Wardround 19v6

A thing of beauty is a joy forever. Even my nemesis pictured here.

This week's two minute tutorials were a challenge; such broad subjects, inflammatory bowel disorders, so little time. Very interesting though. If you email your talks to me I will incorporate them in the blog.

The week's Reading had been The Iowa Car Crop by S E Landsberg. I had asked you why you thought I had chosen it and how it might be relevent to medicine. HmmmH.... I admit to being seduced by the first three lines: "A thing of beauty is a joy forever and there is nothing more beautiful than a succinct and flawless argument." The paper was chosen because any critical criteria I may use for choosing our reading were corrupted by the paper's rhetoric (or more correctly the author's rhetoric). The opening lines appealed to me and so the paper was chosen. The relevance to medicine is two fold. Firstly beware accepting or rejecting papers because of rhetoric rather than substance. the second part relates to the ships that disappear over the horizon and return later loaded with Toyotas. The author suggests that for an economist to analyse this phenomenon it is not necessary to understand the nature of Japan...it is adequate to imagine it a amagic box which convertts wheat into Toyotas. Diagnoses are similar. It is not always necessary to know everything about a patient's disease (indeed we never know everything) in order to produce a workable management plan. It is only important to know those things which are necessary to produce the plan. I do not know the cause of polymyalgia rheumatica, but I do know the prognosis, complications, treatment and differential diagnosis.

Next week's two minute tutorials are related to Hypertension:
Ace inhibitors (TS)
Beta-blockers (EB)
Calcium channel blockers (AJ)
Diuretics (CC)
Non-drug treatment (JCM)
Investigation of HT (MC)
Keep up the excellent standard. Quote your sources, keep it concise and precise.

The reading for the week is A mysterious death. David W Oldach, Robert E Richard, Eugene N Borza, R Michael Benitez. The New England Journal of Medicine. Jun 11, 1998.Vol.338, Iss. 24; pg. 1764, 6 pgs

I am away this week, see you next week. MJM

QUIZ

The houseman has searched in vain. Where to look?

Wardround 12v6

This week’s theme was Spirochaetal diseases, Syphilis, Yaws, Pinta, Leptospirosis and Lyme disease. I think this was quite a challenge, but the talks were excellent and a good stimulus for further reading on my part. I will try to get the fact sheets you made scanned and made available, but if you could email the files to me it would be easier.

Next week’s theme is inflammatory bowel diseases: UC, Crohn’s, Coeliac, C.difficile. You have your assignments. Two minute talks please, concise and precise.

This week’s reading was Clinical craft: a lesson from Liverpool. D M Gore Journal of Medical Ethics 27:74-75 (2001). "Surely now is a good time to revisit the concept of clinical craft. ... we also need a certain amount of pride to keep up our morale. By celebrating our craft we can identify with skilled workers anywhere." Pride in a job well done is a precious crop, full of nourisment for the spirit and vitamins for the soul. It is all too easy to tend the plant but allow the fruit to wither on the branch or fall to rot on the ground. My advice: Take some time each week to reflect on what you have achieved as an individual or as part of a team.

For next week I have chosen a different subject: The Iowa Car Crop, S E Landsburg, from The Armchair Economist (1995). I have left a copy on the ward. I would like you to read this and ponder two things: why I have chosen it and what relevance it has for medicine.

Interesting topics this week
SIRS (Systemic inflammatory response syndrome) with hypoxia, eosinophilia, myalgia and anti-MPO antibodies.
CSS
SIRS
Eosinophilia myalgia syndrome (as a fascinoma)

Ultrasound for pleural effusions

Staph. septicaemia. How to confirm SBE; do you know the Duke criteria? And if you do....Are they useful in clinical practice?

MJM

Wardround 5v6

The two minute tutorials this week were themed around common drugs: Furosemide, Coamoxiclav, Metformin, Citalopram, Omeprazole. It is always useful to focus on those things that would otherwise be part of the background. It was clear that there were important actions one can take when assessing a patient taking one of these agents.

Has it been effective? Is it still needed? Can it be withdrawn? should that be rapid or slow? Are there warnings for the patient? do those warnings change the patient's views about using the treatment.

What sticks in my mind? Do not stop citalopram abruptly, warn patients on PPIs about infection risks (and how to reduce them), warn patients to stop metformin if they become breathless or are vomiting, beware clavulanic acid (coamoxiclav) with liver disease.

The reading this week was Bandolier: What patients think. A comment on the 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. There seems to be a gap between the risk/benefit thresholds exhibited by doctors and patients, at least in so far as this study shows.

The Bandolier comment includes "This is an interesting and imaginative paper that tells us what patients think. Half were happy to take a preventive drug if the hypothetical five year absolute risk reduction was 20%, or an NNT of 5. ..... There is a clear discrepancy. Few preventive medicines for preventing heart attacks would seem to meet patient expectation.... the power of the doctor to advise. If their doctor recommended it, more than twice as many subjects would take the medicine. This, though, imposes a significant burden on doctors properly to inform their patients. Much less attention has been paid to how patients think about their own versus population benefit, and especially how the information is presented. "

Interesting topics this week:

Trigeminal neuralgia and Lyme disease

Next week's two minute talks are themed around spirochaetes (I hope Dr Jones has handed out the assignments).

The reading for next week is: Clinical craft: a lesson from Liverpool. D M Gore Journal of Medical Ethics 27:74-75 (2001)

MJM

Connective Tissue Disorders

MP3 File

A brief introduction to diagnosis of CTDs

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

MP3 File

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

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.


MP3 File

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