Wardround 23xii05

This being the festive season the blog is short.
Our two minute tutorials are non-medical. We each talked about our favourite film or book. I did make a list but have left it at work and the sound of Blink-182 is interfering with my brain function. Here is what I remember:

Romantic Highlights (music) ?
The Matrix, (A & L Wachoski)
A time for drunken horses (Bahman Ghobadi)
Sophie’s World (J Gaarder)
Snatch (G. Ritchie)
Singing in the Rain (Kelly, Donen)
Legend, (David Gemmel)
To Kill a Mockingbird (Harper Lee)

An interesting mix. At least I have some ideas for next year's viewing.

Interesting topics this week:
Empyema
BTS guidelines for the management of pleural infection. Thorax 2003;58(Suppl II):ii18-ii28

Congratulations to Claire for success in the Xmas quiz.

Have a good Christmas time, see you next week.


MJM

Wardround 16xii05

16xii05

This week’s theme for the two minute tutorials was osteoporosis:

Pathophysiology MJM
Epidemiology AA
Dexa AS
Non-pharmacological treatments GAJ
Bisphosphonates HG
Other drugs CT

This week’s prize to Dr Anand (for effort and perceived excitement). The SIGN guidelines are a good source for basic information and links to other sources. Newer agents such as Parathyroid hormone and strontium ranelate are not covered in the SIGN document. If you want a ‘ten second tutorial’ on these have a look at the SMC statements.

http://www.scottishmedicines.org.uk/updocs/Teriparatide%20(Forsteo).pdf
http://www.scottishmedicines.org.uk/updocs/strontium%20ranelate%20(Protelos)%20(178-05).pdf

I would see these as aperitifs...they whet your appetite but are not really enough to satisfy your hunger for knowledge.

How can I sum up these tutorials? Osteoporosis is common, it manifests as fractures, deformity, respiratory compromise, increased mortality, pain and disability and is very common. The costs of untreated and unprevented (oh! english teacher, forgive me for that word) osteoporosis are substantial.

Peak bone mass is reached in the fourth decade and genetic factors are the most important in the absence of malnutrition. It all starts going pear shaped with middle age as the bone remodelling units (osteoblasts and osteoclasts) break down more bone than is produced. Oestrogenic suppression of osteoblast produced iL-6 fails at the menopause leading to increased osteoclast activity and even greater bone loss.

Post menopausal osteoporosis particularly increases fragility fractures in bones dependent on trabecular bone (vertebrae, distal radius), senile osteoporosis increases fractures in these and long bones ( neck of femur, humerus). Steroid osteoporosis has a ‘trabecular pattern’.

Falls, age and bone density are the important triad of risk factors for osteoporotic fractures.Treatment should be aimed at reducing falls and minimising bone loss by ensuring adequate calcium and vitamin D intake, addressing other reversible risks (controlling active systemic inflammatory disease), inhibiting bone resorbtion and stimulating bone formation (less easy).

The indications for DEXA are in the SIGN document.

We did not have time to discuss the In a Stew paper due to the staff Christmas dinner. Another time perhaps.

Interesting topics this week:

Marfan’s...how do you diagnose a ‘sporadic’ case. This paper lists and discusses the diagnostic criteria.

Thalidomide for Behçet’s ulceration

Clinical experience with thalidomide in the management of severe oral and genital ulceration in conditions such as Behcet's disease: use of neurophysiological studies to detect thalidomide neuropathy. JM Gardner-Medwin, NJ Smith and RJ Powell. Annals of the Rheumatic Diseases, 1994, Vol 53, 828-832. It's not available on-line but I have a copy in my office if you would like to read it.

Sjogren’s syndrome


Next week is a special tutorial theme...you are invited to regale us with two minutes about your favourite film or book. Medical textbooks are not allowed as choices!

The reading for next week is Polythenia gravis: the downside of evidence based medicine
Down End Research Group. BMJ 1995;311:1666-1668.


Merry Christmas

MJM

wardround 9xii05


MP3 File

Wardround 9xii05

Two Minute tutorials: the theme this week was the safe use of anti-rheumatic drugs:

Dr Gunn Methotrexate
Dr Tuck Leflunomide
Dr Anand Etanercept
Dr McMahon Steroids (Summary sheet)
Dr Jones Minocycline
Dr S(?) Gold

I was impressed by the variety of approaches used for the talks. Dr Tuck continued her winning approach of quoting sources, producing a handout and keeping to time, but Dr Gunn brought a new approach by talking around a patient scenario. I had not come accross the use of allopurinol mouth washes before...that’s my reading for the weekend. This week’s prize (Dr Jones disqualified as usual...too senior) is shared between Drs Tuck and Gunn.

The reading for the week was.. Nonsteroidal anti-inflammatory drug associated gastropathy: incidence and risk factor models. Fries JF, Williams AW. The American Journal of Medicine. 1991; 91: 213-222. I find this is an interesting paper for several reasons, some obvious, others less so. Clearly this was not a view shared by the rest of the team. It is one of the first papers to identify disease severity in RA as a risk factor for NSAID gastropathy. It quantifies risk and offers a way to identify patients at high risk of NSAID ulcer complications. Good grounding though for the department journal club which turned out to be about prophylaxis against NSAID gastropathy.

NSAID gastropathy was long recognised but its impact began to be quantified and advertised (see NSAID gastropathy: the second most deadly rheumatic disease? Epidemiology and risk appraisal." Fries JF J Rheumatol Suppl 1991; 28: 6-10...I have a copy if you wish to see it). The paper we read was followed by studies to identify the relative toxicity of the various NSAIDs. This needed a method of assessing relative risk...the same methodology was then applied to second line drugs and it transpired that many NSAIDs were more toxic than DMARDs.

Rheumatoid arthritis had been thought to be indolent and relatively benign; and NSAIDs benign while DMARDs toxic. It had been recognised that RA was far from benign and that the onset of disability was rapid (most rapid in the fist few weeks/months). The recognition that the DMARDs were not more toxic than NSAIDs was a catalyst for early DMARD use. The era of modern RA treatment was underway.

Interesting topics this week

Systolic murmurs
Bedside diagnosis of systolic murmurs. NJ Lembo, LJ Dell'Italia, MH Crawford, and RA O'Rourke. NEJM 1988; 318 (24): 1572-1578.
You will have to get it from the library (the real one, not the e-library!)

ACIS risk (again)

Pneumothorax
BTS guidelines for the management of spontaneous pneumothorax
Thorax 2003;58:ii39

Wegener’s (again!)
An Approach to Diagnosis and Initial Management of Systemic Vasculitis. Roane DW, and Griger DR. AFP Oct 1999

Save those ovaries
Ovarian failure due to anticancer drugs and radiation. Look it up in UpToDate


The theme for next week is Osteoporosis, aespecially glucocorticorticoid associated osteoporosis.

Pathophysiology MJM
Epidemiology AA
Dexa Dr S
Bisphosphonates HG
Other drugs CT
Non-drug treatments GAJ

Two minutes, sources, handouts please

Next week’s reading 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.

MJM

Wardround 2xii05

The theme this week was anti-arrhythmics and the Vaughan-Williams classification. This classification is not perfect since within a class, drugs may have different actions and drugs may exist in more than one class. It is, however, a good starting point for understanding anti-arrhythmics.

Class I agents interfere with the sodium (Na+) channel.
Class 1a eg disopyramide, prolong the action potential. They are effective against SVT and VT.
Class 1b eg lignocaine, shorten the action potential. They are used for the treatment of VT.
Class 1c eg flecainide, have little effect on the action potential duration. They are effective in AF, SVT and VT
Class II agents are beta blockers.
Class III agents affect potassium (K+) influx. eg amiodarone prolong the action potential and refractory period. They are used for re-entry tachycardias, SVT and VT.
Class IV agents affect the AV node.

An excellent summary can be found at:
http://lysine.pharm.utah.edu/netpharm/netpharm_00/notes/antiarrhythmics.html

Next week’s theme is reducing drug risks and we will be using rheumatological drugs as our examples. The challenge is to wax lyrical for two minutes about reducing risk when using:

Methotrexate (HG)
Leflunomide (CT)
Sulfasalazine (NM)
Etanercept (Ash)
Steroids (MJM)
(and if GAJ wishes she can have any antibiotic used long term...minocycline would be rheumatological)

The reading for next week is
Nonsteroidal anti-inflammatory drug associated gastropathy: incidence and risk factor models. Fries JF, Williams AW. The American Journal of Medicine. 1991; 91: 213-222.
You will need to get this from the elibrary

Interesting topics this week?

NFRs

Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. February 2001.

UK clinical ethics network

Acute inflammatory arthritis

Guidelines for the Initial Evaluation of the Adult Patient with Acute Musculoskeletal Symptoms. American College of Rheumatology.

MJM

podcast - digoxin


MP3 File

Wardround 25xi05

I have fixed the paraprotein link.

This week’s theme was related to the NEJM review of bacterial infections in intravenous drug users. Bacterial Infections in Drug Users. Gordon RJ, Lowy FD. NEJM November 3, 2005; 353 (18):1945-1954. (link in last week's blog)

Epidemiology (PS) : Most bacterial infections among drug users are caused by commensal flora, unusual organisms, such as clostridia and Pseudomonas indicate that a particular drug or drug-use behavior is involved. Drug users have a 10-fold increase in community-acquired pneumonia. and an incidence of one abscess per three years of injection.

Pathogenesis (HG): Bacteria are acquired from the commensal flora, the drugs or adulterants, or paraphernalia. The skin barrier is breached and non-aseptic techniques contibute to increased rrisk and use of the groin is a particular risk. Popping, which is relatively unusual locally, increases the risk of anaerobic infection. An example of paraphernalia introducing infection is candidal endophthalmitis, contracted from citric acid used to dissolve heroin.

Clinical features (AS & BA): The clinical presentation of bacterial infections in drug users is generally similar to that encountered in patients who do not use drugs but some features are unique to the drug user.

Treatment (NJ): Recognising the specific risks such as right sided SBE is the first step. Issues of the management of drug withdrawal, adherence to therapy, and difficulties of intravenous access must be a part of the therapeutic strategy. Attention to local outbreaks and bacterial antibiotic-resistance profiles is important.

Prevention (CT): Eliminating drug use is the surest way to control associated infections, but may not be possible. Risk-reducing strategies may help prevent bacterial infections among drug users, particularly among new users, the ones at greatest risk. Advise on using clean needles, not sharing, alcohol skin swabs, avoiding the neck and groin as injection sites. Don’t miss the opportunity for screening (Hep B, C, HIV, TB) and immunisation (Hep B, Hep A, tetanus).

This week’s prize to Dr Tuck...timing, handouts, good precis.

Next week’s theme is anti-arrhythmic drugs, two minutes please on:

Class Ia (AS)
Class Ib (Ash)
Class Ic (CT)
Class II (NM)
Class III (BA)
Class IV (HG)
Cardiac glycosides (MJM)

Interesting topics this week

Paraproteins

Cardiac action potentials and Vaughan-Williams

Technetium bone scans:
Am Fam Physician 1996 Oct;54(5):1639-47. Sutter CW et al. Three-phase bone scan in osteomyelitis and other musculoskeletal disorders. (you can get this through the e-library with your Athens login)

The Reading for next week is Outputs and Utility. Bandolier November 2002
http://www.jr2.ox.ac.uk/bandolier/Extraforbando/Outputs.pdf

MJM

Polymyalgia Rheumatica

Polymyalgia Rheumatica


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Wardround 18xi05

This week’s two minute tutorials were about palliative care issues. I would like each of you to post one item from your talk in the comments section please.

Pain (AS)
Nausea/vomiting (CT)
Fatigue (BA)
Hiccoughs (MJM)
Constipation (HG)
Dyspnoea (PS)
Dysphagia (NJ)
Itching (GAJ)

I award this week’s prize (kudos but no money) to Dr Tuck....unhurried, spoken rather then read out, accompanied by a handout, and sources quoted. It is interesting that these areas are taken so seriously in palliative care, yet are relatively ignored in acute medicine even though the benefits in improved quality of life can be immense. I remember talking to a colleague who had a serious stroke while still young...on the rehab unit he told me that he had not realised how serious a problem constipation was until he was the one afflicted.

The minor challenge had been to tell me the p value for my experiment. I postulated that saying the magic word “abracadabra” had increased the number of heads when tossing a coin. The experiment was carried out on Tuesday: I tossed a coin and got three tails in a row; then repeated the process after the magic word and had 2 heads and a tail. What is the p value? Answer...the p value (probability of tossing more coins by chance as tails) in this experiment was 0.875.

The paper for discussion had been "The Medical Effects of Kissing Booboos" by Hansen GL. Originally published as "The Palliative Effects of Osculation on the Prognosis of Pediatric Wounds" in the Annals of Improbable Research 1995 Volume 1: Number 5. I had asked you to identify any methodological flaws.

This paper describes an observational study of kissing wounds better. Only 23 of 24,617 cases were enrolled: the numbers themselves are not a problem since most studies use only a sample of the possible subjects. What is important is that the subjects should be selected randomly otherwise there may be bias in the selection process. Bias can be reduced by randomly allocating patients to treatment groups and blinding subjects and investigators to the treatment used. Since this is an observational study randomisation has already been foregone...and we are given no information to suggest that the assessment is blinded. In an RCT you can get some idea about the success of randomisation by looking at the rather boring table called something like “baseline characteristics”. Most of these should be similar in each group if the randomisation procedure has worked. Don’t fall for the arguments such as “ there were more diabetics in group A so the improvement in survival is even more impressive”. You should be thinking “is the randomisation process robust?” Of course this paper has no statistical testing.

Some reading for related to this...read them for Tuesday’s wardround.

What are confidence intervals? Davies HT

Bandolier Bias guide

Interesting topics this week:

Neurofibromatosis

TIMI score
see below October 5, 2005

Alcoholic hepatitis

Next week’s reading is Bacterial Infections in Drug Users. Gordon RJ, Lowy FD. NEJM November 3, 2005; 353 (18):1945-1954.
You should be able to get a copy from the NHSES e-library with your Athens password.

The two minute tutorials will be based on sections of this paper:

Epidemiology (PS)
Pathogenesis (HG)
Clinical Features (AS & BA)
Prevention (CT)
Treatment (NJ)

Try to deliver your talks rather than read them out.

MJM

Hiccoughs

Hiccoughs


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The minor challenge for this week had been to tell me the p value for the following experiment. I postulated that saying the magic word “abracadabra” had increased the number of heads when tossing a coin. The experiment was carried out on Tuesday: I tossed a coin and got three tails in a row; then repeated the process after the magic word and had 2 heads and a tail. There we have it...proof (just send the Nobel prize in the post). What is the p value?

Wardround 11xi05

This weeks two minute tutorials were themed around common drugs.

We heard about:
Furosemide (Dr Kidder)
Coamoxiclav (Dr Tuck)
Salbutamol (Dr Johnstone)
Paracetamol (Dr Szulakowski)
Morphine (Dr Jones)
Warfarin (MJM)

I award this week's prize to Dr Kidder. It is useful to review drugs we use commonly as it is easy to begin thinking that something we use often is something we know all about. Confidence can breed mistaken assessments of competence. Coincidentally, our friendly renal doc had, earlier in the week been asking me if I knew how furosemide got into the renal tubules...I must own up that I foolishly thought it was filtered...he put me right on that one and Dr Kidder I see began his talk by mentioning that Furosemide is highly protein bound and is not therefore filtered, but actively transported into the tubules. This is important since in a setting of glomerular protein leakage the tubular furosemide can become bound to albumin and its activity reduced.

A question for you. Did you learn anything from the talks? If so...why not read up on common drugs every now and then.

The week's reading was in house so to speak: How to report an ETT... from our own wiki (http://mjms.pbwiki.com). I will draw up a pro-forma for ward staff to use.

Since there has been a request for discussion of p values I have set next weeks reading as "The Medical Effects of Kissing Booboos" by Hansen GL. Originally published as "The Palliative Effects of Osculation on the Prognosis of Pediatric Wounds" in the Annals of Improbable Research 1995 Volume 1: Number 5. This is not available online without paying a subscription, so I will bring a copy in to the ward on Monday. The paper contains more than one methodological flaw. I would like you to draw up a list for Friday's discussion.

Interesting topics this week:

Diagnosing Endocarditis

Hypernatraemia


Next weeks two minute tutorials are themed around palliative care: I have misplaced my academic diary where the assignments were listed but you all know what you must do. (I will update the post when I can -done)

Pain (AS)
Nausea/vomiting (CT)
Fatigue (BA)
Hiccoughs (MJM)
Constipation (HG)
Dyspnoea (PS)
Dysphagia (NJ)
Itching (GAJ)

Make the two minutes unhurried and informative.

Podcast to follow.

MJM

Warfarin 101


MP3 File

Wardround 04xi05

Wow...we're in the BMJ this week. Netlines

This weeks two minute tutorials were themed around the U&E.

Sodium (Dr Szulakowski chose to give us a talk on inappropriate ADH. One might argue that is a disturbance of water tonicity/volume control, but perhaps its just me being pedantic).
Potassium (Dr Kidder)
Chloride (duet)
Creatinine (Dr Johnstone)
Bicarbonate (Dr Islam)

Naomi's talk on creatinine receives the prize for this week since she managed to give a precise and concise talk. I am afraid all the others tried to fit too much into the limited time. The task of presenting a two minute talk on a subject is difficult (at first) and clearly most of you are very generous...you try to give me as much as possible...but there is only so much that can be said in two minutes.

More musing on two minute tutorials. These are a discipline. If you can learn how to distill the fruits of your reading into this short time you will be able to produce revision notes very easily. When the time comes to move on and give longer talks you will be able to build them up in two minute sized aliquots. Believe me, when you go to pick up that Nobel prize, you may not thank me, but I will be running around shouting 'I taught her how to give a concise .talk'.

Next week's tutorial theme is 'common drugs'...here are the assignments:

DK Furosemide
CT Coamoxiclav (go on, make Dr J proud of you)
NJ Salbutamol
PS Paracetamol
GAJ (free choice....)
MJM (mmmmmm...I'll take requests...post them in the comments section)

Interesting topics this week

RB-ILD

Wikis: if you don't know what a wiki is have a look at Wikipedia. I hope we can put together a wardround wiki (see link to the right) collecting the information from our discussions. I have put together a couple of pages on the normal ECG and reporting ETTs. At the moment it is hosted externally but we should have an in house wiki soon which could contain the doctor's handbook...I have pasted some pages from the last (ie out of date) handbook but BEWARE a colleague has vandalised some pages to illustrate a point. We do not advocate giving Elephant guns to aggressive patients.



Next week's reading:
Our wiki page on reporting an ETT (link is to the right)


A paper for your collection:
Treatment of stable chronic obstructive pulmonary disease
Stephen I Rennard. Lancet
28 August 2004, Pages 791-802

Don't forget your two minute tutorials, just two minutes worth. All knowledge can be categorised as:

Must know
Should know
Nice to know
Don't need to know

Which will you include in your talk?

MJM



MP3 File

The Normal ECG


MP3

http://mjms.pbwiki.com/ECG

Wardround 28x05

This week's two minute tutorials: theme COPD (I will talk about these on the podcast)

Steroids in COPD (link) Dr Tuck
Antibiotics in COPD Dr Kidder
LTOT Dr Johnstone
Non-invasive Ventilation Dr Szulakowski
Smoking cessation Dr Islam


Further reading
NICE guidance on COPD 2004 ,
European Respiratory Society COPD standards


Interesting topics this week

Weight loss with HIV
http://www.hivmedicine.com/textbook/wasting.htm

Klebsiella septicaemia
http://www.emedicine.com/med/topic1237.htm

Lymphocytosis
http://www.aafp.org/afp/20001101/2053.html

Gastric erosions
http://www.emedicine.com/med/topic3565.htm

Anticoagulation in AF
http://www.sign.ac.uk/pdf/sign36.pdf


This week’s reading for discussion was A Necessary Inhumanity? Ruth Richardson. Journal of Medical Ethics 2000;26;104-106, from which I have reproduced the abstract below.

“It is argued that the phrase “Necessary Inhumanity” more accurately describes the alienation required of doctors in some circumstances, than do modern sanitized coinages such as ‘clinical detachment’. ‘Detachment’ and ‘objectivity’ imply separation, not engagement: creating distance not only from patients, but from the self: the process may well be required, but where it becomes too extreme or prolonged, it can damage everybody, including patients, family members, doctors themselves, and wider society. An awareness of the history of health care in the context of our society might assist self reflection–might help keep initiates in touch with the culture they have been induced to leave and might help them remain humane despite the bruising process of training.”


The reading for next week is Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S. Wang; J. Mark FitzGerald; Michael Schulzer; Edwin Mak; Najib T. Ayas JAMA. 2005;294:1944-1956.

Next week’s two minute tutorials are themed on the U&E

Sodium PS
Potassium DK
Creatinine NJ
Bicarbonate TI
Chloride M

Don’t forget your two minute tutorials should be concise and precise.




podcast



If anyone out there would like to submit two minute tutorials for the podcast, just leave me a note in one of the comments.

Podcast - assessing RA

Assessing disease activity in rheumatoid arthritis


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Development and preliminary assessment of a simple measure of overall status in rheumatoid arthritis (OSRA) for routine clinical use. Symmons DPM, Hassell AB, Gunatillaka KAN, Jones PW, Schollum J, Dawes PT. Q J Med 1995;88:429–37

Disease activity score The home of the DAS

The DAS28 in rheumatoid arthritis and fibromyalgia patients. B. F. Leeb, I. Andel, J. Sautner, T. Nothnagl and B. Rintelen. Rheumatology 2004 43(12):1504-1507

In this podcast I have not addressed the wider assessment beyond disease activity, but will address this in a later podcast which will include discussion of questionnaires in assessment.

The QRS in the exercise ECG. Audio only version.


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No wardround blog for this week since I am away at the the weekend. I hope Dr Jones will give out the two minute tutorials, but if not I will allocate some on Tuesday.

We better have some reading, though. Since we did not have much of an opportunity to discuss this paper from a couple of weeks ago, perhaps we should go over it once more...I expect everyone to have a (reasoned) opinion about it.

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

But I must say I am very tempted by Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S. Wang; J. Mark FitzGerald; Michael Schulzer; Edwin Mak; Najib T. Ayas JAMA. 2005;294:1944-1956. But perhaps we could leave that for the next week (hint...that means you have two weeks to read it).

And now you all have your 'ECG reporter' badges We can expect thorough assessment of ECGs next week.

I am off south of the border for a few days...but back in bonny Scotland soon.

The QRS complex and the exercise ECG

Wardround 14x05


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Wardround 14x05

This week’s two minute tutorials were based on the theme of a normal ECG.

P wave and PR interval MJM
QRS Dr Mohan
ST/T Dr Kidder
QT and axis (and unsolicited infectious disease associations!) Dr Jones

You can listen to an extended version of the P wave tutorial on the midweek podcast. I will attach links to the summary sheets from my own and Dr Mohan’s talks.

The challenge for next week is to identify what we mean (or should mean) if we say an ECG is normal.

My initial thoughts would be:

Correct patient and date
Scan for lead misplacement (aVr being positive or II of much lower amplitude than other limb leads)
Normal rhythm and rate (Sinus rhythm between 60-100 bpm)
Normal axis (-30 to +90, t axis similar to QRS axis)
Normal P waves (present, not too tall, too wide or abnormally inverted)
Normal PR interval
Normal QRS ( not too wide, not too big, no pathological Qs, )
Normal QT (QTC = 0.35-0.43)
Normal ST (not deviated)
Normal T
Normal U
Unchanged from previous recordings

Have I missed anything important?

The reading for next week is:

Swots Corner: What is an odds ratio? Bandolier


Interesting cases this week:

A patient with syncope and significant injury, mixed aortic valve disease, paroxysmal AF, hypertension with postural hypotension, vertigo, tinnitus and hypokalaemia, to mention just some of her problems. Investigation of syncope.

Cerebral vasculitis

Acute polyarticular gout

Paracetamol poisoning

Korsakoff’s syndrome

Kluver-Bucy Syndrome

And have a look at Naveen's page for an ECG quiz and link to more ECG quizzes.

Don’t forget your two minute tutorials…make them concise and precise.
Next week’s theme is the Exercise ECG…what’s normal?

If you haven't subscribed to the podcast, why not do it now? The easiest way is to download iTunes from www.apple.com (its free), then go to the podcast section of the store and search for MJM's wardround (its free).

If anyone out there would like to submit two minute tutorials for the podcast, just leave me a note in one of the comments.

P waves

The P wave and PR interval


MP3 File

SummaryA4 sheet

Introduction to ECGs: an excellent, clear and simple intro

ECG library look at example ECGs

Usefulness of standard electrocardiographic parameters for predicting cardiac events after acute myocardial infarction during modern treatment era. Juha S. Perkiomaki, et al. The American Journal of Cardiology 2002;90 (3): 205-209

Watch the P Wave, It Can Change! Patrick Yue et al Chest 2003; 124; 424-426

MJM

Wardround 07x05, audio: NNTs for treatments in acute coronary syndrome, moaning about the quality of this weeks tutorials, interesting cases, next weeks reading...and a little music.


MP3 File


This week's music is Jennifer Helane, Delivery....podsafe music network

Wardround 07x05

This week’s two minute tutorials were about acute coronary syndrome. The risk stratification talk has been podcasted and is available as an audioblog in the post below this. Naveen and Dilshad gave us brief updates on beta blockers and heparin in ACS. I will ask them to post something in the comments.

If you want a brief review of ACS treatment have a look at Treating non-ST-segment elevation ACS: Pros and cons of current strategies. Enrique V. Carbajal, MD; Prakash Deedwania, MD
VOL 118 / NO 3 / SEPTEMBER 2005 / POSTGRADUATE MEDICINE

Or Unstable Angina and NSTEMI:Tailoring Treatment Based on Risk. Eve Kaiyala, MD, and Deborah B. Diercks, MD. Emerg Med 36(11):20-38, 2004

We did not get chance to discuss the The practice of clinical medicine as an art and as a science paper today but I will expect some comments over coffee on Tuesday.

The reading for next week is:

ACC/AHA 2002 Guideline Update for Exercise Testing
http://www.acc.org/clinical/guidelines/exercise/dirindex.htm

Integration of the complete contents into your brain is not required…the task is to gain some useful information to allow you to better report and interpret a test you perform on a patient with known IHD. Discuss..

Interesting cases this week:

Pericardial effusion and cancer
Pericardial effusion in patients with cancer: outcome with contemporary management strategies. RJ Laham, DJ Cohen, RE Kuntz, DS Baim, BH Lorell and M Simons Heart, 1996;75: 67-71, http://heart.bmjjournals.com/cgi/content/abstract/75/1/67

Acute Monoarthritis
http://www.rheumatology.org/publications/guidelines/musc/musc-dis.asp

Haemolysis – Cold agglutinins
http://www.emedicine.com/med/topic408.htm
Uptodate has a good article as well


Don’t forget your two minute tutorials…make them concise and precise.
The theme next week will be the normal ecg… when you say “the ECG is normal”, what does this actually mean (or what should it mean)?

MJM P wave and PR interval
Dr Mohan QRS
Dr Kidder T wave and ST segment
Dr Jones Axis (and by special request the QT interval) (I’ll bet she even manages to sneak some infectious disease stuff into this!)


If anyone out there would like to submit two minute tutorials for the podcast, just leave me a note in one of the comments.

Risk scoring in ACS

TIMI scoring


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Summary sheet

The TIMI risk score for unstable angina/non-ST-elevation MI. Altman EM et al. JAMA 2000;284;835-42.

ACC unstable angina/NSTEMI guidelines

Relative value of N-terminal probrain natriuretic peptide, TIMI risk score, ACC/AHA prognostic classification and other risk markers in patients with non-ST-elevation acute coronary syndromes. Bazzino O et al. European Heart Journal 2004;25:859-866.

Wardround 30ix05

This week’s two minute tutorials were based around hospital acquired infection.

Dr Jones told us about Semmelweiss and his discovery of the importance of hygiene in preventing death in hospitals. You can find a brief biography in the wikipedia.

Other two minute talks were:
MRSA bacteraemia (8/8) Dr Mohan has posted an A4 sheet summarising his talk on MRSA bacteraemia. (How about putting an HTML version out there Naveen?) You will see that handwashing is the core preventative measure.
Pseudomonal pneumonia (Nawaz, 5/8)
Catheter related urinary tract infection (Dr Siddiqui 8/8)
Clostridium difficile (Bhasker 5/8)
Hospital acquired pneumonia (Dr Kidder 8/8)

We were able to discuss the concept of ‘judicious’ antibiotic use. I hope my summary here does this some justice:
1. Be sure an antibiotic is needed
2. Take the necessary samples
3. Use local antibiotic guidelines
4. Give the correct dose, guided by levels when necessary
5. Use narrow spectrum when you can; if broad spectrum cover is required, narrow it as soon as culture results allow.

The term ‘aggressive’ antibiotic was voiced in discussion….synonymous, I presume, with very broad spectrum combinations. Can I suggest an alternative adjective for antibiotic use …let’s be meticulous rather than aggressive?

The reading for next week is: The practice of clinical medicine as an art and as a science
John Saunders. J Med Ethics: Medical Humanities 2000;26:18–22
You should be able to get the PDF using your Athens password.

Interesting topics this week:

Wolff-Parkinson-White
Split second heart sound (I’ll put more about this on the podcast)
Horner’s syndrome
Cerebellopontine angle tumours

Don’t forget your two minute tutorials…next week is acute coronary syndrome…make it concise and precise.

If anyone out there would like to submit two minute tutorials for the podcast, just leave me a note in one of the comments.

Semmelweiss, split second heart sounds, next week's reading...and some music.


MP3 File

MJM Wardround 23ix05

This week’s two minute tutorials were themed around pneumonia:
There is an extended version of my talk about aspiration pneumonia on the podcast (see below). I will record the two minute version and publish that after the weekend. The prize for this week goes to Dr Kidder (for his excellent timing!). Would each person post one fact from their talk in the comments, please?

I have found the themed tutorials much better than random subject choices and we have decided to make the two minute tutorials themed each week. Perhaps we will have an occasional freestyle week? Dr Jones had suggested the theme for next week, keeping the ID flavour: hospital acquired infection. Here are the topics:

MRSA bacteraemia - NM
Hospital acquired pneumonia - DK
Pseudomonas Pneumonia (not CF) - Nawaz
C. Difficile - Bhasker
Catheter related UTI - SS

We would like an A4 sheet to highlight the important points. You can see my effort from this week in the aspiration pneumonia post (click on summary)


The reading for next week is:
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.

We have decided in future to discuss the week’s paper at coffee on Tuesday rather than Friday, which is already quite busy, so I will write a little about the antibiotic timing paper (see WR 16ix05) next week.


Interesting topics this week:

Hypercalcaemia and bilateral hilar lymphadenopathy
Mycobacterium avium
Giardiasis
Indications for pacing in Heart block
Hypothalamic function
AIDS lipodystrophy

Don’t forget your two minute tutorials should be concise and precise.



If anyone out there would like to submit two minute tutorials for the podcast, just leave me a note in one of the comments.

Aspiration Pneumonia

A brief summary


MP3 File


Summary sheet

Aspiration pneumonitis and aspiration pneumonia. Paul E Marik. The New England Journal of Medicine. 2001 (Mar 1) 344 (9); 665-7
Aspiration Pneumonia: Recognizing and managing a potentially growing disorder. John L. Johnson, Christina S. Hirsch. VOL 113 / NO 3 / MARCH 2003 / POSTGRADUATE MEDICINE

Materia non medica

What is the diagnosis?
Clue
Culprit

MJM wardround 16ix05

This week’s two minute tutorials were:

Dr Tuck: Colchicine overdose (6/8)
Dr Mohan: Glucocorticoids and the risk of heart disease (6/8)
Dr Queen: Using interpreters (6/8)
(would you each post the references/links in the comments, please)

Dr Jones has now given her considered opinion on last week’s emergency drug choices:

The prize is awarded to Dr Queen for emphasis on sanitation and oral rehydration therapy. I liked his idea to use mefloquine for prophylaxis and treatment. I would have chosen a broader spectrum penicillin in this setting (not on the ward) and a once daily cephalosporin for ease of administration. Vancomycin could be swapped for clindamycin for the penicillin allergic, for ease of treatment and broader cover including anaerobes and reducing the need for anti-tetanus. Dr Tuck had started with a slightly different approach, considering how to treat the most common conditions worldwide which perhaps influenced her choice more than the rest of us who focussed on survival in a disaster area. Dr Mohan produced a well balanced list with oxygen, fluids and I see has been persuaded to make antibiotic changes.

The week’s reading had been The case for an all-female crew to Mars. William J. Rowe. Journal of Men’s Health and Gender. 2004 Dec Vol 1 (No.4) 341-344

You will remember that I posed the questions: Is this for real or is it a spoof? How do you assess the credibility of a paper like this?

It was interesting to see that the first methods of addressing the credibility question were attempts to identify the character of the author and publication. Though this is a common way of approaching the problem of credibility, I would argue that these are not really valid ways to test the credibility of this paper’s content. In logic these are well enough recognised as fallacies to have been named: argumentum ad hominem (arguing against a person, rather than against what a person says) and arguing from authority (the prestige of the journal does not guarantee the paper’s truth). Returning to the content, the paper presents a hypothesis based on inductive reasoning. This is the method by which most scientific hypotheses are produced. The paper however, describes the hypothesis as if it is the result of a deductive argument. The difference is that a hypothesis (produced by inductive reasoning) would need to be further tested by experiment whereas deductive reasoning produces a ready proven answer. It is important to recognise and differentiate hypothesis (possibility) from deduction (certainty). A good hypothesis will come with suggestions as to the experiments needed to test it…remember that when you hypothesise a diagnosis.

Ok…checking the credibility of a hypothesis…Check that the propositions on which the reasoning is based are correct; check the reasoning is valid (logical); look for a clear exposition of the hypothesis and suggestions as to how it can be checked. Enough logic for now.

The reading for next week is:

Timing of Antibiotic Administration and Outcomes for Medicare Patients Hospitalized With Community-Acquired Pneumonia. Houck P, Bratzler D, Nsa W, Ma A, Bartlett G
Archives of Internal Medicine, 2004 (22 March);164(6):637–644

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

Interesting topics this week:

RS3PE, pitting oedema of the hands
Exercise tolerance tests, tell me more
Vertebro-basilar insufficiency, how is it diagnosed?
Cellulitis, do you really know about it?
Alcohol associated collapse, alcohol effects
Clostridium perfringens, tell me more
LBBB, tell me more (use uptodate on the intranet)

Don’t forget your two minute tutorials…make them concise and precise.

The tutorial topics this time are not free choices: you are given a specific pneumonia to both speak about and produce an A4 size sheet highlighting important features and facts.

Sandip Mycoplasma
Naveen Pneumococcus
Dilshad Legionairres
Nawaz Chlamydia
Bhasker Q-fever
MJM Aspiration
GAJ Gp A Strep

If anyone out there would like to submit two minute tutorials for the podcast, just leave me a note in one of the comments.

MJM

Easy Neurology 101

Simple screening tests in the hand for peripheral nerve lesions.


MP3 File

Free Speech

Oh No!! I see we have an alternative chronicle of the ward round...(click on the title "free speech" to see it)...but who should we believe? I must sort this out...where did I put my Machiavelli?

MJM Wardrounds - Lister

This week’s two minute tutorials were in support of a choice of antibiotics/drugs for an emergency…including our first input from a pharmacist. I need to speak to Dr Jones, to get the marks, before announcing the winner. The various drug choices are listed in the comments for last week’s wardround post, except Dr Tuck’s which is in the trichotillomania comments. (Bad aim Claire, have you been posting comments half asleep?).

I enjoyed the exercise of choosing the 5 antibiotics and five other drugs. It was interesting that several of us ran into the same problem: finding that only 4 non-antibiotics were needed. That 10th drug proved to be a problem, I think, not because it was not needed but because it opened up so many possible disorders for consideration. Hopefully you found the exercise useful.

The choices were backed up by sound argument and support from sources such as the Red Cross. There did seem to be, perhaps unsurprisingly, many broad areas of agreement: antiseptics, cover for tetanus (be it with anti-tetanus Ig or clindamycin), antibiotics to provide broad cover for G+, G-, anaerobes, protozoa etc. Most of you chose to take rehydration fluids (oral or IV), opiate analgesics and oxygen. I had not thought of activated charcoal but on reflection I quite like the idea. I will look at the Red Cross site again (Thank you to Naveen Mohan for pointing it out to me.)

I suggested a tree of woes exercise for each of you. For my part I would now ditch Anti-tetanus Ig and diclofenac for clindamycin and activated charcoal.


This week’s reading was On the antiseptic principle in the Practice of surgery. Joseph Lister. Lancet 1867, Sept 21, 90 (2299) 353-356

This is a landmark paper without any doubt, describing what must be one of the most important advances in the practice of medicine. The effects of the work are shown in Lister’s last paragraph….

"There is, however, one point more that I cannot but advert to-namely, the influence of this mode of treatment upon the general healthiness of an hospital. Previously to its introduction, the two large wards in which most of my cases of accident and of operation are treated were amongst the unhealthiest in the whole surgical division of the Glasgow Royal Infirmary… But since the antiseptic treatment has been brought into full operation, and wounds and abscesses no longer poison the atmosphere with putrid exhalations, my wards, though in other respects under precisely the same circumstances as before, have completely changed their character; so that during the last nine months not a single instance of pyaemia, hospital gangrene, or erysipelas has occurred in them. As there appears to be no doubt regarding the cause of this change, the importance of the fact can hardly be exaggerated."



The reading for next week is:
The case for an all-female crew to Mars. William J. Rowe. Journal of Men’s Health and Gender. 2004 Dec Vol 1 (No.4) 341-344

If you prefer it as a PDF, click here and you should be able to get the file with your Athens password. Is this for real or is it a spoof? How do you assess the credibility of a paper like this? And what can you learn from it?

Interesting problems this week:

Small joint inflammatory arthritis in polymyalgia rheumatica, tell me more
Miller-Fisher syndrome. What is anti GQ1B?
Stent thrombosis, tell me more
Tarsal tunnel syndrome, what are the symptoms?
Dressler’s syndrome after pacemaker insertion, tell me more
Hypomagnesaemia, tell me more
Pacemaker Syndrome, what’s that?


Don’t forget your two minute tutorials…make them concise and precise.

If anyone would like to submit two minute tutorials for the podcast, or make a suggestion for future topics, just leave me a note in one of the comments.

MJM

Preventing trichotillomania in secretaries

How to use a dictophone


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Physician Dictation Guide
An excellent brief guide...anyone who uses a dictation machine should read this at least once.

A history of the machine
Find out the difference between a dictaphone and a dictophone.

MJM Wardrounds

This week’s two minute tutorials were:
Dr Mohan -Obesity as a risk factor for AF (8/8)
Dr Tuck - Mobile phone safety in hospitals (6/8)
Dr Queen – Diagnosis of Churg-Strauss (3/8)

I have asked Dr Mohan to post the reference of the paper in the comments section and I see he has done so in the comments section of 'palindromic rheumatism'.

For next Friday you are challenged to choose the ten drugs you would take in your ‘doctor’s bag’ to a disaster area. You must choose five antibiotics and five others. Please post your choices in the comments before next Friday. If you are not on the wardround please feel free to post your choices as well. As ever, a prize of kudos for the best.

For those on the wardround next week, your two minute tutorial will be your chance to support your choice. I am still waiting for info on clavulanic acid (next week, Dr Queen, please), and glycopeptide antibiotics (Dr Mohan)

The reading for next week 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)

Interesting cases this week (I’ve cheated a bit by listing some things seen earlier in the week but not on the actual round).

Nephrogenic fibrosing dermopathy (one of the pseudosclerodermas)
Hypercalcaemia (how is it treated) 2
Acute renal failure with normal urea but high creatinine (how does that happen?)
Pancytopenia with myocrisin (Is that bad news?)
Hickman lines and infection (should it stay or should it go?) ...also
Stridor in Wegener’s Granulomatosis
Unilateral wheeze (what could that be?)
Acute Arterial occlusion (tell me more)
Rash and fever after returning from rural Nicaragua (what could that be?...have you tried travax?)

Don’t forget your two minute tutorials…defend your choice of drugs...be precise and concise

If anyone out there would like to submit a two minute tutorial for the podcast just leave me a note in one of the comments.

MJM

Palindromic Rheumatism

One of the more unusual forms of inflammatory arthritis


MP3 File

Palindromic rheumatism and other relapsing arthritis. Sanmarti R. Canete JD. Salvador G. Best Practice & Research in Clinical Rheumatology. 2004 Oct, 18(5):647-61.

Palindromic rheumatism: part of or apart from the spectrum of rheumatoid arthritis. Guerne PA. Weisman MH. American Journal of Medicine. 1992 Oct, 93(4):451-60.

MJM Wardround - Plague of Athens

The two minute tutorials this week were:
Dr Szulkowski - Typhus (6/8)
Dr Tuck - Smallpox (8/8)
Dr Queen - Typhoid (2/8)
Dr McMahon - Epidemic ergotism (not eligible for marking - too clever)

With regard to the plague of athens, Dr Jones awarded the prize best to Dr Tuck for her arguments supporting a diagnosis of smallpox. It is clearly difficult, if not impossible to know the diagnosis but 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. One learning point is that the epidemiology can help differentiate infectious and non-infectious agents, but also point to the mode of transmission. This could prove life saving if you find yourself in the middle of an undiagnosed epidemic.

I would choose measles as my choice of diagnosis, but this week was an opportunity to review the clinical features of the other diseases. One paper that I found particularly interesting is Osler on typhoid fever: differentiating typhoid from typhus and malaria. Cunha BA. Infect Dis Clin North Am. 2004 Mar;18(1):111-25.

If you would like to know a little more about ergotism have a glance at:
Ergot of Rye - I: Introduction and History
Poisons of the past / ergotism

And if you feel a little more scholarly check out Convulsive ergotism: epidemics of the serotonin syndrome? Mervyn J Eadie, Lancet Neurology 2003; 2: 429–34.


The reading for next week is"Antibiotics, Microsoft® Encarta® Online Encyclopedia 2005 http://encarta.msn.com © 1997-2005 Microsoft Corporation. All Rights Reserved. (All four pages). You should also use your initiative to read a little more about the mechanisms of antibiotic resistance.

Think you know it all already...test yourself with Jeopardy

A non compulsory read is Pearls....glance at the site and see if you find any of the advice useful.


Interesting cases this week:

Late onset asthma, with eosinophilia, renal impairment, and cutaneous ulceration (will this be CSS?)
Erysipelas (do you know the three commonest organisms?)
Lacunar infarction (what are the characteristic features?)
Ace inhibitor induced acute renal failure (Do you know the incidence?)
Hepatorenal failure (what is the prognosis?)

I have still to hear back about clavulanic acid....by Tuesday please.

Don't forget your two minute tutorial...be concise and precise.

Horsemen of the Apocalypse

Use the eight horsemen to defeat difficult diagnoses.


MP3 File

MJM Wardrounds

The two minute tutorials this week were:
Dr Queen: Incidence and prevalence of upper GI bleeding (4/4)
Dr Tuck: Statin use in cerebrovascular disease (4/4)
Dr Szulakowski: Behcet's disease (4/4)

These were all well presented, hence the full four marks for each. I find it difficult to choose the best, but it must be done: Dr Queen wins this week.

I was surprised at the overall mortality for upper gi bleeds at 14%; we went on to discuss the use of Rockall scores for grading the severity of GI bleeders. You can see an explanation of Rockall scores in the GI haemorrage section of Evidence Based On-call (click on the link and go to 'guides' then 'GI haemorrhage' then 'prognosis'. )

Despite Dr Tuck's efforts I am still unclear about the use of statins in cerebral infarction when the total cholesterol is below 5mmol/l. I will seek specialist advice on this.

Following the Behcet's talk and the ensuing discussion we decided to move to combination therapy for our patient with refractory Behcet's. The patient does not wish to use Thalidomide, so we will be combining cyclosporin with pentoxifylline and colchicine.

The week's reading was The Rational Clinical Examination. Does this patient have abnormal central venous pressure? Cook DJ, Simel DL. JAMA 1996 Feb 28;275(8):630-4. I will look out for rulers over the next few days! I will bring in some more stuff on JVPs next week and perhaps we can have a look for some real examples?

Minor learning points from the round.

1. I have hypersensitivity to the term 'chest infection'...never again may I hear it spoken of as a diagnosis ... And beware 'coffee ground' vomit too.
2. Faecal occult blood testing is used to identify occult blood loss and is unnecessary in overt blood loss.

Dr Szulakowski has found some papers to support his contention about vitamin B12 and cancer. I have asked him to put them in the comments section.

Dr Tuck has given me a paper on statins and cerebrovascular disease...I will let you know what I think next week (can't read it just yet because I have left it at work by mistake).

On 26th August we discuss your diagnoses for the Plague of Athens... impress us with your diagnosis... then convince us you are correct. Dr Jones will choose the best effort.

Don't forget your two minute tutorial....make it concise and precise. Don't pick too large a subject.

Hints on the diagnosis of acute gout. Duration 4 minutes, 28 seconds.


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MJM wardrounds

The two minute tutorials this week were on non-cardiac causes of ST/T changes on the ECG(Drs Queen & Tucker), Cervical radiculopathy (Dr Szulakowski), and Irritable bowel syndrome (Dr Tuck). Dr Szulokowski wins the best talk award for this week.

Richard Asher's paper Why are medical journals so dull? was the Friday discussion paper. Many of the problems he mentions, such as lack of colour, have now been eradicated in the 47 years since the paper was written. I am old enough, however, to remember journals being mailed rolled-up rather than flat and sympathise with his irritation at journals which spontaneously rolled up when being read. The concerns he raised about style are still voiced at times nowadays. Dr Szulakowski felt that some of the style of journal writing, and the associated 'dullness' was dictated by the required methodological descriptions, but I am not sure that I agree with him on this.

Asher believes that authors "clog their meaning with muddy words and pompous prolixity; they spend little time in seeking the shortest, neatest, and plainest way of putting down their meaning". I recognise this, though admittedly it is as nothing compared with some sociology texts I have read. This is not to say that the authors of scientific papers are lazy wasters; they have often put in gargantuan effort in organising and conducting their research and they then provide papers in the style the journals expect. Unfortunately the 'pompous prolixity' can be seen in speech, such as when a resident tells me that he cannot 'visualise the fundus'. My response, "your imagination must be rather poor" is usually met with incomprehension until I suggest that he did not "see" the fundus. Let's keep it plain and simple.

In order to support my argument against Dr Szulokowski I need to find examples of papers which despite their complex nature can escape dullness. Off the top of my head I wondered about Molecular structure of Nucleic Acids, Watson J D & Crick FHC. Nature 171, 737-738 (1953) . When did you last read a scientific paper with such modesty? Any other suggestions?

The reading for discussion on Friday 26th is the description of the plague of Athens 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. Your two minute tutorials could be on some aspect of your chosen disease. I will post the discussion the following week and award a prize to the best argument/diagnosis.

This week's reading is The Rational Clinical Examination. Does this patient have abnormal central venous pressure? Cook DJ, Simel DL. JAMA 1996 Feb 28;275(8):630-4. Many articles from this series are available free online, but not this one. See if you can retrieve a copy from the NHSES elibrary. A copy will be in the homework folder on the ward...for the technologically challenged among you....but only if I am asked to place it there.

It was suggested during the round that treatment with hydroxocobalamin could worsen the prognosis in malignant disease...I have thrown down my don't-believe-it-gauntlet on this one. Dr Szulokowski is challenged to provide supporting evidence next week. Dr Tuck will tell us the indications for statins in acute stroke next week.

Interesting cases:
1. Behcet's refractory to steroids, azathioprine, colchicine, methotrexate and infliximab.
2. Microcytic anaemia with very low B12.
3. Stapylococcal bursitis and hypogammaglobulinaemia.
4. Neutropenia and recurrent C. difficile

Don't forget your two minute tutorial....make it concise and precise. Don't pick too large a subject.

Why not leave a comment...click on the comment button.

A brief history of gout from the dinosaurs to 50 years ago.


MP3 File

Simple diagnostic hierarchy for patients presenting with polyarthritis.


MP3 File

Aerobic medicine

Dumfries Medical Department on Screel Hill

Where should we go on the next outing?

MJM Wardrounds

Tuesday:

The questions posed for this Friday were:
1. Indications for statins in CVA?
2. Non-cardiac causes of ST/T changes on the ECG?
2. Use of Ampicillin in meningitis?

The reading for the week is "Why are medical journals so dull" by Richard Asher. Originally published in the BMJ in 23 August 1958 but reprinted in The Healing Arts by Robin Downie. I have given a photocopy of the article to Patryk.


Interesting cases so far this week:
- Tension pneumothorax
- Phlegmasia cerulens dolens (was I correct to treat this with alteplase?)

Don't forget your two minute tutorials...make them concise but precise.

MJM