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The 76 year old patient recently reported in this journal with left
atrial diameter of 10 cm(1), has been superseded, in the record books, by
a 40 year old man with left atrial diameter of 21.5 cm attributable to
severe mitral stenosis(2). The latter patient presented with dysphagia,
hoarseness, and exertional dyspnoea.
References
(1)Shah BN., Rubens M
Giant left atrium: a forgotten cause of cardiomegaly
Postgrad Med J 2...
The 76 year old patient recently reported in this journal with left
atrial diameter of 10 cm(1), has been superseded, in the record books, by
a 40 year old man with left atrial diameter of 21.5 cm attributable to
severe mitral stenosis(2). The latter patient presented with dysphagia,
hoarseness, and exertional dyspnoea.
References
(1)Shah BN., Rubens M
Giant left atrium: a forgotten cause of cardiomegaly
Postgrad Med J 2012;88:673-4
(2) Puri A., Vijay SK., Chaudhary G et al
A rare cause of cardiomegaly
Journal of the American College of Cardiology
dx.doi.org/10.1016/j.jacc.2012.04.061
We recognise and acknowledge the issues raised by Dr Levine in his
letter (13th July 2012). Newly qualified doctors can expect to be as
prepared as their undergraduate training allows and their level of
clinical supervision facilitates. These are important additional factors
when considering preparedness of medical graduates commencing work at
foundation year 1 (F1) level. F1 doctors must be able to increase their
leve...
We recognise and acknowledge the issues raised by Dr Levine in his
letter (13th July 2012). Newly qualified doctors can expect to be as
prepared as their undergraduate training allows and their level of
clinical supervision facilitates. These are important additional factors
when considering preparedness of medical graduates commencing work at
foundation year 1 (F1) level. F1 doctors must be able to increase their
level of competence in relation to the assessment of critically ill
patients, by working in functional teams both during the day and also at
night.
NHS hospitals have traditionally relied on multiple tiers of
postgraduate doctors in-training to provide immediate patient care at
night, with consultants being non-resident but available on-call from
home. This model was and still is the subject of continuing debate.
Particular concerns were raised about the impact of working excessive
hours on the mental and physical health of newly qualified doctors and the
quality of care they provided to patients. The European Working Time
Directive (EWTD) acted as a major catalyst for changing the working
pattern of these F1 doctors and the Hospital at Night concept was rolled
out across a number of NHS trusts in response. This scheme proposes that
the way to achieve effective clinical care in the hospital at night is to
have one or more multi-professional teams working who, between them, have
the full range of skills and competences to meet patients' immediate
needs. There is now huge variation across NHS trusts with some hospitals
employing no F1 doctors at night. Provided the supervision is appropriate,
significant training opportunities exist at night, which are additional to
those experienced in the day [1] and we, like Dr Levine, have concerns
about this reduction in training opportunities at night for undergraduates
and F1 doctors. Over 90% of F1 doctors (n = 1,084) recently surveyed
reported that night shifts improved their prioritisation, decision making
and planning [1]. In conclusion, when considering preparedness of medical
students for medical practice we must consider the environment in which
they are asked to work, as well as the training they have received.
[1] London Deanery Foundation Conference 2012 - submitted for
publication. http://www.londondeanery.ac.uk/foundation-
schools/conferences/2012-foundation-programme-conference
Newly qualified doctors can expect to be as prepared as their
undergraduate training allows. For the initial management of acutely ill
patients, perhaps involving practical procedures, we have to ensure that
training and assessment of both students and doctors occur, as far as
possible, under similar conditions to those in which doctors will work. 4
days of shadowing help but are not enough. The reality for many newly...
Newly qualified doctors can expect to be as prepared as their
undergraduate training allows. For the initial management of acutely ill
patients, perhaps involving practical procedures, we have to ensure that
training and assessment of both students and doctors occur, as far as
possible, under similar conditions to those in which doctors will work. 4
days of shadowing help but are not enough. The reality for many newly
qualified doctors may be dealing with very sick patients at night in
unfamiliar surroundings, in poor light and without much immediate
assistance from even nurses, let alone more experienced doctors. Many new
doctors report that they are at their most anxious and feel least prepared
under these conditions. It would be interesting to review how much acute
work medical students are now made to experience at night. I suspect that
the results of such a survey might make uncomfortable reading.
Few formative or summative assessments are carried out at these times
by colleagues who are properly trained both in assessment and discussion
of the factors that can impair performance (as opposed to competence under
controlled conditions). Feedback capable of boosting confidence or
generating insight into unhelpful behaviour is best carried out as soon as
possible after the event; criticism the next day often misses the point.
Effective decision-making, particularly for novices, involves clinical
reasoning techniques that are not on the curricula of enough medical
schools. Being able to talk through these thought processes at the time
is invaluable for both senior and junior doctors but is too often denied
to the latter by circumstances.
Tackling this sort of unpreparedness certainly benefits from simulation,
particularly in teams, but, where real life conditions can be so chaotic
and unsupported by anything resembling a team, we may have to do much more
to improve the working conditions themselves. Assessing ill patients is
difficult enough for experienced doctors who are supported by other staff
and not being constantly interrupted by pagers. It should cause no
surprise that performance and perception of acute work by very junior
doctors is inadequate when working without such benefits. Competence and
performance can be very different things.
Xanthelasma palpebrarum ia a sharply demarcated yellowish flat plaque
om the upper and lower eyelid, mostly near the inner canthus.In a
prospective study done in Copenhagen University revealed that xanthelasme
palpebrarum predict risk of myocardial infarction, ischaemic heart
disease, severe atherosclerosis, and death in the general population[1].In
present study which is a cross-sectional study revealed that xanthelasma...
Xanthelasma palpebrarum ia a sharply demarcated yellowish flat plaque
om the upper and lower eyelid, mostly near the inner canthus.In a
prospective study done in Copenhagen University revealed that xanthelasme
palpebrarum predict risk of myocardial infarction, ischaemic heart
disease, severe atherosclerosis, and death in the general population[1].In
present study which is a cross-sectional study revealed that xanthelasma
is associated with increased proatherogenic markers thus there may be
increased risk.Another study revealed that in patients with xanthelasma,
no increase was observed in the rate or risk of cardiovascular disease,
Moreover, no relationship was found between Lp (a) levels and xanthelasma
though hyperlipidemia is common in patients with xanthelasma[2]. so, i
want to highlight few points.As xanthelasma is quite common in asian
individuals we need a nation wide, age and sex match, cohort study to
strenghthen the hypothesis.Another point is that we should go for an
randomised controlled trial evaluating the role of statin in patients with
xanthelasme palpebrarum without any other cardiovascular and
cerebrovascular risk factors in reducing the risk of death due to
cardiovascular and cerebrovascular causes compared to placebo.Thus we can
strengthen our present view in support.
References:
1. . Mette Christoffersen, Ruth Frikke-Schmidt, Peter Schnohr, Gorm B
Jensen, B?rge G Nordestgaard, Anne Tybj?rg-Hansen. BMJ 2011; 343 doi:
10.1136/bmj.d5497.
2. Ozd?l S, Sahin S, Tokg?zo?lu L. Xanthelasma palpebrarum and its
relation to atherosclerotic risk factors and lipoprotein (a). Int J
Dermatol. 2008 Aug;47(8):785-9.
Given the recognition that "choosing appropriate thresholds[for serum
natriuretic peptide] is problematic"(1), the best diagnostic strategy for
obtaining maximum diagnostic "mileage" from natriuretic peptide levels
might be that of interpreting any given result in the light of whether the
patient has high, medium, or low clinical probability of heart failure.
For that to come about, instead of reinforcing the idea that "In...
Given the recognition that "choosing appropriate thresholds[for serum
natriuretic peptide] is problematic"(1), the best diagnostic strategy for
obtaining maximum diagnostic "mileage" from natriuretic peptide levels
might be that of interpreting any given result in the light of whether the
patient has high, medium, or low clinical probability of heart failure.
For that to come about, instead of reinforcing the idea that "Individual
symptoms...and signs...are generally weak predictors of heart failure"(2),
we should embrace the use of a scoring system such as the one recently
compiled in the Netherlands which recognises the diagnostic value of
physical examination by allocating points to individual clinical
stigmata(3). We must also recognise that, as is the case with
biomarkers(such as natriuretic peptides), even echocardiography is hedged
in by caveats, not only in systolic heart failure(4), but also in
diastolic heart failure(5). In the former context the redeeming feature is
that, notwithstanding the fact that a subnormal left ventricular ejection
fraction(LVEF) does not equate with clinically overt heart failure(6), in
its own right, however, a subnormal LVEF does justify the use of
modulators of the renin-angiotensin-aldosterone system(RAAS) such as
angiotensin converting enzyme inhibitors(ACE-inhibitors) even if only to
exert a favourable influence on the natural history of both subclinical
and clinically overt heart failure(6). This means that, even if clinical
symptoms and signs are not those of heart failure, ACE_inhibitors would
still be justified in the event of a subnormal LVEF. A similar parallel
does not exist for left ventricular diastolic dysfunction(when it does not
co-exist with left ventricular systolic dysfunction) because there is no
evidence base for justifying modulation of the RAAS through the use either
of ACE inhibitors or spironolactone(or both) regardless of whether or not
left ventricular diastolic dysfunction co-exists with symptoms
attributable to heart failure. Accordingly, for patients with intact LVEF
in whom echocardiographically validated left ventricular diastolic
dysfunction coexists with "problematic" natriuretic peptide blood levels
the central issue is whether or not associated clinical signs and symptoms signify clinical congestion and, hence heart failure, whether it be acute
or chronic. Evidence-based parameters which have been utilised as criteria
for clinical congestion include symptoms such as effort dyspnoea and
orthopnoea, signs such as peripheral oedema, resting hugular venous
distension, and the presence of a third heart sound, and radiographic
stigmata such as cardiomegaly, pulmonary vascular redistribution,
interstitial oeadema, and pleural effusion. All these have been evaluated
for positive predictive value as well as for negative predictive value(7).
We now need to optimise the accuracy of non-echocardiographic stigmata(3)(7) so as to respond constructively to the
criticism levelled by a distinguished American physician at the
"downplaying" of clinical evelaution in the NICE guidelines, when he said
"Clinical evaluation is central to all complex clinical syndromes"(8),
References
(1)Al-Muhammad A., Mant J
Republished technology and guidelines: The diagnosis and management of
chronic heart failure: review following the publication of the NICE
guidelines
Postgrad Med J 2011;87:841-6
(2) Hobbs FDR., Doust J., Mant J., Cowie MR
Diagnosis of heart failure in primary care
Heart 2010;96:1773-7
(3) Kelder JC., Cramer MJ., van Wijngaarden J et al
The diagnostic value of physical examination and additional testing in
primary care patients with suspected heart failure
Circulation 2011;124:2865-73
(4) Jolobe OMP
Usefulness of left ventricular ejection fraction in patients with overt
heart failure(letter)
Mayo Clinic Proceedings 2006;81:1636-9
(5)Paulus WJ., Tschope C., Sanderson JE et al
How to diagnose diastolic heart failure: a consensus statement on the
diagnosis of heart failure with normal left ventricular ejection fraction
by the Haert Failure and Echocardiography Association of the European
Society of Cardiology
Eur Heart J 2007;28:1539-50
(6)The SOLVD Investigators
Effect of enalapril on mortality and the development of heart failure in
asymptomatic patients with reduced left ventricular ejection fractions
N Engl J Med 1992;327:685-91
(7)Gheorghiade M., Follath F., Ponikowski P et al
Assessing and grading congestion in acute heart failure: A scientific
statement from the Acute Heart Failure Committee of the Heart Failure
Association of the European Society of Cardiology and endorsed by the
European Society of Intensive Care Medicine
European Journal of Heart Failuer 2010;12;423-33
(8) Finucane TE
NICE Guideline for Management of Chronic Heart Failure in Adults(letter)
Annals of Inernal Medicine 2012;156:69
I can well remember my feelings of unpreparedness in both the areas
that current graduates identify as feeling most unready for.
However, I suspect that having this perception is not a bad thing. I
hope that they are able to maintain such a degree of insight and use it to
the advantage of their patients and themselves in the long term.
Should I be asked, I would encourage them to think on it in terms of...
I can well remember my feelings of unpreparedness in both the areas
that current graduates identify as feeling most unready for.
However, I suspect that having this perception is not a bad thing. I
hope that they are able to maintain such a degree of insight and use it to
the advantage of their patients and themselves in the long term.
Should I be asked, I would encourage them to think on it in terms of
having identified areas for development and to plan their continuing
education accordingly.
Notwithstanding the absence of robust evidence to justify the use of
antipyretic analgesics either for reducing patient discomfort or for
reducing morbidity and mortality in febrile illnesses(1), it is only in
recent times(2)(3) that the issue of drug-related mortality has been
adressed in patients receiving either nonsteroidal anti-inflammatory
drugs(NSAIDs) or paracetamol for febrile illnesses. Due to insensible
losse...
Notwithstanding the absence of robust evidence to justify the use of
antipyretic analgesics either for reducing patient discomfort or for
reducing morbidity and mortality in febrile illnesses(1), it is only in
recent times(2)(3) that the issue of drug-related mortality has been
adressed in patients receiving either nonsteroidal anti-inflammatory
drugs(NSAIDs) or paracetamol for febrile illnesses. Due to insensible
losses via the skin and also via the respiratory tract, patients with
pneumonia seem to be uniquely predisposed to NSAID-related nephrotoxicity,
as was the case in a five year old girl who received recommended doses of
ibuprofen(presumably for its antipyretic action) over a period of 4 days
before she developed acute renal failure, characterised by peak serum
creatinine 171 mcmol/l, and peak serum urea 23 mmol/l. Following the
discontinuation of ibuprofen these parameters took 3 days to revert to the
normal range(4). Both hepatitis and non-oliguric renal failure were the
cardinal complications of the administration of paracetamol, followed by
ibuprofen, in a 5 year old girl with febrile convulsions and vomiting. The
former was prescribed as 11 mg/kg/dose, two total doses, over 5 hours.
This was followed by ibuprofen 5 mg/kg/dose every 8 hours, three total
doses. Both drugs were administered by mouth. Although her renal function
tests and liver function tests had been within the normal range on
admisssion, on day six aspartate transaminase and gammaglutamyl
transaminase had increased to 144 iu/l, and 1394 iu/l, respectively.
Correspondigly, serum urea and serum creatinine had increased to 67.9
mg/dl and 6.34 mg/dl, respectively. By day 60 all the abnormal parameters
had reverted to the normal range(5). In the non febrile context,
recommended doses of paracetamol administerd to adult patients over a
period of 4-5 days, have been documented as being the cause of acute liver
failure(6). Accordingly, especially in the context of febrile illnesses
where insensible loss of fluid via the skin is compouded by fluid loss via
the respiratory tract(as in pneumonia)(4) or compouded by fluid loss via
the gastrointestinal tract as in the second case(5), there should be a
high index of suspicion for subsequent development of renal failure. Where
paracetamol is administered to patients with poor nutritional status,
clinicians should be alert to the risk of drug-related hepatotoxicity(6)
References
(1) Greisman L., Mackowiak PA
Fever: beneficial and detrimental effects of antipyretics
Current Opinion in Infectious Diseases 2002;15:241-5
(2) Plaisance
Toxicities of drugs used in the management of fever
Clinical Infectious Diseases 2000;31(Suppl 5): S219-23
(3)Jefferies S., Weatherall M., Young P., Eyers S., Beasley R
Ssystematic review and meta analysis of the effects of antipyretic
medications on mortality in Streptococcus Pneumoniae infections
Postgraduate Medical Journal 2012;88:21-27
(4)Ulinski T., Guigonis V., Dunan O., Bensman A
Acute renal failure after treatment with nonsteroidal antiinflammatory
drugs
Eur J Pediatr 2004;163:148-150
(5) Zaffanello M., Brugnara M., Angeli S., Cuzzolin L
Acute non-oliguric kidney failure and cholestatic hepatitis induced by
ibuprofen and acetoaminophen: a case report
Acta Paediatrica 2009;96:901-9
(6)Claridge LC., Eksteen B., Smith A., Shah T., Holt AP
Acute liver failure after administration of paracetamol at the maximum
recommended daily dose in adults
BMJ 2010;341:1269-1271
I want to highlight few points about the study.First, IgA nephropathy
is seen in nearly 40% of renal biopsy specimens of acute
glomerulonephritis patients in asia in various study.In this study it is
comprising only 8.1% of cases.Second, it is an crossectional study, taking
data from the renal biopsy report thus not showing the exact % of acute
glomerulonephritis caused by IgA nephropathy.So the finding is quite
exaggerat...
I want to highlight few points about the study.First, IgA nephropathy
is seen in nearly 40% of renal biopsy specimens of acute
glomerulonephritis patients in asia in various study.In this study it is
comprising only 8.1% of cases.Second, it is an crossectional study, taking
data from the renal biopsy report thus not showing the exact % of acute
glomerulonephritis caused by IgA nephropathy.So the finding is quite
exaggerated, though 10% of IgA nephropathy patient develop ESRD after 10
year & 20% after 20 years.
Management of special type of dyslipidemia; Low HDL-C, high TG, Type-
B size LDL-P in patients with T2DM is a big challenge for a physician. For
primary LDL-C goal, we the physician usually go for stronger statins like
atorvastatin or rosuvastatin. Addition of fenofibrate to the above statins
to reduce concomitant high TG really reduces TG level but does such
combination offer any strong role in reducing mortality in this p...
Management of special type of dyslipidemia; Low HDL-C, high TG, Type-
B size LDL-P in patients with T2DM is a big challenge for a physician. For
primary LDL-C goal, we the physician usually go for stronger statins like
atorvastatin or rosuvastatin. Addition of fenofibrate to the above statins
to reduce concomitant high TG really reduces TG level but does such
combination offer any strong role in reducing mortality in this population
[1]?
To increase HDL-C, trials with CETP inhibitors like torcetrapib or
anacetrapib failed to reduce CV mortality. Newer CETP inhibitor
evacetrapib although leading to increase HDL-C but cardiovascular
protection is still under question [2].
We were using extended release nicotinic acid along with statin (ARBITER 6
-HALTS trial) but my practice did not show any significant benefit.
Recently, after premature halting of AIM-HIGH trial, efficacy of nicotinic
acid also became under question and even increased events of ischemic
stroke in this population leading me to change my treatment strategy.
Currently no safe drug to increase HDL-C is available. More ever, drug
induced increased HDL has no CV benefit.
Lifestyle modification is still remaining the best strategy along with
statin and if necessary, n-3 to manage dyslipidemia in patients with
diabetes and other high risk population.
Ref:
1. Hyperlipidaemia and cardiovascular disease: do fibrates have a role?
Current Opinion in Lipidology:
August 2011 - Volume 22 - Issue 4 - p 270-276
doi: 10.1097/MOL.0b013e32834701c3
2. Effects of the CETP Inhibitor Evacetrapib Administered as Monotherapy
or in Combination With Statins on HDL and LDL Cholesterol.
JAMA.2011;306(19):2099-2109. doi:10.1001/jama.2011.1649
Kouzes and Posner (1) once wrote that "The domain of leaders is the
future. The leaders unique legacy is the creation of valued institutions
that survive over time. The most significant contribution leaders make is
not simply to today's bottom line; it is to the long-term development of
people and institutions so they can adapt, change, prosper, and grow."
As Warren and Carnall (2) stated, medical leadership is...
Kouzes and Posner (1) once wrote that "The domain of leaders is the
future. The leaders unique legacy is the creation of valued institutions
that survive over time. The most significant contribution leaders make is
not simply to today's bottom line; it is to the long-term development of
people and institutions so they can adapt, change, prosper, and grow."
As Warren and Carnall (2) stated, medical leadership is important for
delivering high-quality healthcare to patients and to function across
professional boundaries in an environment that is becoming increasingly
complex. Physicians are well educated academically and clinically, but
training in leadership lags somewhat behind. There also appears to be a
gap in leadership capabilities between junior and senior doctors. The
authors suggest several approaches to develop the non-technical, often
called "softer" skills in physicians, including mentoring by establishing
a relationship that will support personal and professional development,
coaching to enhance the performance in specific areas, and action learning
to solve jointly "real-world" problems that arise at work. There is also
formal and informal networking with peers and/or senior leaders, and
experiential learning through exposure to new environments, assignments,
etc., which trains the individual to work outside their comfort zone. The
authors also discuss participation in specific programs, schemes,
fellowships, and courses aimed at developing medical leadership skills.
As a scientist, I found myself in a similar situation as many
physicians: I did not receive any kind of training in management and
leadership during my education. Yet, after graduation with a Ph.D. in
microbiology, I was expected to lead a research laboratory, instruct
students in the classroom and guide them through their thesis experience,
and to professionally interact with administrative staff of the
organization as well as representatives of research funding agencies. So,
how did I do it? I essentially studied the way how others (e.g., mentors,
senior peers, and selected role models from the literature) lead people,
then "copied" certain leadership behaviors, and put a "personal touch" on
my leadership attempts. I used the principle of "trial and error." Not
surprisingly, it did not take me long to realize that this way of leading
was a superficial attempt to be effective and to "survive" in the highly
competitive field of biomedical science. Most significantly, I lacked
authenticity and did not know the tools needed for self-observation and
self-discovery. As it turned out, I was not alone in my leadership
insecurities as several of my young colleagues expressed similar soft-
skill deficiencies.
Since the science curriculum (apparently similar to the medical
curriculum) does not include management and leadership courses, I
eventually decided to enroll in business graduate programs to formally
study this subject matter. I was surprised how much I learned from books
and articles, group discussions, and case studies about interpersonal and
intercultural communication, management techniques, theories and elements
of leadership practice, strategic thinking approaches, ethics in action,
and organizational behavior, among many other topics. I realized that what
I have learned in business school I could immediately apply to many
aspects of my work in science. I greatly improved my understanding of
leadership and, I believe, it also made me a more attentive person in
private life. I know now that leadership is a process, which means a
transactional event that occurs between the leader and followers (3), thus
it is a collective activity (4), and undoubtedly a real challenge worth
taking on (1). Leadership is a universal phenomenon, it is real and not a
figment of the imagination, and it has a substantial effect on
organizational outcomes (5). Providing good leadership requires a
willingness for continuing learning (6), an understanding of the
importance of effective and efficient listening to others (7), and the
capability and opportunity for deep introspection and self-reflection (8,
9). One must understand that developing and refining leadership skills
takes time and requires from the individual passion, commitment, and
endurance.
In hindsight, I wish that I would have taken management and
leadership courses much earlier in my scientific career. In this regard, I
strongly support the notion that leadership training should become a part
of medical and science education. I believe that resources dedicated to
leadership education would pay off immediately during the time students
spend in medical and graduate school as well as prepare them well for
every stage of their professional life. Last, but not least, leadership
training can have positive effects on the development of one's personal
life.
I would like to conclude my letter with another citation from the
book by Kouzes and Posner (1): "Leadership is important not just in your
own career and within your own organization. It's important in every
sector, in every community, and in every country. We need more exemplary
leaders, and we need them more than ever. There is so much extraordinary
work to be done. We need leaders who can unite us and ignite us."
REFERENCES
1. Kouzes MJ, Posner BZ. The Leadership Challenge. 3rd edn. San
Francisco, California: Jossey-Bass, 2002.
2. Warren OJ, Carnall R. Medical leadership: why it's important, what
is required, and how we develop it. Postgrad Med J 2011;87:27-32.
3. Northouse PG. Leadership: Theory And Practice. 4th edn. Thousand
Oaks, California: Sage Publications, 2007.
4. Noonan SJ. The Elements Of Leadership: What You Should Know.
Lanham, Maryland: Scarecrow Press, 2003.
5. Bass BM, Bass R. The Bass Handbook Of Leadership: Theory,
Research, And Managerial Applications. 4th edn. New York: Free Press,
2008.
6. Preskill S, Brookfield SD. Learning As A Way Of Leading: Lessons
From The Struggle For Social Justice. San Francisco, California: Jossey-
Bass, 2009.
7. Treece M. Successful Communication For Business And The
Professions. 6th edn. Needham Heights, Massachusetts: Allyn and Bacon,
1994.
8. Cashman K. Leadership From The Inside Out: Becoming A Leader For
Life. Provo, Utah: Executive Excellence Publishing, 1998.
9. Palmer PJ. Let Your Life Speak: Listening For The Voice Of
Vocation. San Francisco, California: Jossey-Bass, 2000.
The 76 year old patient recently reported in this journal with left atrial diameter of 10 cm(1), has been superseded, in the record books, by a 40 year old man with left atrial diameter of 21.5 cm attributable to severe mitral stenosis(2). The latter patient presented with dysphagia, hoarseness, and exertional dyspnoea. References (1)Shah BN., Rubens M Giant left atrium: a forgotten cause of cardiomegaly Postgrad Med J 2...
We recognise and acknowledge the issues raised by Dr Levine in his letter (13th July 2012). Newly qualified doctors can expect to be as prepared as their undergraduate training allows and their level of clinical supervision facilitates. These are important additional factors when considering preparedness of medical graduates commencing work at foundation year 1 (F1) level. F1 doctors must be able to increase their leve...
Newly qualified doctors can expect to be as prepared as their undergraduate training allows. For the initial management of acutely ill patients, perhaps involving practical procedures, we have to ensure that training and assessment of both students and doctors occur, as far as possible, under similar conditions to those in which doctors will work. 4 days of shadowing help but are not enough. The reality for many newly...
Xanthelasma palpebrarum ia a sharply demarcated yellowish flat plaque om the upper and lower eyelid, mostly near the inner canthus.In a prospective study done in Copenhagen University revealed that xanthelasme palpebrarum predict risk of myocardial infarction, ischaemic heart disease, severe atherosclerosis, and death in the general population[1].In present study which is a cross-sectional study revealed that xanthelasma...
Given the recognition that "choosing appropriate thresholds[for serum natriuretic peptide] is problematic"(1), the best diagnostic strategy for obtaining maximum diagnostic "mileage" from natriuretic peptide levels might be that of interpreting any given result in the light of whether the patient has high, medium, or low clinical probability of heart failure. For that to come about, instead of reinforcing the idea that "In...
I can well remember my feelings of unpreparedness in both the areas that current graduates identify as feeling most unready for.
However, I suspect that having this perception is not a bad thing. I hope that they are able to maintain such a degree of insight and use it to the advantage of their patients and themselves in the long term.
Should I be asked, I would encourage them to think on it in terms of...
Notwithstanding the absence of robust evidence to justify the use of antipyretic analgesics either for reducing patient discomfort or for reducing morbidity and mortality in febrile illnesses(1), it is only in recent times(2)(3) that the issue of drug-related mortality has been adressed in patients receiving either nonsteroidal anti-inflammatory drugs(NSAIDs) or paracetamol for febrile illnesses. Due to insensible losse...
I want to highlight few points about the study.First, IgA nephropathy is seen in nearly 40% of renal biopsy specimens of acute glomerulonephritis patients in asia in various study.In this study it is comprising only 8.1% of cases.Second, it is an crossectional study, taking data from the renal biopsy report thus not showing the exact % of acute glomerulonephritis caused by IgA nephropathy.So the finding is quite exaggerat...
Management of special type of dyslipidemia; Low HDL-C, high TG, Type- B size LDL-P in patients with T2DM is a big challenge for a physician. For primary LDL-C goal, we the physician usually go for stronger statins like atorvastatin or rosuvastatin. Addition of fenofibrate to the above statins to reduce concomitant high TG really reduces TG level but does such combination offer any strong role in reducing mortality in this p...
Kouzes and Posner (1) once wrote that "The domain of leaders is the future. The leaders unique legacy is the creation of valued institutions that survive over time. The most significant contribution leaders make is not simply to today's bottom line; it is to the long-term development of people and institutions so they can adapt, change, prosper, and grow."
As Warren and Carnall (2) stated, medical leadership is...
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