Common drugs

This week’s paper for discussion is not a real paper, but a comment. I did promise a brief paper for this week. You can of course read the original if it suits you to so do. The reading is from Bandolier: What patients think.

Original paper: PN Trewby et al. Are preventative drugs preventive enough? A study of patients' expectation of benefits from preventive drugs. Clinical Medicine 2002 2: 527-533.

The two minute tutorials are themed about common drugs: Furosemide, Metformin, Citalopram, Omeprazole, Coamoxiclav. Remember, two minutes only. Be concise and precise, quote sources and a handout please.

MJM

Monoarthritis

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Wardround 14iv6

This week’s two minute tutorial theme was monoarthritis. We heard about Gout (CC), Investigation (GYD), septic arthritis (KP), RA (DK), epidemiology (MH) and pseudogout (SM).

I found the talks detailed and well delivered. A deal of work obviously went into each talk but I award the prize this week to Dr Pearson for a well presented talk with just the right amount of information for two minutes, a clear handhout and citing of sources.

In the approach to monoarthritis the important considerations are:

Is this a problem in a joint (arthritis)?
Is it monoarthritis (or are more joints involved)?
Then get some synovial fluid or get someone who can and ask yourself "How likely is sepsis? can I exclude it?"

The latter question is critical especially in the setting of acute monoarthritis, or sub-acute monoarthritis in the immunocompromised patient. I generally take the view that when I cannot show it is not sepsis, it should be treated as septic arthritis until an alternative diagnosis is found.

Remember that gonococcal arthritis presents differently to non-gonococcal pyogenic arthritis. (have a look at UpToDate)

A podcast will follow soon, until then, a useful description can be found in Infection and arthritis.

Next week’s theme is connective tissue diseases:

SLE (GYD)
Sjögren’s Syndrome (PK)
Myositis (MH)
Systemic sclerosis (CC)
Behçet’s disease (SM)
Diagnosis (DK)

These will be difficult to squeeze into two minutes, so you will have to choose your information carefully. Try to think about the assignment as relating to a patient coming to the clinic. What are the important points you would highlight for a student? Be concise and precise, and cite your sources. And why not try to learn a little more be asking yourself what you know about the subjects your colleagues will be talking about?

Interesting topics this week:

I recommend you have a look at the NEJM’s video on arterial line placement.

Lobar Collapse
The lobar collapse tutorial.

Migratory arthritis (turned out to be CPPD, but make sure you know how to investigate Rheumatic fever)

Next week’s reading will be The rest is silence. Michael Rowe. Health Affairs, July/August 2002; 21(4): 232-236. I recommend you read this unhurriedly and with plenty of time for reflection.
MJM

Wardround 24iii6

The two minute tutorials this week were themed around fungal infection. Amphotericin B (PS); New antifungals (GYD); Aspergillus (HG) *; Candida in catheters (KP); Cryptococcus (DK). The general quality of presentation was excellent this week and I was pleased to see the re-emergence of visual aids and citing of sources. Prize this week to Dr Gunn.

I found doctorfungus.org an interesting source for revision.

Next week we will stick with infectious disease but viruses this time. The assignments are related to Hepatitis B:
Treatment of chronic Hep B (DK)
Prevention/immunisation (KP)
Interpretation of serology (HG)
Clinical epidemiology (GYD)
Acute fulminant hepatitis (PS)

Be precise and concise, just two minutes. Cite your sources and let’s have visual aids.

This week’s reading had been Laments, and I would like to continue the discussion with Jerome Lowenstein’s essay “Can you teach compassion”. I presume he meant “Can one teach compassion” but, you never know, he may have meant it to be personal. It is not available on the internet but my copy will be available on the ward.

Rather a short post this week as my weekend has been spent away from internet access.

MJM

Neuropathy

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Recommended reading: Clinical Evaluation and Investigation of neuropathy. Hugh J Willison and John B Winer. Journal of Neurology Neurosurgery and Psychiatry 2003;74:ii3

Wardround 17iii6

This week’s two minute tutorials were themed around transfusion (blood, platelets, FFP, cryoprecipitate, immunoglobulins and albumin). I was pleased to see that handouts have made a come back, but our original idea had been that visual aids would be brief revision notes rather than detailed notes. Have a look at mediglyphics.

The British Committee for Standards in Haematology (BCSH) have a collection of guidelines on transfusion that are well worth browsing.

The week’s reading had been Doctors and thin slicing. Interesting findings which none of the senior colleagues who read it found surprising. Certainly food for thought. I attended a course about communication last year and was told that communication was more important than what a doctor actually did with a patient. This strikes me as being unlikely. Worse though, if accepted as a correct premise it could undermine the practice of medicine. Is satisfaction a reasonable outcome measure when used alone? Is satisfaction now the same as satisfaction later? Richard Wakeford wrote a letter to the BMJ in 2003 (BMJ 2003;327:161 (19 July), doi:10.1136/bmj.327.7407.161) I quote a section of it here...

In its revalidation guidance documents for doctors the GMC says that one good professional comparison is with airline pilots. This comparison is helpful. Imagine two airlines, whose pilots' revalidation arrangements are on the following bases:
• Airline A—flight simulator skills tests, including rarely met but crucial challenges; a thorough medical examination
• Airline B—informal personal development plans, agreed privately with a colleague, maybe of their choice; cabin crew and passenger surveys of the gentleness of their landings and the clarity of their communications; a self declaration of sobriety, health, and honesty.

For the sake of argument, let us assume that one in every 15 pilots is shown by research to have at some point in their career an alcohol or other substance abuse problem. Which airline would you travel with?


Interesting topics this week
Tophaceous gout, which reminds me of this interesting paper regarding communication of information about gout treatment. Effective management of gout: an analogy. Wortmann R
Am J Med. 1998 Dec;105(6):513-4.

Chronic Q fever

The undiagnosable case (there is no such thing!....I’ll do a podcast on this sometime). We have certainly had some diagnostic challenges lately.

Next week’s reading for discussion continues the communication theme, The patient’s lament: hidden key to effective communication: how to recognise and transform. B Bub. Medical humanities 2004;30:63-69

The two minute tutorial topic for next week is Fungi. I will give more info on specific assignments when ID doc espeaks to me.

The team bids goodbye to Dr CT this week. No more dayglo stethoscopes.

MJM

ecthyma gangrenosum


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Wardround 10iii6

The theme this week was everyday microbes with two minute talks on: S. aureus, Str. pneumoniae, E. coli, and P. aeruginosa. I was pleased that so much information was gathered, and if you would like to read a little more have a look at Medical Microbiology for some further basic information. If you would like a little more information on the military use of Serratia marcescans in San Francisco, have a look at the wikipedia entry.

Next week’s theme is blood transfusion products.
Blood
FFP & Cryo
Platelets
IVIg

Just to repeat the rules: two minutes on the subject, which should be a talk rather than a reading. Quote your sources and use handouts to illustrate points.

The reading for next week is Doctors and Thin Slicing from Blink, by Malcolm Gladwell.

Interesting cases this week
Myocardial infarction and diabetes
....and more at xxxxxxx

Trifascicular block

Bronchiolitis and macrolides

Mycobacterium avium complex

Cricoarytenoid arthritis (a patient with rheumatoid who could no longer play the trumpet!)

MJM

The unresponsive patient

Coma...initial management.


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Wardround 3iii6

The two minute tutorials this week were about aortic stenosis. Epidemiology (CT), clinical features (BK), investigation (HG), and treatment (CC). There are plenty of brief summaries on the net but this is a subject worthy of more detailed understanding and knowledge for GIM trainees. Certainly the investigation, assessment and indications for surgery should roll off your tongue with ease. The prize for this week’s talk goes to Dr Tuck, for a concise summary with sources quoted. It is about time someone stepped up to the mark and knocked her off the top spot.

The discussion paper this week was The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives. Howard Brody, Annals of Family Medicine 2005;3:82-85. I particularly like the ‘fanciful analogy’ in the paper’s introduction: read it for yourself. I will leave you to muse over one of the conclusions. Reps are not evil, but they are time-consuming and serve interests that often are at odds with those of our patients. To spend time with reps in a manner that preserves professional integrity would require both refusing to accept their gifts and spending a great deal of valuable time double-checking their information. I propose that the vast majority of physicians could spend their time in better ways. Do you feel this is true? Will you be putting your time to better use?

Next week’s reading continues the ethics theme and though the paper relates to research, you should decide if the ideas give any insights into medical practice. Can Mary Shelley’s Frankenstein be read as an early research ethics text? H Davies, Medical Humanities Jun 01, 2004 30: 32-35.

Next week’s theme is basic microbiology. Two minutes please on the following:
Staphylococcus aureus (CC)
Streptococcus pneumoniae (BK)
Escherichia coli (HG)
Pseudomonas aeruginosa (CT)

Interesting topics this week
Ecthyma Gangrenosum

Coma, look at the coma section of www.eboncall.org

Agranulocytosis

And review your knowledge of the normal ECG


MJM

Subarachnoid Haemorrhage

Subarachnoid Haemorrhage


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Valproate


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Wardround 17ii6

This week’s reading and two minute tutorials were themed around epilepsy. The turn out was a little poor with only MJM (epidemiology), CC (investigations) and HG (classification) stepping up to face the music. So perhaps we can repeat this subject in a few weeks. I recommend the SIGN national clinical guideline No.70, Diagnosis and Management of epilepsy in Adults (from April 2003, updated 2005). The Quick guide is well worth a look for revision.

The reading for the week was The Falling Sickness, Jones J, Southern Medical Journal 2000;93(12):1169-1172, which I hope was enlightening. Though some of the views of epilepsy described may seem strange, if not outrageous, you should bear in mind that similar ideas may be held by patients with newly diagnosed epilepsy, or their relatives. It is important to educate patients about the reality of the disease. The aim of treating epilepsy is to render a patient able to live a normal life. Seizure control is but one aspect of this aim.

Next week’s theme is aortic stenosis:
Epidemiology (CT)
Clinical effects (BK)
Investigations (HG)
Treatment (CC)

Two minutes please, with sources quoted.

The reading for next week is The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives. Howard Brody. Annals of Family Medicine 2005; 3:82-85.

Interesting cases this week:

Pulmonary eosinophilia

SIADH

Paroxysmal AF

Gout

I will be away next Friday so there will be no blog for 24ii6. I will leave it to Dr Jones to set the assignments. (How about fungal infections?).

MJM

Wardround 10ii6

The reading for this week was Does This Woman Have Osteoporosis? Green AD et al, JAMA 2004; 292: 2890 - 2900.
The paper reports that “no single maneuver is sufficient to rule in or rule out osteoporosis or spinal fracture without further testing. The following yielded the greatest positive likelihood ratios (LR+): weight less than 51 kg, LR+, 7.3 (95% confidence interval [CI], 5.0–10.8); tooth count less than 20, LR+, 3.4 (95% CI, 1.4–8.0); rib-pelvis distance less than 2 finger breadths, LR+, 3.8 (95% CI, 2.9–5.1); wall-occiput distance greater than 0 cm, LR+, 4.6 (95% CI, 2.9–7.3), and self-reported humped back, LR+, 3.0 (95% CI, 2.2–4.1). Conclusions: In patients who do not meet current bone mineral density screening recommendations, several convenient examination maneuvers, especially low weight, can significantly change the pretest probability of osteoporosis and suggest the need for earlier screening. Wall-occiput distance greater than 0 cm and rib-pelvis distance less than 2 finger breadths suggest the presence of occult spinal fracture.” I chose this paper because it described several clinical signs that are not routine for most of us in internal medicine (but perhaps less strange to rheumatologists).

The two minute tutorial theme was Dementia. My congratulations on the choice of subject. As I read/revised this, it became obvious to me that I have not given enough time to formally reviewing the subject. The talks were all well constructed and revised. Timing generally good. having said all that, my prize for this week goes to Dr Tuck.

Next week’s topic is Epilepsy...you have your assignments (I will include them later, but they are left the list at work).
Epidemiology
Important clinical points in the history
Investigation
Social aspects
Treatment

The reading for next week is The Falling Sickness, Jones J, Southern Medical Journal 2000;93(12):1169-1172. (get it from the elibrary)
You may also wish to look over, Epilepsy: historical overview. WHO factsheet no. 168. February 2001

MJM

Wardround 3ii6

The reading for this week was Hedgehog zoonoses Riley PL, Chomel BB. Emerg Infect Dis. 2005 Jan. I suggested this as a catalyst to promote thought about zoonoses in general rather than intimating the specific importance of our prickly friends in human disease.

The talks were interesting and certainly stimulated discussion, particularly since we had one of our new microbiologists in attendance. Specifics included in discussion were Leptospirosis (icteric and anicteric), Lyme (remember the different clinical patterns in US and UK disease),
Rabies, and Toxoplasmosis.

Learning points: know the local zoonoses; take a history of animal contacts.

A second question was the definition of zoonosis. The World Health Organization defines a zoonosis as an infection or infectious disease transmissible from vertebrate animals to man. Merriam-Webster's Medical Dictionary suggests it is a disease communicable from animals to humans under natural conditions. I was slightly put out to find that my two volume shorter Oxford English dictionary does not list zoonois though it does list zoonosology as the study of the diseases of animals. I believe that the medical term zoonosis is in fact a contraction of the more precise anthropozoonosis, a zoonosis maintained in nature by animals and transmissible to humans. (The American Heritage Stedman's Medical Dictionary). Pedantry award to MJM. I lay down a challenge. Using this last definition find a non-infective anthropozoonosis.

Interesting cases this week:
Cryptococcal meningitis
I would also recommend the Uptodate article (available on the hospital intranet).

Next week’s reading is:
Does This Woman Have Osteoporosis? Green AD et al, JAMA 2004; 292: 2890 - 2900 (Get it from the elibrary)

The two minute tutorials next week are on Dementia: epidemiology, assessment, investigation and treatment. Talks precise and concise please, with some indication of your sources.

MJM

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


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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


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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.