MJM Wardrounds

Wardround 2xii11

2011-12-02T14:22:00.001Z

Our Topic for discussion this week was Driving and Medical illness with regard to the DVLA medical regulations. It was instructive to look how these would impact on patients on the ward.

One way to bring driving history into our routine assessments is to regard driving as part of our ambulation/motility questions. If it is missed during initial clerking it should then come up as we approach discharge planning.

The DVLA has its at a glance guide which can be easily assessed but a good aide memoire for fitness to drive at patient.co.uk.

I missed the discussion about avoiding finding yourself out of your depth, but hope it stimulted some thought.

For Next Week:

Tuesday, please read the consensus document for the use of dabigatran in atrial fibrillation available from the Health Improvement Scotland website. You may find it useful to refer to the SMC detailed advice document to which their is a link on the same page.

Friday's two minute talks are on common tests. Please choose between d-dimer, troponin, CRP and choose another if there are enough people. We need to know when to use them and how to interpret them given the hard facts about their accuracy etc.

Interesting papers:

Can we reverse Factor Xa inhibitors

MJM

Wardround 25xi11

2011-11-25T14:34:00.002Z

Reading for Tuesday

How to Handle Being Out of Your Depth: 6 Tips from a Con Man
Can be found on website www.artofmanliness.com

Two minute talks for Friday

If each of the patients on today’s wardround had asked “can I drive when I go home?” what would be the answer?

Have a look at the DVLA guidance on driving and tell us what you have learned

Clinical Question

How common are serious infusion reactions with Infliximab and how should they be managed?

Review and Expert Opinion on Prevention and Treatment of Infliximab-related Infusion Reactions. Medscape. LLA Lecluse, et al

Audit question

If patients have a condition that would require advice on driving has that advice been recorded in the case notes. Had a driving history been taken?

MJM

Have you fallen? Not a question of morals.

2011-08-19T14:07:00.003+01:00

An interesting set of talks about nosocomial illness. I liked the Falls in Hospital handout: Simple, clear, no waffle. We have agreed that "have you had any falls" should be a routine question. I tend to put it in the neurology section of systems review.

It was good to see our local data for C. difficile. Always good to include local information in a talk. SS will read one of the C. Difficile ICP sheets.

Next Friday's topic is Electrolyte disturbance. Research, cogitate and give the group two minutes on one of the topics below. Clarity, practicality and memorability (for the right reasons) will be assessed.

Sodium
Potassium
Calcium
Magnesium

The reading for Tuesday is Mistakes. R Lesnewski. JAMA 2006: 296 (11); 1327-8

Monday's Audit: Have you fallen?

Interesting topics

Ecthyma Gangenosum
Staphylococcal infection
Amiodarone Lung
Campylobacter

MJM

Glucocorticoid adverse effects

2011-08-12T13:35:00.002+01:00

Our topic today was adverse effects of glucocorticoids. These are commonly used drugs with significant adverse effects. If we wish to limit unwanted effects we need to know how common they are, harness patient's concerns to help us and have a plan for when we use steroids.

Your talks showed that you had put effort into researching the topic, but there needs to be a little more planning on the presentation side. The time allowed means that you have to be concise, and to make it sharp you must always be precise. Numbers (10%) not descriptors (quite common). List your sources on the handout so the audience can follow up if they want to.

Here are some useful papers. The links are to abstracts but the full versions are only a password away via ATHENS.

Monitoring adverse effects of low dose glucocorticoid therapy: EULAR recommendations for clinicalk trials and daily practice. MC van der Goes et al Ann Rheum Dis 2010;69:1913-1919

Epidemiology of glucocorticoid-assoiated adverse events. AK McDonough et al. Curr Opin Rheumatol 2008 Mar;20(2):131-7.

Patients’ and rheumatologists’ perspectives on glucocorticoids. MC van der Goes et al. Ann Rheum Dis 2010;69:1015-1021.

The acronym below which is an aide-memoire for reducing adverse drug effects in general. Apologies to its author, who I can't remember, but I first heard it at a meeting about 5 years ago.

S...Stratify: is the patient at higher risk of an ADR: comorbidities, drugs, age.
A...Assess: Hepatitis status, TB risk, vaccinations up to date?
F...Fend-off: vaccinate, optimise health (stop smoking etc).
E...Evaluate: check what ADRs might be expected, look for them.
T...Treat: nip it in the bud (UTI is easier to treat than septic multi-organ failure).
Y...Yearly: re-evaluate all of the above regularly. The frequency depends on the drug.

The topic for next Friday is Nosocomial illness:

Falls
C. Difficile
MRSA
Line infections

Two minutes please. Be concise yet precise. Tell us your sources. you are allowed an A4 (single side) handout.

Audit standard for next week. All casenote sheets have the patient's name and CHI.

MJM

11viii11

2011-08-11T15:19:00.005+01:00

The two minute tutorials for Friday are focused on the adverse effects of corticosteroid therapy:

General overview
How to work up a patient prior to treatment
How to assess a patient on treatment
What are patient's views on steoid side effects

Tuesday's read and think will be A 76-Year-Old Man With Multiple Medical Problems and Limited Health Literacy. Amy Ship. JAMA August 10 2011.

Interesting topics

Illiteracy in rheumatoid arthritis patients as determined by the Rapid Estimate of Adult Literacy in Medicine (REALM) score. Gordon et al. Rheumatology (2002) 41 (7): 750-754

It's Good to Feel Better But It's Better To Feel Good and Even Better to Feel Good as Soon as Possible for as Long as Possible. Response Criteria and the Importance of Change at OMERACT 10. V Strand et al. J Rheumatol August 2011 38(8):1720-1727

MJM

It starts again: August 2011

2011-08-03T11:31:00.004+01:00

Welcome to Ward 10. I hope you will both enjoy your stay with us and make the most of it. Learning does require a little effort but hopefully we can help each other by sharing the task.

The two minute tutorial topic for Friday is The Normal ECG. I would like you to choose amongst yourselves from: P wave, QRS complex, T wave, PR interval, Axis. The goal is for us to be able to recognise a normal ECG. You are limited to two minutes. Be precise yet concise and tell us your sources.

The paper to read, digest (intellectually) and then discuss on Tuesday is The Road to Recovery, by David Psetsky.

We usually have a weekly topic for audit, but we can choose our first topic on Friday.

There are at least two on-going audits of which you should be aware:

Antibiotic use is checked against local guidance (available on the intranet and due to be updated any day). It is important that the correct empirical antibiotic is chosen or the reason for chosing an alternative is clearly stated in the case notes or prescription kardex. The indication and expected duration of treatment or review date should be recorded.

We audit the recording of DNA-CPR and ceiling of care weekly (well you do).

Interesting papers:

Paracetamol, ibuprofen, or a combination of both drugs against knee pain: an excellent new randomised clinical trial answers old questions and suggests new therapeutic recommendations.

PS the links in the frame on the left are mostly inactive at present, awaiting my guiding hand.

MJM

Interesting Publication

2011-01-12T08:41:00.002Z

EXPERT CONSENSUS DOCUMENT
ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use

There is a brief comment in JAMA 2011;305(2):135-136.

Welcome to 2011

2011-01-12T08:39:00.001Z

My Work related NYR for 2011 is to reanimate this blog. Wish me luck.

MJM

Reading for Tuesday 31viii10

2010-08-25T13:21:00.001+01:00

RANDOMISED TRIAL OF INTRAVENOUS STREPTOKINASE, ORAL ASPIRIN, BOTH, OR NEITHER AMONG 17 187 CASES OF SUSPECTED ACUTE MYOCARDIAL INFARCTION: ISIS-2.

The Lancet, Volume 332, Issue 8607, Pages 349 - 360, 13 August 1988

Why have I chosen this paper.

MJM

16viii10

2010-08-16T14:17:00.002+01:00

The reading for Tuesday 24th will be Assessing a learning disabled patient's capacity to manage his own care and make important decisions. Read the material and share your thoughts with the team.

Friday 2oth two minute talks are on the topic of cellulitis: epidemiology; diagnosis; treatment (uncomplicated case); complicated cellulitis; recurrent cellulitis. Keep it concise yet precise. Quote your sources.

Pre-warning for Friday 27th because it might take a little more work...
Thucydides described of the plague of Athens, in 431BC in The History of the Peloponnesian War. If you click on the link it will take you to a copy of the piece. The web page begins with chapter VI, but you can skip down to chapter VII (unless you would like to read about the war). If you cannot find the right section, press ctrl-F and type in plague. The challenge is to make a diagnosis. You will have two minutes to make your case for the diagnosis of your choice. We will then have a chat about how you would manage the situation.

MJM

Wardround 11viii10

2010-08-11T21:13:00.002+01:00

The read and think for Tuesday is Communication discrepancies between Physicians and Hospitalized patients. DP Olsen, DM Windish. Arch Intern Med 2010: 170 (15); 1302-1307.

Two minute talks for Friday: Reducing adverse effects from:

NSAIDs

Glucocorticoids

Anticoagulants

Antibiotics

Statins

Pilot Audit for Monday:

DVT prophylaxis; standard=handbook.

Interesting Topics:

New classification criteria for Rheumatoid arthritis

Glioblastoma

GIFTASUP

MJM

Welcome to ward 10

2010-08-04T14:17:00.003+01:00

Welcome to your attachment on Ward 10

Farewell to the old guard and welcome to the new batch. Get ready to gorge yourself on fruit from the tree of knowledge.This blog will be a reminder of your training assignments each week. In addition to the departmental teaching sessions we have three ward based events:

1. Read & think :Each Tuesday there is a discussion of a subject or paper. I will usually set a paper but if you come across something which you believe we should read, I am happy to include it. Give yourself time to think.

2. Two Minute talks: each Friday you will give the team a talk on a subject you have researched that week. Again I will set the topics unless you come up with one yourselves. I am strict about the time and will not allow more than two minutes. Don't waste time telling us things that are obvious. Your talk can be illustrated with an A4 size handout which should be info-graphic rather than prose.

3. Morbidity and mortality meeting: monthly, I will give more info nearer the meeting.

Do read regularly and check your management against protocols and guidelines.

The paper to read for next Tuesday is Clinical craft: a lesson from Liverpool. DM Gore. Med. Humanit. 2001;27;74-75

The two minute talks this Friday will be medical emergencies: choose between yourselves from the following topics...

Anaphylaxis
Hyperkalaemia
Sudden loss of consciousness

If any other doctors are taking part they can choose from...
Sudden hypotension
Sudden hypoxia

Practice your talk, get the timing right, make it illuminating and tell us your sources. Have a look at this example handout... Anaphylaxis by Dr Hannah Gunn, or this slightly busier one on aspiration pneumonia by YT. The talk is more important than the handout so use your time appropriately. The trust blocks access to images but if you have internet access elsewhere you should be able to see them.

Next week we will start an audit of ..... HIV testing. Have a look at BHIVA guidelines for HIV testing 2008.

MJM

What's the diagnosis?

2010-02-09T22:52:00.000Z

The reading for Friday is a description of the plague of Athens, written in 431BC by Thucydides in The History of the Peloponnesian War. If you click on the link it will take you to a copy of the piece. The web page begins with chapter VI, but you can skip down to chapter VII (unless you would like to read about the war). If you cannot find the right section, press ctrl-F and type in plague. The challenge is to make a diagnosis. You will have two minutes to make your case for the diagnosis of your choice. We will then have a chat about how to manage the situation.

MJM

Something to read 5i10

2010-01-05T11:39:00.001Z

Medical Care for the Final Years of Life: "When You're 83, It's Not Going to Be 20 Years"

JAMA. 2009;302(24):2686-2694 (doi:10.1001/jama.2009.1871)
David B. Reuben

This is the first in a series....

Is this true in medicine?

2009-11-29T09:42:00.000Z

“Any truth is better than indefinite doubt… – Arthur Conan Doyle”

Something to read

2009-11-25T08:56:00.002Z

The Personal Equation in Medicine. JAMA. 2009;302(20):2265 reprinted from JAMA. 1909;53(22):1825-1826

Couldn't find it? !!!

2009-10-29T20:58:00.004Z

If you would like to read more, there is a good discussion of the approach to diagnosis in The cause of the plague of Athens: plague, typhoid, typhus, smallpox, or measles? Burke A. Cunha, Infect Dis Clin N Am 18 (2004) 29–43.

MJM

Making a diagnosis

2009-10-13T13:04:00.001+01:00

The reading for Friday 18th is a description of the plague of Athens, written in 431BC by Thucydides in The History of the Peloponnesian War. If you click on the link it will take you to a copy of the piece. The web page begins with chapter VI, but you can skip down to chapter VII (unless you would like to read about the war). If you cannot find the right section, press ctrl-F and type in plague. The challenge is to make a diagnosis. You will have two minutes to make your case for the diagnosis of your choice. We will then have a chat about how to manage the situation.

MJM

Pharmaceutical Sponsorship

2009-09-01T22:16:00.004+01:00

There is a suggestion that pharmaceutical companies sponsoring meetings should only be able to talk about drugs on the area formulary. What do you think about this? Do you think we should have sponsorship at all?

Have a read of The road to recovery. Is it time to bid farewell to the drug reps? by David Psetsky. It is on Medscape, but registration is both easy and free.

For the Friday meeting, those not presenting the case (and only one is doing that) are asked to give brief presentations on:
Benign Intracranial Hypertension
Aseptic meningitis related to drugs
Tuberculous meningitis
Herpes simplex encephalitis

Share them out between yourselves. I am looking for two minutes on the subject. Keep it concise and precise. No waffling. No powerpoint!

MJM

What's this?

2009-07-31T14:50:00.002+01:00

Welcome to Ward 10

2009-07-30T20:39:00.005+01:00

Welcome to Dumfries and Galloway. I will consider giving a prize to anyone who can identify where this picture is.

And welcome to the ward. You will find more information about your time on ward 10 by clicking here.

If you are reading this page in the hospital you will not be able to see the image above.

MJM

2vii9

2009-07-02T22:18:00.000+01:00

Summer Break....

Back for the new intake in August.

MJM

Wardround 5vi9

2009-06-07T18:55:00.007+01:00

The talks for Friday will be The use of serology in the diagnosis of:

Hepatitis B (ZB)

Hepatitis C (CM)

HIV (FY1)

Keep to the two minutes, drop the snippets of information that we already know and aim to leave your audience able to use serology appropriately in these situations. Remember to quote your sources. I am away on Friday, but will be testing the effects of the talks by asking some questions on the following Tuesday.

The paper to read for Tuesday will be Spellbinding and spellbreaking in convalescence<. George Day. Lancet 1961; 279 (7222):211-213. Log on to the NHS Scotland elibrary with your Athens password and choose the Lancet. You will be offered several sources, choose the Sciencedirect Lancet site.

For 19v9

2009-05-17T22:48:00.002+01:00

The reading for Tuesday will be Ethical Debate: serious drug overdoses, B Dahal, BMJ 1995;311:115-116

You already have your talks for Friday, about diagnosis of various rheumatological conditions. remember classification criteria are not diagnostic criteria....or are they?

MJM

Wardround 24iv9

2009-04-24T15:15:00.001+01:00

The reading for Tuesday will be "Stepford doctors": an allegory. GM Sayers. Medical Humanities 2006;32:57-58. Read and think.

This week’s two minute talks were about drugs with significant potential for adverse effects: warfarin, rifampicin, aminoglycosides and penicillin (with reported allergy). Take a minute or two and ask yourself what you now know about the the use of these drugs that you didn’t know before.

For next Friday the task is a two minute tutorial on the interpretation of results from:
Urinalysis
Arterial blood gases
Pulmonary Function tests
(and an extra in case we have an extra person…oxygen saturations)

MJM

wardround 3iv9

2009-04-06T08:24:00.003+01:00

This week's talks were a challenge of summarising what needs to be done about a coincidental chronic illnes in a surgical patient. Both of you recognised the need to address issues directly related to the surgical aspects (risk of hypoadrenalism and thrombosis in lupus and blood sugar/ketones in diabetes) as well as a plan for checking that their longer term management was on track. That's your first two minutes out of the way. Now for next week, the two minute talks onFriday will be recognising the effects of:

Heroin (AB)
Cannabis (free)
Cocaine (CM)
Amphetamine (BS)

Be concise yet precise, and remain anchored in the real world... and just two minutes please.

For discussion on Tuesday I would like you to read Why are medical journals so dull by Richard Asher. Originally published in the BMJ in 23 August 1958. Tempted as I am to leave you to get hold of the paper using your own initiative there is a link here if you do not feel like taking up the challenge. The link works for me but if you are unsuccessful I can give you a paper copy (folded in the shape of a dunce's hat!)

MJM

Wardround 27iii9

2009-03-27T15:03:00.002Z

We did not get to discuss our paper on Tuesday so let's give it ago this coming week. Read and think, then discuss intelligently It's the evidence stupid, F Godlee, BMJ 2008;337:a2119

The talks today were the management, in two minutes of particular scenarios. The mild biochemical hypothyroidism (FI) was well researched and summarised, since it is in fact quite a complex topic. It is important to consider the usefulness of recommended tests both from a resources standpoint but also as a discipline for yourself. When would you order thyroid autoantibodies?

The abnormal LFT scenario talk (BS) had less meat to it, but thereis always next week eh? Think carefully about timing of tests and use investigations as part of an overall plan.

For next Friday the scenario is a patient under orthopaedic care with a wrist fracture. The surgeons have asked for the patient's medical condition and treatment to be reviewed and optimised. The osteoporosis team are already on the case. So what will you be checking for this patient with:
SLE (FY1)
Chronic liver disease (BS)
Type 2 Diabetes mellitus (CM)

MJM

Wardround 20iii9

2009-03-23T20:43:00.004Z

The two minute tutorials for Friday are "What to do about..."
A 45 year old woman with aches and positive ANA (CM)
A 60 year old woman with abnormal LFTS ALP167 AST 60 ALT 90 (BS)
A 40 year old with TSH 7 T4 12 (FI)

Two minutes only, be practical rather than theoretical.

The tuesday reading is It's the evidence stupid, F Godlee, BMJ 2008;337:a2119

MJM

Wardround 13iii9

2009-03-13T15:38:00.004Z

The choices for important figures in infection were Fleming (FI), Koch (ST), Pasteur (BJ). Anybody turning in their grave about being overlooked?

For those who would like to read more about the plague of Athens could pass a little time reading The cause of the plague of Athens: plague, typhoid, typhus, smallpox, or measles? Burke A. Cunha, Infect Dis Clin N Am 18 (2004) 29–43.

The paper to read and discuss for next Tuesday is On the antiseptic principle in the Practice of surgery. Joseph Lister. Lancet 1867, Sept 21, 90 (2299) 353-356. You should be able to get the PDF using your Athens password. doi:10.1016/S0140-6736(02)51827-4 (don’t know what a DOI is?....better find out, you will come across them again).

The two minute tutorials for Friday are based on occupational lung disease:
Lung (FI)
Skin (ST)
Other important Occupational diseases (CM) - or choose from neurological, GI/GU, musculoskeletal, infectious.

Remember two minutes only; be concise yet precise, make it worthwhile to listen and quote your sources.

Interesting Topics:
Eplerenone
GI bleeding on low dose aspirin
Paronychia

MJM
P.S. Why the above picture?

Wardround 27ii9

2009-02-27T15:39:00.003Z

The two minute talks on Gram positive cocci and gram negative bacilli were well researched and presented.You should now have a structure to help choose an appropriate antibiotic regime. We will test this on the ward rounds over the coming weeks. Dr Jones has also asked for a brief on the use of Tigecycline and Daptomycin for next week

The paper for discussion next Tuesday is Unburdening the Difficult Clinical Encounter, Kurt Kroenke, Arch Intern Med 2009;169 333-334.

Friday will be you opportunity to shine while solving the Plague of Athens.

Interesting Topics:
Nutritional support in chronic liver disease
Aortic stenosis

MJM

Wardround 20ii9

2009-02-21T21:15:00.003Z

Good efforts in your talks about thrombolysis. I would like you to make the talks more specific and precise. Tell us the actual evidence, precise numbers and sources. Don't waste time with introductions or telling us stuff we all know already. Make the two minutes count. Let's have the re-hashed talks on thrombolysis on Tuesday.

The assignment for Friday is to produce a diagnosis of the illness in Athens described by Thucydides in 431 B.C. in The History of the Peloponnesian War . If you click on the link it will take you to a copy of the piece. The web page begins with chapter VI, but you can skip down to chapter VII (unless you would like to read about the war). If you cannot find the right section, press ctrl-F and type in plague.

You need to have an opinion on the diagnosis and be prepared to argue your corner. Make sure you revise the signs and symptoms of the disease you choose. Your two minute tutorials could be on some aspect of your chosen disease.

MJM

Wardround 6ii9

2009-02-08T17:14:00.002Z

The reading for discussion on Tuesday is Aunt Sophie’s Choice: the perils of paternalism. Schafer A.

The two minute talks this week were about abscesses. Good talks which I hope you found helpful. Remember the basics: consider the types of organisms that are possible, which will be altered by travel and immunocompetence. Always, ALWAYS, have your own plan in mind when seeking advice, then make sure you understand why any new plan differs from your own.

For nest week the two minute talks will be Neurology: recognising and understanding the following as causes of impaired walking:
Amyotrophic lateral sclerosis
Myelopathy (Dr Teo)
Peripheral neuropathy (Dr Jani)

Two minutes only. Be concise and precise. Quote your sources.

Interesting Topics

Benzodiazepine withdrawal exacerbated by quinolones (papers in patient's notes)

MJM

Wardround 30i9

2009-02-01T22:37:00.002Z

The reading for Tuesday will be "Human guinea pigs"--a history. M H Pappworth. BMJ 1990 December 22; 301(6766): 1456–1460. Read and think.

This week's talks were about clinical assessment of parietal lesions, cerebellar dysfunction and differentiating bulbar and pseudobulbar palsy.

To simplify things, I like to think of parietal dysfunction as Motor: Dysphasia (dominant) and Dyspraxia (non-dominant); Sensory: Inattention and astereognosis. (The inability to recognise a deficit is called anosagnosia). I had not come across cerebellar DASHING before, and being stuck in my ways I will be keeping to DANISH. Pseudo and true bulbar palsy have many subtle differences, I would concentrate on tongue wasting with fasciculation and absent gag in bulbar palsy and increased jaw jerk and choking episodes in pseudobulbar disease.

For Friday, the assignments as two minute talks are Abscesses: contributing factors, organism and treatment. Choose among yourselves which sites to talk about from:
Brain
Liver
Psoas
Empyema (not an abscess, I know)

Interesting topics

Dyspraxia

Arteria Lusoria, see here for diagrams of the anatomy, and NEJM Volume 346(21), 23 May 2002, p 1637 for a case report.

MJM

Wardround 9i9

2009-01-11T19:18:00.002Z

The reading for Tuesday is Immoral advances: Is science out of control? - science-in-society - 09 January 2009 - New Scientist. Read and think.

For Friday the two minute tutorials are about imported fevers. Two minutes please on your choice of these cases returning to the UK with a fever:

Fell in the water of Lake Malawai
Was bitten by a dog at Giza
Was bitten by a bug on the Amazon
Has a nosebleed having returned from Wagadugu
Fell in a well in Thailand

Post in the comments which you will be doing.

Interesting topics:

Very Basic Echocardiography
Diastolic failure

MJM

Last Post of 2008

2008-12-30T15:03:00.002Z

It is time to start thinking again.

No wardround meeting on Friday but for Tuesday we can have a paper to discuss: Culture shock - patient as Icon, Icon as Patient. A Verghese. NEJM 2008: 359(26); 2748–2751. Elibrary

Read and think.

MJM

Merry Christmas

2008-12-21T18:00:00.002Z

The Christmas break in talks is upon us. Almost.

For Tuesday, come ready to tell us about a book or film (or other text) that has influenced you as a doctor.

Interesting Topics

Following on from our discusions about adverse drug reactions, you may want to have a look at Managing Drug-Drug Interaction Risks and Recognizing, Reporting, and Reducing Adverse Drug Reactions.

You are challenged to find at least one ADR from each of the groups A-F. Get to it.

MJM

Wardound 12xii8

2008-12-14T18:38:00.002Z

If you are not in DGRI you will see a screen shot above. I hope it will give a clue how to get the article for Tuesday's discussion. So yet again get it, read it and think about it. In a stew. Michael A Lacombe. American Journal of Medicine. 1991;91:276-278. from the E-library. There is an accompanying editorial if you are up to it.

The two minute talks will be about adverse drug reactions:
Epidemiology R
Mechanisms E
Management Dr Pope
Prevention G

There are a number of excellent resources available about this subject..see what you can find. Remember, time the talk for two minutes, quote your sources and make a handoiut which will be useful.

Interesting topics this week
Progressive supranuclear palsy
Refeeding syndrome

MJM

We don't need no stinkin' help findin' book learnin'

2008-12-10T21:04:00.006Z

I ridicule your pathetic excuses for failing to get the "In a Stew" article. I got the pdf at the weekend and again tonight without problems.

Get it....it's a challenge... and we can then discuss it.

MJM

Wardround 5xii8

2008-12-07T10:57:00.002Z

Sepsis bundle summary ↑ (you cannot see it at DGRI...images blocked)

The reading for Tuesday is In a stew. Michael A Lacombe. American Journal of Medicine. 1991;91:276-278. from the E-library. There is an accompanying editorial if you are up to it.

This week's talks were about antibiotics. This led to a discussion of the precipitants for MRSA such as antibiotic pressure and the ways we might try to limit this. Dr Jones outlined a method of deferring antibiotic use in non-urgent cases and stressed the need to identify specific about diagnoses. It should be clear to all that MJM and GAJ do not regard antibiotics as harmless, and MJM in particular decries the term "chest infection"....never use this in his hearing since it has the effect of decoupling frontal lobe function. Our hospital policy regarding IV antibiotics is a must read as is the antibiotic prescribing policy. Remember to look at the HPS site about C. difficile.

For next Friday the theme is decompensated liver disease:
Epidemiology G
Varices L
Ascites E
Encephalopathy R
Transplantation ?

Two minutes please. Be concise and precise. Quote your sources so others can read up more if inclined. Handouts can have more than bullet points again....but not mini-essays please. Think before you speak. Make the talk count. Don't tell us things we already know; there isn't time.

Interesting topics

Sepsis in Coeliac Disease (Dr Else's journal club talk about Gut 2008 Aug;57(8):1034-5).
Sepsis bundles

Remember we have some textbooks in the right hand Ward office

Wardround 28xi8

2008-11-30T10:39:00.004Z

This week's talks were about common tests such as cholesterol, creatinine and glucose. It is useful to revise things which we come to regard as so common that our knowledge of them sinks into our subconscious. Knowledge in the subconscious can become corrupted or merely fade away. As an SHO I was given some advice by a consultant Dr Avinash Mithal. He suggested that when reading a journal article, editorial or review paper I should first write down what I know about the subject. IHD is common...how common, exactly? In doing this I am surprised how quickly "things_I_know" have become "things_I_think_I_know_but_don't". Next time you read a paper, try Mithal's method.

For Friday the two minute talks are about Antibiotics. This is a free for all. Decide which talk you want to do and stake your claim by posting in the comments section. The choices are:

Who needs IV antibiotics?

What are the precipitants of C. difficile?

What are the precipitants of MRSA?

What is new in the antibiotic field?

What is antibiotic allergy, and what can be done about it?

Two minutes only. Be clear and concise. And here I am going to change the rules on the written handouts. You are allowed up to six bullet points only in text. Drawings or illustrations can be unlimited but must fit on one side of A4 and be large enough to be read without squinting or using a magnifying glass.

Our inability to read the paper on the last two Tuesdays I take as a message from the fates. Said paper will be cast to the furies. Though casting to the furries conjures more surreal images.

The reading for Tuesday will be Just how tainted has medicine become? The Lancet 2002: 359 (9313), Page 1167, (6 April)

Interesting topics:

Tilt testing in syncope

Gout

MJM

Wardround 21xi8

2008-11-24T11:47:00.002Z

Since we could not discuss the reading for last week, klet's carry it over to Tuesday.

Friday's talks are on everyday tests. You have free rein to choose the most useful aspect of each for your talks. Make them interesting, concise and illuminating.

MJM

Wardround 14xi8

2008-11-17T08:39:00.002Z

The reading k for next week will be Measuring quality of life. Is there such a thing as a life not worth living? Bobbie Farsides, Robert J Dunlop BMJ 2001;322:1481-1483

Two minute talks for Friday: SEPSIS
Recognition O
Circulation R
Antibiotics S
Epidemiology J

www.survivingsepsis.org is a good place to start your background reading.

MJM

Wardround 7xi8

2008-11-08T14:17:00.003Z

The reading for Tuesday is Comment: When not to write about autism, Ewen Calloway. New Scientist. Read it, think, and discuss.

The Two Minute talks for Friday will be about poisoning:
Paracetamol
Tricyclics
Carbon Monoxide
Ecstasy

Please plan your talk to last just two minutes. Be concise and precise, quote your sources and make a simple handout. A hundred words on the handout is too much. Don't waste time on the obvious. Let me help you out by saying I want facts specific to your topic. I will take it as read that Resuscitation/ABCDE etc are going to be done. The test you must pass is that those listening to the talk will be able to manage a case.

MJM

Wardround 24x8

2008-10-24T15:27:00.002+01:00

The Two minute talks today were about arrythmias. Well researched and reasonably timed, but I would suggest more thought is given to the two minute limit. For next week : opportunistic infections with HIV: Pneumocystis pneumonia, atypical mycobacteria, toxoplasma, candida and cryptococcus. You have your assignments. If we have any extra people gatecrashing the talk they should choose another to do eg aspergillus, TB etc.

The paper for discussion on Tuesday will be The kindness of strangers. Eileen Palmer, BMJ 2008;337:a1993.

MJM

Wardround 10x8

2008-10-13T10:35:00.003+01:00

The Reading for Tuesday is Trust, Anonymous, Bandolier. Read and think. Articles can be like lamps. Look at them carefully before choosing to use one for illumination. It could enlighten the subject matter, cast important issues into relative shadow, or even blind you to the whole subject.

The talks this week were excellent. Imported infections are not as uncommon as you might think, even in a place like D&G. The important thinks to know are where they have been, what they have been doing, who else has been involved. Use a resource such as travalax to find what is happening in the region and don't overlook the treatable (malaria, bacterial sepsis). I wondered about putting rabies in those parentheses, but perhaps that should be in the preventable category. I would suggest you read the local viral haemorrhagic fever protocol.

For next Friday the talks will be about the patient with an acute abdomen who finds themselves on a medical unit. No cop-outs here, I don't want a two second talk "refer to surgeons". The surgical team are all very busy in theatre. Only the surgical F1 is available and you are going to be forced to manage the patient initially.

Acute Pancreatitis F
Acute Vascular Events A
Perforated hollow Viscus O

Two minutes please. Keep it precise and concise.

Interesting Topics

Sepsis resuscitation bundle

How tired are you?

MJM

Wardround 3x8

2008-10-06T10:35:00.002+01:00

The reading material for Tuesday is Commercial Features of Placebo and Therapeutic Efficacy, Rebecca L. Waber; Baba Shiv; Ziv Carmon; Dan Ariely, Journal of the American Medical Association, March 5, 2008; 299: 1016-1017. Get it via the elibrary, read and think.

Our two minute tutorials for Friday are Imported diseases. You each have two minutes to enlighten us on the patient who is feverish and:

Fell in the water of Lake Malawai (H)
Was bitten by a dog at Giza (F)
Was bitten by a bug on the Amazon (A)
Has a nosebleed having returned from Wagadugu (Z)

MJM

WR 27ix8

2008-09-28T21:02:00.002+01:00

The read and think for Tuesday is Orphan diseases: which ones do we adopt? T Richards, BMJ 2008;337:a1225.

The two minute talks for Friday are themed around Acute Hepatitis. Educate the yourself and the group.

Alcoholic (H)
Viral (A)
Autoimmune (F)
Toxic (Z)

MJM

Wardround 12ix8

2008-09-14T21:36:00.002+01:00

The reading assignment for Tuesday is Titrating Guidance, Nathan Goldstein, Anthony Back, Sean Morrison. Arch Intern Med. 2008;168(16):1733-1739.

Friday's two minute talks are the recognition and management of psychiatric disorders on medical wards: Delerium tremens, Depression, the aggressive patient.

MJM

Wardround 5ix8

2008-09-07T18:14:00.002+01:00

The reading for next Tuesday will be Mistakes. Ruth Lesnewski. JAMA. 2006;296:1327-1328. get it with elibrary.

Read and think.

Friday's tutorial assignments will be Acute Colitis

Ischaemic

Infective

Inflammatory

Two minutes please, keep it precise and concise, quote your sources and illustrate with a handout.

Interesting Topics

Transverse Myelitis

MJM

Wardround 29viii8

2008-08-29T21:20:00.006+01:00

Why was a rheumatologist asked to see this patient?

The reading this week about the methods magicians use to distract their audience led to some discussion of distraction, its benefits and pitfalls in medicine, the importance of not interrupting the 'rituals' of medicine that doctors use to keep on track and recognising when we ourselves have been distracted from the path.

For next week I would like you to read Why are medical journals so dull by Richard Asher. Originally published in the BMJ in 23 August 1958. Tempted as I am to leave you to get hold of the paper using your own initiative there is a link here if you do not feel like taking up the challenge. The link works for me but if you are unsuccessful I can give you a paper copy (folded in the shape of a dunce's hat!)

As ever the original responses to a paper can be illuminating. It is well worth getting used to reading the letters written to the editor about papers you read.

I was sorry to have been called away before the end of the Gram talks. It sounds obvious but the information Gram pos/negative cocci/bacilli should prompt immediate thoughts: does the patient have features of systemic sepsis syndrome? what do I need to check to further identify the type of organism and the likely spectrum of antibiotic sensitivity. Be sceptical about any comment from someone who has not assessed the patient that an organism could be a just a contaminant. How about clicking the comment button and writing in one sentence about something particularly interesting you found in your reading on the subject.

The talks for next week will be Epilepsy.
I was not able to assign these so it will be first come first served. Click the comment and claim the subject you will take. On offer are:
Epidemiology
Classification
Investigation
What to tell a patient after their first seizure
Treatment

Interesting topics

Lofgren's syndrome (what I was called away to see)

MJM

How weary, stale, flat and unprofitable, seem to me all the uses of this world
Fie on't ah fie! 'tis an unweeded garden, that grows to seed ...
That it should come to this.

Wardround 22viii8

2008-08-22T12:42:00.002+01:00

The reading for next Tuesday will be Magician's Hand: How Humor And Misdirection Can Manipulate Levels Of Attention. You may also want to look at this related article.

Please read the articles and give them some thought. Is this relevant to medicine?

The two minute talks this week were the ECG. What is normal and what is not? What do you think was the most interesting or useful point in your talk. Click the comment button and type it in. I put together a little list a couple of years ago that you could revise from.

The two minute talks for next Friday will be mibrobiology 101: what should go through your mind when you get a call that your sick patient's blood cultures have grown:

Gram positive cooci HM
Gram negative cocci SV
Gram positive rods ZB
Gram negative rods HJ

Keep it precise (actual figures not general descriptions) and concise, educate your audience, quote sources, produce a handout and keep to two minutes.

Interesting topics:

Hyperkalaemia...read the handbook
Atrial flutter
Korsakoff syndrome

MJM

Wardround 15viii8

2008-08-15T14:01:00.002+01:00

The reading for next Tuesday will be The road to recovery. D Pisetsky. Please read the article and give it some thought.

The two minute talks this week were about common drugs: Furosemide, Coamoxiclav, Enoxaparin. The prize this week goes to HM. What do you think was the most interesting or useful point in your talk. Click the comment button and type it in.

The two minute talks for next Friday will be The ECG. What is normal and what is not? Let's have two minutes on:

P wave HJ
QRS complex
Axis
ST segment HM
T wave SG

Keep it precise (actual figures not general descriptions) and concise, educate your audience, quote sources, produce a handout and keep to two minutes.

The morbidity/mortality meeting is on Thursday 28th August. Time to start preparing now.

Interesting topics:

Fallot's tetralogy

Wernicke's encephalopathy

Dressler's Syndrome

MJM

Wardround 8viii8

2008-08-06T16:17:00.002+01:00

On Friday I will talk to you about the training side of the ward work, so you are spared giving a talk until next week.

The reading for next Tuesday will be The minefield of medical morals. D Sokol.
Please read the article and give it some thought.

The two minute talks for next Friday will be common drugs. Let's have two minutes on:

Furosemide HM
Coamoxiclav HJ
Enoxaparin SG
Omeprazole RV
Prednisolone just in case

Remember, the aim of the aassignment is that both you and your audience increase your knowledge or understanding of the topic. Don't waste too much time telling us things we will already know. The time is limited to two minutes and you should practice your talk and timing before the big day. Don't give a five minute talk in two minutes, edit it down to time. Always quote your sources so others know where to go to check things out for themselves. You should produce a single side of A4 handout. This is to illustrate your talk, not to provide a textbook level detailed article. Hand drawn pictures with arrows and signs beat something that looks like a cv every time.

The usual advice is keep your talk precise and concise, educate your audience, quote sources, produce a handout and keep it to two minutes.

Interesting topics this week:

Where to look up complementary medicines
DGRI antibiotic guidelines (I can't make the link work so you will need to navigate to it so it's intranet only. Go to the DGRI homepage, at the top choose select a service, then prescribing support, then click go. The document is listed there).

MJM

Welcome to the new trainees, goodbye to the old.

2008-08-03T23:45:00.002+01:00

The reading for thought on Tuesday will be Meeting the ethical needs of doctors. Daniel K Sokol. BMJ 2005;330:741-742.

Welcome to the new trainees. Could I ask you to look over to the right hand side of this page and click on the "Training" link please. There is a little about work on the ward there and a timetable for yourself and me.

There will not be any assigned two minute talks this Friday. What I would like each of you to do is tell us a little about yourself and what you wish to do this year, and after that. The usual Friday rules apply. Only two minutes please.

MJM

Holiday break

2008-07-09T20:33:00.002+01:00

I am off to the land of large portions for a couple of weeks, there to stress my labyrinths and top up my vitamin D. The blog will resume on the 28th.

MJM

Wardround 4vii8

2008-07-06T22:46:00.002+01:00

The reading for Tuesday will be Precision in diagnosis, John Todd, Lancet 1952: 260 (6748); 1235-37. It is available via the elibrary. You may be able to use this link after logging in to elibrary/Athens...but if the link fails you....you should still have enough information to find the pdf.

We will decide upon Friday's topics on Tuesday.

MJM

Wardround 20vi8

2008-06-23T09:30:00.002+01:00

The reading for Tuesday will be The rational clinical examination. Does this patient have abnormal central venous pressure? Cook DJ, Simel DL. JAMA 1996; 275: 630-4.

The two minute talks for Friday will be slightly different. I would like you to look over a guideline of your choice (but related to adult general internal medicine, of course) and present 5 useful points from the document. As a warning example I would not find it useful to be told that nebulised beta agonists are useful in the management of acute exacerbations of COPD (I know that already), but I don't know how useful.

Not education except in its widest sense, but here are some pictures from the Summer Ball.

MJM

Wardround 13vi8

2008-06-13T16:26:00.003+01:00

The reading for next Tuesday will be The Midnight Meal and Other Essays about Doctors, Patients, and Medicine, Jerome Lowenstein. I have put a copy on the ward.

The two minute talks for next week will be your diagnosis of the Plague of Athens. You will find a description of the outbreak in The History of the Peloponnesian War written by Thucydides in 431 B.C. If you click on the link it will take you to a copy of the piece. The web page begins with chapter VI, but you can skip down to chapter VII (unless you would like to read about the war). If you cannot find the right section, press ctrl-F and type in plague.

You need to have an opinion on the diagnosis and be prepared to argue your corner. Make sure you revise the signs and symptoms of the disease you choose. I will post the discussion the following week and award a prize to the best argument/diagnosis.

The NPSA have issued guidance to improve the safety of chest drains.

MJM

Wardround 6vi8

2008-06-08T23:02:00.003+01:00

The reading for Tuesday is Doctors, Lawyers and Wolves. George J Annas, Lancet 31 May 2008. Read and reflect please.

The two minute talks are neurologically themed. The specific assignments are no longer in my possession, but you have them and can forewarn the newcomers.

A short post I am afraid but as well as working this weekend I have been sorting out my email account at home which had been reporting "2,147,433,168 messages unread".

MJM

Wardround 30v8

2008-06-01T14:21:00.002+01:00

An interesting update on skin infections. What did you learn?

Cellulitis is a common condition in acute medicine. Always ask yourself if this is 'simple' or complicated. Is there immunosuppression, skin integrity, rapid progression, unexpected pain, recurrence, poor response to treatment?

You already have your asssignments for next week's talks and the discussion for Tuesday was posted last week.

The May M&M meeting when very well I felt.

Interesting topics

Unsuspected Pulmonary thromboembolism

MJM

Wardround 23v8

2008-05-25T23:31:00.003+01:00

Endocrine emergencies. Well done. I had given YA 10/10 in my notebook for his talk on acute hypoadrenalism, so I was forced to give Thyrotoxic storm by EM a 10+. I think you have grasped what is needed.

Many of the emergencies discussed can be misdiagnosed as other common conditions and considering the possibility is just as important as knowing what to do.

I will share with you that my soul shudders each time someone recommends "routine bloods". I can cope with "x, y and z should be routine bloods in the investigation of...". Be specific.

For next Friday the assignments are based on skin infections:
Infection following animal bites
Lower leg cellulitis (A)
Cellulitis in the immunocompromised host. (S)
Necrotising fasciitis (Y)
Facial cellulitis (N)
Shingles

requirements: Concise, unrushed, precise, sources quoted, USEFUL.

For Tuesday you have been given a grey case to consider. By the way, what is a grey case and how should you deal with it? Prize 9virtual) to the best definition of a grey case.

The reading for a week on Tuesday will be The boards and executives of drug companies could catalyse action against the AIDS epidemic by immediately reducing the costs of HIV drugs in poor countries to zero. Donald Berwick BMJ 2002;324:214-218

Interesting topics

Pneumocystis pneumonia see uptodate

Adult onset Still's disease

Neurofibromatosis

MJM

Wardound 16v8

2008-05-18T15:45:00.002+01:00

Our discussion paper last week was The reading for discussion on Tuesday will be DNR or PEACE. J Crampton. BMJ 2008;336:1015. An interesting discussion ensued. If you would like to read more on the subject could I suggest you take a look at Decisions relating to cardiopulmonary resuscitation A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing from October 2007

For next Tuesday the reading will be Liz Wager: Training and the placebo effect.

Our talks this week were about poisoning, and overall I think they were well researched and presented as spoken mini-essays. I would like you, now, to think about these talks in a different way. The aim is to teach/train/educate your audience. This differs from writing an essay (or giving presentations, which are much the same thing) as you have done in the past. Those were to assess your ability to collect and critically appraise information. I want you to take that information and teach me and your colleagues. And by teach, I mean convert me from someone who could not do something into someone who can. Your handout is for that purpose as well.

Bear that in mind for this week's two minute talks on endocrine emergencies:

Hypoglycaemia A
Thyrotoxic Storm E
DKA N
Adrenal crisis Y
Phaeochromcytoma crisis S

Interesting topics

Antibiotics and seizures

MJM

Wardround 9v8

2008-05-09T17:05:00.001+01:00

Our discussion this week, in the absence of a paper to read, was about improving practice by Morbidity and mortality meetings. We will now run an M&M meeting on the last Thursday of each month. There is an M&M folder in the Nurses office. All deaths for the month should be listed there. The GAJ team will review MJM patients and vice versa. The Necessary patients notes will need to be pulled the week before.

Our two minute talks were about the investigation of malignancy of unknown origin. A useful discussion I think. We heard about the more common cancers nad discussed how that should guide our history, examination and investigation. The use of tumour markers produced further discussion, which can I think be generalised to the use of many tests in medicine.

For next week:

The reading for discussion on Tuesday will be DNR or PEACE. J Crampton. BMJ 2008;336:1015

Read it, think, and share your thoughts.

The two minute talks for Friday will be about Poisoning:

Paracetamol (ST)

Carbon Monoxide (NV)

Methanol (EM)

Tricyclics (YA)

The usual advice. Keep it concise and precise, quote your sources and make a handout. Having heard your talk I should be able to manage a poisoned patient. The handout should be visual rather than textual. Example.

Interesting Topics

Group A streptococci

Do you know what streptococcal toxic shock is? UpToDate also has some good articles on the subject.

MJM

Wardround 25iv8

2008-04-28T09:10:00.000+01:00

The discussion this Tuesday began with the paper The strange malady of Alessandro’s uncle, Neil A (Tony) Holtzman. I was prompted to choose the paper following the journal club discussion last week about the genetic markers for responses to warfarin. The paper describes the development of a new (genetic) investigation and treatment and its impact on the aforementioned uncle. Many interventions will appear better than they prove to be when evidence is limited.and the passage of time gives more accurate assessments.

The paper for discussion next week will be Screening for MRSA, M Wilcox, BMJ 2008;336:899-900

The two minute tutorials on diagnoses were well done but I would recommend adding an additional aliquot of thought to the planning stage. Ask yourself, “what do I want the listener to be able to do or know after this two minutes?” Detailed discussion of diagnostic criteria may contain all the necessary information but that alone does not complete the task. Keep the handout to one side of A4 and make it memorable. Ask yourself the questions MJM or GAJ might ask. Be honest with yourself about the handout. Would you read or keep somethiong that can be printed from a website in 10 seconds? What would be more useful?

Next week’s talks are about Colitits: epidemiology, investigation, treatment.

MJM

Wardround 18iv8

2008-04-20T14:44:00.003+01:00

Back on-line.

The reading for Tuesday will be The strange malady of Alessandro’s uncle, Neil A (Tony) Holtzman. BMJ 2007;335:1306-1307, (doi:10.1136/bmj.39407.647014.80). Read it and think, then share your views.

The two minute talks for Friday will be Making a diagnosis: you can decide among yourselves who will make each presentation.

What constitutes Diabetes mellitus?
What constitutes COPD?
What constitutes Coronary artery disease?
What constitutes Delirium?

Two minutes please. practice it and make sure your timing is accurate. be concise and precise, quote your sources.

Interesting topics

Hypereosinophilic syndrome or look in uptodate which has an excellent article on the subject.

And here is an article worth a read, Blood Eosinophilia: A New Paradigm in Disease Classification, Diagnosis, and Treatment, A Tefferi, Mayo Clin Proc. 2005;80:75-83

MJM

Out of action at present

2008-04-03T14:07:00.002+01:00

Wardround 7iii8

2008-03-08T15:40:00.002Z

Last week's talks were about substance abuse: acute management and harm reduction. Good talks, full of useful information but the handouts were a little to bulky for my liking...try something that can be taken in with one or two glances rather than a page that requires reading. Have a look at this as an example. This would probably be the equivalent of all the talks at a Friday meeting.

What pearls have I taken away from these talks? (if I've missed a good one just add it to the comments section)

Myocardial sensitisation to catecholamines with solvent inhalation: aim for calm and quiet surroundings, monitor cardiac rhythm and use sedation if necessary. The acute effects should have worn off by 6 hours , and if not consider a complication such as myocarditis.

In acute alcohol withdrawal there is no one-size-fits-all regime. The benzodiazepine dosing must be titrated to control withdrawal but avoid over sedation. SIPS scoring is a good way to do this but if not in use you will have to use some common sense. (It's certainly better than using none.)

Identifying alcohol misuse in patients presenting with other conditions is important. A reported alcohol intake less than the recommended level does not exclude abuse. Be aware, ask more detailed questions (eg CAGE) if you are suspicious.

Further reading

Alcohol - problem drinking
Opiod dependence

Next week's two minute talks will be about Parkinson's disease:

Diagnosis
Management
Problems with treatment

This time try to have visual rather than written handouts. If you want to give out lists, just tell us where to find them e.g. more information at www.listsofcauses.com.

The discussion for Tuesday will be "Should doctor's who see prisoners insist hand-cuffs are removed?" You may want to read Restraint of detainees in NHS facilities.

MJM

Wardround 29ii8

2008-03-02T22:14:00.003Z

The talks this week were about interstitial lung diseases. You are getting the hang of it now; Information targeted at clinical practice and delivered so as to be memorable. The best talk/handout this week was Extrinsic allergic alveolitis (Dr NNT). Remember to ask about activities up to 6 hours before the onset of acute dyspnoea. Always consider infective causes. (I have a feeling that I need to take care not to evolve into an Infectious Diseases evangelist.)

For next week the assignments are based on substance misuse:

Glue (MR)
Alcohol (NNT)
Cocaine (KL)
Crystal Meth (R)

Two minutes please on the management of acute toxicity and harm reduction.

The reading last week was Doctors’ education: the invisible influence of drug company sponsorship. Ray Moynihan. BMJ 2008;336:416-417. You may want to have a look at Who pays for the pizza? by the same author.

For next Tuesday I would like you to read and think about Junior doctors' shifts and sleep deprivation. Carol Black et al, BMJ 2005;330:1404.

You may want to test your own level of tiredness with this online psychometric test

Interesting topics

Alternative causes for elevated cardiac troponin levels.
Ann Intern Med 2005;142:786-791

Clozapine myocarditis

Marfan's Syndrome

MJM

Wardround 22ii8

2008-02-25T12:19:00.002Z

The reading for Tuesday will be, Doctors’ education: the invisible influence of drug company sponsorship. Ray Moynihan. BMJ 2008;336:416-417 (23 February).

There is an extended podcast on rheumatoid arthritis, with slides available (60 minutes duration) at the training site.

MJM

Wardround 15ii8

2008-02-17T21:51:00.003Z

A good attempt (first/second stabs) at the two minute talks on Friday. Much effort for so little gain. But this is the point of training...getting better. Next week we have Neuropathy as our topics, split into acute, subacute and chronic. Ask yourself "what do I want to learn?" "what do I want my colleagues to remember?" " how can I get he message accross so they remember?"

Then prune it to two minutes, keep it concise and yet precise and quote your sources. make a handout to get the message accross. And be realistic; no one will read a 400 word A4 handout but they will glance at pictures. And another piece of advice. Have the handouts ready before the wardround starts.

Here is my old podcast on Neuropathy

It won't be visible inside DGRI but it is also available here.

The reading for Tuesday is The Interpreter of Facts, HW Horowitz. JAMA 2008; 299: 497-498.
Get it from the elibrary, or be old-fashioned and caress the journal in your own hands. Read and think.

Interesting Topics

Status Epilepticus

MJM

Wardround 8ii8

2008-02-10T21:39:00.000Z

The reading for Tuesday is Clinical craft: a lesson from Liverpool. D M Gore. Journal of Medical Ethics 27:74-75 (2001). Read and think.

The talks this week were about rheumatological presentations to admissions units. Well done to Dr Lewin for a well presented (and acutely timed) talk on the red eye, diarrhoea, sore joints syndrome, and with little warning. It is worth having a looke at the recently produced guidelines for the hot swollen joint. By the way (SZ) it wasn't that difficult to find, being the second hit when I googled it. You might want to see my summary sheet. In dealing with the various scenarios, I would recommend differentiating joint/muscle symptoms with or without objective signs and with or without involvement of other organ systems. SIRS is sepsis until you know otherwise.

The talks for next week are about stroke. Thrombolysis (NN), anti-platelet treatment (MR) and surgical treatments (KL). Two minutes please, keep it precise and concise, quote your sources and give a handout you would be proud to be shown in twenty years....yes I am that cruel.

Interesting topic

Pulmonary Embolism
Hereditary Thrombophilia

MJM

Wardround 1ii8

2008-02-03T19:32:00.001Z

The Reading for next Tuesday is Waste in the NHS, Andrew Moore, Bandolier Extra, February 2002. Give yourself time to read it, then let's hear what you think.

The two minute talks this week were about Gram stained rods and cocci. You should now be able to target appropriate antibiotics a little better. Don't ever think "I'll use a broad spectrum antibiotic".....plan the spectrum to cover the clinical situation.

The talks for next week will be about rheumatological emergencies.
The single hot joint SZ
Generalised myalgia/arthralgia CG
Red eye, diarrhoea, and sore joints PM

A two minute talk please, keep it concise and precise, quote your sources and provide a one sheet handout.

Interesting topics

Helicobacter

MJM

Wardround 25i8

2008-01-25T15:21:00.001Z

Our discussion this week was about ethics. The use of jokes which might offend, open-ness with patients, harrassment, ethics committees, politics and medicine all had their moment. It can be helpful to think out loud. For next week the discussion will be about the ethics of offering or declining transplantation to a patient with several co-morbid conditions and difficulty adhering to established models of care.

You will have an opinion (that’s an order). But why do you have that opinion? Can you see why others may have a different opinion? Who is right? How can you best structure the problem for analysis? Would an ethics committee help? How? How can you recognise whether you are virtuous (in your decision) or lacking both virtue and insight?

The two minute talks this week were about urinary tract infections. I hope you have learnt about the subject and your methods of research. Did you ask ‘why?’ when you should have done?

Next week is microbiology. You get a phone call from bacteriology. The blood culture is positive for: G+R (MG), G-R (NS), G+C (SZ), G-C (CG). You have been given a little background to work on. So what do you want to know? Each result should ring some bells of recognition and some alarms. Give the group two minutes on your case.

Interesting topics

Pernicious anaemia

Behcet’s and thalidomide

MJM

Wardround 18i8

2008-01-20T22:51:00.000Z

The ethical dilemmas to read for Tuesday are to be found here and then An ethical dilemma, BMJ 2001;322: 1236-1240.

Tutorials for Friday (Urinary infections)

Interesting Topics

PICC lines (This is I think the original poster and can be read without visual aids )

MJM

Wardround 11i8

2008-01-13T16:16:00.000Z

The discussion for Tuesday is this video by students. You may need to view it outside DGRI, I think youtube access will be blocked in the hospital network.

The two minute tutorial theme this week (and next week) is immunisation. We heard about Pneumococcus (NS), HiB (SZ), meningococcus (MG) and influenza (CG). A little more tweaking is needed to get the essential information into two minutes. For next week we will hear about: BCG, smallpox, polio and Hep B. Any audits spring to mind?

Two minutes please. Identify what you think is the essential information to get across, and remember that diluting that with waffle/unimportant points will impair meme transfer.

Interesting topics.

Pancreatitis

Trimethoprim and creatinine

MJM

Wardround 4i8

2008-01-04T16:17:00.001Z

Happy new year for 2008. May your knowledge expand, ignorance regress and wisdom blossom.

The reading for Tuesday 8 january will be The practice of clinical medicine as an art and as a science , John Saunders, Journal of Medical Ethics 26:18-22 (2000).

The two minute tutorial theme for friday is immunisation: there is a medscape CME session which covers five main areas (a page each). Your task is to read the page allocated to you and translate it into UK guidance for the rest of us.

There is a 'Green book' issued in the UK with guidance on immunisation so you could look into that for inspiration. You can find an on-line version here.

Pneumococcus NS
HiB SZ
meningococcus MG
influenza CG
polio SS

Two minutes maximum, keep it concise and precise with an A4 size handout to make it clearer. Don't put all the info on the handout, just the essentials.

Interesting topics

candida glabrata

colchicine for gout

MJM

2007-12-14T16:37:00.000Z

Our two minute talks this week were about malaria. I have put in links for the HPA malaria page and CDC malaria page as well as the UK guidelines: HPA Advisory Committee on Malaria Prevention in UK Travellers, UK malaria treatment guidelines. Journal of Infection 2007; 54(2):111-21

KG’s handout for malaria prophylaxis has been voted into the permanent collection.

Please remember that the talks need to be precise and the source of information quoted so that its authenticity can be weighed. Non-UK guidance may not be appropriate to management of a condition in the UK.

For next week there will be a lighter topic choice. Two minutes on a film or book which has influenced your practice of medicine, and why.

The paper for discussion on Tuesday will be Time, Now, to Recover the Fun in the Physical Examination Rather Than Abandon It. ARCH INTERN MED 166, 603-604, MAR 27, 2006

You can get it via the elibrary.

Interesting topics

Malaria – see above.

Dr Gilchrist, welcome to the fold. Please look at the 'training' link on the right.

MJM

Wardround 7xii7

2007-12-10T10:10:00.000Z

The two minute tutorials this week were acute endocrine emergencies. I will upload the Addisonoan Crisis sheet to the summary sheet section. Remember, think about hypoadrenalism in any patient with shock, especially if they have a history of steroid use.

For next week the talks are themed around Malaria:

Epidemiology HJ
Falciparum JR
Vivax (Kaur)
Malariae/Ovale NS
Acute malaria SS
Travel prophylaxis KG

Two minutes please. Concise yet precise and quote your sources. The aim is not ‘to give a talk’ but to educate by giving a talk. Those handouts deemed up to scratch will be added to the permanent collection. We know this is a difficult task, that is why we challenge you with it.

The paper for discussion on Tuesday is

Clinical decision-making: Coping with uncertainty. A F West; R R West
Postgraduate Medical Journal; Jun 2002; 78, 920.

Interesting topics

Pericardial effusions

Yohimbine

MJM

Wardround 30xi7

2007-12-02T22:22:00.000Z

This week’s intellectual task, if it can be so called, was the three minute test. The score you achieved is far less important than what you learned from the exercise. When one looks up the treatment of “an emergency”, in this case (life threatening) hyperkalaemia, it is essential to see how you would enact it in real life. For example, drugs must get from the cupboard/trolley into the patient’s bloodstream and do not just magically do so as they might in your mind. When reading the book ask yourself how you would get each step done. And don't forget to get and use help efficiently.

The case began with “Doctor, the lab have rung with his results. The creatinine is 491”. Elevated creatinine levels must always be qualified with a potassium result. Your response should have been a reflex “and the potassium?” Get into the habit of feeling incomplete if you are aware of SC but not K results, and always offer both when further disseminating the information.

The reading for Tuesday is Truth, stardust and comfort blankies by “ Aphra Behn”, presumably a nom de plume.

We are failing the great moral test of our times and retreating into the comfort of a new mediaevalism, surrounding ourselves with ideology... and warm and righteous certainties .... Discuss.

The two minute talks for Friday will be endocrine emergencies: recognition and management.

Thyroid crisis RR
Acute hypoadrenalism MJM
DKA SS
Acute hypopit HJ
Carcinoid KG
Vipoma JB
SIADH NS

Only two minutes, keep it concise and precise. Concentrate on th emergency aspect. And remember that the goal is to educate the group. Education achieved is not proportional to the number of words spoken. A one page visual aid is allowed.

Interesting topics
Thunderclap headache, uptodate has a good article

MJM

Wardround 24xi7

2007-11-26T07:20:00.000Z

This week we had our occasional quiz. You will know, in your hearts and minds, two things.....what score you got and what proportion of your correct answers you guessed. Your next task is to revise the areas of which you were unsure.

For next week:

The reading for Tuesday will be What's wrong with the wards? K Teale BMJ 2007;334:97 (13 January).

The two minute tutorials are suspended again on Friday, to be replaced by the 3 minute emergency quiz. bring a pen and piece of paper.

Interesting topics

Duodenal ulcer

MJM

Assessing a patient with Spondylarthropathy

2007-11-17T20:44:00.001Z

How to assess a patient with spondyloarthropathy.

mp3 file

also available here with notes

Wardround 9xi7

2007-11-11T21:53:00.000Z

The two minute talks this week were based around “the use of...” various drugs. I hope that these have stimulated some thought....and curiosity about other drugs you use regularly. It is important as you continue in your training to give increasing thought to the reasons and evidence behind the guidelines and advice associated with drugs.

Gentamicin: (SS) a drug with a narrow therapeutic window. Various methods exist for monitoring gentamicin levels. The aim is to give the correct dose (to achieve levels high enough for effect and low enough to be safe). It is because dose calculations do not always predict the correct dose that levels must be monitored to allow fine tuning of dose and frquency.

Thrombolytics (HJ) nostalgia prompted my question about fibrinolytics (apologies). Another drug with significant risks to balance against benefits. Before PCI was easily available the decision for patients with a relative contra-indication was thrombolyse or nothing and greater risks may have been accepted than would now be appropriate.

Amiodarone (JB) the ‘greedy’ anti-arrythmic with a bit of each class activity, broad spectrum activity and plenty of drawbacks. Time to review the Vaughn Williams Classification, but before you do revise, the cardiac action potential. I used to find it difficult to understand the why particular drug classes had their effects until tied them in with the action potential and the fact, that escaped me for years, that the fast depolarisation channel in the SA node and AV node is calcium rather sodium mediated.

Heparin (R) I hold my head in shame. I did not know that heparin could produce hyperkalaemia yet the Oxford textbook says hyperkalaemia occurs in 7% of heparin treated patients due to inhibition of aldosterone production. I will be on the look out now.
Warfarin (HA) I now know that vitamin K is named for Koagulation. You now know why we need to continue heparin for a couple of days after the INR is therapeutic. That pesky protein C.

For next week you are excused the two minute tutorials but sentenced to the three minute tests. You will be asked to give the initial management of an emergency. There aren’t that many possibilities, so get revising.

The paper discussed on Tuesday was Thoughts for new medical students at a new medical school, Richard Smith. By the way, have you read his articles about Dumfries? How about leaving your advice for newly appointed house officers in the comments? I’ll post it with your photo in the hall of fame if you like.

For next Tuesday I would like you to read In a stew. Michael A Lacombe. American Journal of Medicine. 1991;91:276-278. If you feel up to it, read the associated editorial Double trouble, boil and bubble. And ask yourself how I came across these articles in a journal I do not regularly read.

Interesting Topics
Pneumomediastinum
See also this link which explains the X-ray above.

MJM

wardround 2xi7

2007-11-02T15:13:00.000Z

This week’s read and think had been The homeless man on morning rounds, an essay by J Lowenstein. If you found it interesting , you might want to read some of his collected essays in The Midnight Meal.

For next Tuesday I would like you to read Thoughts for new medical students at a new medical school, Richard Smith BMJ 2003;327:1430-1433 (20 December),

…and tell me which is your favourite box in the paper.

This week’s two minute tutorials were themed around respiratory problems, addressing the respiratory history (nicely done SS, don’t forget occupational history); PFTs (needed a bit more work on transfer factor etc, KM); ABGs (good clear talk AA; NIV (you should have been able to explain why BiPAP helps, HA); The assessment of a breathless patient (quite rightly focussed on practical issues such as beginning treatment and assessment at the same time, getting help, IV access etc, but was a four minute talk in two minutes, JB).

For next week the theme is “The use of…”

Warfarin HA
Heparin JR
Gentamicin SS
Amiodarone JB
Thrombolytics HJ (are they really fibrinolytics?)

Two minutes please, keep it concise yet precise. Arm yourself, intellectually, to ward off those probing questions.

Interesting topics this week

Hyponatraemia again
Vasculitis

MJM

Wardround 26x7

2007-10-29T14:22:00.000Z

The paper for discussion on Tuesday will be The homeless man on morning rounds from The Midnight Meal and Other Essays about Doctors, Patients, and Medicine by Jerome Lowenstein. I have left a copy on the ward. ...and what is a home?

The two minute tutorials for Friday will have a respiratory theme.:
A respiratory history SS
PFTs KM
CXR interpretation HJ
ABG interpretation AA
The approach to the (acutely) breathless patient JB
NIV HA

These will be a challenge. Remember to keep it concise yet precise. Don't try to squeeze too much information in. Produce a handout and quote your sources.

Interesting topics:
Has Chlamydia changed to Chlamydophila?

Extra-articular RA

2007-10-25T20:44:00.001+01:00

A brief talk about extra-articular disease in RA.

If you cannot see the pictures look at this other version.

Wardround 5x7

2007-10-08T11:11:00.000+01:00

Thank you for the talks on skin infection which I very much enjoyed. I hope you now have a background knowledge to help you choose, or guide the choice, of antibiotics and their route of administration. Remember to ask yourself "what can I do to reduce the likelihood of recurrence?" when you see a patient with these disorders. What would you do?

The two minute talks for next weekwill be on Atrial Fibrillation: two minutes please on the topics listed. Keep it concise yet precise, educate yourself and your colleagues, and quote your sources. Keep the info sheet short and simple.

assessing thrombotic risk AA
the case for rate control SYC
the case for rhythm control KM

If anybody else wishes to join the group they must bring a two minute talk.

I do not think there will be time for a discussion paper on Tuesday (reasons will become obvious) but for next week I would like you to read Risk: aspirin or car? in Bandolier. The original paper this refers to is available via the elibrary and is worth a look especially the discussion section.

What's More Dangerous, Your Aspirin Or Your Car? Thinking Rationally About Drug Risks (And Benefits). Cohen, Joshua T.; Neumann, Peter J.. Health Affairs, May/Jun2007, Vol. 26 Issue 3, p636-646; DOI: 10.1377/hlthaff.26.3.636

Interesting topics this week:
Erythromelalgia
Pseudobulbar palsy.

MJM

21ix7

2007-09-24T14:37:00.000+01:00

Our two minute talks last week were based on the investigation of abnormal LFTs but we got sidetracked into the interpretation of hepatitis B serology. This was I hope a useful time both for the specifics of understanding HepB serology and the general point of structuring your knowledge in a way which is useful for practical use. When learning a new topic, or revising an old one remember that the way it is structured in the textbook may need translating to make it easier to remember or apply.

Test yourself…which tests are useful for:

Assessing response to Hep B immunisation?

Checking for previous contact with Hep B?

Acute hepB?

Chronic Hep B?

Next is Opportunistic infection (in HIV)

Pneumocystis SYC

Cytomegalovierus AA

Atypical Mycobacteria AA

Kaposi’s MR

Two minutes please. Keep it precise and concise, quote your sources and educate your colleagues.

Last week’s discussion was about waste and how we might address the problem. This week we will discuss Measuring quality of life. Is there such a thing as a life not worth living? B. Farsides, RJ Dunlop BMJ 2001;322:1481-1483.

Next week the Tuesday discussion will be replaced with (by?) a quiz.

Interesting topics

PEG tubes
Aortic stenosis: indications for valve replacement in adults (uptodate)

Pneumocystis jiroveci

MJM

Wardround 14ix7

2007-09-16T23:15:00.000+01:00

The two minute talks for next week will be about the appropriate use of investigations in the patient with abnormal LFTs. Tell me how to use and interpret:

Viral tests AA' s successor
autoimmune serology (and metabolic tests if you can fit it in) MR
imaging SYC

The paper for discussion on Tuesday is WASTE IN THE NHS: THE PROBLEM, ITS SIZE, AND HOW WE CAN TACKLE IT. Andrew Moore, Bandolier.

For Tuesday 25th the discussion paper is Measuring quality of life. Is there such a thing as a life not worth living? B. Farsides, RJ Dunlop BMJ 2001;322:1481-1483.

Interesting topics:

Sheffield tables
ETTs - have a look at Ordering and Understanding the Exercise Stress Test by M Darrow.
Aspirin primary prevention there is much written on this, but you have to start somewhere

Wardround 7ix7

2007-09-10T13:55:00.001+01:00

The two minute talks for next Friday will be on the Organisms causing community acquired pneumonia and their associated clinical syndromes. Two minutes please on:
Pneumococcus AA
Mycoplasma SYC
Chlamydia (has its name chasnged?)
Legionella MR

The paper for discussion a week on Tuesday will be WASTE IN THE NHS: THE PROBLEM, ITS SIZE, AND HOW WE CAN TACKLE IT. Andrew Moore DSc, Editor of Bandolier.

MJM

Wardround 31viii7

2007-09-03T15:48:00.000+01:00

The ophthalmoscope, stethoscope, pulse oximeter, otoscope and sphygmomanometer all explained in less than half an hour...what an achievement. I still remain uncertain about the correct cuff size for a sphyg. The AHA arec quoted as saying Proper cuff size selection is critical to accurate measurement. The bladder length and width of the cuff should be 80% and 40%, respectively, of the arm circumference. Blood pressure measurement errors are generally worse in cuffs that are too small vs those that are too big. That sounds like an audit just waiting to happen.

For next week we will ahve two minute talks on practical procedures:
Blood cultures (including from lines) GAJ
Chest drain insertion AA
LP AW
Ascitic tap AG
Joint aspiration MJM

The paper for discussion this week was What patients want to know about adverse events. Whatever we may think, the people who took part in this study wanted to know just about everything. We may disagree or have reasons why we believe this is impractical, but should not dismiss it out of hand. Try asking a patient "What do you want to know about this treatment?" next time you suggest something.

The paper for discussion on 11 September is....to be decided.

Interesting topics

Haemolysis

MJM

Wardround 24viii7

2007-08-27T14:29:00.000+01:00

Thank you for your ideas about the cause of the plague in Athens. If you want to read more there is much to be found on the internet. If you would like to see a published discussion about the plague of Athens have a look at The cause of the plague of Athens: plague, typhoid, typhus, smallpox, or measles? Burke A. Cunha, Infect Dis Clin N Am 18 (2004) 29–43.

The two minute talks for this week will be about instruments in medicine:

Ophthalmoscope GAJ
Stethoscope AG
Saturation meter MJM
Auroscope AW
Sphygmomanometer AA

Two minutes please. Keep it precise and concise, and quote sources.

The reading for next week (4ix7) will be Metaphorical Medicine: using metaphors to enhance communication with patients who have pulmonary disease. Arroliga AC et al. Ann Intern Med. 2002 Sep 3;137(5 Part 1):376-9

For this week the reading is What patients want to know about adverse events. Bandolier 153 November 2006

MJM

Wardround 17viii7

2007-08-20T10:53:00.000+01:00

The Roth Spot is a white-centered hemorrhage. It is a cotton wool spot surrounded by hemorrhage. The cotton wool comes from ischemic bursting of axons; the small hemorrhage comes from ischemic bursting of a pre-capillary arteriole. It is not specific to bacterial endocarditis.

I will scan in this week's handouts on HSVE and JE. The prize for best talk this week goes to Dr Anderson for a novel way of presenting the information about Japanese encephalitis.

Herpes simplex encephalitis
Japanese encephalitis

The talks this week are your diagnostic choices for the plague of Athens. Read the article and come up with a diagnosis. You have two minutes to convince the group you are correct.

The History of the Peloponnesian War written by Thucydides in 431 B.C. If you click on the link it will take you to a copy of the piece. The web page begins with chapter VI, but you can skip down to chapter VII (unless you would like to read about the war). If you cannot find the right section, press ctrl-F and type in plague.

Don't forget to read Does this patient have abnormal central venous pressure? Cook, Deborah J; Simel, David L JAMA; Feb 28, 1996; vol 275 (8): 630-634, for Tuesday.

Interesting topics

Endocarditis

Intravascular Catheter–Related Infections.

Klebsiella.

MJM

Wardround 10viii7

2007-08-13T11:57:00.000+01:00

This week’s talks were about common drugs.. Coamoxiclav, Loop diuretics, LMWH and aspirin. You will become aware over time that I tend to be impressed by talks with a practical bent to them. So I may not care that furosemide is protein bound, but I am very interested that its effectiveness may be impaired in nephrotic syndrome due to the drug remaining bound to protein in the tubular lumen, since I need to give higher doses. It was good to see sources quoted. The week’s prize to Dr Reidy: good handout, sources quoted and an interesting slant on aspirin.

The reading last week had been A Necessary Inhumanity? Ruth Richardson. Journal of Medical Ethics 2000;26;104-106. The inhumanity discussed is apparently developed by doctors, for our own protection and to allow us to provide better care. We call it clinical detachment. I have no douibt that some doctors are inhumane, as her examples illustrate, but are we all? I do not think that I am inhumane when I remain calm (detached from the expected emotional response) in the face of severe illness in my patient. What do you think?

The talks for the coming week are related to encephalitis:

Herpes simplex encephalitis Dr Reidy
West Nile Virus Encephalitis Dr Waters
Japanese encephalitis Dr Anderson
Cerebral lupus Dr Ghanbari

The reading for next week is Does this patient have abnormal central venous pressure? Cook, Deborah J; Simel, David L JAMA; Feb 28, 1996; vol 275 (8): 630-634

Interesting topics

Staphylococcal septicaemia, excellent articles in uptodate.

DIC

MJM

Wardround 3viii7

2007-08-03T15:49:00.000+01:00

The new session begins and with next to no warning the new batch came up with two minute talks on the normal ECG. We heard about the p wave from Dr Ghanbari, PR interval from Dr Waters, QRS from MJM, ST from Dr Reidy, T wave from Dr Anderson and Axis from Dr Cameron. You can see a brief resume of a normal ecg here. The prize for best talk goes to Dr Cameron for making a difficult topic so simple that a big brother halfwit would understand it.

Now that you have all had a chance to see how the talks are done I can give the assignments for next week and be a bit more insistent about the rules. Next week’s two minute tutorials will be on common drugs:

Low molecular weight heparin (Dr Waters)
Aspirin (Dr Reidy)
Co-amoxiclav (Dr Anderson)
Loop diuretic (or was it PPI?) (Dr Ghanbari)

Keep it concise yet precise. Practical rather than theoretical. Heretical if you must. Produce a handout and quote your sources. This is helpful for your colleagues. If they find it interesting they can go and read it themselves.

Next Tuesday’s reading you already have. For the Tuesday after we will read The homeless man on morning rounds, from The midnight meal and other essays about doctors, patients and medicine. By Jerome Lowenstein. I will put a copy on the ward next week.

Interesting topics arising this week:

Encephalitis

West Nile Virus

Aspiration Pneumonia, good article on Uptodate

MJM

Welcome to Ward 10

2007-07-31T22:35:00.000+01:00

Farewell to the old guard and welcome to the new batch. Get ready to gorge yourself on fruit from the tree of knowledge.

This blog will be a reminder of your training assignments each week. In addition to your usual training there are two recurring assignments:

Two minute presentations

You will give a two minute presentation to the team each Friday. The topic for your talk each week will be recorded here. The aim is to enlighten yourself and your colleagues about the subject. You are only allowed two minutes (we have a timer) so don’t waste time waffling about why you chose to talk about the subject, just get down to it. This is a difficult task but not impossible, many have done it before you. The sources of your information should be mentioned. An A4 size handout is encouraged. Have a look at this example... Anaphylaxis by Dr Hannah Gunn, or this slightly busier one on aspiration pneumonia by YT. The talk is more important than the handout so use your time appropriately.

Read and think

There is a paper to read each week. These are to stimulate discussion so read them in good time so you have time to think before we discuss them on Tuesdays.

You will be given timetables for wardrounds, clinics etc when you arrive.

The read and think for next week will be

A Necessary Inhumanity? Ruth Richardson. Journal of Medical Ethics 2000;26;104-106

You should be able to get the PDF using your Athens password.

MJM

Wardround 29vi7

2007-07-01T21:18:00.000+01:00

Our two minute talks this week were about endocrine disorders, specifically the clinical features of hypoadrenalism, hypothyroidism and hyperprolactinaemia. This has stimulated me to be more aware of prolactin levels in my patients with unexplained symtoms.

For next week we will be focussing on the eye with topics of the sore/red eye, visual loss and diplopia. So two minutes please on the work up and management of patients with these common problems.

The reading for next week will be Does This Patient Have Temporal Arteritis? Smetana and Shmerling. JAMA.2002; 287: 92-101. Get it via the elibrary. Hopefully we can start the meeting on time and be able to discuss the paper this time.

Interesting topics
Miller-Fisher Syndrome

And for those who fancy a trip to the real library, why not have a look at An unusual variant of acute idiopathic polyneuritis (syndrome of ophthalmolplegia, ataxia and areflexia). M Fisher:
New England Journal of Medicine, 1956, 255: 57-65.

MJM

Tardy wardround

2007-06-27T11:22:00.001+01:00

Sorry folks. The posting is late this week due to foreign travel and computer problems.

I will just cut to the quick and give next week's reading:

BMJ 2003;326:151 ( 18 January )

Filler

Endpiece

A good physician versus no physician

The difference between a good physician and a bad one is certainly very great; but the difference between a good physicianand no physician at all, in many cases, is verylittle.

If during the course of the common epidemic diseases which occur in this island every spring and autumn, two hundred patientswere taken promiscuously, and one half delivered to the care ofthe faculty to be treated according to the art; that is, as privatepatients by whom they are fee'd every time they prescribe, andthe other half delivered to the care of nurses, instructed togive them no physic whatever, but merely cooling drinks, and suchlight and simple foods as the patients' appetites might lead themto, I am convinced the world would be a good deal surprised atthe result of theexperiment.

J Moore, Medical Sketches. London: A Strahan and T Cadell, 1786

Jeremy Hugh Baron, honorary professorial lecturer, Mount Sinai School of Medicine, New York

Remember that a short read means more time for reflection.

You already have your assignments for two minute talks on endocrine dysfunctions.

MJM

EULAR

2007-06-16T09:18:00.000+01:00

The EULAR meeting has been interesting and thought provoking. As well as the usual expected tide of data regarding biologics efficacy and safety, there has been a growing focus on strategies for treating Rheumatoid disease. More of which over the next few days.

Other sessions included neuroendocrine and intracrine influences on RA, circadian rhythms, SLE and crystals.

I hope the team back on Ward 10 will choose a subject for the two minute talks next week.

MJM (Barcelona)

Wardround 8vi7

2007-06-10T23:54:00.001+01:00

The two minute talks this week were stimulated by a recent case of tetanus. We heard about the toxin effects of Tetanus (J Wallace); C. diff (G Bell); Botulism (N Mohan); Staph Toxin (L Frame). Very interesting topics. I was not aware of the neuromuscular effects of aminoglycosides. My prize goes to NM. You can find out more trivia about botulism at Naveen’s blog.

For next week’s talks we will address the four giants of geriatrics. Our mental search for the fifth giant reminded me of Terry Pratchett’s fifth horseman of the apocalypse. I once did a podcast on the subject and remain taken by the thought of that fifth horseman, Ronnie, who left before they became famous. The assignments for next Friday are:

Falls (MJM’s SHO)
Delirium (KL)
Incontinence (JW)
Immobility (NM)

Two minutes please. Keep it precise and concise, quote your sources and make a one page handout that is so perfect people will want to keep a copy to show their grandchildren. Given the subject matter I would prefer that you avoided practical demonstrations, especially JW.

The paper discussed this week was The dogged physical examination in the era of the C.A.T. Riegelman K. Primary Care 1980 Dec;7(4):625-35. I hope this has stimulated each of you to think about those parts of the exam that are particularly useful, yet easily and often omitted. You might want to read the last paragraph of the previous paper as well.

For next week I would like you to read and think about: Aunt Sophie’s Choice: the perils of paternalism. Schafer A.

PS beware Pratchett's four minor horsemen of the apocralypse: panic, bewilderment, ignorance and shouting.

MJM

Wardround 11v7

2007-05-13T23:22:00.000+01:00

Next week’s two minute tutorials are on dangerous drugs. Two minutes please on:

Warfarin GB
Antibiotics JW
Antipsychotics LF
Aspirin R
Steroids SS

Let’s lift ourselves up...no lacklustre talks this week please. No excuses. Give the group an interesting couple of minutes on your topic.

The read and think for next week is The rational clinical examination: Is this patient clinically depressed? Williams JW, et al. JAMA 2002; 287: 1160-70.

Interesting topics:
Wegener’s granulomatosis
Diffuse alveolar hemorrhage syndromes. U Specks. Current Opinion in Rheumatology. 13(1):12-17, January 2001.

MJM