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

MP3 File

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


MP3 File

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


MP3 File

Valproate


MP3 File

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


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

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

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