podcast - digoxin
MP3 File
Wednesday, November 30, 2005
Saturday, November 26, 2005
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
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
Thursday, November 24, 2005
Friday, November 18, 2005
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
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
Thursday, November 17, 2005
Hiccoughs
HiccoughsMP3 File
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?
Sunday, November 13, 2005
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
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
Thursday, November 10, 2005
Sunday, November 06, 2005
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
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
Wednesday, November 02, 2005
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