Effective Medical Presentations and Trainings

1. Wim Willems Craiova, September 2011 Presenting a medical topic to colleagues

2. Program Who is everybody? What makes a medical presentation good / what makes it bad? A medical program: carpal tunnel syndrome Rules & take home messages

3. What makes a training good / bad? Tell your colleagues about a training / seminar that was really bad and didnt teach you anything. Why was it bad? Tell your colleagues about a training / seminar that was really good and educational. Why was it good?

4. Rule 1 avoid boredom

5. 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)

6. 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)

7. Keep it small Carpal tunnel syndrome

8. Start with the needs of the group What do you want to know?

9. What do Dutch GPs 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 ?

10. 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

11. 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

12. Quiz 3 Where is the carpal tunnel ?

13. 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

14. 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?

15. Carpal tunnel syndrome

16. Epidemiology Open population (history + nerve conduction examination): Female: 9 % Male: 0,6% Peak between 40-60 year

17. Risk factors Weight Pregnancy Diabetes mellitus Hypo/hyperthyreoidy Ovariectomy Anatomic deviation (traumatic / RA / congenital) Work related

18. Natural course - 1/3 significant improvement > 1 year After pregnancy 50% without complaints

19. Pathofysiology Narrow tunnel compression n. medianus in carpal tunnel 90% idiopatic

20. 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

21. Sensory innervation N. Medianus

22. Atypical localisations tingling sensations Often outside median nerve area Sometimes ulnar nerve area

23. Provocation tests: CBO 2006 / NHG 2009: Limited usefulness

24. 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

25. Tests Tinel: percussion median nerve Phalen: flexion during 60 seconds Further: -sensory loss median nerve area -thenar dystrophy -dry skin (thumb / index / middle finger)

26. sensitivity specificity EMG 60-82 95-100% Neurophysiological examination Verification of clinical diagnosis prior to operation

27. 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

28. Treatment

29. Splint Day and night Short term effective Minor complaints / recent onset

30. Surgery : Highly effective Major / recurrent complaints. Patients wish Open / endoscopic Success: 75-90% Complications: damage to nerve, pain, scar, complex regional pain syndrome)

31. Corticosteroid injection Short term effectiveness + 50% without complaints after one year Diagnostic use?

32. Referral Insufficient reaction to symptomatic treatment (2 injectons) Common sense Diagnostic uncertainty Severe complaints

33. Corticosteroid injection Several techniques Safe Effective Tradition / experience / authority determines technique

34. 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: 1 st injection 80%, after 2 injections 15%, after 3 injections 5%

35. Needle? - - orange/ light brown (0,45x23mm) -light blue (0,5x25mm) -green (0,8x40mm)

36. Localisation carpal tunnel Os pisiforme Os scaphoideum

37. m. Palmaris longus

38. Tendon m. Palmaris longus Absent tendon: ulnar to median axis

39. Localisation insertion ulnar to tendon m. palmaris longus 3-4 cm before distal wrist line 3

40. Injection underneath retinaculum Angle 30 degrees

41. Hygiene Wash hands, wear gloves or disinfect fingers Once-only ampoules Change needles Disinfect skin

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. Material www. hovumc.nl/gp www.nice.org.uk www.cks.nhs.uk/home

49. 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)

50. Va M ulumesc, la revedere