Monday, October 22, 2012

Medical Book Review - Mechanisms of Clinical Signs by Dennis, Bowen and Cho

Mechanisms of Clinical Signs
Mark Dennis, William Talbot Bowen, Lucy Cho
Churchill Livingstone Elsevier 2012
Paperback 515 pages RRP $75.00
A Student Consult title - full text searchable online (after registration).
Further information (including a sample chapter) available at: http://www.elsevierhealth.com.au/au/product.jsp?sid=&isbn=9780729540759&lid=EHS_ANZ_BS-DIS-1&iid

Thanks are due to Elsevier Australia for kindly providing a review copy of this book. The authors have crafted a gem of a book, which would not be out of place in any medical library, regardless of the seniority of the practitioner. It is all the more remarkable for being put together by three Resident Medical Officers (two Australians and an American), and this international approach serves to increase its utility.

Each chapter was reviewed by experts in the relevant discipline, and the authors explain the provenance of their research in a caveat concerning the rate of change of medical knowledge and the possibility of obsolesence of their work: "... the authors used reference texts as well as Medline, PubMed, Embase, SCIRUS and other databases - firstly to identify all relevant signs and secondly to find the most up-to-date information about them. Every attempt has been made to provide the reader with the most recent information, however ...".

The book opens with two separate Contents listings. The first is divided up by 'Signs' - Musculoskeletal, Respiratory, Cardiovascular, Haematological/Oncological, Neurological and Endocrinological. The second lists Contents by Condition. There is also a detailed Index at the back of the book. By working between these three resources, it is fairly easy to find what you are looking for. the actual layout of the book is in seven chapters, as per the categorisation of the 'Signs' above. Each chapter is followed by a list of references, and there is also a listing of picture credits preceding the Index at the back. A list of abbreviations is also provided prior to Chapter 1.

The degree of coverage of each sign is quite variable. Some are covered very briefly in just a couple of paragraphs, while others ('dyspnoea' for example) are given 2-3 pages, and figures, tables and flow-chart mechanisms sometimes provided. There is a consistent internal layout, in general consisting of 'Description', 'Condition/s associated with ...', 'Mechanism/s' and 'Sign Value'.

The emphasis of the book is very much on general (or 'internal') medicine, and as such does not offer an equal level of coverage for either paediatrics or obstetric medicine, but some signs are acknowledged as occurring in pregnancy and a brief discussion provided.

Taking COPD (chronic obstructive pulmonary disease) as an example, it is important to realise that this condition is a constellation of signs and symptoms, and this book is not designed to provide an overall pathophysiological mechanism (this is the province of other references on the market). Thus COPD is not listed as a respiratory 'sign', but in the 'Contents by Condition' index, there is fairly comprehensive coverage of many common signs which are associated with COPD. These are: dyspnoea, Harrison's sign, tachypnoea, pursed lips breathing, barrel chest, crackles, wheeze, hyperventilation, clubbing, intercostal recession, paradoxical respiration, hyper-resonance to percussion, vocal fremitus and vocal resonance.

It is probably useful to illustrate the contents by randomly choosing three signs to examine. The first one selected is 'clubbing'. Most medical students will tell you that the mechanism is not clearly understood, and the text acknowledges this. This section is clearly written, well set-out and useful. It commences with a picture of clubbing of the fingers and toes followed by a multi-point description, a listing of conditions commonly associated with clubbing, a survey of the current thinking regarding the underlying mechanism, a short flow chart ('mechanism') reflecting this thinking, a succinct summary concerning the 'sign value' and a table setting out the causes of bilateral clubbing by body system.

The second example is a 'relative afferent pupillary defect' (Marcus Gunn pupil). The chapter on neurological signs contains some extra material designed to assist the reader in the form of coloured boxes entitled "Relevant neuroanatomy and topographical anatomy", which demonstrate the relevant anatomical pathways. It would be fair to say that understanding this sign is commonly found to be challenging. An anatomical pathway is provided for both the afferent and efferent limb (but this does not go into detail as to whether parasympathetic or sympathetic fibres are involved) as well as a helpful diagram illustrating the appearance of the pupils with the 'swinging torch test'. The second page contains a further diagrammatical representation of the anatomical structures and pathways. The text sets out common and less common conditions associated with a RAPD, and then provides a short discussion of the mechanism and optic nerve disorders and retinal neuroepithelium disorders (rare), concluding with the 'sign value'. Having researched this topic when teaching it to students several months ago, I would reflectively say that this exposition, whilst clear and helpful to the novice, does not present the level of detail that I was looking for at the time. However, for a simple and superficial explanation it is more than adequate.

The third topic selected is haematemesis. I also recently researched this topic whilst reviewing a proposed clinical exam paper. This is covered in the gastrointestinal chapter as "Coffee ground vomiting/bloody vomitus/haematemesis". One and a bit pages are devoted to the topic. The text contains a description together with a list of more common and less common conditions associated with upper gastrointestinal bleeding. These listings are quite helpful, but as some examples of 'nitpicking', the generic term 'peptic ulcer disease' is used without explanation (and the 'upper GIT' is not defined either). Having been involved in teaching, I have come to appreciate that there are many commonly used terms that have a 'rubbery' understanding of what they actually mean, and that there is value in clarification in such cases. Where this section shines is in the explanation of the General Mechanism/s and specific explanations for peptic ulcer disease, Mallory-Weiss tears and oesophageal varices (including their relationship to portal hypertension). There are also simple mechanisms provided for a Mallory-Weiss tear and bleeding from oesophageal varices. The section concludes with the 'Sign Value', which provides helpful and pragmatic advice.

A book like this cannot be all things to all people. Some topics will provide you with a 'light-bulb moment' and others will leave you wanting more. It is however an invaluable resource, not only for the practitioner in terms of individual understanding of clinical signs, but also in providing clear, simple and comprehensible explanations that can form the basis of an authoritative explanation to patients and their carers. I can also see that it would have enormous utility in General Practice, where patients will randomly present with unfamiliar signs (particularly if you are a Registrar). It is the kind of book that we all really should read from cover to cover, "if only I had the time ..."!

Highly recommended. A good investment which will more than repay its purchase price over time.

Friday, October 19, 2012

St Francis' Choir sings Haydn's "Nelson Mass" at SS Peter and Paul

On Sunday 9 September 2012, St Francis' Choir (joined by orchestra and soloists) sung Haydn's "Nelson Mass" at the Church of Saints Peter and Paul in South Melbourne (http://www.sppchurch.org.au/). This was by invitation of the congregation to help celebrate an historic occasion for the church (the centenary of the new extensions).

On the St Francis' Choir Facebook page there is a photo gallery from the day and recordings of the Kyrie and Agnus Dei from the Nelson Mass.
https://www.facebook.com/pages/St-Francis-Choir/58534273651

For those without Facebook access, these recordings have now also been posted on YouTube:
Kyrie: http://youtu.be/-NV4_aRHI-w



Agnus Dei: http://youtu.be/ExDzRmT1z6I



It is my very favourite orchestral mass, and it was wonderful to have an opportunity to sing it again under such enjoyable circumstances.

Tasty treats at Tiamo!

Tiamo (03) 9347 5759
Tiamo2 (03) 9347 0911
Italian, Pizza, Mediterranean
303-307 Lygon St, Carlton
www.tiamo.com.au

A colleague and I recently lunched here on the recommendation of some of my students.

It is a little confusing in that there are two Tiamo restaurants, side by side, and depending on which menu you order from (you can order from either) the food will come from one kitchen or another. The menus offer mainly pasta, substantial main courses and pizza. We decided to order from the original Tiamo menu (Black) rather than the Tiamo2 menu (Red). As I cook a pretty mean Pasta Carbonara myself, I always like to try it in Italian restaurants to compare it to mine. As it turned out, my colleague also likes Carbonara, so he chose fettucini whilst I chose penne as the pasta base. Water was provided at the table as well as some fresh sliced and buttered bread. A pepper grinder was supplied on request.

Both pasta dishes were supplied reasonably promptly and were attractively presented in white bowls with flecks of parsley through the dish and a sprig of parsley and freshly grated parmesan cheese on top. Both the bacon and the egg were nicely cooked but not overly so, and still retained their moisture and freshness. There was a generous quantity of both, and the saltiness of the bacon well complemented the sweetness of the egg and the overall flavour was very moreish. The only criticism that I would have is that there was a bit too much cooking oil for my taste, with a pool left in the bottom of the dish as the other ingredients were consumed. However, other than aesthetically, this did not overly detract from the success of the dish. This problem was less apparent in my colleague's serving.

We both ordered a coffee - my colleague a flat white and a cappucino for myself. These were served in smallish white cups and were visually attractive, with caramel and cream-coloured swirls on top. Perhaps a little less than desirable in temperature, but my colleague downed his quickly without complaint and I enjoyed mine. It was a rich, creamy and smooth blend with no hint of bitterness and a subtle aftertaste; as such a cup of coffee that would suit most tastes.

The restaurant was a little noisy and very busy, but not overly so, and despite the fact that we were sitting not too far from the pizza ovens the ambient temperature was well-controlled. The wait-staff were attentive and helpful. I did book in advance, but gathered from the staff that this was normally not strictly necessary. There was certainly a constant stream of patrons entering both restaurants and there is also a reasonably large outdoor eating area on Lygon Street in front of both restaurants. I was waiting outside for my colleague for quite a while and I am pleased to say that although restaurant staff coming in and out and going between restaurants and looking after the outdoor area noticed I was there, I was not approached or hustled at all.

Verdict: Recommended.
This restaurant receives the Seal of Approval!



Tiamo on Urbanspoon

Tiamo 2 on Urbanspoon

Make your own coffee blend!

One of the fun things about being able to buy a variety of coffee beans at the supermarket is being able to experiment and make your own coffee blends as a 'home barista'!.

For this particular experiment I ground and mixed together equal ratios of the following three varieties of beans:
  • Harris Reserve Colombian High Altitude Grown 100% Arabica Coffee Beans;
  • Coles Dark Roast Coffee Beans; and
  • Harris Espresso Coffee Beans.
(All of these have previously been reviewed in this blog.)

What was the result? Well, here is a review of the blended coffee brewed in a plunger for tasting.

Served black it has a very robust and full-bodied flavour. The flavour has good depth from the front of the tongue to the back, and there is a fortright after-taste which lingers. There is a hint of bitterness but overall it is well-rounded if strong and there is a a subtle underlying burst of sweetness.

With milk added, the underlying character of the flavour is still quite apparent but takes on a slight smokiness.

This proved to be a successful blend - a cup of coffee with loads of personality and a depth of sophistication in its flavour.