Wardround 30i9

The reading for Tuesday will be "Human guinea pigs"--a history. M H Pappworth. BMJ 1990 December 22; 301(6766): 1456–1460. Read and think.

This week's talks were about clinical assessment of parietal lesions, cerebellar dysfunction and differentiating bulbar and pseudobulbar palsy.

To simplify things, I like to think of parietal dysfunction as Motor: Dysphasia (dominant) and Dyspraxia (non-dominant); Sensory: Inattention and astereognosis. (The inability to recognise a deficit is called anosagnosia). I had not come across cerebellar DASHING before, and being stuck in my ways I will be keeping to DANISH. Pseudo and true bulbar palsy have many subtle differences, I would concentrate on tongue wasting with fasciculation and absent gag in bulbar palsy and increased jaw jerk and choking episodes in pseudobulbar disease.

For Friday, the assignments as two minute talks are Abscesses: contributing factors, organism and treatment. Choose among yourselves which sites to talk about from:
Brain
Liver
Psoas
Empyema (not an abscess, I know)

Interesting topics

Dyspraxia

Arteria Lusoria, see here for diagrams of the anatomy, and NEJM Volume 346(21), 23 May 2002, p 1637 for a case report.

MJM

Wardround 9i9

The reading for Tuesday is Immoral advances: Is science out of control? - science-in-society - 09 January 2009 - New Scientist. Read and think.

For Friday the two minute tutorials are about imported fevers. Two minutes please on your choice of these cases returning to the UK with a fever:

Fell in the water of Lake Malawai
Was bitten by a dog at Giza
Was bitten by a bug on the Amazon
Has a nosebleed having returned from Wagadugu
Fell in a well in Thailand

Post in the comments which you will be doing.

Interesting topics:

Very Basic Echocardiography
Diastolic failure



MJM

Last Post of 2008

It is time to start thinking again.

No wardround meeting on Friday but for Tuesday we can have a paper to discuss: Culture shock - patient as Icon, Icon as Patient. A Verghese. NEJM 2008: 359(26); 2748–2751. Elibrary

Read and think.

MJM

Merry Christmas

The Christmas break in talks is upon us. Almost.

For Tuesday, come ready to tell us about a book or film (or other text) that has influenced you as a doctor.

Interesting Topics

Following on from our discusions about adverse drug reactions, you may want to have a look at Managing Drug-Drug Interaction Risks and Recognizing, Reporting, and Reducing Adverse Drug Reactions.

You are challenged to find at least one ADR from each of the groups A-F. Get to it.

MJM

Wardound 12xii8

If you are not in DGRI you will see a screen shot above. I hope it will give a clue how to get the article for Tuesday's discussion. So yet again get it, read it and think about it. 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.

The two minute talks will be about adverse drug reactions:
Epidemiology R
Mechanisms E
Management Dr Pope
Prevention G

There are a number of excellent resources available about this subject..see what you can find. Remember, time the talk for two minutes, quote your sources and make a handoiut which will be useful.

Interesting topics this week
Progressive supranuclear palsy
Refeeding syndrome

MJM

We don't need no stinkin' help findin' book learnin'

I ridicule your pathetic excuses for failing to get the "In a Stew" article. I got the pdf at the weekend and again tonight without problems. 

Get it....it's a challenge... and we can then discuss it.

MJM

Wardround 5xii8

Sepsis bundle summary ↑ (you cannot see it at DGRI...images blocked)

The reading for Tuesday 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.

This week's talks were about antibiotics. This led to a discussion of the precipitants for MRSA such as antibiotic pressure and the ways we might try to limit this. Dr Jones outlined a method of deferring antibiotic use in non-urgent cases and stressed the need to identify specific about diagnoses. It should be clear to all that MJM and GAJ do not regard antibiotics as harmless, and MJM in particular decries the term "chest infection"....never use this in his hearing since it has the effect of decoupling frontal lobe function. Our hospital policy regarding IV antibiotics is a must read as is the antibiotic prescribing policy. Remember to look at the HPS site about C. difficile.

For next Friday the theme is decompensated liver disease:
Epidemiology G
Varices L
Ascites E
Encephalopathy R
Transplantation ?

Two minutes please. Be concise and precise. Quote your sources so others can read up more if inclined. Handouts can have more than bullet points again....but not mini-essays please. Think before you speak. Make the talk count. Don't tell us things we already know; there isn't time.

Interesting topics

Sepsis in Coeliac Disease (Dr Else's journal club talk about Gut 2008 Aug;57(8):1034-5).
Sepsis bundles

Remember we have some textbooks in the right hand Ward office

Wardround 28xi8

This week's talks were about common tests such as cholesterol, creatinine and glucose. It is useful to revise things which we come to regard as so common that our knowledge of them sinks into our subconscious. Knowledge in the subconscious can become corrupted or merely fade away. As an SHO I was given some advice by a consultant Dr Avinash Mithal. He suggested that when reading a journal article, editorial or review paper I should first write down what I know about the subject. IHD is common...how common, exactly? In doing this I am surprised how quickly "things_I_know" have become "things_I_think_I_know_but_don't". Next time you read a paper, try Mithal's method.

For Friday the two minute talks are about Antibiotics. This is a free for all. Decide which talk you want to do and stake your claim by posting in the comments section. The choices are:

Who needs IV antibiotics?

What are the precipitants of C. difficile?

What are the precipitants of MRSA?

What is new in the antibiotic field?

What is antibiotic allergy, and what can be done about it?

Two minutes only. Be clear and concise. And here I am going to change the rules on the written handouts. You are allowed up to six bullet points only in text. Drawings or illustrations can be unlimited but must fit on one side of A4 and be large enough to be read without squinting or using a magnifying glass.

Our inability to read the paper on the last two Tuesdays I take as a message from the fates. Said paper will be cast to the furies. Though casting to the furries conjures more surreal images.

The reading for Tuesday will be Just how tainted has medicine become?  The Lancet 2002: 359 (9313), Page 1167, (6 April)

Interesting topics:

Tilt testing in syncope

Gout

MJM

Wardround 21xi8

Since we could not discuss the reading for last week, klet's carry it over to Tuesday.

Friday's talks are on everyday tests. You have free rein to choose the most useful aspect of each for your talks. Make them interesting, concise and illuminating.

MJM

Wardround 14xi8

The reading k for next week will be Measuring quality of life. Is there such a thing as a life not worth living? Bobbie Farsides, Robert J Dunlop BMJ 2001;322:1481-1483

Two minute talks for Friday: SEPSIS
Recognition O
Circulation R
Antibiotics S
Epidemiology J

www.survivingsepsis.org is a good place to start your background reading.

MJM

Wardround 7xi8

The reading for Tuesday is Comment: When not to write about autism, Ewen Calloway. New Scientist. Read it, think, and discuss.

The Two Minute talks for Friday will be about poisoning:
Paracetamol
Tricyclics
Carbon Monoxide
Ecstasy

Please plan your talk to last just two minutes. Be concise and precise, quote your sources and make a simple handout. A hundred words on the handout is too much. Don't waste time on the obvious. Let me help you out by saying I want facts specific to your topic. I will take it as read that Resuscitation/ABCDE etc are going to be done. The test you must pass is that those listening to the talk will be able to manage a case.

MJM

Wardround 24x8

The Two minute talks today were about arrythmias. Well researched and reasonably timed, but I would suggest more thought is given to the two minute limit. For next week : opportunistic infections with HIV: Pneumocystis pneumonia, atypical mycobacteria, toxoplasma, candida and cryptococcus. You have your assignments. If we have any extra people gatecrashing the talk they should choose another to do eg aspergillus, TB etc.

The paper for discussion on Tuesday will be The kindness of strangers. Eileen Palmer, BMJ 2008;337:a1993.



MJM

Wardround 10x8

The Reading for Tuesday is Trust, Anonymous, Bandolier. Read and think. Articles can be like lamps. Look at them carefully before choosing to use one for illumination. It could enlighten the subject matter, cast important issues into relative shadow, or even blind you to the whole subject.

The talks this week were excellent. Imported infections are not as uncommon as you might think, even in a place like D&G. The important thinks to know are where they have been, what they have been doing, who else has been involved. Use a resource such as travalax to find what is happening in the region and don't overlook the treatable (malaria, bacterial sepsis). I wondered about putting rabies in those parentheses, but perhaps that should be in the preventable category. I would suggest you read the local viral haemorrhagic fever protocol.

For next Friday the talks will be about the patient with an acute abdomen who finds themselves on a medical unit. No cop-outs here, I don't want a two second talk "refer to surgeons". The surgical team are all very busy in theatre. Only the surgical F1 is available and you are going to be forced to manage the patient initially.

Acute Pancreatitis F
Acute Vascular Events A
Perforated hollow Viscus O

Two minutes please. Keep it precise and concise.

Interesting Topics

Sepsis resuscitation bundle

How tired are you?


MJM

Wardround 3x8

The reading material for Tuesday is Commercial Features of Placebo and Therapeutic Efficacy, Rebecca L. Waber; Baba Shiv; Ziv Carmon; Dan Ariely, Journal of the American Medical Association, March 5, 2008; 299: 1016-1017. Get it via the elibrary, read and think.

Our two minute tutorials for Friday are Imported diseases. You each have two minutes to enlighten us on the patient who is feverish and:

Fell in the water of Lake Malawai (H)
Was bitten by a dog at Giza (F)
Was bitten by a bug on the Amazon (A)
Has a nosebleed having returned from Wagadugu (Z)

MJM

WR 27ix8

The read and think for Tuesday is Orphan diseases: which ones do we adopt? T Richards, BMJ 2008;337:a1225.

The two minute talks for Friday are themed around Acute Hepatitis. Educate the yourself and the group.

Alcoholic (H)
Viral (A)
Autoimmune (F)
Toxic (Z)

MJM

Wardround 12ix8

The reading assignment for Tuesday is Titrating Guidance, Nathan Goldstein, Anthony Back, Sean Morrison. Arch Intern Med. 2008;168(16):1733-1739. 

Friday's two minute talks are the recognition and management of psychiatric disorders on medical wards: Delerium tremens, Depression, the aggressive patient.

MJM

Wardround 5ix8

The reading for next Tuesday will be Mistakes. Ruth Lesnewski. JAMA. 2006;296:1327-1328. get it with elibrary.

Read and think.

Friday's tutorial assignments will be Acute Colitis

Ischaemic

Infective

Inflammatory

Two minutes please, keep it precise and concise, quote your sources and illustrate with a handout.

Interesting Topics

Transverse Myelitis

MJM

Wardround 29viii8

Why was a rheumatologist asked to see this patient?

The reading this week about the methods magicians use to distract their audience led to some discussion of distraction, its benefits and pitfalls in medicine, the importance of not interrupting the 'rituals' of medicine that doctors use to keep on track and recognising when we ourselves have been distracted from the path.

For next week I would like you to read Why are medical journals so dull by Richard Asher. Originally published in the BMJ in 23 August 1958. Tempted as I am to leave you to get hold of the paper using your own initiative there is a link here if you do not feel like taking up the challenge. The link works for me but if you are unsuccessful I can give you a paper copy (folded in the shape of a dunce's hat!)

As ever the original responses to a paper can be illuminating. It is well worth getting used to reading the letters written to the editor about papers you read.

I was sorry to have been called away before the end of the Gram talks. It sounds obvious but the information Gram pos/negative cocci/bacilli should prompt immediate thoughts: does the patient have features of systemic sepsis syndrome? what do I need to check to further identify the type of organism and the likely spectrum of antibiotic sensitivity. Be sceptical about any comment from someone who has not assessed the patient that an organism could be a just a contaminant. How about clicking the comment button and writing in one sentence about something particularly interesting you found in your reading on the subject.

The talks for next week will be Epilepsy.
I was not able to assign these so it will be first come first served. Click the comment and claim the subject you will take. On offer are:
Epidemiology
Classification
Investigation
What to tell a patient after their first seizure
Treatment

Interesting topics

Lofgren's syndrome (what I was called away to see)


MJM

How weary, stale, flat and unprofitable, seem to me all the uses of this world
Fie on't ah fie! 'tis an unweeded garden, that grows to seed ...
That it should come to this.

Wardround 22viii8

The reading for next Tuesday will be Magician's Hand: How Humor And Misdirection Can Manipulate Levels Of Attention. You may also want to look at this related article.

Please read the articles and give them some thought. Is this relevant to medicine?

The two minute talks this week were the ECG. What is normal and what is not? What do you think was the most interesting or useful point in your talk. Click the comment button and type it in. I put together a little list a couple of years ago that you could revise from.

The two minute talks for next Friday will be mibrobiology 101: what should go through your mind when you get a call that your sick patient's blood cultures have grown:

Gram positive cooci HM
Gram negative cocci SV
Gram positive rods ZB
Gram negative rods HJ

Keep it precise (actual figures not general descriptions) and concise, educate your audience, quote sources, produce a handout and keep to two minutes.

Interesting topics:

Hyperkalaemia...read the handbook
Atrial flutter
Korsakoff syndrome

MJM

Wardround 15viii8

The reading for next Tuesday will be The road to recovery. D Pisetsky. Please read the article and give it some thought.

The two minute talks this week were about common drugs: Furosemide, Coamoxiclav, Enoxaparin. The prize this week goes to HM. What do you think was the most interesting or useful point in your talk. Click the comment button and type it in.

The two minute talks for next Friday will be The ECG. What is normal and what is not? Let's have two minutes on:

P wave HJ
QRS complex
Axis
ST segment HM
T wave SG

Keep it precise (actual figures not general descriptions) and concise, educate your audience, quote sources, produce a handout and keep to two minutes.

The morbidity/mortality meeting is on Thursday 28th August. Time to start preparing now.

Interesting topics:

Fallot's tetralogy

Wernicke's encephalopathy

Dressler's Syndrome

MJM