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