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Foo20151013 2023 7owyf5?1444773963
3
158

Benchmarking Outpatient Referral Rates

Introduction GPs for a little while have been asked to compare each other’s outpatient referrals rates. The idea is that this peer to peer open review will help us understand each others referral patterns. For some reason and due to a natural competitive nature of human behaviour, I think we have these peer to peer figures put to us to try to get us to refer less into hospital outpatients. It’s always hard to benchmark GP surgeries but outpatient referral benchmarking is particularly poor for several reasons It's Very Difficult to Normalise Surgeries Surgeries have different mortalities morbidities ages and other confounding factors that it becomes very hard to create an algorithm to create a weighting factor to properly compare one surgery against another. There Are Several Reasons For The Referral I’ll go into more detail on this point later but there are several reasons why doctors refer patients into hospital which can range from: doctors knowing a lot about the condition and picking up subtle symptoms and signs lesser experienced doctors would have ignored; all the way to not knowing about the condition and needing some advice from an expert in the condition. We Need To Look At The Bigger Picture The biggest killer to our budget is non-elective admissions and it’s the one area where patient, commissioner and doctor converge. Patients want to keep out of hospital, it’s cheaper for the NHS and Doctors don’t like the lack of continuity when patients go in. For me I see every admission to hospital as a fail. Of course it’s more complex than this and it might be totally appropriate but if we work on this concept backwards, it will help us more. Likewise if we try to reduce outpatient referrals because we are pressurised to, they may end up in hospitalisation and cost the NHS £10,000s rather than £100s as an outpatient. We need to look at the bigger picture and refer especially if we believe that referrals will lead to less hospitalisation of patients further down the line. To put things into perspective 2 symptoms patients present which I take very seriously are palpitations in the elderly and breathlessness. Both symptoms are very real and normally lead to undiagnosed conditions which if we don’t tackle and diagnose early enough will cause patients to deteriorate and end up in hospital. Education, Education, Education When I first went into commissioning as a lead in 2006 I had this idea of getting to the bottom of why GPs refer patients to outpatients. The idea being if we knew why, we would know how to best tackle specialities. I asked my GPs to record which speciality to refer to and why they referred over a 7 month period. The reason for admission was complex but we divided them up into these categories: 2nd care input required for management of the condition. We know about the condition but have drawn the line with what we can do in primary care. An example of this is when we’ve done a 24 hour tape and found a patient has 2sec pauses and needs a pace maker. 2nd care input required for diagnosis. We think this patient has these symptoms which are related to this condition but don’t really know about the diagnosis and need help with this. An example of this is when a patient presents with diarrhoea to a gastroenterologist There could be several reasons for this and we need help from the gastroenterologist to confirm the diagnosis via a colonscopy and ogd etc. Management Advice. We know what the patient has but need help with managing the condition. For example uncontrolled heart failure or recurrent sinusitis. Consultant to Consultant Referral. As advised between consultants. Patient Choice. Sometimes the patient just wants to see the hospital doctor. The results are enclosed here in Excel and displayed below. Please click on the graph thumbnail below. Reasons For Referrals Firstly a few disclaimers and thoughts. These figures were before any GPSI ENT, Dermatology or Musculosketal services which probably would have made an impact on the figures. There are a few anomalies which may need further thought eg I’m surprised Rheumatology for 2nd input for diagnosis is so low, as frequently I have patients with high ESRs and CRPs which I need advise on diagnoses. Also audiology medicine doesn’t quite look right. The cardiology referral is probably high for management advise due to help on ECG interpretation although this is an assumption. This is just a 7 month period from a subset of 8-9 GPs. Although we were careful to explain each category and it’s meaning, more work might need to be done to clarify the findings further. In my opinion the one area where GPs need to get grips with is management advice as it’s an admission that I know what the patient has and need help on how to treat them. This graph is listed in order of management advice for this reason. So what do you do to respond to this? The most logical step is to education GPs on the left hand side of this graph and invest in your work force but more and more I see intermediary GPSI services which are the provider arm of a commissioning group led to help intercept referrals to hospital. In favour of the data most of the left hand side of the graph have been converted into a GPSI service at one point. In my area what has happened is that referrals rates have actually gone up into these services with no decline in the outgoing speciality as GPs become dis-empowered and just off load any symptoms which patients have which they would have probably had a higher threshold to refer on if these GPSI services were not available. Having said that GPSI services can have a role in the pathway and I’m not averse to their implementation, we just have to find a better way to use their services. 3 Step Plan As I’m not one to just give problems here are my 3 suggestions to help referrals. To have a more responsive Layered Outpatient Service. Setting up an 18 week target for all outpatients is strange, as symptoms and specialities need to be prioritised. For example I don’t mind waiting 20 weeks for a ENT referral on a condition which is bothering me but not life threatening but need to only have a 3 week turn over if I’m breathless with a sudden reduction in my exercise tolerance. This adds an extra layer of complexity but always in the back of my mind it’s about getting them seen sooner to prevent hospitalisation. Education, education, education It’s ironic that the first budget to be slashed in my area was education. We need to education our GPs to empower them to bring the management advice category down as this is the category which will make the biggest impact to improving health care. In essence we need to focus on working on the left hand side of this graph first. Diagnose Earlier and Refer Appropriately The worst case scenario is when GPs refer patients to the wrong speciality and it can happen frequently as symptoms blur between conditions. This leads to delayed diagnosis, delayed management and you guessed it, increased hospitalisation. The obvious example is whether patients with breathlessness is caused by heart or lung or is psychogenic. As GPs we need to work up patients appropriately and make a best choice based on the evidence in front of us. Peer to peer GP delayed referral letter analysis groups have a place in this process. Conclusion At the end of the day it's about appropriate referrals always, not just a reduction. Indeed for us to get a grip on the NHS Budgets as future Clinical Commissioners, I would expect outpatient referrals to go up at the expense of non-elective, as then you are looking at patients being seen and diagnosed earlier and kept out of hospital.  
Raza Toosy
about 8 years ago
Foo20151013 2023 2njk5o?1444774020
4
1355

LWW: Case Of The Month - April 2013

This month’s case is by David R Bell PhD, co-author of Medical Physiology: Principles for Clinical Medicine, 3e (ISBN: 9781451110395) For more information, or to purchase your copy, visit: http://tiny.cc/Rhoades4e, with 15% off using the discount code: MEDUCATION. The case below is followed by a quiz question, allowing you a choice of diagnoses. Select the one letter section that best describes the patient’s condition. The Case A 28-year old woman has an unremarkable pregnancy through her first 28 weeks of gestation, with normal weight gain and no serious complications. She has no previous history of diabetes, hypertension of other systemic disease before or during her current pregnancy. During her 30-week checkup, her blood pressure measures 128/85, and she complains about feeling slightly more “bloated” than usual with swelling in her legs that seems to get more uncomfortable as the day goes on. Her obsterician recommends that she get more bed rest, stay off her feet as much as possible and return for evaluation in one week. At the one-week follow-up, the patient presents with noticable”puffiness” in her face, and a blood pressure of 145/95. She complains she has been developing headaches, sporadic blurred vision, right-sided discomfort and some shortness of breath. She has gained more than 10 lb (4.5kg) in the past week. A urinalysis on the patient revelas no glucose but a 3+ reading for protein. Her obstetrician decides to admit her immediately to a local tertiary care hospital for further evaluation. Over the next 24 hours, the patient’s urine output is recorded as 500mL and contains 6.8 grams of protein. Her plasma albumin level is 3.1 g/dl, hemacrit 48%, indirect bilirubin 1.5mg/dl and blood platelets=77000/uL, respectively. Her blood pressure is now 190/100. It is decided to try to deliver the foetus. The expelled placenta is small and shows signs of widespread ischmic damage. Within a week of delivery, the mother’s blood pressure returns to normal, and her oedema subsides. One month later, the mother shows no ill effects of thos later-term syndrome. Question What is the clinical diagnosis of this patient’s condition and its underlying pathophysiology? A. Gestational Hypertension B. Preeclampsia C. Gestational Diabetes D. Compression of the Inferior Vena Cava Answer The correct answer is "B. Preeclampsia". The patient’s symptoms and laboratory findings are consistent with a diagnosis of Preeclampsia, which is a condition occurring in some pregnancies that causes life-threatening organ and whole body regulatory malfunctions. The patient’s negative urine glucose is inconsistent with gestational diabetes. Gestational hypertension or vena caval compression cannot explain all of the patient findings. The patient has three major abnormal findings- generalised oedema, hypertension and proteinuria which are all common in preeclampsia. Although sequalae of a normal pregnancy can include water and salt retention, bloating, modest hypertension and leg swelling (secondary to capillary fluid loss from increased lower limb capillary hydrostatic pressure due to compression of the inferior vena cava by the growing foetus/uterus), oedema in the head and upper extremities, a rapid 10 pound weight gain and shortness of breath suggests a generalized and serious oedematous state. The patient did not have hypertension before or within 20 weeks gestation (primary hypertension) and did not develop hypertension after the 20th week of pregnancy with no other abnormal findings (gestational hypertension). Hypertension with proteinuria occurring beyond the 20th week of pregnancy however is a hallmark of preeclampsia. In addition, the patient has hemolysis (elevated bilirubin and LDH levels), elevated liver enzyme levels and thrombocytopenia. This is called the HELLP syndrome (HELLP = Hemolysis, Elevated Liver enzymes and Low Platelets.), and is considered evidence of serious patient deterioration in preeclampsia. A urine output of 500 ml in 24 hours is 1/2 to 1/4 of normal output in a hydrated female and indicates renal insufficiency. Protein should never be found in the urine and indicates loss of capillaries integrity in glomeruli which normally are not permeable to proteins. The patient has substantial 24 urine protein loss and hypoalbuminemia. However, generally plasma albumin levels must drop below 2.5 gm/dl to decrease plasma oncotic pressure enough to cause general oedema. The patient’s total urinary protein loss was insufficient in this regard. Capillary hyperpermeability occurs with preeclampsia and, along with hypertension, could facilitate capillary water efflux and generalized oedema. However myogenic constriction of pre-capillary arterioles could reduce the effect of high blood pressure on capillary water efflux. An early increase in hematocrit in this patient suggests hemoconcentration which could be caused by capillary fluid loss but the patient’s value of 48 is unremarkable and of little diagnostic value because increased hematocrit occurs in both preeclampsia and normal pregnancy. PGI2, PGE2 and NO, produced during normal pregnancy, cause vasorelaxation and luminal expansion of uterine arteries, which supports placental blood flow and development. Current theory suggests that over production of endothelin, thromboxane and oxygen radicals in preeclampsia antagonize vasorelaxation while stimulating platelet aggregation, microthrombi formation and endothelial destruction. These could cause oedema, hypertension, renal/hepatic deterioration and placental ischemia with release of vasotoxic factors. The patient’s right-sided pain is consistent with liver pathology (secondary to hepatic DIC or oedematous distention). Severe hypertension in preeclampsia can lead to maternal end organ damage, stroke, and death. Oedematous distension of the liver can cause hepatic rupture and internal hemorrhagic shock. Having this patient carry the baby to term markedly risks the life of the mother and is not considered current acceptable clinical practice. Delivery of the foetus and termination of the pregnancy is the only certain way to end preeclampsia. Read more This case is by David R Bell PhD, co-author of Medical Physiology: Principles for Clinical Medicine, 3e (ISBN: 9781451110395) For more information, or to purchase your copy, visit: http://tiny.cc/Rhoades4e. Save 15% (and get free P&P) on this, and a whole host of other LWW titles at (lww.co.uk)[http://lww.co.uk] when you use the code MEDUCATION when you check out! About LWW/ Wolters Kluwer Health Lippincott Williams and Wilkins (LWW) is a leading publisher of high-quality content for students and practitioners in medical and related fields. Their text and review products, eBooks, mobile apps and online solutions support students, educators, and instiutions throughout the professional’s career. LWW are proud to partner with Meducation.  
Lippincott Williams & Wilkins
almost 8 years ago
Foo20151013 2023 1eqve0g?1444774030
1
99

LWW: Case Of The Month - May 2013

This month’s case is by Barbara J. Mroz, M.D. and Robin R. Preston, Ph.D., author of Lippincott’s Illustrated Reviews: .Physiology (ISBN: 9781451175677). For more information, or to purchase your copy, visit: http://tiny.cc/PrestonLIR, with 15% off using the discount code: MEDUCATION. The case below is followed by a choice of diagnostic tests. Select the one lettered selection that would be most helpful in diagnosing the patient’s condition. The Case A 54-year-old male 2 pack-per-day smoker presents to your office complaining of cough and shortness of breath (SOB). He reports chronic mild dyspnea on exertion with a daily cough productive of clear mucus. During the past week, his cough has increased in frequency and is now productive of frothy pink-tinged sputum; his dyspnea is worse and he is now short of breath sometimes even at rest. He has had difficulty breathing when lying flat in bed and has spent the past two nights sleeping upright in a recliner. On physical examination, he is a moderately obese male with a blood pressure of 180/80 mm Hg, pulse of 98, and respiratory rate of 22. His temperature is 98.6°F. He becomes winded from climbing onto the exam table. Auscultation of the lungs reveals bilateral wheezing and crackles in the lower posterior lung fields. There is pitting edema in the lower extremities extending up to the knees.  Question Which if the following tests would be most helpful in confirming the correct diagnosis? A. Spirometry B. Arterial blood gas C. Complete blood count D. B-type natriuretic peptide blood test E. Electrocardiogram Answer? The correct answer is B-type natriuretic peptide blood test. Uncomfortable breathing, or feeling short of breath, is a common medical complaint with multiple causes. When approaching a patient with dyspnea, it is helpful to remember that normal breathing requires both a respiratory system that facilitates gas exchange between blood and the atmosphere, and a cardiovascular system that transports O2 and CO¬2 between the lungs and tissues. Dysfunction in either system may cause dyspnea, and wheezing (or bronchospasm) may be present in both cardiac and pulmonary disease. In this patient, the presence of lower extremity edema and orthopnea (discomfort when lying flat) are both suggestive of congestive heart failure (CHF). Elevated blood pressure (systolic of 180) and a cough productive of frothy pink sputum may also be associated symptoms. While wheezing could also be caused by COPD (chronic obstructive pulmonary disease) in the setting of chronic tobacco use, the additional exam findings of lung crackles and edema plus systolic hypertension are all more consistent with CHF. What does the B-type natriuretic peptide blood test tell us? When the left ventricle (LV) fails to maintain cardiac output (CO) at levels required for adequate tissue perfusion, pathways are activated to increase renal fluid retention. A rising plasma volume increases LV preload and sustains CO via the Frank-Starling mechanism. Volume loading also stimulates cardiomyocytes to release atrial- (ANP) and B-type (BNP) natriuretic peptides. BNP has a longer half-life than ANP and provides a convenient marker for volume loading. Plasma BNP levels are measured using immunoassay; levels >100 pg/mL are suggestive of overload resulting in heart failure. How does heart failure cause dyspnea? Increasing venous pressure increases mean capillary hydrostatic pressure and promotes fluid filtration from the vasculature. Excess filtration from pulmonary capillaries causes fluid accumulation within the alveoli (pulmonary edema) and interferes with normal gas exchange, resulting in SOB. Physical signs and symptoms caused by high volume loading include: (1) Lung crackles, caused by fluid within alveoli (2) Orthopnea. Reclining increases pulmonary capillary hydrostatic pressure through gravitational effects, worsening dyspnea when lying flat. (3) Pitting dependent edema caused by filtration from systemic capillaries, an effect also influenced by position (causing edema in the lower legs as in our ambulatory patient or in dependent areas like the sacrum in a bedridden patient). What would an electrocardiogram show? Heart failure can result in LV hypertrophy and manifest as a left axis deviation on an electrocardiogram (ECG), but some patients in failure show a normal ECG. An ECG is not a useful diagnostic tool for dyspnea or CHF per se. Wouldn’t spirometry be more suitable for diagnosing the cause of dyspnea in a smoker? Simple spirometry will readily identify the presence of airflow limitation (obstruction) as a cause of dyspnea. It's a valuable test to perform in any smoker and can establish a diagnosis of chronic obstructive pulmonary disease (COPD) if abnormal. While this wheezing patient is an active smoker who could have airflow obstruction, the additional exam findings above point more to a diagnosis of CHF. What would an arterial blood gas show? An arterial blood gas measures arterial pH, PaCO¬2, and PaO2. While both CHF and COPD could cause derangements in the values measured, these abnormalities would not necessarily be diagnostic (e.g., a low PaO2 could be seen in both conditions, as could an elevated PaCO¬2). Would a complete blood count provide useful information? A complete blood count could prove useful if anemia is a suspected cause of dyspnea. Test result BNP was elevated (842 pg/mL), consistent with CHF. Diuretic treatment was initiated to help reduce volume overload and an afterload reducing agent was started to lower blood pressure and improve systolic function.  
Lippincott Williams & Wilkins
almost 8 years ago
Foo20151013 2023 38zku8?1444774057
1
2775

The BioPsychoSocial Model of Disease comes to life

The biopsychosocial model of disease existed in my notes... an excuse to get out the colouring crayons and draw a diagram, but ultimately another collection of facts that needed to be digested then regurgitated in the summer exams, something to be fitted in around learning about the important stuff - the science. But the biopsychosocial model has come alive for me recently, now I realise what an impact the later two components, psychological and social, can have on patients. As a former medical student and now full time patient, the model really means something to me now. In the 1977 paper in Science, George Engel introduced the biopsychosocial model: "The dominant model of disease today is biomedical, and it leaves no room within it's framework for the social, psychological and behavioural dimensions of illness. A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching and a design for action in the real world of health care." Following some conversations on Twitter recently and from my own experience at medical school and now as a patient, I wanted to explore my thoughts on this model. Twitter, in the wonderful way it does, recently introduced me to the Disabled Medic blog, which among many other great posts, has also explored the biopsychosocial model, and I would recommend a read. The biopsychosocial model shows the influence that emotions and social circumstances have on physical health, which is important. But while conversations about the model focus on the way it can be used by healthcare professionals (very important!), it needs emphasising that the model can provide a framework for patients to look at/after themselves. The model highlights the psychological and social causes of disease, but more optimistically, it can show that there are a range of treatments for disease, from the medical to the social and psychological. A diagnosis of a long-term health conditions is often simultaneous with loss of control. There are limitations to the success of medications, treatments and surgeries. And in receiving these, we are relatively passive as patients, no matter how engaged we are. The biopsychosocial model looks at our biological, psychological and social needs, and how these factors influence our overall health. Establishing that these factors affect our health is only the first step. As patients, when psychological and social factors are brought in to the equation, it becomes clear that we ourselves have some power to help ourselves. By framing our health in this more holistic way, as patients we are not as powerless as suggested by the medical model. Through self-management we can make positive changes to our own psychological and social situations, which can in turn benefit our physical biological health. To return to the traditional ground of the model - healthcare professionals.... One strength of the model is that it places psychology side beside its (generally considered) more superior counter-part, biology. I hope that by seeing the biopsychosocial model in action, physicians can appreciate the detrimental psychological impact of a diagnosis, and the assumption of "it is all in the mind" can fall by the way side. By integrating all three elements, the model shows that neither is independent of the others, so it can't be all in the mind, because other factors, biological or social, will be involved to some degree. For me personally, the biopsychosocial model makes me look at what a 'life' is. One of the attractions of medicine is saving lives. Without getting too deeply into philosophy or ethics, I just want to explore for a second what saving a life really means for me, as a patient. I still believe that A&E staff heroically save lives. But I have come to realise that a life is more than a swiggly line on a heart rate monitor. My counsellor has been just as heroic in saving my life, through addressing my emotions. My life is now something I can live, rather than endure. With saving lives being a key (and honourable) motivation among medical staff, it is important that we can allow them to save lives as often as possible, and in many different ways. It may not always be through emergency treatment in resuscitation, but if we embrace the biopsychosical model, they can save lives in many more ways. When there is a limit to the effectiveness of the biological approaches to an ill person, and they can't be returned to the land of the healthy, medical science becomes unstuck. Within the biopsychosocial model, the issue of doctors not being able to do anything is slightly less. As I mentioned in my post about making the transition from medical student to patient, I went to medical school because I wanted to make people better. But I was only being taught one way to make people better - drugs and surgery. If we really embraces the biopsychosocial model, doctors could make a difference, even if their standard tools of drugs aren't available because they could turn to psychological and social support. This isn't to say that all clinicians have to be counsellors or social workers - far from it. But an awareness and appreciation of their contribution to the management of a patient is important, as well as an understanding of the basic principles and skills such as motivational interviewing. In 2013, I don't think I can talk about social in this context without mentioning social media. It was not was Engel originally meant in 1977, but social media has become a vital social tool for patients to manage their health. Ignoring anxieties and postural problems associated with sitting at a screen seeing everyone else's photo-shopped lives, it is undeniable that social media is a big and good resource that can empower patients to take responsibility and manage their own health. To see the best examples in action, take a look at Michael Seres and his blog, Being a Patient Isn't Easy to see a whole new meaning to the social in biopsychosocial! I am still very grateful for the biological expertise of my medical team. Don't get me wrong - it's a good place to start and I wouldn't be here writing this post today if it wasn't for the biological support. But with chronic illness, when you are past the dramatic relapses, the biological isn't enough.... The biology has allowed me to live, but its the psychological and social support I have received that has allowed me to live. Anya de Iongh @anyadei www.thepatientpatient2011.blogspot.co.uk  
Anya de Iongh
almost 8 years ago
Foo20151013 2023 qo3u6t?1444774095
3
1014

Prostate and Bladder Cancer Staging and Grading - A review for students

Amended from Wikipedia and other sources T.I Lemon Stage means spread Grade means histology Prostate cancer staging – spread of the cancer There are two schemes commonly used to stage prostate cancer. TMN and Whitmore Jewett Stage I disease is cancer that is found incidentally in a small part of the sample when prostate tissue was removed for other reasons, such as benign prostatic hypertrophy, and the cells closely resemble normal cells and the gland feels normal to the examining finger Stage II more of the prostate is involved and a lump can be felt within the gland. Stage III, the tumour has spread through the prostatic capsule and the lump can be felt on the surface of the gland. In Stage IV disease, the tumour has invaded nearby structures, or has spread to lymph nodes or other organs. Grading - Gleason Grading System is based on cellular content and tissue architecture from biopsies, which provides an estimate of the destructive potential and ultimate prognosis of the disease. TX: cannot evaluate the primary tumor T0: no evidence of tumor T1: tumor present, but not detectable clinically or with imaging • T1a: tumor was incidentally found in less than 5% of prostate tissue resected (for other reasons) • T1b: tumor was incidentally found in greater than 5% of prostate tissue resected • T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate • T2a: the tumor is in half or less than half of one of the prostate gland's two lobes • T2b: the tumor is in more than half of one lobe, but not both • T2c: the tumor is in both lobes but within the prostatic capsule • T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2) • T3a: the tumor has spread through the capsule on one or both sides • T3b: the tumor has invaded one or both seminal vesicles • T4: the tumor has invaded other nearby structures It should be stressed that the designation "T2c" implies a tumor which is palpable in both lobes of the prostate. Tumors which are found to be bilateral on biopsy only but which are not palpable bilaterally should not be staged as T2c. Evaluation of the regional lymph nodes ('N') NX: cannot evaluate the regional lymph nodes • N0: there has been no spread to the regional lymph nodes • N1: there has been spread to the regional lymph nodes Evaluation of distant metastasis ('M') • MX: cannot evaluate distant metastasis • M0: there is no distant metastasis • M1: there is distant metastasis • M1a: the cancer has spread to lymph nodes beyond the regional ones • M1b: the cancer has spread to bone • M1c: the cancer has spread to other sites (regardless of bone involvement) Evaluation of the histologic grade ('G') Usually, the grade of the cancer (how different the tissue is from normal tissue) is evaluated separately from the stage; however, for prostate cancer, grade information is used in conjunction with TNM status to group cases into four overall stages. • GX: cannot assess grade • G1: the tumor closely resembles normal tissue (Gleason 2–4) • G2: the tumor somewhat resembles normal tissue (Gleason 5–6) • G3–4: the tumor resembles normal tissue barely or not at all (Gleason 7–10) Of note, this system of describing tumors as "well-", "moderately-", and "poorly-" differentiated based on Gleason score of 2-4, 5-6, and 7-10, respectively, persists in SEER and other databases but is generally outdated. In recent years pathologists rarely assign a tumor a grade less than 3, particularly in biopsy tissue. A more contemporary consideration of Gleason grade is: • Gleason 3+3: tumor is low grade (favorable prognosis) • Gleason 3+4 / 3+5: tumor is mostly low grade with some high grade • Gleason 4+3 / 5+3: tumor is mostly high grade with some low grade • Gleason 4+4 / 4+5 / 5+4 / 5+5: tumor is all high grade Note that under current guidelines, if any Pattern 5 is present it is included in final score, regardless of the percentage of the tissue having this pattern, as the presence of any pattern 5 is considered to be a poor prognostic marker. Overall staging The tumor, lymph node, metastasis, and grade status can be combined into four stages of worsening severity. Stage Tumor Nodes Metastasis Grade Stage I T1a N0 M0 G1 Stage II T1a N0 M0 G2–4 T1b N0 M0 Any G T1c N0 M0 Any G T1 N0 M0 Any G T2 N0 M0 Any G Stage III T3 N0 M0 Any G Stage IV T4 N0 M0 Any G Any T N1 M0 Any G Any T Any N M1 Any G Bladder T (Primary tumour) • TX Primary tumour cannot be assessed • T0 No evidence of primary tumour • Ta Non-invasive papillary carcinoma • Tis Carcinoma in situ (‘flat tumour’) • T1 Tumour invades subepithelial connective tissue • T2a Tumour invades superficial muscle (inner half) • T2b Tumour invades deep muscle (outer half) • T3 Tumour invades perivesical tissue: • T3a Microscopically • T3b Macroscopically (extravesical mass) • T4a Tumour invades prostate, uterus or vagina • T4b Tumour invades pelvic wall or abdominal wall N (Lymph nodes) • NX Regional lymph nodes cannot be assessed • N0 No regional lymph node metastasis • N1 Metastasis in a single lymph node 2 cm or less in greatest dimension • N2 Metastasis in a single lymph node more than 2 cm but not more than 5 cm in greatest dimension,or multiple lymph nodes, none more than 5 cm in greatest dimension • N3 Metastasis in a lymph node more than 5 cm in greatest dimension M (Distant metastasis) • MX Distant metastasis cannot be assessed • M0 No distant metastasis • M1 Distant metastasis. Grade Urothelial papilloma – non cancerous (benign) tumour •Papillary urothelial neoplasm of low malignant potential (PUNLMP) – very slow growing and unlikely to spread •Low grade papillary urothelial carcinoma – slow growing and unlikely to spread •High grade papillary urothelial carcinoma – more quickly growing and more likely to spread  
Thomas Lemon
over 7 years ago
Foo20151013 2023 qbpcwm?1444774114
2
157

"It’s not art, it’s not science – it’s the same thing" Dr. Mangione

Our most popular tweet this week comes from Forbes contributor, Robert Glatter. Robert discusses how medicine and art are a complementary skill set. EMBED TWEET: https://twitter.com/Meducation/status/394399394210263040 As universities look to improve the selection process for medical school, they are giving increased focus to natural traits that encompass the ideal candidate. In his article Robert looks at how typically “right brain” characteristics, such as artistic flair, are highly valued selection criteria and in some cases rank more favourably than “left brain” thinking. Dr. Mangione, a master of artistic expression and physical diagnosis, agrees that medical students with creative thinking as part of their skillset are likely to excel. Do you agree that this is an important factor to consider when predicting an individual's potential for success in medicine? If not, what traits do you believe are important? The full article can be seen here - it's a very thought provoking read. Nicole  
Nicole Chalmers
over 7 years ago
Foo20151013 2023 xta4hx?1444774129
2
345

Cardiff University Research Society (CUReS) Annual Event

The Cardiff University Research Society (CUReS) held its second annual student research symposium on the 13th of November 2013 at the University Hospital of Wales. Medical students were invited to submit posters and oral presentations for the symposium. The event also launched this year’s INSPIRE program, a joint effort between Cardiff, Bristol, Exeter and Plymouth to give students connections to research groups through taster days and summer research programs. CUReS is a research society for medical students in Cardiff. All events and projects are completely free and available to all years. The research society has a particular focus on developing close bonds between researchers and students. In addition to INSPIRE, the society also releases a yearly list of summer research projects where medical students can find researchers interested in hosting projects over the summer. The purpose of the conference was to mark the launch of the INSPIRE taster days and display some of the impressive work that has been accomplished from the taster sessions and the funded summer projects. The symposium aims to give Cardiff medical students valuable experience in presenting their research and to motivate students interested in pursuing an academic career. CUReS president Huw Davies gave the opening speech, while INSPIRE lead Colin Dayan introduced the INSPIRE program. Previous INSPIRE students gave talks on their research and experiences gained from the program. Three successful applicants were invited to give oral presentations that were judged by the Cardiff Dean of Medicine Professor Paul Morgan, Professor Colin Dayan and Professor Julian Sampson, who also gave the keynote speech on his research. The symposium was a great success thanks to the enthusiastic medical students who presented posters and gave oral presentations on their research. First prize for an oral presentation was awarded to Georgiana Samoila for her work on Histological Diagnosis of Lung and Pleural Malignancies, while Lisa Roberts and Jason Chai were awarded runner-ups. The award for best poster was given to Thomas Lemon. Two further awards sponsored by Meducation, assessed by Peter Winter, were given to George Kimpton and Ryan Preece for their poster presentations. There was also a Meducation stall and the Cardiff University Research Society greatly appreciates the support. To get in touch with the CUReS, please email cures@cardiff.ac.uk or visit our website at www.cu-res.co.uk for more information. Written by Robert Lundin  
Nicole Chalmers
over 7 years ago
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Dealing with Personal Illness in Med School

Hey guys! I’m Nicole and I’m a second year medical student at Glasgow University. I’ve decided to start this blog to write about my experiences as a med student and the difficulties I encounter along the way, hopefully giving you something you can relate to. Since June of last year I have been suffering with a personal illness, with symptoms of persistent nausea, gastric pain and lethargy. At first I thought it was just a bug that would pass on fairly quickly, but as the summer months went on it was clear that this illness wasn’t going to disappear overnight. I spent my summer going through a copious amount of medications in hope that I’d feel better for term starting. I visited my GP several times and had bloods taken regularly. After 2 months, I finally got given a diagnosis; I had a helicobacter pylori infection. I started eradication therapy for a week and although it made my symptoms worse, I was positive would make me better and I’d be well again within the week. The week passed with no improvements in my condition. Frustrated, I went back to my GP who referred me for an endoscopy. Term started back the next week and despite feeling miserable I managed to drag myself out to every lecture, tutorial and lab. Within a few weeks I began to fall behind in my work, doing the bare minimum required to get through. Getting up each morning was a struggle and forcing myself to sit in lectures despite the severe nausea I was experiencing was becoming a bigger challenge each day. In October I went for my endoscopy which, for those of you that don't know, is a horribly uncomfortable procedure. My family and friends assured me that this would be the final stage and I’d be better very very soon. The results came back and my GP gave me a different PPI in hope that it would fix everything. I waited a few weeks and struggled through uni constantly hoping that everything would magically get better. I gave up almost all my extra-circular activities which for me, the extrovert I am, was possibly the hardest part of it all. I wanted to stay in bed all the time and I become more miserable every day. I was stressing about falling behind in uni and tensions began to build up in my personal life. It got to the point where I couldn’t eat a meal without it coming back up causing me to lose a substantial amount of weight. I got so stressed that I had to leave an exam to throw up. I was truly miserable. I seen a consultant just before Christmas who scheduled me in for some scans, but it wasn’t until January. I was frustrated at how long this was going on for and I thought it was about time I told the medical school about my situation. They were very understanding and I was slightly surprised at just how supportive they were. I contacted my head of year who arranged a visit with me for January. During the Christmas break I had a chance to relax and forget about everything that was stressing me. I got put on a stronger anti-sickness medication which, surprisingly, seemed to work. The tensions in my life that had built up in the last few months seemed to resolve themselves and I began to feel a lot more positive! I met with my head of year just last week who was encouraged by my newly found positive behaviour. We’ve agreed to see how things progress over the next few months, but things are looking a lot brighter than before. I’ve taken on a new attitude and I’m determined to work my hardest to get through this year. I’m currently undertaking an SSC so I have lots of free time to catch up on work I missed during the last term. My head of year has assured me that situations like the one I’m in happen all the time and I’m definitely not alone. I feel better knowing that the medical school are behind me and are willing to help and support me through this time. The most important thing I have taken from this experience is the fact that you’ll never know the full extent of what a patient is going through. Illness effects different people in different ways and it may not just be a persons health thats affected, it can affect all aspects of their life. This experience has definitely opened my eyes up and hopefully I’ll be able to understand patients’ situations a little better.  
Nicole Mooney
about 7 years ago
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174

Is ADHD a difficult diagnosis?

In a recent article in the BMJ the author wonders about the reasons beyond the rising trend diagnosing Attention Deficit Hyperactivity Disorder (ADHD). The article attempts to infer reasons for this. One possible reason was that the diagnostic criteria especially DSM may seem for some to be more inclusive than ICD-10. The speculation may explain the rise of the diagnosis where DSM is used officially or have an influence. In a rather constructive way, an alternative to rushing to diagnosis is offered and discussed in some details. The tentative deduction that the Diagnostic Statistical Manual (DSM) may be one of the causes of rising diagnosis, due to raising the cut-off of age, and widening the inclusion criteria, as opposed to International Classification of Diseases, 10th revision (ICD-10), captured my attention. On reading the ICD-10 diagnostic criteria for research (DCR) and DSM-5 diagnostic criteria, I found them quite similar in most aspects, even the phraseology that starts with 'Often' in many diagnostic criteria, they seem to differ a bit in age. In a way both classification, are attempting to describe the disorder, however, it sounds as if someone is trying to explain a person's behaviour to you, however, this is not a substitute to direct clinical learning, and observing the behaviour, as if the missing sentence is 'when you see the person, it will be clearer'. El-Islam agrees with the notion that DSM-5 seems to be a bit more inclusive than ICD-10. A colleague of mine who is a child psychiatrist and she is doing her MSc. thesis in ADHD told me, that DSM-5 seems to be a substantial improvement as compared to its predecessor. The criteria - to her - though apparently are more inclusive, they are more descriptive with many examples, and she infers that this will payback in the reliability of the diagnosis. She hopes gene research can yield in biological tests for implicated genes and neurotransmitters in ADHD e.g. DRD4, DAT, gene 5,6,11 etc. One child psychiatrist, regretted the fact that misdiagnosis and under-diagnoses, deprive the patient from one of the most effective treatments in psychiatry. It is hoped the nearest forthcoming diagnostic classification (ICD-11), will address the issue of the diagnosis from a different perspective, or else converge with DSM-5 to provide coherence and a generalised newer standard of practice. The grading of ADHD into mild, moderate, and severe seem to blur the border between disorder and non-disorder, however, this quasi-dimensional approach seems realistic, it does not translate yet directly in differences in treatment approaches as with the case of mild, moderate, severe, and severe depression with psychotic symptoms, or intellectual disability. The author states that one counter argument could be that child psychiatrists are better at diagnosing the disorder. I wonder if this is a reflection of a rising trend of a disorder. If ADHD is compared to catatonia, it is generally agreed that catatonia is less diagnosed now, may be the epidemiology of ADHD is not artefact, and that we may need to look beyond the diagnosis to learn for example from environmental factors. Another issue is that there seems to be significant epidemiological differences in the rates of diagnosis across cultures. This may give rise to whether ADHD can be classified as a culture-bound syndrome, or whether it is influenced by culture like anorexia nervosa, or it may be just because of the raising awareness to such disorders. Historically, it is difficult to attempt to pinpoint what would be the closest predecessor to ADHD. For schizophrenia and mania, older terms may have included insanity, for depression it was probably melancholia, there are other terms that still reside in contemporary culture e.g. hypochondriasis, hysteria, paranoia etc. Though, it would be too simplistic to believe that what is meant by these terms was exactly what ancient cultures meant by them, but, they are not too far. ADHD seems to lack such historical underpinning. Crichton described a disorder he refers to as 'mental restlessness'. Still who is most often credited with the first description of ADHD, in his 1902 address to the Royal College of Physicians. Still describes a number of patients with problems in self-regulation or, as he then termed it, 'moral control' (De Zeeuw et al, 2011). The costs and the risks related to over-diagnosis, ring a warning bell, to enhance scrutiny in the diagnosis, due to subsequent stigma, costs, and lowered societal expectations. They all seem to stem from the consequences of the methodology of diagnosis. The article touches in an important part in the psychiatric diagnosis, and classifications, which is the subjective nature of disorders. The enormous effort done in DSM-5 & ICD-10 reflect the best available evidence, but in order to eliminate the subjective nature of illness, a biological test seems to be the only definitive answer, to ADHD in particular and psychiatry in general. Given that ADHD is an illness and that it is a homogeneous thing; developments in gene studies would seem to hold the key to understanding our current status of diagnosis. The suggested approach for using psychosocial interventions and then administering treatment after making sure that it is a must, seems quite reasonable. El-Islam, agrees that in ADHD caution prior to giving treatment is a recommended course of action. Another consultant child psychiatrist mentioned that one hour might not be enough to reach a comfortable diagnosis of ADHD. It may take up to 90 minutes, to become confident in a clinical diagnosis, in addition to commonly used rating scales. Though on the other hand, families and carers may hypothetically raise the issue of time urgency due to scholastic pressure. In a discussion with Dr Hend Badawy, a colleague child psychiatrist; she stated the following with regards to her own experience, and her opinion about the article. The following is written with her consent. 'ADHD is a clinically based diagnosis that has three core symptoms, inattention, hyperactivity and impulsivity in - at least - two settings. The risk of over-diagnosis in ADHD is one of the potentially problematic, however, the risk of over-diagnosis is not confined to ADHD, it can be present in other psychiatric diagnoses, as they rely on subjective experience of the patient and doctor's interviewing skills. In ADHD in particular the risk of under-diagnosis is even more problematic. An undiagnosed child who has ADHD may suffer various complications as moral stigma of 'lack of conduct' due to impuslivity and hyperactivity, poor scholastic achievement, potential alienation, ostracization and even exclusion by peer due to perceived 'difference', consequent feelings of low self esteem and potential revengeful attitude on the side of the child. An end result, would be development of substance use disorders, or involvement in dissocial behaviours. The answer to the problem of over-diagnosis/under-diagnosis can be helped by an initial step of raising public awareness of people about ADHD, including campaigns to families, carers, teachers and general practitioners. These campaigns would help people identify children with possible ADHD. The only risk is that child psychiatrists may be met with children who their parents believe they might have the disorder while they do not. In a way, raising awareness can serve as a sensitive laboratory investigation. The next step is that the child psychiatrist should scrutinise children carefully. The risk of over-diagnosis can be limited via routine using of checklists, to make sure that the practice is standardised and that every child was diagnosed properly according to the diagnostic criteria. The use of proper scales as Strengths and Difficulties Questionnaire (SDQ) in its two forms (for parents SDQ-P and for teachers SDQ-T) which enables the assessor to learn about the behaviour of the child in two different settings. Conner's scale can help give better understanding of the magnitude of the problem. Though some people may voice criticism as they are mainly filled out by parents and teachers, they are the best tools available at hands. Training on diagnosis, regular auditing and restricting doctors to a standard practice of ensuring that the child and carer have been interviewed thoroughly can help minimise the risk of over-diagnosis. The issue does not stop by diagnosis, follow-up can give a clue whether the child is improving on the management plan or not. The effects and side effects of treatments as methylphenidate should be monitored regularly, including regular measurement height and weight, paying attention to nausea, poor appetite, and even the rare side effects which are usually missed. More restrictions and supervision on the medication may have an indirect effect on enhancing the diagnostic assessment. To summarise, the public advocacy does not increase the risk of over-diagnosis, as asking about suicidal ideas does not increase its risk. The awareness may help people learn more and empower them and will lead to more acceptance of the diagnosed child in the community. Even the potential risk of having more case loads for doctors to assess for ADHD may help give more exposure of cases, and reaching more meaningful epidemiological finding. From my experience, it is quite unlikely to have marked over-representation of children who the families suspect ADHD without sufficient evidence. ADHD remains a clinical diagnosis, and it is unlikely that it will be replaced by a biological marker or an imaging test in the near future. After all, even if there will be objective diagnostic tests, without clinical diagnostic interviewing their value will be doubtful. It is ironic that the two most effective treatments in psychiatry methylphenidate and Electroconvulsive Therapy (ECT) are the two most controversial treatments. May be because both were used prior to having a full understanding of their mechanism of action, may be because, on the outset both seem unusual, electricity through the head, and a stimulant for hyperactive children. Authored by E. Sidhom, H. Badawy DISCLAIMER The original post is on The BMJ doc2doc website at http://doc2doc.bmj.com/blogs/clinicalblog/#plckblogpage=BlogPost&plckpostid=Blog%3A15d27772-5908-4452-9411-8eef67833d66Post%3Acb6e5828-8280-4989-9128-d41789ed76ee BMJ Article: (http://www.bmj.com/content/347/bmj.f6172). Bibliography Badawy, H., personal communication, 2013 El-Islam, M.F., personal communication, 2013 Thomas R, Mitchell GK, B.L., Attention-deficit/hyperactivity disorder: are we helping or harming?, British Medical Journal, 2013, Vol. 5(347) De Zeeuw P., Mandl R.C.W., Hulshoff-Pol H.E., et al., Decreased frontostriatal microstructural organization in ADHD. Human Brain Mapping. DOI: 10.1002/hbm.21335, 2011) Diagnostic Statistical Manual 5, American Psychiatric Association, 2013 Diagnostic Statistical Manual-IV, American Psychiatric Association, 1994 International Classification of Diseases, World Health Organization, 1992  
Dr Emad Sidhom
about 7 years ago
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227

Male Postnatal Depression - a sign of equality or a load of nonsense?

Storylines on popular TV dramas are a great way of raising the public's awareness of a disease. They're almost as effective as a celebrity contracting an illness. For example, when Wiggles member Greg Page quit the group because of postural orthostatic tachycardia syndrome, I had a spate of patients, mostly young and female, coming in with self-diagnosed "Wiggles Disease". A 30% increase in the number of mammograms in the under-40s was attributed to Kylie Minogue's breast cancer diagnosis. The list goes on. Thanks to a storyline on the TV drama Desperate Housewives, I received questions about male postnatal depression from local housewives desperate for information: "Does it really exist?" "I thought postnatal depression was to do with hormones, so how can males get it?" "First it's male menopause, now it's male postnatal depression. Why can't they keep their grubby mitts off our conditions?" "It's like that politically correct crap about a 'couple' being pregnant. 'We' weren't pregnant, 'I' was. His contribution was five seconds of ecstasy and I was landed with nine months of morning sickness, tiredness, stretch marks and sore boobs!" One of my patients, a retired hospital matron now in her 90s, had quite a few words to say on the subject. "Male postnatal depression -- what rot! The women's liberation movement started insisting on equality and now the men are getting their revenge. You know, dear, it all began going downhill for women when they started letting fathers into the labour wards. How can a man look at his wife in the same way if he has seen a blood-and-muck-covered baby come out of her … you know? Men don't really want to be there. They just think they should -- it's a modern expectation. Poor things have no real choice." Before I had the chance to express my paucity of empathy she continued to pontificate. "Modern women just don't understand men. They are going about it the wrong way. Take young couples who live with each other out of wedlock and share all kind of intimacies. I'm not talking about sex; no, things more intimate than that, like bathroom activities, make-up removal, shaving, and so on." Her voice dropped to a horrified whisper. "And I'm told that some young women don't even shut the door when they're toileting. No wonder they can't get their de facto boyfriends to marry them. Foolish girls. Men need some mystery. Even when you're married, toileting should definitely be kept private." I have mixed feelings about male postnatal depression. I have no doubt that males can develop depression after the arrival of a newborn into the household; however, labelling it "postnatal depression" doesn't sit all that comfortably with me. I'm all for equality, but the simple fact of the matter is that males and females are biologically different, especially in the reproductive arena, and no amount of political correctness or male sharing-and-caring can alter that. Depressed fathers need to be identified, supported and treated, that goes without saying, but how about we leave the "postnatal" tag to the ladies? As one of my female patients said: "We are the ones who go through the 'natal'. When the boys start giving birth, then they can be prenatal, postnatal or any kind of natal they want!" (This blog post has been adapted from a column first published in Australian Doctor http://bit.ly/1aKdvMM)  
Dr Genevieve Yates
about 7 years ago
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Grand Round: Dos and Don’ts

“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” The words of Sir William Osler, the acclaimed father of modern medicine, are still no less profound. They hark from an age when medicine still retained a sense of ceremony: an amphitheatre filled to the rafters, the clinicians poised in their white coats and ties, all eyes convergent on their quarry or rather the patient seated before them. Any memory of such scenes live out a vestigial existence in black&white photos or histrionic depictions recalling the rise of modern medicine. To think this is how the tradition of grand rounds proceeded in the not so distant past. Today grand rounds have a more tuitional flavour to them. The Socratic dialogue which reportedly took place has been superseded by the much less appetising PowerPoint presentation. It’s a weekly event marked in the calendar. For the ever-busy junior doctor it at least offers the prospect of a free lunch. I gest, they serve a social as well as an educational function. On the other hand medical student grand rounds are purely a learning exercise. They are most importantly not a race to find and present the most ‘interesting’ case in the trust because this is usually interpretted as a vanishingly rare condition, which even your ejudicating consultant has never encountered in a lifetime of experience. It falls short of the primary aim: to learn about the patients who you will be seeing as a junior doctor and as the addage goes - common things are common. What will make your grand round interesting, is not the patient you choose but how you choose to present that patient. Unfortunately, as fair a point Sir Osler makes, the old practice of patient participation in grand rounds has long since faded. You will have to call upon your thespian talents to retell the story to your fellow students. Of course not everyone’s a natural showman, however fortune favours the prepared and in my experience there are only a handful of things to worry about. Structure. This is the back bone of your presentation. Obviously a solid introductory line about the patient with all the salient points goes without saying, it’s no different to presenting to the consultant on ward rounds or in the clinic. Always set the scene. If you clerked your patient on a hectic night oncall down in majors, then say so. It makes the case less one dimensional. The history is your chance to show off - to consider the presenting complaint expressed in the patient’s own words and to form a working differential, which you can encourage your colleagues to reel off at the outset. The quality of the history should guide your audience to the right diagnosis. Equip them with all the information they need, so not just the positive findings. Showing that you have ruled out important red flag symptoms or signs will illustrate good detective work on your part. However you wish to order the relevant past medical/family history, medications, social impact etc is up to you. It’s a subjective thing, you just have to play the game and cater to the consultant’s likes. You can only gage these after a few cases so do the honourable thing and let your colleagues present first. Performance. Never read your slides in front of an audience. Their attention will rapidly wane (especially if they’re postprandial). The slides are an aide-memoire and to treat them as a script is to admit your presence adds nothing more to your presentation. Communicating with the audience requires you to present uncluttered slides, expanding on short headings and obliging your colleagues to listen for the little nuggets of clinical knowledge you have so generously lain in store. Insight. When the consultant asks you the significance of an investigation, always know on what grounds it was ordered and the limitations of the results. The astute student will be aware of its diagnostic or prognostic potential.The same may be said of imaging. Perusing the radiologists report and using it to guide the audience through (anoynmised) CXRs, CTs, US etc is a feather in your cap. Literature reviews of your choosing constitute a mandatory part of the presentation. They are demonstrative of not only your wider reading but your initiative to find the relevant evidence base e.g. the research underlying the management plan of a condition or perhaps its future treatments. Timing. Waffling is only detrimental to the performance. Rehearsing the presentation with a firm mate is a sure way to keep to time constraints. Memorability, for the right reasons, relies on a concise and interactive presentation. A splash of imagination will not go unnoticed. The consultant marking you has seen it all before; surprising titbits of knowledge or amusing quirks in your presentation will hopefully appeal to their curious and humorous side. If anything it might break the tedium grand rounds are renown for. Oratory is a universal skill and is responsible for so much (undue) anxiety. The more timid can take comfort grand rounds aren’t quite the grand occasions they used to be. Illustrator Edward Wong This blog post is a reproduction of an article published in the Medical Student Newspaper, December 2013 issue.  
James Wong
about 7 years ago
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138

A Modest Man

The registrar's face was taking on a testy look. So enduring was the silence our furtive glances had developed a nystagmic quality. “Galactosaemia” came her peremptory reply. Right on queue the disjointed chorus of ahs and head nods did little to hide our mental whiteboard of differentials being wiped clean. At the time conjugated bilirubinaemia in children only meant one thing: biliary atresia. A fair assumption; we were sitting in one of three specialist centres in the country equipped to treat these patients. Ironically the condition has become the unwieldy yardstick I now measure the incidence of paediatric disease. Biliary atresia is the most common surgical cause of neonatal jaundice with a reported incidence of 1 in 14-16ooo live births in the West. It is described as a progressive inflammatory obliteration of the extrahapatic bile duct. And Dr Charles West, the founder of Great Ormond Street Hospital, offers an eloquent description of the presenting triad of prolonged jaundice, pale acholic stools and dark yellow urine: ‘Case 18...It was born at full term, though small, apparently healthy. At 3 days however, it began to get yellow and at the end of 3 weeks was very yellow. Her motions at no time after the second day appeared natural on examination, but were white, like cream, and her urine was very high coloured.’ 1855 was the year of Dr West's hospital note. An almost universally fatal diagnosis and it would remain so for the next 100 years. The time's primordial classification of biliary atresia afforded children with the 'noncorrectable' type, a complete absence of patent extrahepatic bile duct, an unfortunate label; they were beyond saving. Having discovered the extent of disease at laparatomy, the surgeons would normally close the wound. The venerable Harvardian surgeon, Robert E. Gross saved an enigmatic observation: “In most instances death followed a downhill course…” K-A-S-A-I read the ward’s board. It was scrawled under half the children's names. I dismissed it as just another devilishly hard acronym to forget. The thought of an eponymous procedure had escaped me and in biliary atresia circles, it's the name everyone should know: Dr Morio Kasai. Originating from Aomori prefecture, Honshu, Japan, Dr Kasai graduated from the National Tohoku University School of Medicine in 1947. His ascension was rapid, having joined the 2nd department of Surgery as a general surgeon, he would assume the role of Assistant Professor in 1953. The department, under the tenure of Professor Shigetsugu Katsura, shared a healthy interest in research. 1955 was the landmark year. Katsura and Kasai operated on their first case: a 72 day old infant. Due to bleeding at the incised porta hepatis, Katsura is said to have 'placed' the duodenum over the site in order to staunch the flow. She made a spectacular postoperative recovery, the jaundice had faded and there was bile pigment in her stool. During the second case, Katsura elected to join the unopened duodenum to the porta hepatis. Sadly the patient's jaundice did not recover, but the post-mortem conducted by Kasai confirmed the development of a spontaneous internal biliary fistula connecting the internal hepatic ducts to the duodenum. Histological inspection of removed extrahepatic duct showed the existence of microscopic biliary channels, hundreds of microns in diameter. Kasai made a pivotal assertion: the transection of the fibrous cord of the obliterated duct must contain these channels before anastomosis with the jejunal limb Roux-en-Y loop. This would ensure communication between the porta hepatis and the intrahepatic biliary system. The operation, entitled hepatic portoenterostomy, was first performed as a planned procedure for the third case at Tohoku. Bile flow was restored and Kasai published the details of the new technique in the Japanese journal Shujutsu in 1959. However, news of this development did not dawn on the West until 1968 in the Journal of Pediatric Surgery. The success of the operation and its refined iterations were eventually recognized and adopted in the 1970s. The operation was and is not without its dangers. Cholangitis, portal hypertension, malnutrition and hepatopulmonary syndrome are the cardinal complications. While diagnosing and operating early (<8 weeks) are essential to the outcome, antibiotic prophylaxis and nutritional support are invaluable prognostic factors. Post operatively, the early clearance of jaundice (within 3 months) and absence of liver cirrhosis on biopsy, are promising signs. At UK centres the survival after a successful procedure is 80%. The concurrent development of liver transplantation boosts this percentage to 90%. Among children, biliary atresia is the commonest indication for transplantation; by five years post-Kasai, 45% will have undergone the procedure. On the 6th December 2008, Dr Kasai passed away. He was 86 years old and had been battling the complications of a stroke he suffered in 1999. His contemporaries and disciples paint a humble and colourful character. A keen skier and mountaineer, Dr Kasai lead the Tohoku University mountain-climbing team to the top of the Nyainquntanglha Mountains, the highest peaks of the Tibetan highlands. It was the first successful expedition of its kind in the world. He carried through this pioneering spirit into his professional life. Paediatric surgery was not a recognized specialty in Japan. By founding and chairing multiple associations including the Japanese Society of Pediatric Surgeons, Dr Kasai gave his specialty and biliary atresia, the attention it deserved. Despite numerous accolades of international acclaim for his contributions to paediatric surgery, Dr Kasai insisted his department refer to his operation as the hepatic portoenterostomy; the rest of the world paid its originator the respect of calling it the ‘Kasia’. Upon completion of their training, he would give each of his surgeons a hand-written form of the word ‘Soshin’ [simple mind], as he believed a modest surgeon was a good one. At 5 foot 2, Kasai cut a more diminutive figure one might expect for an Emeritus Professor and Hospital Director of a university hospital. During the course of his lifetime he had developed the procedure and lived to see its fruition. The Kasia remains the gold standard treatment for biliary atresia; it has been the shinning light for what Willis J. Potts called the darkest chapter in paediatric surgery. It earned Dr Kasai an affectionate but apt name among his peers, the small giant. References Miyano T. Morio Kasai, MD, 1922–2008. Pediatr Surg Int. 2009;25(4):307–308. Garcia A V, Cowles RA, Kato T, Hardy MA. Morio Kasai: a remarkable impact beyond the Kasai procedure. J Pediatr Surg. 2012;47(5):1023–1027. Mowat AP. Biliary atresia into the 21st century: A historical perspective. Hepatology. 1996;23(6):1693–1695. Ohi R. A history of the Kasai operation: Hepatic portoenterostomy for biliary atresia. World J Surg. 1988;12(6):871–874. Ohi R. Morio Kasai, MD 1922-2008. J Pediatr Surg. 2009;44(3):481–482. Lewis N, Millar A. Biliary atresia. Surg. 2007;25(7):291–294. This blog post is a reproduction of an article published in the Medical Student Newspaper, April 2014 issue.  
James Wong
about 7 years ago
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Medical Blogging, an overview, pearl or peril

Medical blogging is blogging in the field of medicine. It is a relatively recent addition to the medical field. While its closest predecessor medical journalism; is about 300 years old, medical blogging is currently about a decade old. This blogpost aims at exploring the field of medical blogging and comparing it to related disciplines when relevant. It examines some opinions of bloggers, and reviews some medical blogs aiming to infer reasons for blogging, derive technique or outline of blog and hopefully arriving at a conclusion to the future prospects of medical blogging. Medicine is the practice of the art and science of healing 'ars medicina'. It is a branch of applied science, which started probably in the pre-historic era. The practice continued to flourish, specialise, sub-specialise and sub-sub-specialise. The word blog is most probably derived from the contraction of the words 'web log' which is a form of website that is more interactive, allowing comments, tagging,and is displayed in counter-chronological order from the most recent at the top of the page. The term 'blog' is currently used as a noun as well as a verb. The aggregation of blogs is named 'blogosphere', and the blog writer is named 'blogger'. There are single author blogs and multi-author blogs, they are as diverse in there content as the diversity of the bloggers, with regards to form they can be written text, images, videos, sounds or combination of more than one medium. The term 'blogroll' is referred to blogs followed by a person. Blogging is just more than a decade old now. However, the number of blogs have been increasing exponentially at times. The concept of blogging is considered as one of the components of the concept of web 2.0. Medical blogs refer to blogs that are primarily concerned with medical/health subjects. The name 'medical blog' is derived from content based taxonomic classification. Medical blogs can be classified by author, there are blogs by physicians, nurses, patients, medical institutions, medical journals, and anonymous blogs. They can be classified by target audience as either to other doctors, patients and carers, general public or a combination of more than one target. There are also medical blogs by patients or patient blogs that expresses their viewpoints. A study examined medical student blogs and concluded that they might be beneficial for students to reflect on their experience (Pinilla et al, 2013). The Nephrology Dialysis and Transplantation (NDT) made it own blog (El Nahas, 2012). The American Journal of Kidney Disorder (AJKD) made its own official blog (Desai et al, 2013). During the same year, the American Heart Association and American Stroke Association launched their official blog (Sanossian & Merino, 2013). Pereira discussed the blogs by neurosurgeons (Pereira et al, 2012). In the BMJ doc2doc blogs, they do not have to meet certain number of word count but will have to be reviewed prior to publication. KevinMD requires blog posts to be of maximum five hundred words, Medical-Reference require a minimum of one thousand words. Meducation requires a blog post to vary between 1500-3000 word. Independent blogs may show more variation in the number of words per blog post. Some blogs are predominantly in text format, other may combine multimedia or get linked to other medical blogs. The BMJ doc2doc tentatively recommends blog posting to be in the frequency of one to two blogs/month. Chrislyn Pepper, a medical blog writer, (2013) states that medical blogging can aim to be 'three blogs of 300+ words each week and three to four short blogs of less than a hundred words five days per week.' Medical bloggers seem to have various reasons to blog, some communicate clinical data to fellow doctors, in this case some blogs seem to resemble research or review articles in content and language which can contain medical jargon. There are diagnosis blogs that were studied by Miller and Pole (2010). The comparison between the electronic predecessors of blogging including Electronic Bulletin Board, USENET, and emailing in addition to the why of blogging in general has been discussed by Mongkolwat (Mongkolwat et al, 2005). Some put their hypotheses forward, others share clinical experience or discuss a clinical matter. Some bloggers direct their attention to the general public providing information about medical topics. Some discuss issues which can be difficult to be put in research topics. Dr Rob discussed that importance of medical blogging as an equivalent to the concept of democracy in an online world. Doctor Blogger website offers 10 reasons for medical blogging including public education, correction of misconceptions and establishing a name. For the medical blogger's direct benefit Medical Rant blog offers an overview of personal benefits from medical blogging including stimulation of thought and stimulation of academic writing. Dr Wible seems to use her medical blog to promote a standard of care that seems to be a mix between the medical model and the befriending model of care. Another study examined the young adults blogging and concluded that powerlessness, loneliness, alienation, and lack of connection with others, where the primary outcomes of young adults as a result of mental health concerns (Eysenbach et al, 2012). Wolinsky (2011) enquires whether scientists should stick to popularizing science or more. Medical blogs are essentially online activity which renders them immediately accessible to any area with internet connection, they are paperless by definition which makes them more environment friendly. The medical blogs are open access by default which adds to the accessibility, and they are decentralised which decreases control over the control and seems to accentuate diversity. As compared to peer reviewed journals, medical blogs seem to be less referenced, are hardly ever taken as academic writing, the process of peer reviewed medical blogs is minimal if any, and they do not get reflected on resume or be considered as publication, though the term 'blogfolio' started to become a watch word. It seems hard to base clinical decisions on medical blogs. However, medical blogs can offer more diversity into research and non-research medical topics. They are published online with no delay or review time, they can comment on the most recent advances in the medical field or most contemporary issues instantaneously. Very recently, citing blogs seems to become a bit accepted. BMJ Journals have their dedicated blogs Some online resources give a comprehensive outline on blogging in general and medical blogging in particular including video interview with a medical blogger Michelle Guilemard in her blog makes a valid point of how medical blogging can enhance career. Medical Squid also highlighted medical blogging as a career Kovic et al (2008) conducted a research on the medical blogosphere an concluded that 'Medical bloggers are highly educated and devoted blog writers, faithful to their sources and readers'. Miller & Pole (2010) concluded that 'Blogs are an integral part of this next stage in the development '. Stanwell-Smith (2013) discussed the aspect as an important tool to communicate with patients. The blur between academia and blogging was discussed in research blogs. (Sheema et al, 2012). During the same another study discussed the impact of blogging on research (Fausto et al, 2012). While Baerlocher & Detsky (2008) warn in an article against the hazards of medical blogging due to potential breach of confidentiality. After an exhaustive study of the content of weblog written by health professional, Lagu reached the concern of breaching of confidentiality (Lagu et al, 2007). Rebecca Golden (2007) cites the perils of medical blogging she concludes her article saying 'Science has a peer-review process for a reason'. Brendan Koerner (2007) in wired magazines posted an article about the problems of giving medical advice via blogging. Dr Val Jones makes a point by concluding that social media provide the 'allure of influence'. Thomas Robey (2008) offers arguments for and against medical blogging, including confidentiality, and ruining personal reputation on the negative side, while enhancing democratization of conversation and having a creative outlet on the positive side. Brendel offers an intriguing discussion to whether it would be ethical or not to monitor patients' blog to determine their health status. (Brendel, 2012). O'Reilly voiced in 2007 the need for blogging code of conduct. The GMC published guidance on the use of social media by doctors and it included blogging as a form of social media. The Royal College of General Practitioners also published the social media high way code to offer guidance on social media including medical blogging. There is also the medblog oath online. Flaherty (2013) argues that blogging is under attack by micro-blogging, and that it is in its deathbed. Mike Myatt in his article Is Blogging Dead, discusses various views about blogging in an era of micro-blogging The Royal College of Psychiatrists recently introduced a number of blogs including the president's blog, overseas blogs and other blogs. The medical blogging seems to occupy a middle space between the quick micro-blogging and the thoughtful research article. Its diversity and freedom are its strongest tools and can have the potential to be its worst enemies. One wonders whether the emergence of guidelines for medical blogging – given the seriousness of the content – would save medical blogging and elevate it to the next level or change the essence of it. After all, the question is how much the medical field which is a top-down hierarchy accept grass-root movement. Freedom of expression is probably at the heart of blogging. It would be logistically impossible to impose rules on it. However, guidelines and code of honour may help delineating the quality of medical blogs from each other. This post is previously posted on doc2doc blogs. Bibliography & Blogiography Brendel, D. Monitoring Blogs: A New Dilemma for Psychiatrists Journal of Ethics, American Medical Association, 2012, Vol. 14(6), pp. 441-444 Desai, T., S.M.A.N.V.S.K.T.J.K.C.K.B.E.J.K.D. The State of the Blog: The First Year of eAJKD Am J Kidney Dis., 2013, Vol. 61(1), pp. 1-2 El Nahas, M. An NDT blog Nephrol Dial Transplant (2012) 27: 3377–3378, 2012, Vol. 27, pp. 3377-3378 Eysenbach, G., B.K.M.M. What Are Young Adults Saying About Mental Health? An Analysis of Internet Blogs Journal of Medical Internet Research, 2012, Vol. 14(1) Fausto, S. Machado, F.B.L.I.A.N.T.M.D. Research Blogging: Indexing and Registering the Change in Science 2.0 PLoS one, 2012, Vol. 7(12), pp. 1-10 Lagu, T, K.E.J.D.A.A.A.K. Content of Weblogs Written by Health Professionals J Gen Intern Med, 2008, Vol. 23(10), pp. 1642–6 Miller, EA., P.A. Diagnosis Blog: Checking Up on Health Blogs in the Blogosphere American Journal of Public Health, 2010, Vol. 8, pp. 1514-1518 Mongkolwat, P. Kogan, A.K.J.C.D. Blogging Your PACS Journal of Digital Imaging, 2005, Vol. 18(4), pp. 326-332 Pereira, JLB., K.P. d.A.L. d.C.G. d.S.A. Blogs for neurosurgeons Surgical Neurology International, 2012, Vol. 3:62 Pinilla, S. Weckbach, L.A.S.B.H.N.D.S.K.T.S. Blogging Medical Students: A Qualitative Analysis  
Dr Emad Sidhom
almost 7 years ago
Foo20151013 2023 e7fpn8?1444774293
3
372

The Importance Of Clinical Skills

In the USA the issue of indiscriminate use of expensive, sophisticated, and time consuming test in lieu of, rather than in addition to, the clinical exam is being much discussed. The cause of this problem is of course multifactorial. One of the factors is the decline of the teaching of clinical skills to our medical students and trainees. Such problems seem to have taken hold in developing countries as well. Two personal anecdotes will illustrate this. In the early nineties I worked for two years as a faculty member in the department of ob & gyn at the Aga Khan University Medical School in Karachi, Pakistan. One day, I received a call from the resident in the emergency room about a woman who had come in because of some abdominal pain and vaginal bleeding. While the resident told me these two symptoms her next sentence was: “… and the pelvic ultrasound showed…” I stopped her right in her tracks before she could tell me the result of the ultrasound scan. I told her: “First tell me more about this patient. Does she look ill? Is she bleeding heavily? Is she in a lot of pain and where is the pain? What are her blood pressure and pulse rate? How long has she been having these symptoms? When was her last menstrual period? What are your findings when you examined her ? What is the result of the pregnancy test?”. The resident could not answer most of these basic clinical questions and findings. She had proceeded straight to a test which might or might not have been necessary or even indicated and she was not using her clinical skills or judgment. In another example, the resident, also in Karachi, called me to the emergency room about a patient with a ruptured ectopic pregnancy. He told me that the patient was pale, and obviously bleeding inside her abdomen and on the verge of going into shock. The resident had accurately made the diagnosis, based on the patient’s history, examination, and a few basic laboratory tests. But when I ran down to see the patient, he was wheeling the patient into the radiology department for an ultrasound. "Why an ultrasound?" I asked. “You already have made the correct diagnosis and she needs an urgent operation not another diagnostic procedure that will take up precious time before we can stop the internal bleeding.” Instead of having the needless ultrasound, the patient was wheeled into the operating room. What I am trying to emphasize is that advances in technology are great but they need to be used judiciously and young medical students and trainees need to be taught to use their clinical skills first and then apply new technologies, if needed, to help them to come to the right diagnosis and treatment. And of course we, practicing physicians need to set the example. Or am I old fashioned and not with it? Medico legal and other issues may come to play here and I am fully aware of these. However the basic issue of clinical exam is still important. Those wanting to read more similar stories can download a free e book from Smashwords. The title is: "CROSSCULTURAL DOCTORING. ON AND OFF THE BEATEN PATH." You can access the e book here.  
DR William LeMaire
almost 7 years ago
Foo20151013 2023 1crpsox?1444774314
5
498

Neuropsychiatry's Fuzzy Borderlands

In NeuroPsychiatry it might be difficult to locate its territory, and find its niche. This might be an uneasy endeavour as its two parent branches neurology and psychiatry are still viable, also it siblings organic psychiatry, behavioural neurology and biological psychiatry are also present. This blogpost attempts to search for the definition and domains of neuropsychiatry. Neuropsychiatry can be defined as the 'biologic face' of mental health (Royal Melbourne Hospital, Neuropsychiatry unit). It is the neurological aspects of psychiatry and the psychiatric aspects of neurology (Pacific Neurpsychiatry Institute). It is not a new term. Many physicians used to brand themselves as neuropsychiatrists at the rise of the twentieth century. It has been looked upon with a sense of unease as a hybrid branch. Also, it was subject to pejorative connotations, as the provenance of amateurs in both parent disciplines (Lishman, 1987). The foundational claim is that 'all' mental disorders are disorders of the brain' (Berrios and Marková, 2002). The American NeuroPsychiatric Association (ANPA) defines it as 'the integrated study of psychiatric and neurologic disorders' (ANPA, 2013). The overlap between neuropsychiatry and biological psychiatry was observed (Trimble and George, 2010) as the domain of enquiry of the first and the approach of the second will meet at point. Berrios and Marková seemed to have focused on the degree of conversion among biological psychiatry, organic psychiatry, neuropsychiatry and behavioural neurology. They stated that they share the same foundational claims (FCcs): (1) mental disorder is a disorder of the brain; (2) reasons are not good enough as causes of mental disorder; and (3) biological psychiatry and its congeners have the patrimony of scientific truth. They further elaborated that the difference is primarily due to difference in historic origins. (D'haenen et al., 2002). The American Neuropsychiatric Association (ANPA) defines neuropsychiatry as the integrative study of neurological and psychiatric disorders on a clinical level, on a theoretical level; ANPA defines it as the bridge between neuroscience and clinical practice. The interrelation between both specialities is adopted by The Royal Australia and New Zealand College of Psychiatrists as it defines it as a psychiatric subspeciality. This seems to resonate the concept that 'biologisation' of psychiatry is inevitable (Sachdev and Mohan, 2013). The definition according to Gale Encyclopedia encompasses the interface between the two disciplines (Fundukian and Wilson, 2008). In order to acknowledge the wide use of the term 'neuropsychiatry'; the fourth edition of Lishman's Organic Psychiatry, appeared and it was renamed as 'textbook of neuropsychiatry'. The editor stated that the term is not used in its more restrictive sense (David, 2009). Ostow backtracked the origin of biological causes for illness to humoral view of temperament.In the nineteenth century, the differentiation between both did not seem to be apparent. The schism seems to have emerged in the twentieth century. The difficulties that arose with such early adoption of neuronal basis to psychiatric disorders are that they were based on on unsubstantiated beliefs and wild logic rather than scientific substance. (Panksepp, 2004). Folstein stated that Freud and Charcot postulated psychological and social roots for abnormal behaviours, thus differentiating neurology from psychiatry. (David, 2009). The separation may have lead to alienation of doctors on both camps and helped in creating an arbitary division in their scope of knowledge and skills. The re-emergence of interest in neurospsychiatry has been described to be due to the growing sense of discomfort in the lack of acknowledgment of brain disorders when considering psychiatric symptoms (Arciniegas and Beresford, 2001). There is considerable blurring regarding defining the territory and the boundaries of neuropsychiatry. The Royal College of Psychiatrists founded section of Neuropsychiatry in 2008. The major working groups include epilepsy, sleep disorders, brain injury and complex neurodisability. In 1987 the British NeuroPsychiatry Association was established, to address the professional need for distinction, without adopting the concept of formal affiliation with parent disciplinary bodies as the Royal College of Psychiatrists. The ANPA was founded in 1988. It issued training guide for residents. The guide included neurological and psychiatric assessments, interpretation of EEG and brain imaging techniques. With regards to the territory, it included delirium, dementia, psychosis, mood and anxiety disorders due to general medical condition. Neurpsychiatric aspects of psychopharmacologic treatments, epilepsy, neuropsychiatric aspects of traumatic brain injury and stroke. The diagnosis of movement disorders, neurobehavioural disorders, demyelinating disease, intellectual and developmental disorders, as well as sleep disorders was also included. The World Federation of Societies of Biological Psychiatry (WFSBP) was established in Buenos Aires in 1974 to address the rising significance of biological psychiatry and to join local national societies together. The National Institute of Mental Health (NIMH), is currently working on a biologically-based diagnosis, that incorporates neural circuits, cells, molecules to behavioural changes. The diagnostic system - named 'Research Domain Criteria (RDoC) - is agnostic to current classification systems DSM-5 & ICD-10. Especially that the current diagnostic classficiations are mostly based on descriptive rather than neurobiological aetiological basis. (Insel et al., 2010). For example, the ICD-10 F-Code designates the first block to Organic illness, however, it seems to stop short of localisation of the cause of illness apart from the common prefix organic. It also addresses adverse drug events as tardive dyskinesia but stops short of describing it neural correlates. Also, psychosocial roots of mental illness seem to be apparent in aetiologically-based diagnoses as Post-Traumatic Stress Disorder, acute stress reaction, and adjustment disorders, the diagnostic cluster emphasise the necessity of having 'stress'. Other diagnoses seem to draw from the psychodynamic literature, e.g. conversion[dissociative] disorder. The need for neuropsychiatry, has been increasing as the advances in diagnostic imaging and laboratory investigations became more clinically relevant. Nowadays, there are tests as DaT-Scan that can tell the difference between neurocognitive disorder with Lewy Bodies and Parkinson's Disease. Vascular neurocognitive disorders warrant imaging as the rule rather than the exception, vascular depression has been addressed is a separate entity. Frontal Lobe Syndromes have been subdivided into orbitofrontal and dorsolateral (Moore,2008) Much training is needed to address this subspeciality. The early cases that may have stirred up the neurological roots of psychiatric disorders can be backdated to the case of Phineas Gage, and later, the case H.M. The eearlier fruits of adopting a neuropsychiatric perspective can be shown in the writings of Eliot Slater, as he attempted to search for the scientific underpinnings of psychiatry, and helped via seminal articles to highlight the organic aspect of psychiatry. Articles like 'The diagnosis of "Hysteria", where Slater, challenged the common wisdom of concepts like hysteria and conversion, rejecting the social roots of mental illness, and presenting a very strong case for the possibility of organicity, and actual cases of for which 'hysteria' was a plain misdiagnosis was way ahead of its time prior to CT Brain. Slater even challenged the mere existence of the concept of 'hysteria. (Slater, 1965) Within the same decade Alwyn Lishman published his textbook 'Organic Psychiatry' addressing the organic aspects of psychiatric disorders. Around the same time, the pioneers of social/psychological roots of mental illness became under attack. Hans Eysenck, published his book 'Decline and Fall of the Freudian Empire'. Eysenck stated clearly that the case of Anna O. seems to have been mispresented and that she never had 'hysteria' and recovered she actually had 'tuberculous meningitis' and she died of its complications (Eysenck, 1986). To summarise, it seems difficult and may be futile to sharply delineate neurpsychiatry, biological psychiatry, organic psychiatry and behavioural neurology. However, it seems important to learn about the biological psychiatry as an approach and practice neuropsychiatry as a subspeciality. The territory is yet unclear from gross organic lesions as stroke to the potential of encompassing entire psychiatry as the arbitary distinction between 'functional' and 'organic' fades away. Perhaps practice will help to shape the domain of the speciality, and imaging will guide it. To date, the number of post-graduate studies are still low in comparison to the need for such speciality, much more board certification may be needed as well as the currently emerging masters and doctoral degrees. This post is previously posted on bmj doc2doc blogs Bibliography Eysenck, H.J., Decline and Fall of the Freudian Empire, Pelican Series, 1986 German E Berrios, I.S.M., The concept of neuropsychiatry: A historical overview, Journal of Psychosomatic Research, 2002, Vol. 53, pp. 629-638 Kieran O’Driscoll, J.P.L., “No longer Gage”: an iron bar through the head, British Medical Journal, 1998, Vol. 317, pp. 1637-1638 Perminder S. Sachdev, A.M., Neuropsychiatry: Where Are We And Where Do We Go From Here?, Mens Sana Monographs, 2013, Vol. 11(1), pp. 4-15 Slater, E., The Diagnosis of "Hysteria", British Medical Journal, 1965, Vol. 5447(1), pp. 1395–1399 Thomas Insel, Bruce Cuthbert, R.H.M.G.K.Q.C.S.P.W., Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders, American Journal of Psychiatry, 2010, Vol. 167:7, pp. 748-751 Organic Psychiatry, Anthony S. David, Simon Fleminger, M. D. K. S. L. J. D. M. (ed.), Wiley-Blackwell, 2009 Neuropsychiatry an introductory approach, Arciniegas & Beresford (ed.), Cambridge University Press, 2001 Biological Psychiatry, Hugo D’haenen, J.A. den Boer, P. W. (ed.), John Wiley and Sons, 2010 Gale Encyclopedia of Mental Health, Laurie J. Fundukian, J. W. (ed.), Thomson Gale, 2008 Biological Psychiatry, M. Trimble, M. G. (ed.), Wiley-Blackwell, 2010 Textbook of Neuropsychiatry, Moore, D. P. (ed.), Hodder Arnold, 2008 Textbook of Biological Psychiatry, Panksepp, J. (ed.), John Wiley and Sons, 2004 The American Neuropsychiatric Association Website www.anpaonline.org The Royal Melbourne Neuropsychiatry Unit Website http://www.neuropsychiatry.org.au/ The British Neuropsychiatry Association website www.bnpa.org.uk The Royal College of Psychiatrists website www.rcpsych.ac.uk The World Federation of Societies of Biological Psychiatry website www.wfsbp.org  
Dr Emad Sidhom
over 6 years ago
12
2
95

Diabetes

Diabetes factsheet from WHO providing key facts and information on types of diabetes, symptoms, common consequences, economic impact, diagnosis and treatment, WHO response. Updated November 2014.  
who.int
about 6 years ago
Preview
1
87

Top 10 Controversial Psychiatric Disorders

The history of psychiatry is littered with impassioned fights over controversial diagnoses.  
livescience.com
about 6 years ago
Preview
1
33

Signs and Symptoms in Family Medicine

Signs and Symptoms in Family Medicine, by Paul M. Paulman, MD et al, provides a unique evidence-based approach to diagnosis based on presenting signs. Focusing on the most common diagnoses observed in a medical practice, the book helps you "think horses, not zebras." A rating system for the sensitivity and specificity of the signs, symptoms, and diagnostic tests aids in the development of a focused and accurate differential diagnosis. This handy, take-along guide is ideal for quick reference at the bedside or a refresher while prepping for the boards. Confidently diagnose and treat common illnesses and conditions using an evidence-based, systematic approach. A unique ratings system indicates how frequently various symptoms and signs are associated with a particular diagnosis. Easily find what you need with consistently organized chapters and an at-a-glance bulleted format. "Think horses, not zebras" with a focus on the most frequently encountered diagnoses. Rule out the most serious possibilities quickly with differential diagnoses listed in descending order of severity. Review symptoms, signs, suggested work-up, and patient disposition for each diagnosis. Patients present with symptoms, not diagnoses  
books.google.co.uk
about 6 years ago
Www.bmj
0
8

Infectious mononucleosis

Infectious mononucleosis is a clinical diagnosis, caused by Epstein-Barr virus in 90% of cases, although in some patients (pregnancy, high risk HIV population) further investigations are warranted  
feeds.bmj.com
almost 6 years ago
Www.bmj
0
7

The management of acute testicular pain in children and adolescents

Although ultrasonography is useful, it should not delay surgical exploration if testicular torsion is suspected. A small but real, negative exploration rate is acceptable to minimise the risk of missing a critical surgical diagnosis  
feeds.bmj.com
almost 6 years ago