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


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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.


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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.


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