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glucocorticoid pre-term improve lung maturity

how does it work? Does it reduce the inflammatory process which can damage the surfactant producing cells or does it increase the production of lung surfactant. If yes, then can we give glucocorticoids in Adult respiratory distress syndrome?  
alex bwn
about 6 years ago
Foo20151013 2023 1i9rgu8?1444773940
3
221

The elephant in the room: Is everything you see on an x-ray relevant?

Recent 'tongue in cheek' research which has been reported in a Washington Post blog recently has caused a lot of questions to be raised concerning inattention blindness, which could cause concern unless you understand the underlying psychology. Here's a CT scan: During psychology lectures at Med School, you may have encountered the basketball bouncing students in front of a bank of elevators where you were asked to count the number of passes the basketball made from the player wearing the white T shirt, while a gorilla ran between the students. (Even if you did watch it before, you can re-watch the video on the Washington Post blog). The recent study asked radiologists to identify and count how many nodules are present in the lungs on a regular CT thorax. If you look at the image you may see a gorilla waving his arms about. As a radiologist, I see the anatomy in the background, the chambers of the heart and mediastinum, but nothing there out of the ordinary. As radiologists, we are looking for pathology, but also report pathological findings that are unexpected. The clinical history of a patient is very important for us in interpretation of imaging examinations, as we need to answer the question you are asking, but have to be careful we do not miss anything else of serious import. As we do not see any other pathology, we would not expect to find a gorilla in the chest, so our brains can pass over distracting findings. The other psychological issue is the satisfaction of search, where we can see the expected pathology, but may miss the other cancer if we do not carefully and systematically look through the images. So the main thing to learn from this is that your training should always keep you alert, not just to expected happening, but to not discount the unexpected, then many lives will be saved as a result of your attention to detail.  
Chris Flowers
over 7 years ago
Foo20151013 2023 7owyf5?1444773963
3
154

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
over 7 years ago
Foo20151013 2023 1eqve0g?1444774030
1
94

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
over 7 years ago
Foo20151013 2023 xta4hx?1444774129
2
343

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
almost 7 years ago
Www.bmj
0
14

Air pollution, stroke, and anxiety

The effects of air pollution on the lungs and heart are now widely appreciated, with expanding evidence for an important role in cardiac disease.1 The Global Burden of Disease Study identified fine particulate matter (PM2.5) in outdoor air and household air pollution from use of solid fuels as the ninth and fourth leading risk factors, respectively, for disease worldwide,2 and the World Health Organization attributes one in every eight deaths to air pollution.3 The effects of air pollution are not limited to cardiopulmonary diseases. Recent evidence suggests a role in diverse outcomes, including diabetes,4 low birth weight, and preterm birth.5 This research stems from improved understanding of the role of air pollution in initiating systemic inflammation, a response that may affect multiple organ systems. Two linked studies (doi:10.1136/bmj.h1295, doi:10.1136/bmj.h1111) add to growing evidence that air pollution is an important risk factor for an increasing number of common diseases.6 7  
feeds.bmj.com
over 5 years ago
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0
40

Lung Abscess

http://usmlefasttrack.com/?p=6073 Lung, Abscess, Findings, symptoms, findings, causes, mnemonics, review, what is, video, study, Rapid Review, Clinical prese...  
youtube.com
over 5 years ago
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0
23

Pancoast Tumor of the Lung and What all it can compress

http://usmlefasttrack.com/?p=6069 Pancoast, Tumor, of, the, Lung, and, What, all, it, can, compress, Findings, symptoms, findings, causes, mnemonics, review,...  
youtube.com
over 5 years ago
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0
1

Pancoast Tumor of the Lung and What all it can compress - YouTube

http://usmlefasttrack.com/?p=6069 Pancoast, Tumor, of, the, Lung, and, What, all, it, can, compress, Findings, symptoms, findings, causes, mnemonics, review,...  
youtube.com
over 5 years ago
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1
12

Large Cell Carcinoma of the Lung

http://usmlefasttrack.com/?p=6066 Large, Cell, Carcinoma, of, the, Lung, Findings, symptoms, findings, causes, mnemonics, review, what is, video, study, Rapi...  
youtube.com
over 5 years ago
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0
8

Squamous Cell Carcinoma of the Lung

http://usmlefasttrack.com/?p=6064 Squamous, Cell, Carcinoma, of, the, Lung, Findings, symptoms, findings, causes, mnemonics, review, what is, video, study, R...  
youtube.com
over 5 years ago
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0
8

Small Cell (Oat Cell) Carcinoma of the Lung

http://usmlefasttrack.com/?p=6065 Small, Cell, (Oat, Cell), Carcinoma, of, the, Lung, Findings, symptoms, findings, causes, mnemonics, review, what is, video...  
youtube.com
over 5 years ago
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0
0

Small Cell (Oat Cell) Carcinoma of the Lung - YouTube

http://usmlefasttrack.com/?p=6065 Small, Cell, (Oat, Cell), Carcinoma, of, the, Lung, Findings, symptoms, findings, causes, mnemonics, review, what is, video...  
youtube.com
over 5 years ago
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0
21

Bronchial & Bronchioloalveolar Adencocarcinoma of the Lung

http://usmlefasttrack.com/?p=6063 Bronchial, &, Bronchioloalveolar, Adencocarcinoma, of, the, Lung, Findings, symptoms, findings, causes, mnemonics, review, ...  
youtube.com
over 5 years ago
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0
0

Bronchial & Bronchioloalveolar Adencocarcinoma of the Lung - YouTube

http://usmlefasttrack.com/?p=6063 Bronchial, &, Bronchioloalveolar, Adencocarcinoma, of, the, Lung, Findings, symptoms, findings, causes, mnemonics, review, ...  
youtube.com
over 5 years ago
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0
28

Lung Cancer - Overview

http://usmlefasttrack.com/?p=6062 Lung, Cancer, -, Overview, Findings, symptoms, findings, causes, mnemonics, review, what is, video, study, Rapid Review, Cl...  
youtube.com
over 5 years ago
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0
0

Lung Cancer - Overview - YouTube

http://usmlefasttrack.com/?p=6062 Lung, Cancer, -, Overview, Findings, symptoms, findings, causes, mnemonics, review, what is, video, study, Rapid Review, Cl...  
youtube.com
over 5 years ago
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0
28

Lung Conditions - Physical Finding

http://usmlefasttrack.com/?p=6061 percussion, fremitus, tracheal deviation, pleural effusion, atelectasis, spontaneous pneumothorax, tension pneumothorax, co...  
youtube.com
over 5 years ago
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0
0

Scientists at Mainz University identify a new population of regulatory T-cells

Discovery improves understanding of the cause of allergic asthma and may serve as an early diagnostic markerWhen the mucosal surfaces in the lungs of healthy people...  
medicalnewstoday.com
over 5 years ago
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0
0

Scientists identify a new population of regulatory T-cells

When the mucosal surfaces in the lungs of healthy people come into contact with allergenic substances, so-called regulatory T cells also known as Treg cells, are activated.  
medicalnewstoday.com
over 5 years ago