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