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