Heart Sounds Tutorial

Another free site with wonderful examples of various normal and abnormal heart sounds with matching physiological explanations. The animations are basic but clear. There is also a testing mode to make sure that you got it. Good revision for Year 3 to 5 students.

Testing, Testing, One, Two, Three...

You should by now be testing yourselves regularly to make sure that the material you are covering is moving from short-term to long-term memory. This website will help you do that by asking you to match structures to their name, and then label them yourself. Fifteen minutes each day should do the trick. Try it!

Aphorism

"Only two things are infinite, the universe and human stupidity, and I'm not sure about the former."

- Albert Einstein (1879-1955)

A Court Case

No, don't worry, I have not been taken to jail. Take a look here though and you will find a tongue in cheek argument between the sympathetic and parasympathetic systems. Rather fun way to learn. Enjoy!

Learn the Blood Supply of the Brain

This website looks primitive but it's a great way to revise the blood supply of the brain and spinal cord. I particularly liked the quiz mode. Try it out and let me know what you think.

Eye Simulator

This website is a great way to revise the movements of the eyes and test yourself on cranial nerve lesions. Rather clunky, but it works, provided you have Shockwave installed.

Medical Mnemonics

Generally speaking, I'm not very keen on mnemonics, as I find them rather difficult to remember (unless I think them up myself). This is very much the case with most of the ones on this website kindly pointed out to me by Stefan (Year 2 Medicine). There are a few good ones though and here are my favourites for Neuro and Head and Neck:

ObliqLiques cause lateral rotation of eyeball.

Action of the obliques is opposite to their names. Action of the rectii is rightly fitting to their names.
Both superiors cause intorsion and both inferiors cause extorsion.

Geniculate bodies: paired to respective colliculi SLIM:
Superior colliculi: Lateral geniculate body.
Inferior colliculi: Medial geniculate body.

Geniculate bodies: medial vs. lateral system MALE:
Medial=Auditory. Lateral=Eye.
Medial geniculate body is for auditory system, lateral geniculate body is for visual system.

Spinal tracts: Gracilus vs. Cuneatus: origin from upper vs. lower limbs Gracilus is the name of a muscle in the legs, so Fasciculus Gracilus is for the lower limbs.

Precentral vs. postcentral gyrus: motor vs. sensory Just an extension of the rule that anterior = ventral = efferent = motor.
The precentral gyrus is on the anterior side of the brain, so is therefore motor.

Olivary nuclei: ear vs. eye roles Superior Olivary nucleus: SOund localization.
· Inferior olivary nucleus is therefore the one for sight [tactile, proprioception also].

Pterygoid muscles: function of lateral vs. medial "Look at how your jaw ends up when saying first syllable of 'Lateral' or 'Medial' ":
"La": your jaw is now open, so Lateral opens mouth.
"Me": your jaw is still closed, so medial closes the mandible.

Bifurcation vertebral landmarks · A bifurcation occurs on 4th level of each vertebral column:
C4: bifurcation of common carotid artery
T4: bifurcation of trachea
L4: bifurcation of aorta

Deep tendon reflexes: root supply "1,2,3,4,5,6,7,8":
S1-2: ankle
L3-4: knee
C5-6: biceps, supinator
C7-8: triceps

Interesting Article

Daniel McKean (Year 2 medicine) has forwarded to me this interesting link from the New Yorker. We have much to learn....

Whole Brain Atlas

Those of you struggling to conceptualise the brain in three dimensions and to distinguish between T1, T2 and CT scan images, would do well to peruse this web site. Great images and a good place to test your knowledge of normal brain structures as well as abnormal situations. Well worth a visit.

Great Student Blog

I came across this blog while looking for evidence that getting students to do dissections themselves improves exam performance. Suggest you scroll through some of the past entries: they are well worth the read.

Missing for a While...

Yes I know I have been too busy to keep this up, but here it goes again. For those of you who need a good revision of the cranial nerves, take a look here.

Interesting Medical Blogs

Once you start blogging, you begin to realise how much good stuff there is out there. Take a look at the BMJ blog. There is something for everyone.

Cinemeducation: Wit

The next movie to be screened is called Wit. It will be shown on Wednesday Nov 21 at the KSU Common Room at 2.30 followed by a discussion at 4pm. Times will be confirmed later. If you can't make it for the screening but wish to join the discussion, contact Daniel Azzopardi at MMSA. I will post some links to the movie later. It's a great movie. Don't miss it.

Biochemistry That Matters

but that apparently you have not covered yet....

A patient with familial hypercholesterolaemia undergoes a detailed serum lipid and lipoprotein analysis. Studies demonstrate elevated cholesterol in the form of increased LDL without elevation of other lipids. This patient's hyperlipidemia is best classified as which of the following types?

A. Type 1
B. Type 2a
C. Type 2b
D. Type 3
E. Type 5

The correct answer is B.

Hyperlipidemia has been subclassified based on the lipid and lipoprotein profiles. Type 2a, which this patient has, can be seen in a hereditary form, known as familial hypercholesterolemia, and
also in secondary, acquired forms related to nephritic syndrome and hyperthyroidism. The root problem appears to be a deficiency of LDL receptors, which leads to a specific elevation of cholesterol in the form of increased LDL. Heterozygotes for the hereditary form generally
develop cardiovascular disease from 30 to 50 years of age. Homozygotes may have cardiovascular disease in childhood.

Type 1 (choice A) is characterized by isolated elevation of chylomicrons.

Type 2b (choice C) is characterized by elevations of both cholesterol and triglycerides in the form of LDL and VLDL.

Type 3 (choice D) is characterized by elevations of triglycerides and cholesterol in the form of chylomicron remnants and IDL.

Type 5 (choice E) is characterized by elevations of triglycerides and cholesterol in the form of VLDL and chylomicrons.

Physiology Question Explanation

Only one of you attempted this question, which actually is extremely important. Hence it's worth re-stating together with the explanation for all you clinical students out there.

A 26-year-old man is admitted through the emergency department to the hospital for a heroin overdose. His heart rate is 45 beats/min, and his blood pressure is 75/40 mm Hg. Which of the following best depicts the results from an arterial blood sample ?

pH PaCO2 (mm Hg) HCO3- (mEq/L)
A. 7.22 66 26
B. 7.34 29 15
C. 7.40 40 24
D. 7.47 20 14
E. 7.49 48 35

The correct answer is A.

This man has a respiratory acidosis. Overdose with drugs that suppress ventilation (e.g., heroin, morphine, barbiturates, methaqualone, and "sleeping pills") often causes hypercapnia. In patients with an intact renal response, the respiratory acidosis causes a compensatory rise in plasma HCO3-, which lessens the fall in pH. However, the renal response requires several days to develop fully. The plasma HCO3- of 26 mEq/L (normal: 22-28 mEq/L) for this man is typical of acute respiratory acidosis with little or no renal compensation.

Choice B reflects metabolic acidosis.

Choice C is normal.

Choice D reflects respiratory alkalosis.

Choice E reflects metabolic alkalosis.

Mastication Question

Question: Contraction of which muscles contributes most to the backward movement of the lower jaw during the process of mastication?

Answer: Mastication is a complex process involving alternating elevation, depression, forward movement, and backward movement of the lower jaw. The backward movement step is accomplished by the posterior fibers of the temporalis muscle.

The digastric helps to depress the lower jaw during chewing.

The lateral pterygoid helps to move the lower jaw forward during chewing.

The medial pterygoid helps to elevate the lower jaw during chewing.

The mylohyoid helps to depress the lower jaw during chewing.

Letter to God

Dear God,

As You undoubtedly know, there is a little argument down here about intelligent design and evolution. If You really did create us in a day, and if You ever find humans worth another try, there are a few anatomical modifications that we hope You might consider the next time around.

As it happens, Lord, some of the organs You included in the mix have not turned out so well. Tonsils and appendixes don't seem to be especially useful apart from keeping surgeons occupied, or as clues to infection with "mad cow disease." And sinuses. Even if they do lighten the head, all they ever do is get infected. Couldn't we just have stronger neck muscles?

Our perversity in wanting to walk upright, when it is clear that this was not Your intention, has led to some real problems with our spines and leg joints. Would it be possible for You either to fix the pelvis at a right angle to prevent us from this error, or strengthen our weight bearing joints? We also hope You will anticipate our penchant for portable email devices by designing tiny little fingertips to operate the keys.

And the aesthetically splendid symmetry—could You extend it even further? It would certainly cut down our problem with trauma and strokes to have each side of our brain perform exactly the same functions. The rest of the head is outstanding, as are the limbs, but when we get into the thorax and abdomen, we have a few requests. You probably did not intend us to discard our diet of berries and nuts for fatty meats and pastries, but that's what happened, with disastrous consequences to our cardiovascular systems. Two hearts and a lipid-resistant lining to blood vessels would be just the thing (or give us an enzyme that transforms our preferred cuisine to harmless molecules).

We found out about alcohol, Lord, so it would be nice to have a liver (and maybe a pancreas) in reserve. Or You might remove the enzymatic chain that metabolises alcohol and make us too sick to consume it. Ditto for all the other drugs we seem so prone to abuse.

Thanks to Your gracious allotment of intelligence, we are on the verge of creating plenipotentiary cell banks, but there is a serious unresolved problem of individual compatibility. Somewhere—perhaps in redesigned sinuses, if for some reason You prefer that we keep them—there might be a little storehouse of such cells that could be tapped into when the need arises.

Despite the beautiful symmetry and economy of design with which we are blessed, it has occurred to us that the placement of our genital and excretory organs in such close proximity was either done to remind us of Original Sin, or because there did not seem to be a satisfactory anatomical alternative. Could You think about this? No obvious repositioning arrangement comes to mind, but some kind of retractable underarm mechanism might be practical.

In fact, this whole survival of the species thing deserves some rethinking. The delicate balance between the pleasures of sex and the pain of reproduction has been an issue for our womenfolk, who have borne the brunt of the pain. Maybe if they were given only two or three eggs together with a comfortable course of pregnancy and childbirth, the need for an endless succession of menstrual periods and the hot flushes of menopause could be eliminated without endangering our continued existence here on earth.

We hope, Lord, that You do not take offence at these suggestions, which are offered in all humility from creatures who surely do not fully understand the reasons that went into Your marvel of design, from its coating of skin to its molecular engineering, and we are truly grateful for Your efforts on our behalf.

PS: We know You have a sense of humour, Lord, but could you please do something about adolescence?

---

Paul Brown, BMJ, June 2006

Medical Maltese

Attention ALL international students. Today is your last chance to register for the crash course in Medical Maltese starting Wednesday. Classes will be held at the Medical School (SLH for 2 weeks, then transferring to MDH) from 2 to 3.30pm.

Be there or be square....

Muscles of Mastication

Some of you appeared confused by the muscles of mastication last week. Try this one:

Contraction of which of the following muscles contributes most to the backward movement of the lower jaw during the process of mastication?

A. Digastric
B. Lateral pterygoid
C. Medial pterygoid
D. Mylohyoid
E. Temporalis

Correct answer and explanation next week.

Achieving Your Childhood Dreams

"Achieving Your Childhood Dreams", the inspirational and moving "Last Lecture" given by Professor Randy Pausch (www.randypausch.com) at Carnegie Mellon University (Sept 2007).

Have patience with the intro….it’s worth it.

Surgery Question

Must not forget our third year students struggling with surgery. Here is one for you:

Crohn's disease:

A. Is caused by Mycobacterium paratuberculosis.
B. Is more common in Asians than in Jews.
C. Tends to occur in families.
D. Is less frequent in temperate climates than in tropical ones.
E. Is improved by smoking.

Physiology That Matters (Almost Medicine)

A 26-year-old man is admitted through the emergency department to the hospital for a heroin overdose. His heart rate is 45 beats/min, and his blood pressure is 75/40 mm Hg. Which of the following best depicts the results from an arterial blood sample ?

pH PaCO2 (mm Hg) HCO3- (mEq/L)
A. 7.22 66 26
B. 7.34 29 15
C. 7.40 40 24
D. 7.47 20 14
E. 7.49 48 35

Correct answer and explanation will be posted next week.

Biochemistry That Matters

And for those of you more interested in biochemistry, here is another:

A patient with familial hypercholesterolaemia undergoes a detailed serum lipid and lipoprotein analysis. Studies demonstrate elevated cholesterol in the form of increased LDL without elevation of other lipids. This patient's hyperlipidemia is best classified as which of the following types?

A. Type 1
B. Type 2a
C. Type 2b
D. Type 3
E. Type 5

Neurophysiology

Just to prove that this site is about more than anatomy, here is a neurophysiology question for Year 2 students:

Administration of an experimental drug that acts on PNS myelin is shown to increase the space constant of an axon in a peripheral nerve. Action potentials traveling down the axon would be predicted to be

A. faster
B. larger
C. slower
D. smaller
E. unchanged

Correct answer and explanation will be posted next week.

Coming Clean on Hand Hygiene

An interesting study conducted in part by your fellow students. Would be good to repeat this at MDH in a few months.

Introduction: Hand hygiene is universally recognized as one of the most effective ways to reduce the cross-transmission of hospital acquired infections. Successful strategies to improve hand hygiene compliance require a baseline knowledge of hand hygiene practices.

Methodology: A direct observational method was used to collect data about hand hygiene practices amongst medical doctors by a group of trained medical students during their clinical assignments. To prevent any bias during the observation, the purpose of the study was not disclosed to the doctors; they only knew that they were being observed for infection control practices. A structured data collection sheet was used to direct the observations. Data on hand hygiene practices was collected during routine clinical work over a number of weeks. Observers recorded the professional grade of physician observed, speciality, location, activity performed, method used, and facilities available.

Results: A total of 898 observations were recorded. Overall compliance before and after doctor-patient contact was 22.7% and 33.5% respectively. Within specialties, hand hygiene practices were lowest in obstetrics and gynaecology and highest in specialized surgical units. Poorest compliance was evident in house officers before patient contact, while the most compliant was the registrar group, following examination. Alcohol hand rub was the preferred method in the wards whilst hand washing was mainly utilised in the outpatient setting.

Conclusion: Hand hygiene amongst doctors in St Luke’s Hospital is low and could be a factor in the high MRSA endemicity.

S Chetcuti, M Montefort, E Scicluna, M Borg, Malta Medical Journal, Sept 2007

Cranial Nerve Quiz

Which cranial nerve exits the skull base at the pars nervosa of the jugular foramen?

Quiz Response

Closure of the neural tube occurs around day 26 of embryonic life.

As the neural tube forms, the closing process is critical, occurring from the cranial to the caudal end as the anterior neuropore closes around day 24, the posterior around day 26. This is a critical event, as defects in closure may result in spina bifida or other neural tube defects. The risk of a neural tube defect can be decreased by folic acid supplements.

Lubricating Plastic Specula Does Not Affect Microbiology

The widespread practice of not lubricating plastic vaginal specula because of fears of interfering with bacteriological sample processing has been shown to be invalid. A water based lubricant, Aquagel, had no effect on colony counts when different dilutions of Neisseria gonorrhoeae were cultured, nor did the gel alter the results of standard assays for Chlamydia spp. Without lubrication, plastic specula are more difficult to insert and cause more discomfort, so they should no longer be used in this way.

L Kozakis, J Vuddamalay and P Munday Sex Transm Infect 2006;82: 263-4

Duties of a Doctor

Teaching, training, appraising and assessing doctors and students are important for the care of patients now and in the future. You should be willing to contribute to these activities.


If you are involved in teaching you must develop the skills, attitudes and practices of a competent teacher.


You must make sure that all staff for whom you are responsible, including locums and students, are properly supervised.


You must be honest and objective when appraising or assessing the performance of colleagues, including locums and students. Patients will be put at risk if you describe as competent someone who has not reached or maintained a satisfactory standard of practice.


You must provide only honest, justifiable and accurate comments when giving references for, or writing reports about, colleagues. When providing references you must do so promptly and include all information that is relevant to your colleague’s competence, performance or conduct.
Good Medical Practice, GMC, 2006

HPV vaccination campaign to go ahead

The UK Department of Health has confirmed that girls aged between 12 and 13 will be routinely vaccinated in an annual human papillomavirus (HPV) immunisation programme from next September. There will also be a two-year catch-up campaign, starting in autumn 2009, for girls up to 18 years.

The decision is directly in line with the advice of the Joint Committee on Vaccination and Immunisation (JCVI), which reviewed the issue in June.

This vaccination is available in Malta at a cost of approximately LM180 for the whole course.

Embryology Resources

A day by day and week by week review of embryological terms with graphical representations from the University of Pennsylvania.

Another one from the University of Cincinnati College of Medicine. In order to play the animations, you need to save them to your computer.

Surgery Quiz Questions for the USMLE

Preparing for the United States Medical Licensing Exam Step 1, 2 or 3 is difficult, time-consuming, and anxiety-provoking. Knowing the information cold is the best way to ace the test. Although the test is multiple-choice, studies have shown that being able to answer unkeyed questions shows a higher level of mastery of the material. Try these to see how you are doing...

High Power Microscopy is Low Power Histology

In the histology lab, a common mistake is to "zoom" right into every tissue. Make sure you spend time with your low-power objectives ... this strategy will really pay off during the exams. Check out the histoweb site for a good overview of why histology matters.

Skeleton and Skull Self-Test

For those of you still unsure of the names of all those cracks and holes, here is a self-test.

Doctors' Gadgets

Doctors' Gadgets covers the latest advances in personal technology for doctors. You will find complete reviews on the latest handheld computers and medical software. Enjoy!

The Duties of a Doctor Registered with the General Medical Council (UK)

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:

• Make the care of your patient your first concern
• Protect and promote the health of patients and the public
• Provide a good standard of practice and care
• Keep your professional knowledge and skills up to date
• Recognise and work within the limits of your competence
• Work with colleagues in the ways that best serve patients' interests
• Treat patients as individuals and respect their dignity
• Treat patients politely and considerately
• Respect patients' right to confidentiality
• Work in partnership with patients
• Listen to patients and respond to their concerns and preferences
• Give patients the information they want or need in a way they can understand
• Respect patients' right to reach decisions with you about their treatment and care
• Support patients in caring for themselves to improve and maintain their health
• Be honest and open and act with integrity
• Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk
• Never discriminate unfairly against patients or colleagues
• Never abuse your patients' trust in you or the public's trust in the profession.

You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

I have been registered with the GMC since 1981. More aspects of good practice will follow......

Renal Physiology

Another FREE site developed by medical students which summarizes the important aspects of renal physiology. Covers:

· Renal Handling of Sodium and Potassium

· Urinary Concentration & Dilution

· Diuresis & Diuretics

· Acid-Base Balance

· Divalent Cations

Take the quiz at the end.

Attention Year 2 Students

Closure of the neural tube occurs on around which day of embryonic life?

a) 26
b) 38
c) 56
d) 74
e) 90

Answers here please. Correct answer will be posted next week.

Attention Year 1 Students

Most fascia of the body that attach to bones attach by which of the following mechanisms?

A. Blending with the covering periosteum
B. Inserting deeply into the cancellous bone
C. Inserting deeply into the cartilage
D. Inserting deeply into the diaphysis
E. Inserting deeply into the marrow

Answers Here please. Correct answer and explanation will be posted next week.

Attention Year 1 and 2 Students

A 25-year-old female presents to her obstetrician after taking a home pregnancy test with a positive result. She states that twins run in her family and would like an ultrasound to determine if she has a twin pregnancy. Splitting of the embryo at the blastocyst stage results in which of the following?

A. Conjoined twins
B. Dizygotic twins
C. Fraternal twins
D. Monozygotic twins
E. Single gestation

Post your answers here. I will post correct answer on Friday.

Lumbar Puncture

Another FREE site regarding the Lumbar Puncture. Covers

INDICATIONS

CONTRAINDICATIONS

ANATOMY

SURGICAL PLANES

EQUIPMENT

PROCEDURE

SPECIMENS

COMPLICATIONS

TREATMENT

QUIZ

Eczema Link to Asthma is Weak

Only a minority of children with atopic eczema go on to develop asthma in later childhood, Dutch researchers have found.

Looking at 13 prospective cohort studies, they reported the pooled odds ratio for the risk of asthma after eczema was 2.14.

van der Hulst and colleagues reported that: 'Although there is an increased risk of developing asthma after eczema in early childhood, only one in every three children with eczema develops asthma during later childhood. This is lower than previously assumed.'

J Allergy Clin Immunol 2007; 120: 565-9

Attention Years 1 & 2 Students: Embryology Question

The heart of an embryo first begins beating at which of the following ages?

A. 2 weeks

B. 3 weeks

C. 4 weeks

D. 6 weeks

E. 8 weeks

NB: Your final exam questions will be True/False and NOT MCQs as above.

Your Answers please.

Attention Year 2 Students: Neuroanatomy Question

A neuroscientist is investigating the development of the nervous system. In his experiments, he microinjects a dye into the embryo of an animal subject in vivo. After birth, he performs histological studies to determine the destination of the dye. In one animal subject, he locates the dye in the dorsal horn of the spinal cord. Which of the following locations in the embryo was the most likely site of the injection?

A. Alar plate

B. Basal plate

C. Neural crest

D. Rostral end of neural tube

E. Sulcus limitans

NB: Your final exam questions will be True/False and NOT MCQs as above.

Your Answers please. I will post correct answers on Friday.

Quote of the Day

Great minds discuss ideas.
Average minds discuss events.
Small minds discuss people.

Anonymous

Quiz Results

1. The neurovascular bundle passes deep to the internal intercostal muscles. True

2. The foramen spinosum transmits the middle meningeal artery. True

3. The dura is neuroectodermal in origin. True

Most of you got this last one wrong. Google the words neuroectoderm and dura and you will find information about a rare tumour called Ewing's Sarcoma.


4. The spinous processes of the thoracic vertebrae allow easy introduction of needles between the vertebrae.

False. This is why a lumbar puncture in the thoracic spine would be difficult. In any case, the spinal cord would be at risk.

Blood Pressure Predicts Type 2 Diabetes in Women

Baseline BP and BP progression independently predict incident type 2 diabetes in women. Researchers followed up 38,172 women over 10.2 years, over which time 1,672 developed type 2 diabetes. Classifying women into four BP categories (<120/75mmhg;>

Eur Heart J 2007

Look here if you want to know more about diabetes in Malta.



Themis

Medical Interventions That Failed the Test of Time: Advice to Lay Sleeping Babies on their Fronts

Dr Benjamin Spock first published "The Common Sense Book of Baby and Child Care" in 1946. Dr. Spock's reputation was damaged by one profoundly incorrect and ultimately tragic piece of advice. Believing that the risk of aspiration would be reduced if babies slept face down, Spock initially equivocated on the advice of sleeping position for babies. The 1955 edition of his book recommended that a baby sleep on its back, but the 1956 edition and subsequent editions until 1978 recommended that parents place their sleeping babies face-down. This advice is believed to have contributed to the deaths of many thousands of children from sudden infant death syndrome (SIDS). Widespread programmes to reverse the advice in the 1990s saw a dramatic fall in the numbers of cases of SIDS.


Yet, at a time of rigid expectation of infant and child behaviour, Spock spoke of flexibility and individuality. He reassured parents of the value of their own parenting skills and that cuddling their crying babies would not damage them for life.

Fifty million books, 39 countries, millions of babies comforted when they might have been left to cry - and one piece of incorrect advice.

Dr Jon Fogarty

For the record, I followed Dr. Spock's advice for my first child (born 1990), but put the next two to sleep on their backs. Themis

Skull Osteology Quiz

Attention Year 2 students!

You should be able to answer all these questions by now.

Medical Interventions That Failed the Test of Time: Deep Sleep Therapy and Psychosurgery

From insulin-induced comas for the treatment of depression to deep sleep therapy for anxiety and obsessive-compulsive disorder, patients suffering from psychiatric disease have intermittently faced a minefield of iatrogenic disasters.


Between 1962 and 1979, at Chelmsford Hospital in Sydney, Australia, 26 patients died as a direct result of deep sleep therapy and 22 committed suicide after treatment. The Medical Journal of Australia in 1973 published a review by Dr Bailey of 150 cases of 'cingulotractotomy', his preferred version of psychosurgery.

Dr Jon Fogarty

Whatever next......
Themis

Spine Trauma

Another FREE site. Learn how to:

- Determine whether there is spinal cord involvement in a trauma patient;
- Recognize the different injury patterns on imaging studies.

The site contains interactive material including:
· ANATOMY
· EPIDEMIOLOGY
· SPINE RADIOGRAPH INTERPRETATION QUIZ
· CASE SCENARIOS
· SPINE RADIOGRAPH INTERPRETATION
· PRACTICE GUIDELINES
· DETERMINING SPINE STABILITY
· IMMOBILIZATION & TRACTION DEVICES

Take the Test

Year 1 students check out directional terms and bone.

Year 2 students: You should be able to answer most questions on the axial skeleton and skull by now.

If not, time to study....

Evidence Based Medicine Modules from BMJ Learning

If you want to improve your understanding of statistics or diagnostics tests BMJ Learning provides helpful modules:
Understanding statistics
Understanding statistics 2: is there a significant difference?
Understanding statistics: tips for hospital doctors (Interactive case history)
What's a good diagnostic test?
How to organise a research project from scratch? (Read, reflect, respond)
These modules are free but you have to register. BMJ Learning also provides a range of other up to date, high quality, clinical and non-clinical learning modules.

Is Dirt Good for the Immune System?

We all know that our immune antibody responses are specific to the particular antigen invading our body. However, our immune response is also geared for non-specific protection. For example, activated macrophages induced by salmonella can also attack other intracellular pathogens such as listeria.

A recent study in mice showed that even latent infection by herpes induces a prolonged stage of macrophage activation that gives protection from other infections. Keeping the immune system alert like this may therefore confer benefits.

Does a higher antigenic load lead to a better and more mature immune system?

Emil R. Unanue. NEJM 2007; 357: 1345

Medical Interventions that Failed the Test of Time: Colectomy to Treat Epilepsy

Throughout much of history, epilepsy has been attributed to divine or satanic forces. The rush to science in the early years of the 20th century led to the 'discovery' of so-called Bacillus epilepticus , an organism said to reside exclusively in the colons and blood of epilepsy sufferers.


Variously referred to as epilepticoccus, streptobaccillus and neurococcus, the organism was described as 'actively mobile' and present in the blood of a patient immediately following a convulsion, but absent in non-ictal periods.

In a determined effort to rid patients of the offending and apparently guilty organism, they were submitted to vaccines, enemas and ultimately colectomy for resistant cases.

Dr Jon Fogarty

Do you have any idea of the prevalence of epilepsy in Malta?

Themis

Medical Inventions that Failed the Test of Time: Prolonged Bedrest after MI

Just as there have been many history-changing medical discoveries and inventions, there have also been ideas that shone brightly for a time and then, thankfully wilted in the glaring light of the retrospectoscope.

There is an inherent logic to the tradition of advising bedrest, even prolonged bedrest, after myocardial infarction (MI). After all, if a broken leg were to rest in a cast for six weeks, and tuberculous lungs were treated with convalescence in remote sanitoria, did it not follow that the damaged heart should also be rested? By lying still and avoiding physical stress, the ischaemic and tremulous myocardium might recover to beat again.

In this model, popular until the 1960s, the post-infarct patient would lie prone for as long as six weeks, forbidden ('doctor's orders') from attending to their own bathing or even brushing their hair. If urinary retention, DVT or pulmonary embolus should spoil the party, this was the price to be paid. Moves to allow post-MI patients to be nursed sitting out of bed, promoted first in the American Journal of Nursing by Drs Mitchell, Lown and Levine in the 1950s, were seen as radical.

Today, patients who have had a coronary artery bypass graft or new aortic valve are not only out of bed within a few days, but back at home and stumbling to the local gym for rehabilitation.

What a change a few decades makes.

Dr Jon Fogarty

Thought For the Day

Great thinkers have always encountered opposition from mediocre minds.

Albert Einstein

Would a Blog Create a Breach of Trust?

Question: I am thinking of starting a blog to record my experiences as an FY1 doctor, as I think it would be interesting for medical students to know what to expect when they qualify. I wanted to include anonymised descriptions of some of my more interesting patients, but one of my colleagues told me I could get into trouble if I don't get their consent. Should I go ahead?

Answer: Confidentiality is central to trust between doctors and patients, and respecting patients' right to confidentiality is one of your core duties as a doctor. Without proper assurances about confidentiality, patients may be reluctant to give doctors the information needed to provide good patient care. The fact that you are planning to write up the more interesting cases increases the likelihood that the details will be identifiable in some way, even if you attempt to anonymise them.

In its Frequently Asked Questions publication that accompanies its core 2004 guidance on confidentiality, the General Medical Council (GMC) says: "It is very difficult to anonymise case studies fully, especially if they are of interest because they deal with a rare condition, or the detailed history of a patient with mental illness. For this reason, you must obtain express consent from patients before publishing personal information about them as individuals in media to which the public has access ... whether or not you believe the patient can be identified. Express consent must therefore be sought to the publication of, for example, case-histories about, or photographs of, patients."

When obtaining consent, you must make sure that patients are given enough information on which to base their decision, including how much information will be disclosed and to whom, the reason for the disclosure, and any likely consequences. It may be safest to let patients see, and expressly agree (subject to necessary amendments), the exact text that is intended to be used.
If you include details that could identify a patient to a third party without first obtaining consent from the patient, then you will have breached your duty of confidentiality, even if this was not your intention. If a patient finds out and makes a complaint about a breach of confidentiality on your blog, you risk disciplinary action by your trust or the GMC, and it may be difficult to justify your actions in accordance with the GMC's confidentiality guidance.

Dr Norwell, Medico-legal adviser at the Medical Defence Union.

I will take this advise and so should you....

He Who Can, Does. He Who Can't, Teaches

This oft quoted phrase harks back to George Bernard Shaw (1903). However, Shaw was referring to revolutionaries, not teachers, so perhaps the phrase is used out of context. Charles H. Mayo, one of the founders of the Mayo Clinic once said: "The safest thing for a patient is to be in the hand of a (wo)man involved in teaching medicine. In order to be a teacher of medicine, the doctor must always be a student."

E-Anatomy

This is a FREE anatomy e-learning web site. More than 1500 slices from normal CT and MR exams were selected in order to cover the entire sectional anatomy of the human body. A user-friendly interface allows you to glide through multi-slice image series combined with interactive textual information, 3D models and anatomy drawings. Year 2 students look at Face CT and Brain MR. Year 1 students look at Lung and Mediastinum. It's worth registering to get full screen access. Remember: this is the anatomy you will be "seeing" in your clinical years, so get used to it!

Anatomy from Berkeley

I have come across an excellent series of FREE lectures from the University of Berkeley by Prof. Diamond on the functional anatomy of the human body as revealed by gross and microscopic examinations. These are available for download as videos or podcasts.

Spinal Nerves

Some of you have been struggling with the concepts of spinal nerves, roots and rami. Click here to download a short slide show that I prepared for another class. Let me know through comments if this is helpful. This show will be deleted on October 19.

Anniversary

It’s my first anniversary: one month since I started blogging. I had heard of blogs before, but I had never read one. Having looked around Blogger, I can see that most are written by young people (well, I’m young at heart!), and most seem to be a sort of modern-day diary: You write about what you have been doing and the random thoughts crossing your mind. I need to try this out.

Perhaps the best way would be to give you an idea of my (almost typical) weekend. Went to Birgu on Friday night with a few friends. Good thing we took a taxi because there was absolutely nowhere to park. The streets were all beautifully candle-lit. The WW II atmosphere evoked by the architecture and lighting clashed with the loud pop and rock music emanating from the piazza below. Dean Martin would have been so much better. So off we went to the Marina to pick up a water taxi to the waterfront (LM 4 for a 5 minute trip one way!), where we had a lovely meal and excellent wine (LM 14 pp including tip). Taxi home (LM 15 for 3 people both ways). Saturday I woke early, as usual, and stepped off for a brisk walk before waking up P to take him down to B’bugia where his father is escaping reality (he calls it writing a book). P is taking the PSAT on Wed and needs all the practice he can get. His dad is much better with him than I am, so there he goes. Back to Sliema for usual Saturday morning clinic, and then off to buy some vegetables and pick up J from his sleep-over. Must have been quite a night, because it was midday and he was still asleep. Anyhow, managed to drag him home to eat something before setting off for basketball practice.

A hour to kill: get the grocery shopping done. Home to deposit the shopping, then off to Mosta for another party and sleep-over (the social life of an 11 year old is mind boggling). Off to Bugibba to give a short talk on Cinemeducation and Community Service at TRD. Short chat to MMSA reps all looking a little worse for wear: it’s not clear to me whether the point of TRD is to listen and learn or to party. In any case, had a little chat about RCSI: It’s amazing how much effort they have put into this already. Then back to B’bugia to pick up P, who has had a full day of “work” and wants to be taken back to Sliema for a sleep-over.

Finally home at 8pm. Just my mother and I for dinner. Settled down in front of the computer to watch a wonderful film called “Wit” starring Emma Thompson. I think I shall recommend this movie for the next Cinemeducation. It’s a real tear jerker. Sunday morning: another brisk walk, then off to pick up J from sleepover. One hour later, take P to his guitar lesson (who gives lessons on Sundays??). Then cook lunch and off to B’bugia again, so that P can do some more work with his dad while I potter around the house sorting out all the bits and pieces that happen when men are left alone in a kitchen. It’s OK we have been married for 20 years: he’s a great cook, but the cleaning-up leaves a little to be desired. Back home to sort out dinner and get ready for weekly call to child no 1 who is studying in the US.

Skype is wonderful: she plugs in her webcam so I can see how bad the acne is this week (pretty good, actually) and observe first-hand the terrible disaster that has befallen her phone (face plate is cracked). Can I buy a new phone, she asks. You can imagine the rest of the conversation. We sorted out one of her college applications and went over her grades online. Imagine this: I can log onto her (state, not private) school’s website and check exactly how she did in all the homeworks, quizzes and tests she has had since school started in August. Not bad: mostly A’s and B’s. Reminded her to make an appointment for an eye exam and to eat well. Love you!

Well, I enjoyed that little piece of writing. Almost feels cathartic. Perhaps that’s why people blog. I think I will do this again. I’m thinking of a Clinic of the Week…..

For Those of You Who are Unsure About What You are Doing Here

If it were not for the great variability among individuals, medicine might as well be a science and not an art. William Osler, 1892

Is There a Need for a Chest Pain Observation Unit and Will it be Cost Effective?

Studies from the USA suggest that using an A&E department based chest pain observation unit (CPOU) saves from $567 to $2030 per patient compared with hospital admission. In the UK cost effectiveness figures are lower at around 78 per patient. This study aims to review current practice for patients presenting with chest pain in St.Lukes Hospital (SLH), to determine the proportion of patients suitable for CPOU evaluation and consequently calculate any related cost effectiveness. Methods: 236 patients presenting with a primary complaint of chest pain to the A&E department at SLH between 1st June and 12th July 2003 were selected. The case histories of these patients were reviewed to ascertain how many of them would qualify for a CPOU management and specific data was collected. Results: Notes were retrieved for 217 patients. A total of 103 (47.5%) patients were suitable for a CPOU management. Mean length of in-hospital stay of these patients was 67.5 hours. Estimated mean cost saving per patient was LM220 and overall LM 19,800 per month. Conclusion: Potential exists for the setting up of CPOU care to reduce health service costs and improve health utility at St.Lukes Hospital. Cassar et al, 2004 Malta Medical Journal 17 (04): 26 - 29.

Poll Results and EBM

Judging from the albeit small number of votes on this week’s poll, it seems that the least useful aspect of what you find here are journal articles. This is not surprising: you are still learning the basics, so why should you bother with journals? Those of you who came to the Fresher’s week introductions might recall my statement: “Welcome to the first day of the rest of your life”. It has taken most of you 2-6 years to get here, doing A levels and in some cases a first degree.

William Osler said “To cover the vast field of medicine in 4 years is an impossible task”. Think about the size of medical knowledge: There are 11,000 diseases and 3,200 drugs listed in Diagnostic Pro. If I wanted to brush up my knowledge it would take me 30 years, if I learned about one disease each day. Over 500,000 new articles enter Medline each year (1,500 per day), and 30,000 randomised controlled trials are published each year (95 per day). So how do we cope with this information overlaod? The answer was given clearly by Prof Cacciattolo at this year’s TRD: learn to read the literature, learn to sift the wheat from the chaff. But, I hear you ask, how should we learn this? Will this be taught in our medical course? Is there a course we can take, maybe something online? I have no idea (but you could start looking). I helped to run a course on Evidence Based Medicine together with a couple of family doctors a couple of months ago. If you are interested, post a comment here and we will see what can be done. In the meantime, keep a log book of answerable questions and read an evidence based journal.

Purple Urine

A 76-year-old male nursing home resident with dementia and end-stage renal disease who was undergoing hemodialysis was admitted to the hospital after a syncopal episode that occurred during dialysis. When a urinary catheter was placed, purple urine was drained. Read the full story.

Effectiveness of Chest Pain Units

Acute chest pain is responsible for one in four emergency medical admissions in the UK. Identifying which patients at low risk of acute coronary syndrome can be safely sent home and which patients need further observation and investigation is not easy, especially when the consequences of misdiagnosis include infarction, arrhythmia, and death. The strategy of evaluating such patients in a chest pain unit based within or near the emergency department is used in 30% of emergency departments in the United States. In theory, a chest pain unit should improve outcomes—but does it? The ESCAPE (effectiveness and safety of chest pain assessment to prevent emergency admissions) cluster randomised controlled trial (Goodacre et al, 2007) enrolled 14 hospitals, seven of which had a chest pain unit. In people admitted to hospitals with a chest pain unit, serial electrocardiography was performed over two to six hours, biochemical markers were measured, and an exercise treadmill test was performed. People admitted to hospitals without a chest pain unit received the usual service typically consisting of admission for troponin measurements over 12 hours, with no early exercise testing. The outcomes were measured the year before and the year after either the introduction of the chest pain unit or continuance of the same service. The introduction of a chest pain unit had no significant effect on the proportion of people attending the emergency department with chest pain, the proportion of people with chest pain who were admitted, or the number of people admitted over the next 30 days. Mike Clancy, BMJ 2007;335:623-624 (29 September)

Enough Said

After all is said and done, more is said than done.

Radiology Resources

Radiology is an essential part of today's practice of medicine. The skill of studying and deciphering radiological images can be greatly enhanced by visiting these websites.

Bones and Joints Lecture

Click here to download today's lecture on Bones and Joints. The audio starts automatically on the third slide. Please let me know through comments how this worked. As most of you will be at the MMSA TRD this weekend, this link will be deleted on October 16.

Risk of Cancer and the Oral Contraceptive Pill

Full assessment of the risk of cancer needs a long follow-up as effects of the pill may persist many years after its use has been stopped. Between 1968 and 1969, 45 950 women in the United Kingdom were enrolled in the study, and they were followed for a mean of 24 years. Incidence rates of cancer in women who ever used the pill were compared with rates in women who never used the pill. On balance, no higher risk of cancer was found in pill users. Risks were significantly lower for cancer of the colon or rectum, uterine body, or ovaries; the main gynaecological cancers combined (uterine body, ovaries, cervix); and for any diagnosis of cancer. The incidence of breast cancer was similar in pill users and never users. The results show that—in a developed country with an effective cervical cancer screening programme such as the UK—the pill is a safe contraceptive method with respect to cancer. In some developing countries—with inadequate cervical cancer screening and healthcare services, and high cervical cancer rates—the balance of cancer risk is probably less favourable.However, in such settings, contraceptive benefits must be weighed against the risk of cervical cancer, and the balance would tilt in favour of the pill because of the high morbidity and mortality associated with unplanned pregnancies.
Hannaford et. al., BMJ 2007 335: 651.

Sex Education Programmes 'not working': Rate of Casual Sex High but Condom Use is Low

Malta needed an "urgent re-appraisal" of its sex education and health promotion programmes, because year after year no improvement was being registered, warned Dr. Carabot, who runs the Genitourinary Clinic. Sexually transmitted diseases are steadily on the rise. In 2006, there were 10 cases of HIV (up from two cases in 2000), and gonorrhoea shot up to 32 cases (from 23 in 2005). The vast majority (on average 70 per cent) of GU clinic users never used contraception. Last year, 1,946 people attended the clinic, with 70 per cent of these being new patients. The report shows that 46 per cent described their partner as casual, while 67 per cent never used a condom. "This pattern of high casual sex with very poor condom use is persistent through the years. We must eventually recognise that our sex education and sexual health promotion efforts are simply not adequate and are not giving any positive results," the report said.

The Patient's Perspective

This site shows you a wide variety of personal experiences of health and illness. You can watch, listen to or read their interviews, find reliable information on treatment choices and where to find support. The site covers cancers, heart disease, mental health, neurological conditions, screening programmes, pregnancy, teenage health, chronic illnesses and many others.

DIPEx was voted by the Times as one of the top 3 patient health sites (2006), was in the Guardian's top 10 health websites (2004) and was singled out in a recent study (Times article March 2007) as a favourite, trusted site for patients.

An Audit of Natural Family Planning and Usage

The Cana Movement has been training couples in Natural Family Planning (NFP) methods for a number of years, in its efforts to support and to strengthen the Maltese family. J. Mizzi and colleagues conducted an audit to evaluate this education programme, including current use and perception of NFP methods. An anonymous postal survey was carried out among all those who took part in NFP courses between 1995 and 2004. Results are compared to data drawn from the Health Interview Survey (HIS) carried out by the Department of Health Information in 2002 on a representative sample of the Maltese population. The great majority of the NFP respondent population (62%) had been married for 5 to 10 years, and were mostly between 30 and 35 years. A large group of female respondents described themselves as housewives (49%). All women had achieved at least secondary education. The top two occupational groups among male respondents were professionals (20%) and skilled labourers (19%). 57% found NFP methods to be very reliable. This proportion peaks to 75% among 40-45 year old women. HIS figures show the three most popular family planning methods among 16 to 25 year olds and 26 to 35 year olds are NFP, condoms and withdrawal, with the latter method being the most popular in the older age group and condoms being preferred by the younger group. J. Mizzi et al Malta Medical Journal 15 Issue 1-2/suppl. (2003)

Reflections after Today's Faculty Board Meeting

Following the path of least resistance is what makes rivers and men crooked.

Six Second ECG Simulator

With all this talk of a new medical school that uses the latest in e Learning resources, it's nice to know that some of the best resources are free!

The Six Second ECG Simulator generates 22 of the more common cardiac rhythms for you to explore and learn. Think you got it? Then test yourself by playing the ECG Challenge. Learning can be fun (and in this case, it won't cost you $30,000 per year).

Secret Worlds: The Universe Within

View the Milky Way at 10 million light years from the Earth. Then move through space towards the Earth in successive orders of magnitude until you reach a tall oak tree just outside the buildings of the National High Magnetic Field Laboratory in Tallahassee, Florida. I lived right here for almost 12 years.

After that, begin to move from the actual size of a leaf into a microscopic world that reveals leaf cell walls, the cell nucleus, chromatin, DNA and finally, into the subatomic universe of electrons and protons. Amazing...

Tuskegee Study of Untreated Syphilis in the Negro Male

In 1932, the US Public Health Service began a study to record the natural history of syphilis in hopes of justifying treatment programs for blacks. The study involved 600 black men – 399 with syphilis, 201 who did not have the disease. The study was conducted without the benefit of patients' informed consent. Researchers told the men they were being treated for "bad blood," a local term used to describe several ailments, including syphilis, anaemia, and fatigue. In truth, they did not receive the proper treatment needed to cure their illness. In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance. Although originally projected to last 6 months, the study actually went on for 40 years.

The American people are sorry -- for the loss, for the years of hurt. You did nothing wrong, but you were grievously wronged. I apologize and I am sorry that this apology has been so long in coming.-- President William J. Clinton, May 16, 1997

Remnants of the Tuskegee Syphilis Study Effects on University Freshmen: Yet a Possible Barrier to Research Participation?

New Poll

Instead of anatomy questions, this week I would like you to vote for your top 3 reasons for accessing this blog. What do you find most useful? Please choose only 3 of the five options allowed (although the system will allow you to select all five).

Post a comment here to tell me what you think can be improved. What would you like to see more of?

Answers to Last Week's Questions

The primary motor cortex is located in the frontal lobe. True

Clinical Relevance: On the lateral aspect of the cortex is the poorly named "central sulcus". The cortex anterior to the central sulcus is the logically named "pre-central gyrus", the main motor area concerned with the initiation of voluntary movement. Look up the blood supply of this area.

The pelvic floor is under involuntary control. False

Clinical Relevance: The pelvic floor or diaphragm (levator ani) is a sheet of voluntary muscle. Apart from functioning as part of the anal and urinary sphincters, it supports the uterus and bladder. If damaged (e.g., childbirth), there may be problems with incontinence and prolapse of the uterus, rectum and bladder. Look up Keegel exercises.

Personal Comment

As a student, and even more often as a junior doctor, I was repeatedly told that the first step to learning is to accept ignorance.

Advice to Smokers

When I am asked, the advice I give to smokers is this: "As a physician I can tell you that if you smoke you will probably die of heart disease or cancer. If you don't smoke you will probably die of heart disease or cancer, but usually some years later. During the extra time non-smoking gives you, you may develop the infirmities, disabilities, illnesses, and aches and pains which go along with old age, and then die. My overall recommendation is not to smoke, however, because it really does increase the risk of dying from emphysema which is a very unpleasant way to die. As a taxpayer, however, I applaud your decision to smoke since you will probably be much less of a financial burden to taxpayers because you will die sooner. You might even be a financial asset to them if you time it right." Robert A Da Prato, physician

ECG Self Assessment for Students and Clinicians

Proficiency in electrocardiogram (ECG) interpretation is an essential skill for medical students, housestaff, and clinicians. However, current textbook and classroom instructional materials do not adequately integrate ECG interpretation into specific contexts where waveform findings must be correlated with other clinical data.

Harvard Medical School has produced this unique web-based tutorial. Makes a change from the traditional lecture format!

MJM Wardrounds

Useful set of podcasts on everything from important topics like pulmonary embolism to the arcane (vipers and ACE inhibitors), and lots more in between. Spoken in Queen's English, which makes a nice change from all that twangy American you find all over U tube!

Life and Death Game

Life and Death is a simulation. You play the role of a surgeon in a general hospital. Apparently you can examine patients and use X Rays to find out what's wrong with them. Then you can operate on the patients and face complications like bleeding and heart problems. The graphics seem rather primitive compared to what I see on my kids' playstation.

As a digital immigrant, I was not able to get this thing to work, but I'm sure you can.

If you are a DS fan, there's also Life and Death 2:The Brain. Apparently you can operate on patients using the touch screen.

Enjoy!

Listen to the Lancet

Audio summaries feature Lancet editorial staff discussing highlights from the week's issue, and usually include at least one interview with the author of a key paper. The Lancet also produces monthly audio summaries for The Lancet Infectious Diseases and The Lancet Neurology.

Listen to The Lancet here or subscribe to the RSS feed via your podcast aggregator.

McGill University Virtual Stethoscope

This site provides a virtual stethoscope interface for auscultating normal and abnormal cardiac and respiratory sounds as well as other material related to auscultation and cardiac and pulmonary physiology and pathophysiology.

Useful for medical students from year 1 onwards.

Can You Tell Crackles From Wheezes?

The Ohio State University College of Medicine and Public Health's Department of Family Medicine has developed an interactive web-based learning center designed to teach medical students the fundamental principles of physical examination.

Practice taking blood pressure, listen to breath sounds, do a fundoscopic examination, or if you are still a freshman, review cardiac physiology.

Teratogenic Medicines

A study published in the Annals of Internal Medicine shows that women who fill prescriptions for potentially teratogenic medicines are rarely counselled for contraception. Researchers assessed the prescriptions filled by almost 500,000 women in a large health maintenance organisation in California in 2001. They found that prescriptions for potentially teratogenic medications were filled by one of every six women studied. These women were no more likely to have received contraceptive counselling, filled a prescription for contraception, or to have been sterilised.

Ann Int Med 2007; 147: 370-6

Blogging Across the Disciplines

As the use of web logs (blogs) becomes increasingly popular, many faculty members have incorporated them into college courses to engage students in discussing course materials, to foster a sense of community, and to enhance learning. This study, conducted at a business institution, introduces blogs as a tool to help students prepare for meaningful classroom discussion. The authors assigned a similar blogging exercise in three different courses—expository writing, e-commerce, and government--in order to introduce students to the use of blogs in their disciplines. This study finds that by completing the required readings and then posting discussion questions and reflections on topics of interest to which their classmates can respond--essentially beginning the conversation prior to the class session--students become more engaged in the course material. This exercise requires students not only to read the required course materials but to engage with them critically in order to move beyond a superficial understanding of the materials. By using the same assignment and assessment tool in three different courses, the authors argue that blogs can be effective in enhancing class discussion across the disciplines.

Angelique Davi et al. Journal of Online Teaching and Learning, Sept 2007

New Version of "Who Moved My Cheese"

See comments on the original version below. Much more interesting from the medical point of view....

Answers to Last Week's Questions

A motor impulse from the cerebral cortex to the left quadriceps synapses on ventral horn cells in the spinal cord. True

Clinical Relevance: Cell bodies of lower motor neurons innervating voluntary muscle are found in the ventral horn. Disease of these cells e.g., poliomyelitis causes paralysis of voluntary muscle.

In adults the right main-stem bronchus is steeper than the left. True

Clinical relevance: Inhaled foreign bodies more often pass into the right main bronchus.

Key Questions in Public Health and Primary Care

Three key questions should be asked about a health care intervention:

Can it work? (Efficacy)
Does it work? (Effectiveness)
Is it worth it? (Efficiency)

Ask yourselves these three questions for every intervention you are asked to endorse.

Adapted from Anna Glasier, Lothian Primary Care NHS Trust

How To Do Just About Anything

There is a belief that while you can learn some skills, such as how to use a computer or drive a car, there are some which you either have or you don't have. The same is often thought about doctors: some seem to have a knack for diagnosis, are extraordinarily adept at practical procedures, or have a natural bedside manner. It was these kinds of beliefs that prompted a group of Californian psychologists in the seventies to ponder the question, "Why do some therapists have consistently excellent results with patients, while others do not?" They looked for the answer to this question by studying three of these excellent therapists: Milton Erickson, a psychiatrist and hypnotherapist; Fritz Perls, cofounder of Gestalt; and Virginia Satir, a family therapist. When they had distilled the factors that were essential for success, they named the resulting framework "neurolinguistic programming." They called the process "modelling," and from there came the premise: "If somebody can do something, anybody can. You just need to know how."

In this excellent article: http://careerfocus.bmj.com/cgi/content/full/335/7617/77-a, Anita Houghton shares a formula for success. See www.workinglives.co.uk