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Dear Editor
Our editorial was triggered by a PMJ paper showing that in a study carried
out in the US, 76% of first year doctors exhibited burnout. We quoted
other evidence that burnout may occur surprisingly early in careers and is
not necessarily related to seniority. We know that jobs which require
daily face to face interaction with people who are distressed or
challenging lead to high levels of burnout. Sadly it is th...
Dear Editor
Our editorial was triggered by a PMJ paper showing that in a study carried
out in the US, 76% of first year doctors exhibited burnout. We quoted
other evidence that burnout may occur surprisingly early in careers and is
not necessarily related to seniority. We know that jobs which require
daily face to face interaction with people who are distressed or
challenging lead to high levels of burnout. Sadly it is those who are
most empathetic who become emotionally exhausted most quickly. We also
know that isolation, overwork, lack of sleep and lack of expertise all add
to the risk of burnout. New doctors should not have to cope with all of
those at once. There is evidence from the GMC's annual National Trainee
Survey (and before that the London-wide Point of View Survey) that over
the past 16 years the proportion of new doctors who feel stressed, bullied
or sleep-deprived has steadily reduced. We are not aware of any evidence
suggesting it has got worse, though stresses may well have been
transferred to those higher up the career ladder. Big problem is
dependence on doctors in training to deliver service. Not a problem as
such, but it is when service demands mean working under stress and without
colleagues and supervision. Unsupervised work provides experience but
cannot be considered as training. Working in teams, even if the membership
of the teams changes, mitigates against isolation and provides supervision
for the junior members.
Diana Hamilton-Fairley. Elisabeth Paice
We agree that delirium is serious, and more structured instruments
are needed for providers of multiple specialties to detect delirium in
multiple health care settings. While we have no experience on the I-AGeD
in our emergency departments, we note that caregivers often are not
available at the time of emergency presentation. Also, we find veracity of
caregiver reports highly dependent on relationship and time spent wit...
We agree that delirium is serious, and more structured instruments
are needed for providers of multiple specialties to detect delirium in
multiple health care settings. While we have no experience on the I-AGeD
in our emergency departments, we note that caregivers often are not
available at the time of emergency presentation. Also, we find veracity of
caregiver reports highly dependent on relationship and time spent with the
patient. Ideally, providers should have access to tools that use only
patient-level information in addition to tools that use caregiver
information for diagnosing delirium.
In their interesting study Suffoletto et al [1] examined delirium
recognition by emergency physicians. Trained researchers identified
delirium in 24/259 (9%) of emergency room older patients. Diagnosis was
based on CAM -ICU criteria, Richmond Agitation and Sedation scale and an
interview with the surrogate. By contrast, emergency physicians recognised
delirium in only 8/24 cases and misidenti...
In their interesting study Suffoletto et al [1] examined delirium
recognition by emergency physicians. Trained researchers identified
delirium in 24/259 (9%) of emergency room older patients. Diagnosis was
based on CAM -ICU criteria, Richmond Agitation and Sedation scale and an
interview with the surrogate. By contrast, emergency physicians recognised
delirium in only 8/24 cases and misidentified delirium in seven cases.
Delirium is a serious condition, and it is associated with poor outcome.
Recognition of delirium is important and might improve patient outcomes.
Study findings are in line with previous studies that showed there is room
for improving delirium recognition,
We have looked at this problem recently and developed and validated a
new screening instrument, the Informant Assessment of Geriatric Delirium
scale (I-AGeD) [2]. It is a 10 items caregiver baser questionnaire. The I-
AGeD was validated in elderly patients admitted to a geriatric wards of
two general hospitals. Average age in the construction cohort was 86,4
yr, 51/88 suffered from dementia and delirium was found in 31/88. In two
validation cohorts, sensitivity and specificity ranged from 70-88.9% and
66.7 -100%.
Given the present demographics, the incidence of delirium will rise,
and recognition of delirium may be difficult, especially in patients with
dementia. Training physicians outside the field of geriatrics on this
issue is important. We think that an caregiver based screening instrument
might be an efficient way to improve early and fast recognition of
delirium in geriatric patients.
With kind regards,
JPCM van Campen1, HFM Rhodius Meester1, JFM de Jonghe2
1 Slotervaart hospital, department of geriatric medicine, Amsterdam,
the Netherlands
2 Medical Center Alkmaar, department of geriatric medicine, Alkmaar, the
Netherlands
References
1 Brian Suffoletto, Thomas Miller, Adam Frisch, Clifton Callaway,
Emergency physician recognition of delirium, Postgrad Med J 2013 June,
ahead of Print
2 Rhodius- Meester HFM, van Campen JPCM, Wung W, Meagher DM et al,
Development and validation of the Informant Assessment of Geriatric
Delirium Scale (I-AGeD). Recognition of delirium in geriatric patients.
EGM , 2013; 4(2):73-7
Avoiding burnout in new doctors: sleep, supervision and teams
Elisabeth Paice, Diana Hamilton-Fairley 2013;89:493-494
doi:10.1136/postgradmedj-2013-132214
I applaud Paice and Hamilton-Fairley's call for better work schedules
and supervision, but burnout seems to increase with seniority and probably
reflects more fundamental problems. Achieving even the aims mentioned may
be more difficult than the authors suggest...
Avoiding burnout in new doctors: sleep, supervision and teams
Elisabeth Paice, Diana Hamilton-Fairley 2013;89:493-494
doi:10.1136/postgradmedj-2013-132214
I applaud Paice and Hamilton-Fairley's call for better work schedules
and supervision, but burnout seems to increase with seniority and probably
reflects more fundamental problems. Achieving even the aims mentioned may
be more difficult than the authors suggest.
They note that instant teams function well in the airline industry
but link this statement to a paper which referenced stability as one
defining factor for well-structured teams1. The questionnaire to identify
team membership in that study across all types of hospital employees
didn't ask about (or exclude) stability in the 'well-structured' teams
correlated with weaker stressor-strain relationships. One criterion
defining membership of a well-structured team was 'regular team meetings',
which surely implies at least moderate stability. 'Ensuring that there is
a leader, shared goals, well-defined roles, and mutual respect' are indeed
important but stability is also necessary for most medical teams. Instant
teams might function on airline flights but such teams in Medicine present
serious problems for care of patients as well as for clinical supervision
and appraisal of new doctors.
If it 'really isn't that hard' to avoid damaging work schedules, we
might ask why they are still so common and why Deaneries and other bodies
haven't been able to stop them. One answer is, presumably, that the
profession has progressively lost influence in many Trusts. The experience
of 'hospital-at-night' in many Trusts is very different from the original
concept. Too often, a few doctors (without the other help provided in
exemplar sites) are responsible for large numbers of patients. There is
evidence of unacceptable demands on many medical registrars for whom
effective supervision of newer doctors is not possible2
It's interesting that stress and dissatisfaction appear to be
increasing despite overall reduction in working hours. Preparing new
doctors to cope with clinical reorganisations, NHS instability and
employers' attitudes to medical staff is a significant problem. In truth,
fewer doctors in both hospital and general practice seem to want to work
at night and the NHS doesn't yet know how to cope with that. I wonder if
current levels of burnout and dissatisfaction reflect a deeper malaise for
which we might need a different type of conversation?
References
1. Buttigieg SC, West MA, Dawson JF. Well-structured teams and the
buffering of hospital employees from stress. Health Serv Manage Res
2011;24:203-12.
2. Royal College of Physicians. The medical registrar: Empowering the
unsung heroes of patient care. London: RCP, 2013
The occurrence of coronary occlusion in patients without protocol
positive ST segment elevation(1) might be attributable either to early
catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter
also being significantly(p < 0.001) commoner in non ST segment
elevation(NSTEMI) patients catheterised within 6 hours of arrival in
hospital than in STEMI counterparts also catheterised within that time
frame(...
The occurrence of coronary occlusion in patients without protocol
positive ST segment elevation(1) might be attributable either to early
catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter
also being significantly(p < 0.001) commoner in non ST segment
elevation(NSTEMI) patients catheterised within 6 hours of arrival in
hospital than in STEMI counterparts also catheterised within that time
frame(4). According to one study, there is a "higher rate of thrombotic
coronary occlusion in the first NSTEMI patients with early catheterization
than in those catheterized later"(2). That conclusion was based on an
analysis of 878 patients in whom an evaluation was made of the prevalence
of thrombotic occlusion with in time frames of 0-6 hrs, 7-24 hrs, 25-48
hrs, and 49-96 hrs encompassing time elapsed from admission with chest
pain to angiography. A multivariate logistic regression analysis showed
that the time frame of 0-6 hours was the most significant(p < 0.001)
independent marker of coronary occlusion(with reference to the 48-96 hour
interval)(Odds Ratio 3.01, 95% Confidence Interval: 1.94-4.66; p<
0.001), whereas, for anterior ST depression corresponding data for those
parameters amounted to 2.09, 1.36-3.21, p=0.001, respectively, and, for
inferolateral ST depression, corresponding data amounted to 1.83, 1.08-
3.11, and p=0.025, respectively. Total(ie 100%) thrombotic occlusion was
documented in 55% of 141 patients who fell within the 0-6 hr time frame,
and this represented a significant(p < 0.001) trend in comparison with
other time frames. The left circumflex artery was identified as the
culprit artery(in association with the marginal branch and the
intermediate branch) in 50% of patients who fell within that time
frame(2). Conversely, in a study which exclusively enrolled 27,711
patients with myocardial infarction attributable to left circumflex artery
occlusion, the prevalence of NSTEMI was as high as 33%(3). What is more,
in a study where 93% of 125 patients with suspected NSTEMI had coronary
angiography within 6 hours of arrival in hospital the left circumflex
artery was the culprit artery in 26%(as opposed to its involvement in 11%
of 279 STEMI patients), the difference in prevalence being highly
significant(p < 0.001)(4). Accordingly, the greater the delay in
cardiac catheterisation the greater the likelihood that the opportunity
will be missed to identify thrombotic coronary artery occlusion,
especially in patients with left circumflex artery involvement.
References
(1)Apps A., Malhotra A., Tarkin J et al
High incidence of acute coronary occlusion in patients without protocol
positive ST segment elevation referred to an open access primary
angioplasty programme
Postgraduate Medical Journal 2013;89:376-381
(2)Fugueras J., Barrabes JA., Andres M et al
Angiographic findings at different time intervals from hospital admission
in first non-ST elevation myocardial infarction
International Journal of Cardiologydoi.org/10.1016/j.ijcard.2012.09.168
(3)Stribling WK., Kontos MC., Abbate A et al
Left circumflex occlusion in acute myocardial infarction(from the National
Cardiovascular Data Registry)
Am J Cardiol 2011;108:959-963
(4)Koyama Y., Hansen PS., Hanratty CG., Nelson GIC., Rasmussen HH
Prevalence of coronary occlusion and outcome of an immediate invasive
strategy in suspected acut myocardial infarction with and without ST-
segement elevation
Am J Cardiol 2002;90:579-584
Respected Editor,
The case report by Lai et al. [1] was both interesting and informative. We
agree with the usefulness of CT thorax to differentiate pneumothorax from
giant bulla with double wall sign. Though CT offers the most accurate
diagnostic information, it is difficult to transport unstable patient to a
CT suite which is in a remote area from a resuscitative area or to wait
for a specialized technician to perform it...
Respected Editor,
The case report by Lai et al. [1] was both interesting and informative. We
agree with the usefulness of CT thorax to differentiate pneumothorax from
giant bulla with double wall sign. Though CT offers the most accurate
diagnostic information, it is difficult to transport unstable patient to a
CT suite which is in a remote area from a resuscitative area or to wait
for a specialized technician to perform it and a radiologist to interpret
it. Traditionally, the presence of bullae and their advancement are
recognized by chest radiography. At times, even forced expiratory films
are used to demonstrate the existence of bullae [2]. However, limitation
is difficult to differentiate the hairline shadows produced by avascular
bullae from irregular walls of a cavity or cysts in the lung parenchyma in
an emergency setting and may easily be mistaken for a pneumothorax [3]
sometimes.
In this scenario, the bedside transthoracic ultrasonography has emerged as
a reliable technique to detect and exclude pneumothorax which is now well
accepted by the medical community. The effectiveness of ultrasound in
detection of bullae and differentiate it from pneumothorax [4] is well
documented. The lung sliding may be minimal because there may be little
movement of the visceral pleura that covers the bulla. As there is no free
air in the pleural space, the reverberation artifact that produces the
'comet tail artifacts' may be noticed in bullous disease. However, it is
absent when the lung is collapsed as in pneumothorax and thereby helps to
arrive at the diagnosis [5].
Speedy and precise diagnosis of bullous emphysema from pneumothorax will
assist in treatment, as the management of these two entities varies
significantly. Many times patients presenting to the emergency departments
were in extremis and call for an immediate decision making and delaying
can be life threatening. In an emerging culture of protocol and guidelines
regarding effectiveness of treatment, transthoracic ultrasonography may be
considered in the emergency department to assure the high quality of
health care given to patients.
References:
1. Lai CC, Huang SH, Wu TT, Lin SH. Vanishing lung syndrome mimicking
pneumothorax. Postgrad Med J. 2013.
2. Shah N N, Bhargava R, Ahmed Z, Pandey D K, Shameem M, Bachh A A,
Akhtar S, Dar K A, Mohsina M. Unilateral bullous emphysema of lung. Lung
India 2007;24:30-2.
3. Waseem M, Jones J, Brutus S, Munyak J, Kapoor R, Gernsheimer J.
Giant bulla mimicking pneumothorax. J EmergMed 2005;29:155?-8.
4. Chan SS. Emergency bedside ultrasound to detect pneumothorax. Acad
Emerg Med 2003;10: 91-4.
5. Simon BC, Paolinetti L. Two cases where bedside ultrasound was
able to distinguish pulmonary bleb fzom pneumothorax. J Emerg Med.
2005.29:201-5
Nwulu and colleagues present a highly relevant analysis of the
financial implications of prescribing by F1 doctors in a UK teaching
hospital1.
It seems that the most important of the recommendations they discuss
are for undergraduate medical education. Whilst they mention that most of
the 79 doctors they investigated graduated from the same medical school,
they do not categorise this further. As their data ind...
Nwulu and colleagues present a highly relevant analysis of the
financial implications of prescribing by F1 doctors in a UK teaching
hospital1.
It seems that the most important of the recommendations they discuss
are for undergraduate medical education. Whilst they mention that most of
the 79 doctors they investigated graduated from the same medical school,
they do not categorise this further. As their data indicate, the large
majority of doctors performed to a very similar level to the reference
doctor, with a minority on either end of the spectrum proving to be the
most cost-effective and lavish prescribers. This raises the possibility
that the doctors at the extremes of this range may have been the minority
that trained at alternative medical schools.
As they highlight, further studies are needed across the country,
although they may prove to be more of a challenge in trusts that do not
have electronic prescribing systems. Future work into this area may
benefit from investigating the medical schools at which doctors trained.
As these doctors are in their first year after graduating, conclusions may
be drawn about the extent to which medical schools are covering the
financial aspects of prescribing in their clinical pharmacology curricula.
With the increasing importance of cost-effectiveness in the NHS, this
important topic should be on the agenda of medical educators across the UK
in order to breed a new generation of financially astute prescribers.
1. Nwulu U, Hodson J, Thomas SK, et al. Variation in cost of newly
qualified doctors' prescriptions: a review of data from a hospital
electronic prescribing system. Postgrad Med J Published Online First: [30
March 2013] doi:10.1136/postgradmedj- 2012-131334
We applaud the timely study by Kennelly et al and agree fully that ED
physicians generally lack proficiency for recognizing and managing
behavioral complications of dementia. As they succinctly state, "Failure
of physicians to identify and highlight cognitive impairment can lead to
disastrous consequences".[1] We venture that ED physicians are even less
aware of the unique and potentially lethal emergenc...
We applaud the timely study by Kennelly et al and agree fully that ED
physicians generally lack proficiency for recognizing and managing
behavioral complications of dementia. As they succinctly state, "Failure
of physicians to identify and highlight cognitive impairment can lead to
disastrous consequences".[1] We venture that ED physicians are even less
aware of the unique and potentially lethal emergency management aspects of
Lewy Body Dementia (LBD). LBD is a degenerative neurological disease
manifested by cognitive impairment, variable Parkinsonism, and marked
psychosis exhibiting both auditory and visual hallucinations. LBD is now
considered the second most common cause of dementia following only
Alzheimer's comprising up to 20-30% of all dementia based on autopsy
studies.[2] Differentiating LBD from other dementias can be difficult but
the key features are daily fluctuation in cognition and the prominent
hallucinations (paradoxically they are not distressful to the patient).
DLB strikes its victims from late middle age up and respects no boundaries
as to gender or race.[3]
ED patients with LBD require careful and distinctive pharmacologic
management of their agitation and psychotic symptoms. Administering
typical neuroleptics will precipitate serious complications ranging from
extrapyramidal symptoms to severe sedation to the often lethal neuroleptic
malignant syndrome (NMS). Up to 50% percent of individuals with LBD are
at an increased risk of these acute reactions to neuroleptics.[2].
The pathophysiology of this phenomenon is based on the finding that
neurons of the basal nucleus of Meynert and substantia nigra are reduced
in LBD thus preferentially depleting acetylcholine and dopamine
neurotransmitters. The typical antipsychotics, such as haloperidol
(Haldol), fluphenazine (Prolixin), and chlorpromazine (Thorazine), block
postsynaptic mesolimbic dopaminergic D1 and D2 receptors which can
typically be helpful for reducing delirium and hallucinations in most
patients with Alzheimer's. The specific neurotransmitter deficits in LBD
however prevent up-regulation of D2 receptors in the affected brain
centers thus uniquely sensitizing these patients to the EPS adverse
effects of antipsychotics.[2] Not only can this exacerbate acute
problems but it may worsen cognitive ability of these patients over the
long term. LBD experts recommend the use of newer and more selective
atypical antipsychotic agents. Importantly, however, case reports show
that even these newer agents are not immune to inducing NMS in LBD, so
small and carefully titrated doses are advised.[4] Employing non-
pharmacologic modalities and the judicious of short acting benzodiazepines
is also advised. Because the Emergency Medicine community is largely
unaware of these unique hazards, the Lewy Body Dementia Association
provides helpful guidelines for ED staff to safely treat these unique
patients at http://www.lbda.org.
1. Kennelly SP, Morley D, Coughlan T, et al. Knowledge, skills and
attitudes of doctors towards assessing cognition in older patients in the
emergency department. Postgraduate medical journal 2012 doi:
10.1136/postgradmedj-2012-131226.
2. Baskys A. Lewy body dementia: the litmus test for neuroleptic
sensitivity and extrapyramidal symptoms. J Clin Psychiatry 2004;65 Suppl
11:16-22
3. Latto J, Jan F. Dementia with Lewy Bodies: Clinical Review.
British Journal of Medical Practitioners 2008;1(1):10 - 14
4. Weintraub D, Hurtig HI. Presentation and management of psychosis
in Parkinson's disease and dementia with Lewy bodies. Am J Psychiatry
2007;164(10):1491-8
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
Dear Editor Our editorial was triggered by a PMJ paper showing that in a study carried out in the US, 76% of first year doctors exhibited burnout. We quoted other evidence that burnout may occur surprisingly early in careers and is not necessarily related to seniority. We know that jobs which require daily face to face interaction with people who are distressed or challenging lead to high levels of burnout. Sadly it is th...
We agree that delirium is serious, and more structured instruments are needed for providers of multiple specialties to detect delirium in multiple health care settings. While we have no experience on the I-AGeD in our emergency departments, we note that caregivers often are not available at the time of emergency presentation. Also, we find veracity of caregiver reports highly dependent on relationship and time spent wit...
Dear Madame, Sir,
In their interesting study Suffoletto et al [1] examined delirium recognition by emergency physicians. Trained researchers identified delirium in 24/259 (9%) of emergency room older patients. Diagnosis was based on CAM -ICU criteria, Richmond Agitation and Sedation scale and an interview with the surrogate. By contrast, emergency physicians recognised delirium in only 8/24 cases and misidenti...
Avoiding burnout in new doctors: sleep, supervision and teams Elisabeth Paice, Diana Hamilton-Fairley 2013;89:493-494 doi:10.1136/postgradmedj-2013-132214
I applaud Paice and Hamilton-Fairley's call for better work schedules and supervision, but burnout seems to increase with seniority and probably reflects more fundamental problems. Achieving even the aims mentioned may be more difficult than the authors suggest...
The occurrence of coronary occlusion in patients without protocol positive ST segment elevation(1) might be attributable either to early catheterisation(2)or to left circumflex artery occlusion(3)(4), the latter also being significantly(p < 0.001) commoner in non ST segment elevation(NSTEMI) patients catheterised within 6 hours of arrival in hospital than in STEMI counterparts also catheterised within that time frame(...
Respected Editor, The case report by Lai et al. [1] was both interesting and informative. We agree with the usefulness of CT thorax to differentiate pneumothorax from giant bulla with double wall sign. Though CT offers the most accurate diagnostic information, it is difficult to transport unstable patient to a CT suite which is in a remote area from a resuscitative area or to wait for a specialized technician to perform it...
Nwulu and colleagues present a highly relevant analysis of the financial implications of prescribing by F1 doctors in a UK teaching hospital1.
It seems that the most important of the recommendations they discuss are for undergraduate medical education. Whilst they mention that most of the 79 doctors they investigated graduated from the same medical school, they do not categorise this further. As their data ind...
Sir,
We applaud the timely study by Kennelly et al and agree fully that ED physicians generally lack proficiency for recognizing and managing behavioral complications of dementia. As they succinctly state, "Failure of physicians to identify and highlight cognitive impairment can lead to disastrous consequences".[1] We venture that ED physicians are even less aware of the unique and potentially lethal emergenc...
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...
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