on methotrexate?
    • change to nightly dose
    • double up on folic acid dose
  • abnormal LFT on methotrexate?
    • ALT is usually first to rise, if continuing to rise at 2 weeks consider stopping
  • abnormal FBC on methotrexate?
    • neuts <1.5 then stop drug.
    • it was suggested that MTX be held in all infections needing antibiotics even when WCC is normal
  • Long term steroids are rarely appropriate any more – if you find someone floating around on long term steroids from 15 yrs ago the they’ve probably been lost to follow up and it’s worth referring them again.

 

References:

  • Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
  • Rosen’s 8th Chap 116

Featured Image: James Heliman MD, CC License, Wikipedia