Presenting a medical topic to
colleagues
Wim Willems
Craiova, September 2011
Program
• Who is everybody?
• What makes a medical presentation good / what
makes it bad?
• A medical program: carpal tunnel syndrome
• Rules & take home messages
What makes a training good / bad?
• Tell your colleagues about a training / seminar that
was really bad and didn’t teach you anything. Why
was it bad?
• Tell your colleagues about a training / seminar that
was really good and educational. Why was it good?
Rule 1 – avoid boredom
Rules to avoid boredom
• Keep it small
• Start with the needs of the group
• Use the knowledge that the group has already
• Be interactive (little groups, avoid monologue)
• Change methods (presentation, quiz, case history,
discussion regarding statements, skills)
Rules to avoid boredom
• Keep it small
• Start with the needs of the group
• Use the knowledge that the group has already
• Be interactive (little groups, avoid monologue)
• Change methods (presentation, quiz, case history,
discussion of statements, skills)
Keep it small
Carpal tunnel syndrome
Start with the needs of the group
• What do you want to know?
What do Dutch GP’s want to know?
• Is it necessary to perform an EMG to establish the
diagnosis CTS ?
• Is it necessary to have positive tests like Tinel,
Phalen etcetera ?
• Are injections with corticosteroids helpful ?
• Can I give an injection with corticosteroids myself ?
What dosage should I give? How can I do this
safely ? How often can I do this ?
Quiz 1
• Mrs A, 53 years old, complains of nightly tingling in
her right hand which wakes her up. When you
examine her you find nothing abnormal. The tests of
Tinel and Phalen are negative.
Mrs A has no carpal tunnel syndrome
Correct / Incorrect
Quiz 2
• Mrs A, 53 years old, complains of nightly tingling in
her right hand which wakes her up. You refer her for
an EMG: this is negative (no nerve conduction
abnormality).
Mrs A has no carpal tunnel syndrome
Correct / Incorrect
Quiz 3
Where is the carpal tunnel ?
“Painful nightly tingling”
• Female, 52 years
• Wakes up in the early morning with painful tingling
in the hand (thumb / index)
• Flapping of hand eases complaints
Carpal tunnel syndrome
•
•
•
Female, 52 years
Wakes up in the early morning with painful tingling in the hand (thumb / index)
Flapping of hand eases complaints
What do you do in Romania?
Carpal tunnel syndrome
Epidemiology
Open population (history + nerve conduction
examination):
– Female: 9 %
– Male: 0,6%
– Peak between 40-60 year
Risk factors
 Weight
 Pregnancy
 Diabetes mellitus
 Hypo/hyperthyreoidy
 Ovariectomy
 Anatomic deviation (traumatic / RA / congenital)
 Work related
Natural course
• ¼ - 1/3 significant improvement > 1 year
• After pregnancy 50% without complaints
Pathofysiology
• Narrow tunnel
• compression n.
medianus in carpal
tunnel
• 90% idiopatic
Diagnosis = history !
Dutch consensus (CBO 2006) / guideline NHG
2009:
•
•
•
•
•
•
Nightly tingling
Median nerve area
Sleep disturbance
Other tingling / pains
Flapping (Flick sign)
Advanced stages: tingling during the day
Sensory innervation N. Medianus
Atypical localisations tingling
sensations
• Often outside median
nerve area
• Sometimes ulnar
nerve area
Provocation tests:
CBO 2006 / NHG 2009:
Limited usefulness
Diagnostic tests CTS
test
sensitivity
specificity
Tinel
0.25-0.60
0.64-0.89
Phalen
0.10-0.91
0.33-0.86
Flick sign
0.93
0.96
Square wrist sign
0.47-0.69
0.73-0.83
Pressure
provocation test
0.28-0.63
0.33-0.74
Tourniquet test
0.21-0.51
0.36-0.87
Tests
• Tinel:
percussion median nerve
• Phalen: flexion during 60 seconds
• Further: -sensory loss median nerve area
-thenar dystrophy
-dry skin (thumb / index / middle
finger)
Neurophysiological examination
• Verification of clinical diagnosis prior to
operation
EMG
sensitivity
specificity
60-82
95-100%
Limitation EMG:
• No golden standard
• 10-15% false negative
• No relation between complaints and
results
• Results not predictive for therapy
• Value unclear for primary health care
Treatment
Splint
• Day and night
• Short term effective
• Minor complaints /
recent onset
Surgery:
• Highly effective
• Major / recurrent complaints.
Patient’s wish
• Open / endoscopic
• Success: 75-90%
• Complications: damage to
nerve, pain, scar, complex
regional pain syndrome)
Corticosteroid injection
• Short term effectiveness +
• 50% without complaints after one year
• Diagnostic use?
Referral
• Insufficient reaction to symptomatic treatment
(2 injectons)
• Common sense
• Diagnostic uncertainty
• Severe complaints
Corticosteroid injection
•
•
•
•
Several techniques
Safe
Effective
Tradition / experience / authority determines
technique
Medicament / Dosage
• Most common: Triamcinolonacetonide 10 mg/ml
(Kenacort® A10), or methylprednisolonacetaae
(Depo-Medrol®) 40 mg/ml
• Volume: 1-2ml
• Interval between injections: 1-3 weeks
• Effectiveness: 1st injection 80%, after 2 injections
15%, after 3 injections 5%
Needle?
-orange/ light brown (0,45x23mm)
-light blue (0,5x25mm)
-green (0,8x40mm)
Localisation carpal tunnel
Os pisiforme
Os
scaphoideum
m. Palmaris longus
Tendon m. Palmaris longus
• Absent tendon:
ulnar to median
axis
Localisation insertion
•
3
ulnar to tendon m.
palmaris longus
3-4 cm before distal wrist
line
Injection underneath retinaculum
• Angle 30 degrees
Hygiene
• Wash hands, wear gloves or disinfect
fingers
• Once-only ampoules
• Change needles
• Disinfect skin
Side effects and complications
• Side effects
-flushing: 1 day after injection
-steroid-flare 24-48 hours
-menstruation problems
-hyperglycemia
-locale effects: redness, atrophy fatty tissue,
hypopigmentation
• Complications
-very rare, case-reports
-tendon ruptures, median neuritis (CTS), local
infection
Take home messages
• Organize and prepare your own training for yourself
and for your colleagues
• Keep it small
• Try to answer only questions that have immediate
consequences for your everyday practice
• Do it yourself – specialists can tell you only what is
important to them
Take home messages
• Organize and prepare your own training for yourself
and for your colleagues
• Keep it small
• Try to answer only questions that have immediate
consequences for your everyday practice
• Do it yourself – specialists can tell you only what is
important to them
Take home messages
• Organize and prepare your own training for yourself
and for your colleagues
• Keep it small
• Try to answer only questions that have immediate
consequences for your everyday practice
• Do it yourself – specialists can tell you only what is
important to them
Take home messages
• Organize and prepare your own training for yourself
and for your colleagues
• Keep it small
• Try to answer only questions that have immediate
consequences for your everyday practice
• Do it yourself – specialists can tell you only what is
important to them
Take home messages
• Organize and prepare your own training for yourself
and for your colleagues
• Keep it small
• Try to answer only questions that have immediate
consequences for your everyday practice
• Do it yourself – specialists can tell you only what is
important to them
Material
• www.hovumc.nl/gp
• www.nice.org.uk
• www.cks.nhs.uk/home
Did you see this? Did it work?
• Keep it small
• Start with the needs of the group
• Use the knowledge that the group has already
• Be interactive (little groups, avoid monologue)
• Change methods (presentation, quiz, case history,
discussion regarding statements, skills)
Va Mulţumesc, la revedere