Rural Forum @ Harrogate


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Rural Forum @ Harrogate

  1. 1. B8 Rural Forum
  2. 2. “something hungry is about to hatch” the emerging threat of tick-borne disease in the UK Richard Birtles Infection Biology Group, University of Liverpool National Centre for Zoonosis Research
  3. 3. ticks in the UK, Europe and around the world o ticks are second only to mosquitoes as vectors of pathogens of medical and veterinary importance. o in UK, Europe and across the temperate northern hemisphere, ticks of the genus Ixodes are widespread and are vectors of numerous pathogens.
  4. 4. ticks in the UK o Ixodes ricinus, the sheep or deer tick, feeds on most mammals/birds, is widespread in the UK and is the most frequent biter of humans o other Ixodes species also present in UK; these species have a far more limited host range, but some will also bite humans.
  5. 5. tick abundance in the UK is on the rise o the distribution of Ixodes ricinus has expanded by 17% in comparison with the previously known distribution. o people perceive there to be more ticks today than in the past at 73% of locations studied. o reported increases in tick numbers coincided spatially with perceived increases in deer numbers. Scharlemann JP et al. Trends in ixodid tick abundance and distribution in Great Britain. Med Vet Entomol 2008;22:238-47.
  6. 6. deer (tick host) abundance in the UK is on the rise Roe deer bag density (number shot per 100 hectares) synoptically by county and by decade from 1960 to 1999. Source: Game & Wildlife Conservation Trust
  7. 7. incidence of tick-borne diseases in the UK is also on the rise England & Wales (HPA) year number of LB cases Scotland (HPS)
  8. 8. tick-borne pathogens in the UK agent disease medical/veterinary relevance in UK Borrelia burgdorferi lyme borreliosis 2,000+ human cases p.a. Disease also reported in companion animals & horses. Anaplasma granulocytic anaplasmosis, Major pathogen of young sheep, also reported phagocytophilum pasture fever, tick pyaemia in companion animals & horses. No human cases (yet). c1,000 human cases p.a. in New England. Babesia spp. Babesiosis B. divergens causes redwater fever in cattle. No known medical relevance. louping ill virus louping ill Major pathogen of young sheep, also reported in horses. No human cases. Close relative of tick- borne encephalitis virus.
  9. 9. clinical manifestations of lyme borreliosis syndrome manifestation erythema migrans expanding red/blue-red patch, with /without (v common) central clearing - advancing edge typically distinct. lyme lymphocytoma painless blue-red nodule (rare) acrodermatitis chronica long-standing red/blue-red lesions, atrophicans eventually becoming atrophic lyme neuroborreliosis meningo-radiculitis, meningitis, facial palsy lyme arthritis recurrent attacks or persisting joint swelling in one/few large joints lyme carditis (rare) acute onset AV conduction disturbances, myocarditis ocular disease conjunctivitis, uvelitis, … Stanek et al. Lyme borreliosis: clinical case definitions for diagnosis & management in Europe. Clin Microbiol Infect 2010
  10. 10. lyme borreliosis – long-term sequelae controversy Objective long-term sequelae o uncommon in properly treated patients o patients with neuroborreliosis may take weeks to months to fully recover – recovering patients may complain of neurasthenic symptoms o in some (<10%) patients with lyme arthritis, recovery may take several months o no evidence of better response to further antibiotic treatment Subjective long-term sequelae o some patients report ongoing, recurrent or persistent symptoms after appropriate treatment of proven LB = post-lyme syndrome. o symptoms include reduced performance, fatigue, irritability, distubances in sleep, concentration and memory o various control studies have failed to support the idea that persistence of borrelial infection is the cause of such symptoms o no evidence that further antibiotic treatment helps resolution Stanek et al. Lyme borreliosis: clinical case definitions for diagnosis & management in Europe. Clin Microbiol Infect 2010
  11. 11. diagnosis & treatment of lyme borreliosis o clinical diagnosis of erythema migrans, esp. with appropriate patient history. o serology is mainstay of lab diagnosis in UK – currently a 2 step approach, involving ELISA then Western blot. o PCR-based methods available, but not widely adopted. Not standardised, but good potential. o oral doxycycline recommended as first-line treatment for all non-neurological, & some neurological, presentations o intravenous ceftriaxone recommended for patients with some forms of neuroborrelosis
  12. 12. Borrelia burgdorferi sensu lato complex Borrelia garinii neuroborreliosis Borrelia afzelii acrodermatitis chronica atrophicans Borrelia burgdorferi sensu strictu arthritis Borrelia valasiana pathogenic?
  13. 13. when & where can you catch LB in the UK? region number of HPA: “The seasonal pattern in 2008 was cases in 2008 similar to that seen in 2007 and in earlier Wales 18 years. Approximately 60% of patients were tested in July, August and Yorkshire & 11 September; representing a likely peak of Humberside onset of symptoms in the early summer. East Midlands 13 This is consistent with the major tick West Midlands 34 feeding period which occurs in the late spring and early summer months. 22% of North West 55 blood samples were received and tested North East 16 during the last quarter of the year, again London 101 consistent with exposure to ticks and 'ticky' environments in the late summer South West 310 and early autumn”. South East 218 East Anglia 35
  14. 14. “where there are ticks there is lyme borreliosis” I. ricinus distribution
  15. 15. “where there are ticks there is lyme borreliosis” no ticks <1% ticks infected >5% ticks infected
  16. 16. “where there are ticks there is lyme borreliosis” Mell Fell, nr Keswick Mabie Forest Dumfries Dalby Forest, Pickering Hampsfell Wood Grange over Sands no ticks <1% ticks infected >5% ticks infected
  17. 17. public awareness of the threat of lyme disease
  18. 18. “where there are ticks there is lyme borreliosis”? B. garinii & B. valasiana only B. garinii, B. valasiana & B. afzelii
  19. 19. summary o the medical importance of tick-borne disease in the UK is becoming increasingly apparent. o climate change is likely to favour ticks. o TBE is progressing north and west across Europe, but is not here yet. o clinical case definitions have been refined and laboratory diagnostics are improving. o we understand little about the ecology of tick- borne pathogens and thus have no idea how to control them.
  20. 20. Pre-hospital Care in Scotland – Today and Tomorrow Colville Laird
  21. 21. BASICS – The Start Dr Ken Easton
  22. 22. Rescue Emergency Care • Published 1977 • Ken Easton
  23. 23. Training courses
  24. 24. Growing demand
  25. 25. Central Funding
  26. 26. Current Situation • 350 course places/year funded • 16 courses / year • Immediate care courses, Emergency Medicine courses, Paediatric pre-hospital care. • Major Incident training – Pre–hospital and In- hospital
  27. 27. Faculty of Pre-hospital Care PHECC Diploma Fellowship
  28. 28. Sub-specialty Recognition Sub-specialty of Pre-hospital Care and Retrieval Medicine.
  29. 29. The Sandpiper Trust
  30. 30. Funding • Education – provided by NHS • Equipment – Sandpiper trust • Consumables – Depends on location • Payment – Depends on location.
  31. 31. New GP Contract • No longer 24 hr responsibility- ? Availability • Funding ??
  32. 32. Historical - Pre-hospital Care • General Practice provided • No Paramedics • Change to ambulance service responsibility • Funding difficult • New GP Contract • Callout difficult
  33. 33. Vehicle Location Systems
  34. 34. Airwave radios
  35. 35. Patient Report Forms BASICS Scotland Patient Report Form Surname Date First name SAS inc. no Address or Age Time of call locus Sex M F Time on scene D of B Time clear RTC Other trauma Medical Other INITIAL ASSESSMENT – POTENTIAL PROBLEMS Record as ‘Y’, ‘N’ or ‘?’ 1y survey problems ? A B C Initial AVPU/GCS_______ C spine Back Head Chest Initial Sp02 _______ Pelvis # Abdo Femur R L History/additional info/drugs given # Interventions performed Bas A - O2 Suction Positioning NPA x1 x2 OPA Adv A - LMA igel ETT Needle-cric Surgical airway B - B+M Ventilated PTx-decomp Ch Drain Chest seal C - IV access IO-needle EZ-IO Tourniquet MAST D - Collar Full-Immob Vacc matt Pelvic splint Fluids given________________________________ Airway problem? Other - Please complete online airway survey! Entrapped? Y / N Extrication time Usual Meds Discharged at scene / Admitted – PCEC / A+E / Wd______ / Other Allergies Time Pulse R/R BP Sp02 C Refill GCS/AVPU Other (temp/BM) E M V E M V E M V Cardiac arrest Initial rhythm VF/pVT Asystole PEA DoA/DoS Prior CPR No of shocks Notes_______________ Time/date certified Drugs given Epinephrine ____ Atropine____ Amiodarone____ Police PF Other Rx GP informed Name Other info Time to RoSC/D Died / survived SAS crew details F.o.S. S.M.C. Helimed F.R. Working assessment E.M.R.S No P/Med R.A.F. H.M.C GP Name/ID ID code R.N.L.I. M.R.T.
  36. 36. EZ-IO
  37. 37. SAM Pelvic Sling
  38. 38. Pulse oximeters • Currently testing • Need to work in sunlight • Need to be used in children
  39. 39. Surgical Airway Changing to 6mm cuffed tube
  40. 40. Tranexamic Acid • 1 over 10 mins, then 1g over 8 hrs • 1g costs £3 ( BNF ) •Watch this space
  41. 41. National Audit Office "Current services for people who suffer major trauma are not good enough. There is unacceptable variation, which means that if you are unlucky enough to have an accident at night or at the weekend, in many areas you are likely to receive worse quality of care and are more likely to die. The Department of Health and the NHS must get a grip on coordinating services through trauma networks, on costs and on information on major trauma care, if they are to prevent unnecessary deaths." Amyas Morse, head of the National Audit Office, 5 February 2010
  42. 42. Emergency and Urgent Response To Remote and Rural Communities Strategic Options Framework October 2009 Report By: Mrs Fiona Grant Remote and Rural Programme Manager REMOTE AND RURAL IMPLEMENTATION
  43. 43. Emergency and Urgent Response To Remote and Rural Communities Strategic Options Framework October 2009 3 level of response • Level 1- CPR capability within the general public • Level 2 – Retained Ambulance service and Allied Health professionals • Level 3 – Community practitioners including GPS, community nurses and Paramedics.
  44. 44. Summary • On-going Education programme • Education – evidenced based and Educational Governance in place • Equipment • Evidenced based equipment improvement • Activity monitoring • National recognition of role in rural Emergency care
  45. 45. Emergency Medical Retrieval Service
  46. 46. Questions
  47. 47. The RCGP Rural Forum Annual Report Harrogate conference 2010 Dr Malcolm Ward
  48. 48. RCGP Rural Practice Standing Group The Rural Practice Group was founded in 1993 to raise the profile of rural medicine in the United Kingdom through education, research and the dissemination of good practice in rural health care.
  49. 49. The Rural Forum is born • February 2009 UK Council votes against NG Faculty (33:17) • Voted for Rural Forum: (44 for, 0 against, 5 abstentions) • Launch Glasgow November Conference 2009
  50. 50. Overall aims of the Rural forum • To represent rural and remote general practitioners within the RCGP with the potential to promote rural issues within and outwith the College faculties and be the rural face of the College • To encourage engagement with the College of those fellows/members working in rural practice. • To facilitate communication between and networking of rural doctors across the UK. • To support the professional development of rural general practitioners, with particular reference to the required knowledge, skills and attitudes of a general practitioner to care for patients in a rural setting. • To promote rural practice and support associates in training with particular reference to the required knowledge, skills and attitudes. • To promote rural practice as a career path for associates in training and through the College strive to ensure availability of appropriate training. • To promote remote and rural issues at appropriate level, engaging with the profession, managers and informing political debate. • Democratic infrastructure
  51. 51. Membership benefits • Belonging to a Forum which specifically represents the interests of rural practitioners in the care of their patients at all levels. • Once a Forum membership/constituency is established a democratic representative structure can be created. • A virtual system of communication via E-communication and web based facilities. • Opportunity to comment on, and influence College policy. • Opportunity to influence College interaction with other relevant agencies where their policies and initiatives may impact upon rural healthcare. E.g. SAS consultation, Scottish OOH consultation • E-learning: sign posting, rural modules, ?CD-ROM option
  52. 52. Achievements?
  53. 53. HQ Mrs Paula Lythgoe Rural & Remote Administrator • RCGP Cumbria Faculty Education Centre West Cumberland Hospital Telephone No: 01946 Whitehaven Cumbria 590169 CA28 8JG Fax No: 01946 692904 E-mail Address: ruralforum •
  54. 54. Democracy RF Steering Group Election
  55. 55. Retiring members: • John Elder (Lincs) • Paul Kettle (Orkney) • Susan Taylor (RPAS)
  56. 56. Incoming members • Angharad Edwards (Wales) • Kristian Mears (England) • Steve McCabe (Portree, Scotland)
  57. 57. Steering Group 2010-2011 Elected Co-opted • Chris Clarke (Devon) • Aidan Egleston (DDA) • A Edwards (Wales) • David Hogg (First 5) • Rob Lambourne • ? (AiT) (Cumbira) • Jayne Randall-Smith • Krystian Mears (IRH) • Malcolm Ward (Derbysh’) • Russell Walshaw (GPC) • John Wynne-Jones (Powys,Wales)
  58. 58. RFSG: How we work • Email: weekly to daily • Small group Skype sessions • Teleconferencing • Face to face: 3 per year
  59. 59. Revalidation: concerns of rural practices: Discussions with College and GMC 1. Multi source feedback (MSF) 2. Clinical audits 3. Significant Event Auditing (SEA) 4. Learning Credits.
  60. 60. Phased introductory requirements Evidence Yr 1 (2010-11) Yr 2 (2011-12) Yr 3 (2012-13) Yr 4 (2013-14) Yr 5 (2014-15) Role Yes Yes Yes Yes Yes description Exceptional Yes Yes Yes Yes Yes circumstances Evidence of one two three four five appraisals PDPs one two three four five PDP reviews - one two three four Learning 50 or CPD 50 100 150 200 credits MSFs - 0ne MSF OR one one two Patient - one PS one one two surveys Review of Yes Yes Yes Yes Yes complaints from 2009/10 SEAs one two three four five Clinical audits - one one two two Probity/Health Yes Yes Yes Yes Yes statement
  61. 61. Responding to consultations • Scottish Ambulance Service: “Our future strategy” • “Your choice of GP practice” (practice boundaries) • GMC Revalidation • Control of Entry regulation Scotland • The White Paper: “Commissioning for patients” •
  62. 62. Networking with other agencies • College hierarchy • GPC • GMC • IRH • RPAS • Euripa • DDA • BASICs
  63. 63. Rural Forum web page
  64. 64. Rural blog: ruralgpgooglegroup • Independent of RCGP but • Independent of RCGP RF associated but RF associated • Rural GP resource and • Popular discussion forum central portal to other for rural GPs resources
  65. 65. What’s changed? • cleaner design • - quicker to load • - easier to manage • - more info on career advice - with more to come • - previously was prohibited by some NHS firewalls - this should be less of a problem
  66. 66. Membership • England – 209 members • Northern Ireland – 11 members • Scotland – 125 members • Wales – 31 members • 7 international members Total: 383
  67. 67. Membership The Rural Forum is open to all RCGP Members, Fellows, and Associates in Training who declare an interest in rural general practice and signal their wish to join.
  68. 68. You need the Rural Forum and the Rural Forum needs you!