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