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
Friday, January 06, 2006
Friday, December 23, 2005
Wardround 23xii05
This being the festive season the blog is short.
Our two minute tutorials are non-medical. We each talked about our favourite film or book. I did make a list but have left it at work and the sound of Blink-182 is interfering with my brain function. Here is what I remember:
Romantic Highlights (music) ?
The Matrix, (A & L Wachoski)
A time for drunken horses (Bahman Ghobadi)
Sophie’s World (J Gaarder)
Snatch (G. Ritchie)
Singing in the Rain (Kelly, Donen)
Legend, (David Gemmel)
To Kill a Mockingbird (Harper Lee)
An interesting mix. At least I have some ideas for next year's viewing.
Interesting topics this week:
Empyema
BTS guidelines for the management of pleural infection. Thorax 2003;58(Suppl II):ii18-ii28
Congratulations to Claire for success in the Xmas quiz.
Have a good Christmas time, see you next week.
MJM
Saturday, December 17, 2005
Wardround 16xii05
16xii05
This week’s theme for the two minute tutorials was osteoporosis:
Pathophysiology MJM
Epidemiology AA
Dexa AS
Non-pharmacological treatments GAJ
Bisphosphonates HG
Other drugs CT
This week’s prize to Dr Anand (for effort and perceived excitement). The SIGN guidelines are a good source for basic information and links to other sources. Newer agents such as Parathyroid hormone and strontium ranelate are not covered in the SIGN document. If you want a ‘ten second tutorial’ on these have a look at the SMC statements.
http://www.scottishmedicines.org.uk/updocs/Teriparatide%20(Forsteo).pdf
http://www.scottishmedicines.org.uk/updocs/strontium%20ranelate%20(Protelos)%20(178-05).pdf
I would see these as aperitifs...they whet your appetite but are not really enough to satisfy your hunger for knowledge.
How can I sum up these tutorials? Osteoporosis is common, it manifests as fractures, deformity, respiratory compromise, increased mortality, pain and disability and is very common. The costs of untreated and unprevented (oh! english teacher, forgive me for that word) osteoporosis are substantial.
Peak bone mass is reached in the fourth decade and genetic factors are the most important in the absence of malnutrition. It all starts going pear shaped with middle age as the bone remodelling units (osteoblasts and osteoclasts) break down more bone than is produced. Oestrogenic suppression of osteoblast produced iL-6 fails at the menopause leading to increased osteoclast activity and even greater bone loss.
Post menopausal osteoporosis particularly increases fragility fractures in bones dependent on trabecular bone (vertebrae, distal radius), senile osteoporosis increases fractures in these and long bones ( neck of femur, humerus). Steroid osteoporosis has a ‘trabecular pattern’.
Falls, age and bone density are the important triad of risk factors for osteoporotic fractures.Treatment should be aimed at reducing falls and minimising bone loss by ensuring adequate calcium and vitamin D intake, addressing other reversible risks (controlling active systemic inflammatory disease), inhibiting bone resorbtion and stimulating bone formation (less easy).
The indications for DEXA are in the SIGN document.
We did not have time to discuss the In a Stew paper due to the staff Christmas dinner. Another time perhaps.
Interesting topics this week:
Marfan’s...how do you diagnose a ‘sporadic’ case. This paper lists and discusses the diagnostic criteria.
Thalidomide for Behçet’s ulceration
Clinical experience with thalidomide in the management of severe oral and genital ulceration in conditions such as Behcet's disease: use of neurophysiological studies to detect thalidomide neuropathy. JM Gardner-Medwin, NJ Smith and RJ Powell. Annals of the Rheumatic Diseases, 1994, Vol 53, 828-832. It's not available on-line but I have a copy in my office if you would like to read it.
Sjogren’s syndrome
Next week is a special tutorial theme...you are invited to regale us with two minutes about your favourite film or book. Medical textbooks are not allowed as choices!
The reading for next week is Polythenia gravis: the downside of evidence based medicine
Down End Research Group. BMJ 1995;311:1666-1668.
Merry Christmas
MJM
This week’s theme for the two minute tutorials was osteoporosis:
Pathophysiology MJM
Epidemiology AA
Dexa AS
Non-pharmacological treatments GAJ
Bisphosphonates HG
Other drugs CT
This week’s prize to Dr Anand (for effort and perceived excitement). The SIGN guidelines are a good source for basic information and links to other sources. Newer agents such as Parathyroid hormone and strontium ranelate are not covered in the SIGN document. If you want a ‘ten second tutorial’ on these have a look at the SMC statements.
http://www.scottishmedicines.org.uk/updocs/Teriparatide%20(Forsteo).pdf
http://www.scottishmedicines.org.uk/updocs/strontium%20ranelate%20(Protelos)%20(178-05).pdf
I would see these as aperitifs...they whet your appetite but are not really enough to satisfy your hunger for knowledge.
How can I sum up these tutorials? Osteoporosis is common, it manifests as fractures, deformity, respiratory compromise, increased mortality, pain and disability and is very common. The costs of untreated and unprevented (oh! english teacher, forgive me for that word) osteoporosis are substantial.
Peak bone mass is reached in the fourth decade and genetic factors are the most important in the absence of malnutrition. It all starts going pear shaped with middle age as the bone remodelling units (osteoblasts and osteoclasts) break down more bone than is produced. Oestrogenic suppression of osteoblast produced iL-6 fails at the menopause leading to increased osteoclast activity and even greater bone loss.
Post menopausal osteoporosis particularly increases fragility fractures in bones dependent on trabecular bone (vertebrae, distal radius), senile osteoporosis increases fractures in these and long bones ( neck of femur, humerus). Steroid osteoporosis has a ‘trabecular pattern’.
Falls, age and bone density are the important triad of risk factors for osteoporotic fractures.Treatment should be aimed at reducing falls and minimising bone loss by ensuring adequate calcium and vitamin D intake, addressing other reversible risks (controlling active systemic inflammatory disease), inhibiting bone resorbtion and stimulating bone formation (less easy).
The indications for DEXA are in the SIGN document.
We did not have time to discuss the In a Stew paper due to the staff Christmas dinner. Another time perhaps.
Interesting topics this week:
Marfan’s...how do you diagnose a ‘sporadic’ case. This paper lists and discusses the diagnostic criteria.
Thalidomide for Behçet’s ulceration
Clinical experience with thalidomide in the management of severe oral and genital ulceration in conditions such as Behcet's disease: use of neurophysiological studies to detect thalidomide neuropathy. JM Gardner-Medwin, NJ Smith and RJ Powell. Annals of the Rheumatic Diseases, 1994, Vol 53, 828-832. It's not available on-line but I have a copy in my office if you would like to read it.
Sjogren’s syndrome
Next week is a special tutorial theme...you are invited to regale us with two minutes about your favourite film or book. Medical textbooks are not allowed as choices!
The reading for next week is Polythenia gravis: the downside of evidence based medicine
Down End Research Group. BMJ 1995;311:1666-1668.
Merry Christmas
MJM
Saturday, December 10, 2005
Friday, December 09, 2005
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
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
Saturday, December 03, 2005
Wardround 2xii05
The theme this week was anti-arrhythmics and the Vaughan-Williams classification. This classification is not perfect since within a class, drugs may have different actions and drugs may exist in more than one class. It is, however, a good starting point for understanding anti-arrhythmics.
Class I agents interfere with the sodium (Na+) channel.
Class 1a eg disopyramide, prolong the action potential. They are effective against SVT and VT.
Class 1b eg lignocaine, shorten the action potential. They are used for the treatment of VT.
Class 1c eg flecainide, have little effect on the action potential duration. They are effective in AF, SVT and VT
Class II agents are beta blockers.
Class III agents affect potassium (K+) influx. eg amiodarone prolong the action potential and refractory period. They are used for re-entry tachycardias, SVT and VT.
Class IV agents affect the AV node.
An excellent summary can be found at:
http://lysine.pharm.utah.edu/netpharm/netpharm_00/notes/antiarrhythmics.html
Next week’s theme is reducing drug risks and we will be using rheumatological drugs as our examples. The challenge is to wax lyrical for two minutes about reducing risk when using:
Methotrexate (HG)
Leflunomide (CT)
Sulfasalazine (NM)
Etanercept (Ash)
Steroids (MJM)
(and if GAJ wishes she can have any antibiotic used long term...minocycline would be rheumatological)
The reading for next week is
Nonsteroidal anti-inflammatory drug associated gastropathy: incidence and risk factor models. Fries JF, Williams AW. The American Journal of Medicine. 1991; 91: 213-222.
You will need to get this from the elibrary
Interesting topics this week?
NFRs
Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. February 2001.
UK clinical ethics network
Acute inflammatory arthritis
Guidelines for the Initial Evaluation of the Adult Patient with Acute Musculoskeletal Symptoms. American College of Rheumatology.
MJM
Class I agents interfere with the sodium (Na+) channel.
Class 1a eg disopyramide, prolong the action potential. They are effective against SVT and VT.
Class 1b eg lignocaine, shorten the action potential. They are used for the treatment of VT.
Class 1c eg flecainide, have little effect on the action potential duration. They are effective in AF, SVT and VT
Class II agents are beta blockers.
Class III agents affect potassium (K+) influx. eg amiodarone prolong the action potential and refractory period. They are used for re-entry tachycardias, SVT and VT.
Class IV agents affect the AV node.
An excellent summary can be found at:
http://lysine.pharm.utah.edu/netpharm/netpharm_00/notes/antiarrhythmics.html
Next week’s theme is reducing drug risks and we will be using rheumatological drugs as our examples. The challenge is to wax lyrical for two minutes about reducing risk when using:
Methotrexate (HG)
Leflunomide (CT)
Sulfasalazine (NM)
Etanercept (Ash)
Steroids (MJM)
(and if GAJ wishes she can have any antibiotic used long term...minocycline would be rheumatological)
The reading for next week is
Nonsteroidal anti-inflammatory drug associated gastropathy: incidence and risk factor models. Fries JF, Williams AW. The American Journal of Medicine. 1991; 91: 213-222.
You will need to get this from the elibrary
Interesting topics this week?
NFRs
Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. February 2001.
UK clinical ethics network
Acute inflammatory arthritis
Guidelines for the Initial Evaluation of the Adult Patient with Acute Musculoskeletal Symptoms. American College of Rheumatology.
MJM
Wednesday, November 30, 2005
Saturday, November 26, 2005
Wardround 25xi05
I have fixed the paraprotein link.
This week’s theme was related to the NEJM review of bacterial infections in intravenous drug users. Bacterial Infections in Drug Users. Gordon RJ, Lowy FD. NEJM November 3, 2005; 353 (18):1945-1954. (link in last week's blog)
Epidemiology (PS) : Most bacterial infections among drug users are caused by commensal flora, unusual organisms, such as clostridia and Pseudomonas indicate that a particular drug or drug-use behavior is involved. Drug users have a 10-fold increase in community-acquired pneumonia. and an incidence of one abscess per three years of injection.
Pathogenesis (HG): Bacteria are acquired from the commensal flora, the drugs or adulterants, or paraphernalia. The skin barrier is breached and non-aseptic techniques contibute to increased rrisk and use of the groin is a particular risk. Popping, which is relatively unusual locally, increases the risk of anaerobic infection. An example of paraphernalia introducing infection is candidal endophthalmitis, contracted from citric acid used to dissolve heroin.
Clinical features (AS & BA): The clinical presentation of bacterial infections in drug users is generally similar to that encountered in patients who do not use drugs but some features are unique to the drug user.
Treatment (NJ): Recognising the specific risks such as right sided SBE is the first step. Issues of the management of drug withdrawal, adherence to therapy, and difficulties of intravenous access must be a part of the therapeutic strategy. Attention to local outbreaks and bacterial antibiotic-resistance profiles is important.
Prevention (CT): Eliminating drug use is the surest way to control associated infections, but may not be possible. Risk-reducing strategies may help prevent bacterial infections among drug users, particularly among new users, the ones at greatest risk. Advise on using clean needles, not sharing, alcohol skin swabs, avoiding the neck and groin as injection sites. Don’t miss the opportunity for screening (Hep B, C, HIV, TB) and immunisation (Hep B, Hep A, tetanus).
This week’s prize to Dr Tuck...timing, handouts, good precis.
Next week’s theme is anti-arrhythmic drugs, two minutes please on:
Class Ia (AS)
Class Ib (Ash)
Class Ic (CT)
Class II (NM)
Class III (BA)
Class IV (HG)
Cardiac glycosides (MJM)
Interesting topics this week
Paraproteins
Cardiac action potentials and Vaughan-Williams
Technetium bone scans:
Am Fam Physician 1996 Oct;54(5):1639-47. Sutter CW et al. Three-phase bone scan in osteomyelitis and other musculoskeletal disorders. (you can get this through the e-library with your Athens login)
The Reading for next week is Outputs and Utility. Bandolier November 2002
http://www.jr2.ox.ac.uk/bandolier/Extraforbando/Outputs.pdf
MJM
This week’s theme was related to the NEJM review of bacterial infections in intravenous drug users. Bacterial Infections in Drug Users. Gordon RJ, Lowy FD. NEJM November 3, 2005; 353 (18):1945-1954. (link in last week's blog)
Epidemiology (PS) : Most bacterial infections among drug users are caused by commensal flora, unusual organisms, such as clostridia and Pseudomonas indicate that a particular drug or drug-use behavior is involved. Drug users have a 10-fold increase in community-acquired pneumonia. and an incidence of one abscess per three years of injection.
Pathogenesis (HG): Bacteria are acquired from the commensal flora, the drugs or adulterants, or paraphernalia. The skin barrier is breached and non-aseptic techniques contibute to increased rrisk and use of the groin is a particular risk. Popping, which is relatively unusual locally, increases the risk of anaerobic infection. An example of paraphernalia introducing infection is candidal endophthalmitis, contracted from citric acid used to dissolve heroin.
Clinical features (AS & BA): The clinical presentation of bacterial infections in drug users is generally similar to that encountered in patients who do not use drugs but some features are unique to the drug user.
Treatment (NJ): Recognising the specific risks such as right sided SBE is the first step. Issues of the management of drug withdrawal, adherence to therapy, and difficulties of intravenous access must be a part of the therapeutic strategy. Attention to local outbreaks and bacterial antibiotic-resistance profiles is important.
Prevention (CT): Eliminating drug use is the surest way to control associated infections, but may not be possible. Risk-reducing strategies may help prevent bacterial infections among drug users, particularly among new users, the ones at greatest risk. Advise on using clean needles, not sharing, alcohol skin swabs, avoiding the neck and groin as injection sites. Don’t miss the opportunity for screening (Hep B, C, HIV, TB) and immunisation (Hep B, Hep A, tetanus).
This week’s prize to Dr Tuck...timing, handouts, good precis.
Next week’s theme is anti-arrhythmic drugs, two minutes please on:
Class Ia (AS)
Class Ib (Ash)
Class Ic (CT)
Class II (NM)
Class III (BA)
Class IV (HG)
Cardiac glycosides (MJM)
Interesting topics this week
Paraproteins
Cardiac action potentials and Vaughan-Williams
Technetium bone scans:
Am Fam Physician 1996 Oct;54(5):1639-47. Sutter CW et al. Three-phase bone scan in osteomyelitis and other musculoskeletal disorders. (you can get this through the e-library with your Athens login)
The Reading for next week is Outputs and Utility. Bandolier November 2002
http://www.jr2.ox.ac.uk/bandolier/Extraforbando/Outputs.pdf
MJM
Thursday, November 24, 2005
Friday, November 18, 2005
Wardround 18xi05
This week’s two minute tutorials were about palliative care issues. I would like each of you to post one item from your talk in the comments section please.
Pain (AS)
Nausea/vomiting (CT)
Fatigue (BA)
Hiccoughs (MJM)
Constipation (HG)
Dyspnoea (PS)
Dysphagia (NJ)
Itching (GAJ)
I award this week’s prize (kudos but no money) to Dr Tuck....unhurried, spoken rather then read out, accompanied by a handout, and sources quoted. It is interesting that these areas are taken so seriously in palliative care, yet are relatively ignored in acute medicine even though the benefits in improved quality of life can be immense. I remember talking to a colleague who had a serious stroke while still young...on the rehab unit he told me that he had not realised how serious a problem constipation was until he was the one afflicted.
The minor challenge had been to tell me the p value for my experiment. I postulated that saying the magic word “abracadabra” had increased the number of heads when tossing a coin. The experiment was carried out on Tuesday: I tossed a coin and got three tails in a row; then repeated the process after the magic word and had 2 heads and a tail. What is the p value? Answer...the p value (probability of tossing more coins by chance as tails) in this experiment was 0.875.
The paper for discussion had been "The Medical Effects of Kissing Booboos" by Hansen GL. Originally published as "The Palliative Effects of Osculation on the Prognosis of Pediatric Wounds" in the Annals of Improbable Research 1995 Volume 1: Number 5. I had asked you to identify any methodological flaws.
This paper describes an observational study of kissing wounds better. Only 23 of 24,617 cases were enrolled: the numbers themselves are not a problem since most studies use only a sample of the possible subjects. What is important is that the subjects should be selected randomly otherwise there may be bias in the selection process. Bias can be reduced by randomly allocating patients to treatment groups and blinding subjects and investigators to the treatment used. Since this is an observational study randomisation has already been foregone...and we are given no information to suggest that the assessment is blinded. In an RCT you can get some idea about the success of randomisation by looking at the rather boring table called something like “baseline characteristics”. Most of these should be similar in each group if the randomisation procedure has worked. Don’t fall for the arguments such as “ there were more diabetics in group A so the improvement in survival is even more impressive”. You should be thinking “is the randomisation process robust?” Of course this paper has no statistical testing.
Some reading for related to this...read them for Tuesday’s wardround.
What are confidence intervals? Davies HT
Bandolier Bias guide
Interesting topics this week:
Neurofibromatosis
TIMI score
see below October 5, 2005
Alcoholic hepatitis
Next week’s reading is Bacterial Infections in Drug Users. Gordon RJ, Lowy FD. NEJM November 3, 2005; 353 (18):1945-1954.
You should be able to get a copy from the NHSES e-library with your Athens password.
The two minute tutorials will be based on sections of this paper:
Epidemiology (PS)
Pathogenesis (HG)
Clinical Features (AS & BA)
Prevention (CT)
Treatment (NJ)
Try to deliver your talks rather than read them out.
MJM
Pain (AS)
Nausea/vomiting (CT)
Fatigue (BA)
Hiccoughs (MJM)
Constipation (HG)
Dyspnoea (PS)
Dysphagia (NJ)
Itching (GAJ)
I award this week’s prize (kudos but no money) to Dr Tuck....unhurried, spoken rather then read out, accompanied by a handout, and sources quoted. It is interesting that these areas are taken so seriously in palliative care, yet are relatively ignored in acute medicine even though the benefits in improved quality of life can be immense. I remember talking to a colleague who had a serious stroke while still young...on the rehab unit he told me that he had not realised how serious a problem constipation was until he was the one afflicted.
The minor challenge had been to tell me the p value for my experiment. I postulated that saying the magic word “abracadabra” had increased the number of heads when tossing a coin. The experiment was carried out on Tuesday: I tossed a coin and got three tails in a row; then repeated the process after the magic word and had 2 heads and a tail. What is the p value? Answer...the p value (probability of tossing more coins by chance as tails) in this experiment was 0.875.
The paper for discussion had been "The Medical Effects of Kissing Booboos" by Hansen GL. Originally published as "The Palliative Effects of Osculation on the Prognosis of Pediatric Wounds" in the Annals of Improbable Research 1995 Volume 1: Number 5. I had asked you to identify any methodological flaws.
This paper describes an observational study of kissing wounds better. Only 23 of 24,617 cases were enrolled: the numbers themselves are not a problem since most studies use only a sample of the possible subjects. What is important is that the subjects should be selected randomly otherwise there may be bias in the selection process. Bias can be reduced by randomly allocating patients to treatment groups and blinding subjects and investigators to the treatment used. Since this is an observational study randomisation has already been foregone...and we are given no information to suggest that the assessment is blinded. In an RCT you can get some idea about the success of randomisation by looking at the rather boring table called something like “baseline characteristics”. Most of these should be similar in each group if the randomisation procedure has worked. Don’t fall for the arguments such as “ there were more diabetics in group A so the improvement in survival is even more impressive”. You should be thinking “is the randomisation process robust?” Of course this paper has no statistical testing.
Some reading for related to this...read them for Tuesday’s wardround.
What are confidence intervals? Davies HT
Bandolier Bias guide
Interesting topics this week:
Neurofibromatosis
TIMI score
see below October 5, 2005
Alcoholic hepatitis
Next week’s reading is Bacterial Infections in Drug Users. Gordon RJ, Lowy FD. NEJM November 3, 2005; 353 (18):1945-1954.
You should be able to get a copy from the NHSES e-library with your Athens password.
The two minute tutorials will be based on sections of this paper:
Epidemiology (PS)
Pathogenesis (HG)
Clinical Features (AS & BA)
Prevention (CT)
Treatment (NJ)
Try to deliver your talks rather than read them out.
MJM
Thursday, November 17, 2005
Hiccoughs
HiccoughsMP3 File
The minor challenge for this week had been to tell me the p value for the following experiment. I postulated that saying the magic word “abracadabra” had increased the number of heads when tossing a coin. The experiment was carried out on Tuesday: I tossed a coin and got three tails in a row; then repeated the process after the magic word and had 2 heads and a tail. There we have it...proof (just send the Nobel prize in the post). What is the p value?
Sunday, November 13, 2005
Wardround 11xi05
This weeks two minute tutorials were themed around common drugs.
We heard about:
Furosemide (Dr Kidder)
Coamoxiclav (Dr Tuck)
Salbutamol (Dr Johnstone)
Paracetamol (Dr Szulakowski)
Morphine (Dr Jones)
Warfarin (MJM)
I award this week's prize to Dr Kidder. It is useful to review drugs we use commonly as it is easy to begin thinking that something we use often is something we know all about. Confidence can breed mistaken assessments of competence. Coincidentally, our friendly renal doc had, earlier in the week been asking me if I knew how furosemide got into the renal tubules...I must own up that I foolishly thought it was filtered...he put me right on that one and Dr Kidder I see began his talk by mentioning that Furosemide is highly protein bound and is not therefore filtered, but actively transported into the tubules. This is important since in a setting of glomerular protein leakage the tubular furosemide can become bound to albumin and its activity reduced.
A question for you. Did you learn anything from the talks? If so...why not read up on common drugs every now and then.
The week's reading was in house so to speak: How to report an ETT... from our own wiki (http://mjms.pbwiki.com). I will draw up a pro-forma for ward staff to use.
Since there has been a request for discussion of p values I have set next weeks reading as "The Medical Effects of Kissing Booboos" by Hansen GL. Originally published as "The Palliative Effects of Osculation on the Prognosis of Pediatric Wounds" in the Annals of Improbable Research 1995 Volume 1: Number 5. This is not available online without paying a subscription, so I will bring a copy in to the ward on Monday. The paper contains more than one methodological flaw. I would like you to draw up a list for Friday's discussion.
Interesting topics this week:
Diagnosing Endocarditis
Hypernatraemia
Next weeks two minute tutorials are themed around palliative care: I have misplaced my academic diary where the assignments were listed but you all know what you must do. (I will update the post when I can -done)
Pain (AS)
Nausea/vomiting (CT)
Fatigue (BA)
Hiccoughs (MJM)
Constipation (HG)
Dyspnoea (PS)
Dysphagia (NJ)
Itching (GAJ)
Make the two minutes unhurried and informative.
Podcast to follow.
MJM
We heard about:
Furosemide (Dr Kidder)
Coamoxiclav (Dr Tuck)
Salbutamol (Dr Johnstone)
Paracetamol (Dr Szulakowski)
Morphine (Dr Jones)
Warfarin (MJM)
I award this week's prize to Dr Kidder. It is useful to review drugs we use commonly as it is easy to begin thinking that something we use often is something we know all about. Confidence can breed mistaken assessments of competence. Coincidentally, our friendly renal doc had, earlier in the week been asking me if I knew how furosemide got into the renal tubules...I must own up that I foolishly thought it was filtered...he put me right on that one and Dr Kidder I see began his talk by mentioning that Furosemide is highly protein bound and is not therefore filtered, but actively transported into the tubules. This is important since in a setting of glomerular protein leakage the tubular furosemide can become bound to albumin and its activity reduced.
A question for you. Did you learn anything from the talks? If so...why not read up on common drugs every now and then.
The week's reading was in house so to speak: How to report an ETT... from our own wiki (http://mjms.pbwiki.com). I will draw up a pro-forma for ward staff to use.
Since there has been a request for discussion of p values I have set next weeks reading as "The Medical Effects of Kissing Booboos" by Hansen GL. Originally published as "The Palliative Effects of Osculation on the Prognosis of Pediatric Wounds" in the Annals of Improbable Research 1995 Volume 1: Number 5. This is not available online without paying a subscription, so I will bring a copy in to the ward on Monday. The paper contains more than one methodological flaw. I would like you to draw up a list for Friday's discussion.
Interesting topics this week:
Diagnosing Endocarditis
Hypernatraemia
Next weeks two minute tutorials are themed around palliative care: I have misplaced my academic diary where the assignments were listed but you all know what you must do. (I will update the post when I can -done)
Pain (AS)
Nausea/vomiting (CT)
Fatigue (BA)
Hiccoughs (MJM)
Constipation (HG)
Dyspnoea (PS)
Dysphagia (NJ)
Itching (GAJ)
Make the two minutes unhurried and informative.
Podcast to follow.
MJM
Thursday, November 10, 2005
Sunday, November 06, 2005
Wardround 04xi05
Wow...we're in the BMJ this week. Netlines
This weeks two minute tutorials were themed around the U&E.
Sodium (Dr Szulakowski chose to give us a talk on inappropriate ADH. One might argue that is a disturbance of water tonicity/volume control, but perhaps its just me being pedantic).
Potassium (Dr Kidder)
Chloride (duet)
Creatinine (Dr Johnstone)
Bicarbonate (Dr Islam)
Naomi's talk on creatinine receives the prize for this week since she managed to give a precise and concise talk. I am afraid all the others tried to fit too much into the limited time. The task of presenting a two minute talk on a subject is difficult (at first) and clearly most of you are very generous...you try to give me as much as possible...but there is only so much that can be said in two minutes.
More musing on two minute tutorials. These are a discipline. If you can learn how to distill the fruits of your reading into this short time you will be able to produce revision notes very easily. When the time comes to move on and give longer talks you will be able to build them up in two minute sized aliquots. Believe me, when you go to pick up that Nobel prize, you may not thank me, but I will be running around shouting 'I taught her how to give a concise .talk'.
Next week's tutorial theme is 'common drugs'...here are the assignments:
DK Furosemide
CT Coamoxiclav (go on, make Dr J proud of you)
NJ Salbutamol
PS Paracetamol
GAJ (free choice....)
MJM (mmmmmm...I'll take requests...post them in the comments section)
Interesting topics this week
RB-ILD
Wikis: if you don't know what a wiki is have a look at Wikipedia. I hope we can put together a wardround wiki (see link to the right) collecting the information from our discussions. I have put together a couple of pages on the normal ECG and reporting ETTs. At the moment it is hosted externally but we should have an in house wiki soon which could contain the doctor's handbook...I have pasted some pages from the last (ie out of date) handbook but BEWARE a colleague has vandalised some pages to illustrate a point. We do not advocate giving Elephant guns to aggressive patients.
Next week's reading:
Our wiki page on reporting an ETT (link is to the right)
A paper for your collection:
Treatment of stable chronic obstructive pulmonary disease
Stephen I Rennard. Lancet
28 August 2004, Pages 791-802
Don't forget your two minute tutorials, just two minutes worth. All knowledge can be categorised as:
Must know
Should know
Nice to know
Don't need to know
Which will you include in your talk?
MJM
MP3 File
This weeks two minute tutorials were themed around the U&E.
Sodium (Dr Szulakowski chose to give us a talk on inappropriate ADH. One might argue that is a disturbance of water tonicity/volume control, but perhaps its just me being pedantic).
Potassium (Dr Kidder)
Chloride (duet)
Creatinine (Dr Johnstone)
Bicarbonate (Dr Islam)
Naomi's talk on creatinine receives the prize for this week since she managed to give a precise and concise talk. I am afraid all the others tried to fit too much into the limited time. The task of presenting a two minute talk on a subject is difficult (at first) and clearly most of you are very generous...you try to give me as much as possible...but there is only so much that can be said in two minutes.
More musing on two minute tutorials. These are a discipline. If you can learn how to distill the fruits of your reading into this short time you will be able to produce revision notes very easily. When the time comes to move on and give longer talks you will be able to build them up in two minute sized aliquots. Believe me, when you go to pick up that Nobel prize, you may not thank me, but I will be running around shouting 'I taught her how to give a concise .talk'.
Next week's tutorial theme is 'common drugs'...here are the assignments:
DK Furosemide
CT Coamoxiclav (go on, make Dr J proud of you)
NJ Salbutamol
PS Paracetamol
GAJ (free choice....)
MJM (mmmmmm...I'll take requests...post them in the comments section)
Interesting topics this week
RB-ILD
Wikis: if you don't know what a wiki is have a look at Wikipedia. I hope we can put together a wardround wiki (see link to the right) collecting the information from our discussions. I have put together a couple of pages on the normal ECG and reporting ETTs. At the moment it is hosted externally but we should have an in house wiki soon which could contain the doctor's handbook...I have pasted some pages from the last (ie out of date) handbook but BEWARE a colleague has vandalised some pages to illustrate a point. We do not advocate giving Elephant guns to aggressive patients.
Next week's reading:
Our wiki page on reporting an ETT (link is to the right)
A paper for your collection:
Treatment of stable chronic obstructive pulmonary disease
Stephen I Rennard. Lancet
28 August 2004, Pages 791-802
Don't forget your two minute tutorials, just two minutes worth. All knowledge can be categorised as:
Must know
Should know
Nice to know
Don't need to know
Which will you include in your talk?
MJM
MP3 File
Wednesday, November 02, 2005
Saturday, October 29, 2005
Wardround 28x05
This week's two minute tutorials: theme COPD (I will talk about these on the podcast)
Steroids in COPD (link) Dr Tuck
Antibiotics in COPD Dr Kidder
LTOT Dr Johnstone
Non-invasive Ventilation Dr Szulakowski
Smoking cessation Dr Islam
Further reading
NICE guidance on COPD 2004 ,
European Respiratory Society COPD standards
Interesting topics this week
Weight loss with HIV
http://www.hivmedicine.com/textbook/wasting.htm
Klebsiella septicaemia
http://www.emedicine.com/med/topic1237.htm
Lymphocytosis
http://www.aafp.org/afp/20001101/2053.html
Gastric erosions
http://www.emedicine.com/med/topic3565.htm
Anticoagulation in AF
http://www.sign.ac.uk/pdf/sign36.pdf
This week’s reading for discussion was A Necessary Inhumanity? Ruth Richardson. Journal of Medical Ethics 2000;26;104-106, from which I have reproduced the abstract below.
“It is argued that the phrase “Necessary Inhumanity” more accurately describes the alienation required of doctors in some circumstances, than do modern sanitized coinages such as ‘clinical detachment’. ‘Detachment’ and ‘objectivity’ imply separation, not engagement: creating distance not only from patients, but from the self: the process may well be required, but where it becomes too extreme or prolonged, it can damage everybody, including patients, family members, doctors themselves, and wider society. An awareness of the history of health care in the context of our society might assist self reflection–might help keep initiates in touch with the culture they have been induced to leave and might help them remain humane despite the bruising process of training.”
The reading for next week is Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S. Wang; J. Mark FitzGerald; Michael Schulzer; Edwin Mak; Najib T. Ayas JAMA. 2005;294:1944-1956.
Next week’s two minute tutorials are themed on the U&E
Sodium PS
Potassium DK
Creatinine NJ
Bicarbonate TI
Chloride M
Don’t forget your two minute tutorials should be concise and precise.
podcast
If anyone out there would like to submit two minute tutorials for the podcast, just leave me a note in one of the comments.
Steroids in COPD (link) Dr Tuck
Antibiotics in COPD Dr Kidder
LTOT Dr Johnstone
Non-invasive Ventilation Dr Szulakowski
Smoking cessation Dr Islam
Further reading
NICE guidance on COPD 2004 ,
European Respiratory Society COPD standards
Interesting topics this week
Weight loss with HIV
http://www.hivmedicine.com/textbook/wasting.htm
Klebsiella septicaemia
http://www.emedicine.com/med/topic1237.htm
Lymphocytosis
http://www.aafp.org/afp/20001101/2053.html
Gastric erosions
http://www.emedicine.com/med/topic3565.htm
Anticoagulation in AF
http://www.sign.ac.uk/pdf/sign36.pdf
This week’s reading for discussion was A Necessary Inhumanity? Ruth Richardson. Journal of Medical Ethics 2000;26;104-106, from which I have reproduced the abstract below.
“It is argued that the phrase “Necessary Inhumanity” more accurately describes the alienation required of doctors in some circumstances, than do modern sanitized coinages such as ‘clinical detachment’. ‘Detachment’ and ‘objectivity’ imply separation, not engagement: creating distance not only from patients, but from the self: the process may well be required, but where it becomes too extreme or prolonged, it can damage everybody, including patients, family members, doctors themselves, and wider society. An awareness of the history of health care in the context of our society might assist self reflection–might help keep initiates in touch with the culture they have been induced to leave and might help them remain humane despite the bruising process of training.”
The reading for next week is Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S. Wang; J. Mark FitzGerald; Michael Schulzer; Edwin Mak; Najib T. Ayas JAMA. 2005;294:1944-1956.
Next week’s two minute tutorials are themed on the U&E
Sodium PS
Potassium DK
Creatinine NJ
Bicarbonate TI
Chloride M
Don’t forget your two minute tutorials should be concise and precise.
podcast
If anyone out there would like to submit two minute tutorials for the podcast, just leave me a note in one of the comments.
Wednesday, October 26, 2005
Podcast - assessing RA
Assessing disease activity in rheumatoid arthritisMP3 File
Development and preliminary assessment of a simple measure of overall status in rheumatoid arthritis (OSRA) for routine clinical use. Symmons DPM, Hassell AB, Gunatillaka KAN, Jones PW, Schollum J, Dawes PT. Q J Med 1995;88:429–37
Disease activity score The home of the DAS
The DAS28 in rheumatoid arthritis and fibromyalgia patients. B. F. Leeb, I. Andel, J. Sautner, T. Nothnagl and B. Rintelen. Rheumatology 2004 43(12):1504-1507
In this podcast I have not addressed the wider assessment beyond disease activity, but will address this in a later podcast which will include discussion of questionnaires in assessment.
Wednesday, October 19, 2005
The QRS in the exercise ECG. Audio only version.
MP3 File
No wardround blog for this week since I am away at the the weekend. I hope Dr Jones will give out the two minute tutorials, but if not I will allocate some on Tuesday.
We better have some reading, though. Since we did not have much of an opportunity to discuss this paper from a couple of weeks ago, perhaps we should go over it once more...I expect everyone to have a (reasoned) opinion about it.
A Necessary Inhumanity? Ruth Richardson. Journal of Medical Ethics 2000;26;104-106
But I must say I am very tempted by Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S. Wang; J. Mark FitzGerald; Michael Schulzer; Edwin Mak; Najib T. Ayas JAMA. 2005;294:1944-1956. But perhaps we could leave that for the next week (hint...that means you have two weeks to read it).
And now you all have your 'ECG reporter' badges We can expect thorough assessment of ECGs next week.
I am off south of the border for a few days...but back in bonny Scotland soon.
MP3 File
No wardround blog for this week since I am away at the the weekend. I hope Dr Jones will give out the two minute tutorials, but if not I will allocate some on Tuesday.
We better have some reading, though. Since we did not have much of an opportunity to discuss this paper from a couple of weeks ago, perhaps we should go over it once more...I expect everyone to have a (reasoned) opinion about it.
A Necessary Inhumanity? Ruth Richardson. Journal of Medical Ethics 2000;26;104-106
But I must say I am very tempted by Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure? Charlie S. Wang; J. Mark FitzGerald; Michael Schulzer; Edwin Mak; Najib T. Ayas JAMA. 2005;294:1944-1956. But perhaps we could leave that for the next week (hint...that means you have two weeks to read it).
And now you all have your 'ECG reporter' badges We can expect thorough assessment of ECGs next week.
I am off south of the border for a few days...but back in bonny Scotland soon.
Saturday, October 15, 2005
Wardround 14x05
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