Wardround 27i6

This week’s discussion papers were Controversies in stable coronary artery disease, Opie LH, et al. Lancet, 2006;367(9504):69-78 and Clinical decision-making: coping with uncertainty. A F West and R R West. Postgraduate Medical Journal 2002;78:319-32.

The controversies are probably best read direct from the paper rather than regurgitated by me but I would like you to consider the points raised in the second paper. Uncertainty is never far away in medicine. We should recognise when there is uncertainty, name it and help patients navigate a course through it. Here are a couple of sections from the paper.

Improving scientific knowledge is clearly a laudable objective, although it may reduce clinical uncertainty less than expected. Pretending that the clinical predicament can be reduced to a series of certainties by the recruitment of "evidence" will not work and unrealistic expectations of that stratagem may make the situation worse. Some degree of uncertainty was always here to stay and evidence, even of the highest quality, is only evidence. There will always be judgments to be made by responsible, informed, and compassionate people. They may not be able to perform these broader roles, in communication, holding anxieties and managing uncertainty, unless trained for and supported in them.

One therapeutic role of a clinician is containing the anxieties aroused in the context of uncertainty, and this role may be becoming more difficult. Reliance on protocols and fear of reprimand may lead to clinicians, in some areas of medical care, abandoning their patients at a time of need.

The reading for next week is:

Hedgehog Zoonoses. PY Riley, BB Chome. Emerging Infectious disease January 2005 Vol.11, No. 1

Next week’s two minute tutorials are semi-freestyle. Two minutes on anything you like, as long as it falls under the heading zoonosis. Extra kudos points available for the best definition of zoonosis.

Interesting topics this week:

Hypomagnesaemic hypoparathyroidism
http://www.emedicine.com/emerg/topic274.htm
http://jasn.asnjournals.org/cgi/content/full/10/7/1616

Hyponatraemic Encephalopathy
Treatment of Hyponatremic Encephalopathy. Smith et al. JAMA.1999; 282: 2298-2299.
Management of Hyponatremia. Kian Peng Goh. American Family Physician Vol. 69/No. 10 (May 15, 2004)

Drug induced agranulocytosis
http://www.jr2.ox.ac.uk/bandolier/band136/b136-5.html

Pneumocystis
A new name (Pneumocystis jiroveci) for pneumocystis from humans. Stringer JR, Beard CB, Miller RF, Wakefield AE. Emerg Infect Dis [serial online] 2002 Sep [date cited];8.

The basics

Hospital acquired pneumonia

MJM

Wardround 20i6

The two minute tutorials for this week are deferred until next week since we were somewhat short of our intellectual quorum. We can discuss the Lancet cardiology paper (see last week's wardound post) in more detail then, but I would like to add some additional reading:

Clinical decision-making: coping with uncertainty. A F West and R R West. Postgraduate Medical Journal 2002;78:319-32. You can get this from the PMJ online site by typing in the volume and page number, or through the elibrary.

Error: I was mistaken in announcing that the CVP tutorials are this month. They are in February. At least this means my lecture notes are ready well ahead of time.

Interesting topics this week

Melioidosis

PUO

A COUNTERBLASTE TO TOBACCO.
by King James I of England, VI of Scotland.

James I and VI (for DK)

Hulusi Behçet

MJM

Vipers and ACE inhibitors

Vipers and ACE inhibitors


MP3 File

From viper's venom to drug design: breakthroughs in bioscience

Angiotensin converting enzyme inhibition: from viper to patient. Komajda M. Heart 2000;84 (supp1):i11-i14

Brazilian arrowhead viper

Wardround 13i6

This week's reading was The midnight meal, Jerome Lowenstein. He sums up with “ The challenge is to identify and preserve, or recapture, the critical components of relationships in medicine – between colleagues and between physicians and patients – that we need to preserve. A good first step would be to devise some new equivalent of the midnight meal.” I agree with him. The question for us is how will we make it happen. More from Dr Lowenstein as the year goes on.

This week’s two minute tutorials were about GI bleeding (non-variceal). What can I say about this? A common problem, with an incidence of 100/100000 in the UK. The mortality is about 10% and has changed little in the last 40 years. This does not necessarily mean we are making no headway in treatment because the epidemiology is changing and the age of bleeders is increasing. The Rockall Score uses age, haemodynamic disturbance, comorbidity, OGD findings and diagnosis to predict mortality. See the link below to evidence based on call to read more about the scores. A simple way to convert the score into a ‘ball-park’ mortality figure is to square the score and add on half the square again. If you have a easier way let me know. This week's prize goes to Dr Kidder (excellent timing).

Resources:

Evidence based on-call

Non-variceal upper gastrointestinal haemorrhage:
Guidelines. British Society of Gastroenterology Endoscopy Committee
Gut 2002;51(Suppl IV):iv1–iv6

The reading for next week, and the theme for tutorials is:
Controversies in stable coronary artery disease, Opie LH, et al. The Lancet, 7 January 2006 Volume 367, Issue 9504, Pages 69-78

The themes for next week’s two minute tutorials are sections from the paper; two minutes please on:

Statins MJM SHO
β blockers GAJ SHO
ACE inhibitors FY1

You are free to choose an alternative topic from the paper, but I ask that topics are not duplicated.

Interesting topics this week:

Claudication presenting as hip pain.
The Illusion of Certainty. [Clinical Problem Solving]. Wolinsky AP. NEJM 1996; 335(1): 46-48 (DK has a copy and it is available from the elibrary)

Snake venom and ACE inhibitors (this appeared, partially formed, from the pit of my memory during the wardround. I will check the details and tell all in the next podcast)

MJM

The JVP


MP3 File


Reading:

Does this patient have an abnormal venous pressure? Rational clinical examination. Cook DJ. JAMA, 1996;275(8):630pp

Jugular Venous Pulse: an appraisal. Garg N et al. Journal, Indian academy of Clinical medicine. 2000; 1(3):260-269.

Venous Pulse

Wikipedia JVP

Central venous pressure: jugular venous pressure is somewhat helpful.

Wardround 6i6

Welcome back and Happy New year.

How empty was the wardround without its two minute tutorials? Well I have tasted the laziness for long enough, so next week we will be on track with tutorials themed around GI bleeding.

Epidemiology
Assessment (DK)
Scoring (GAJ)
Treatment (AS)
Prognosis (MJM)

Remember to make the talks concise and precise. Avoid speaking at twice the normal rate. Visual aids will attract extra points.

It has only just occurred to me that this is another ID topic (arrgh...Dr J must know that I am squirming. They will always be campylobacter to me).

The main discussion topic this week was central venous catheter related sepsis. There are a number of excellent guidelines summarising management of this problem. For example Guidelines for the Management of Intravascular Catheter–Related Infections. Clin Infect Dis. 2001 May 1;32(9):1249-72. Leonard A. Mermel, et al.

There will be afternoon tutorials this month about central lines so there will be chance to discuss this in more detail. There will be a handout with the tutorials.

Interesting cases discussed this week:
Conservative management of bowel perforation: the published mortality figures are surprisingly good.
Diarrhoea in HIV disease. (Can you name 10 AIDS defining disorders? I will be impressed if someone comes up with a mnemonic for the lot).
Complicated PUO (we really must do PUO as a topic one week....as much as it pains me to do yet more ID).
Acute tubular necrosis read more.

The reading for next week is The Midnight Meal, from the collection of essays, The Midnight Meal and Other Essays about Doctors, Patients, and Medicine by Jerome Lowenstein. I will leave it on the ward. Estimated reading time is 5 minutes, but thinking time should be much longer.

MJM