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Examining the morbidly obese abdomen; plumbing the depths

Posted in General clinical at Tue, 22 Jul 2014 03:22:07

Odysseus

Posts: 3979
Joined: 24 Feb 2009

I often see obese and morbidly obese patients and wonder should I examine their abdomens as I usually do a full physical examination at the first visit, being a specialist physician.  Indeed I often order abdominal ultrasounds in these folk for this and other reasons as I think it is so easy to miss an abnormality.

Which brings me to the point;

1. Is there any point examining the abdomen in a morbidly obese patient?

2. If you do an abdominal ultrasound, does physicial examination add anything?

My own opinion is that you can find things on examination which may not be apparent on an ultrasound and this examination can direct the ultrasonographer to areas of interest. The ultrasonographer here is usually not a radiologist but the radiologist can be called in to look at areas of interest and check the result. 

Odysseus

Re: Yes, Cheetos, Funnel Cake, and Domino's Are Approved School Lunch Items

Posted in Diabetes at Tue, 22 Jul 2014 02:42:32

Odysseus

Posts: 3979
Joined: 24 Feb 2009

This is what happens when you remove people from their terroire. It is food capitalism at its nadir.

"Tell me what you eat and I shall tell you who you are"..a developed country with an undeveloped appetite.

Odysseus

Should we be considering a new primary care paradigm for the care of people with chronic diseases?

Posted in Diabetes at Mon, 21 Jul 2014 22:49:53

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Effects of Nurse-Managed Protocols in the Outpatient Management of Adults With Chronic Conditions: A Systematic Review and Meta-analysis

Ann Intern Med. 2014;161(2):113-121. doi:10.7326/M13-2567

Abstract

Background: Changes in federal health policy are providing more access to medical care for persons with chronic disease. Providing quality care may require a team approach, which the American College of Physicians calls the “medical home.” One new model may involve nurse-managed protocols.

Purpose: To determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia.

Data Sources: MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL from January 1980 through January 2014.

Study Selection: Two reviewers used eligibility criteria to assess all titles, abstracts, and full texts and resolved disagreements by discussion or by consulting a third reviewer.

Data Extraction: One reviewer did data abstractions and quality assessments, which were confirmed by a second reviewer.

Data Synthesis: From 2954 studies, 18 were included. All studies used a registered nurse or equivalent who titrated medications by following a protocol. In a meta-analysis, hemoglobin A1c level decreased by 0.4% (95% CI, 0.1% to 0.7%) (n = 8); systolic and diastolic blood pressure decreased by 3.68 mm Hg (CI, 1.05 to 6.31 mm Hg) and 1.56 mm Hg (CI, 0.36 to 2.76 mm Hg), respectively (n = 12); total cholesterol level decreased by 0.24 mmol/L (9.37 mg/dL) (CI, 0.54-mmol/L decrease to 0.05-mmol/L increase [20.77-mg/dL decrease to 2.02-mg/dL increase]) (n = 9); and low-density-lipoprotein cholesterol level decreased by 0.31 mmol/L (12.07 mg/dL) (CI, 0.73-mmol/L decrease to 0.11-mmol/L increase [28.27-mg/dL decrease to 4.13-mg/dL increase]) (n = 6).

Limitation: Studies had limited descriptions of the interventions and protocols used.

Conclusion: A team approach that uses nurse-managed protocols may have positive effects on the outpatient management of adults with chronic conditions, such as diabetes, hypertension, and hyperlipidemia.

COMMENT:  For those of us who follow the health services research literature, this is not a surprising study.  However, it comes at a time when we in the US are wringing our hands over the predicted shortfall of 65,000 primary care physicians by 2020.  So the study generates the questions should we be considering a new paradigm in chronic disease care that includes nurses?

 

Do statins have an independent effect on mortality in type 2 diabetes?

Posted in Diabetes at Mon, 21 Jul 2014 20:58:38

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Contributors to Mortality in High-Risk Diabetic Patients in the Diabetes Heart Study

Diabetes Care July 2, 2014  

Abstract

OBJECTIVE Not all individuals with type 2 diabetes and high coronary artery calcified plaque (CAC) experience the same risk for adverse outcomes. This study examined a subset of high-risk individuals based on CAC >1,000 mg (using a total mass score) and evaluated whether differences in a range of modifiable cardiovascular disease (CVD) risk factors provided further insights into risk for mortality.

RESEARCH DESIGN AND METHODS We assessed contributors to all-cause mortality among 371 European American individuals with type 2 diabetes and CAC >1,000 from the Diabetes Heart Study (DHS) after 8.2 ± 3.0 years (mean ± SD) of follow-up. Differences in known CVD risk factors, including modifiable CVD risk factors, were compared between living (n = 218) and deceased (n = 153) participants. Cox proportional hazards regression models were used to quantify risk for all-cause mortality.

RESULTS Deceased participants had a longer duration of type 2 diabetes (P = 0.02) and reduced use of cholesterol-lowering medications (P = 0.004). Adjusted analyses revealed that vascular calcified plaque scores were associated with increased risk for mortality (hazard ratio 1.31–1.63; 3.89 × 10−5 < P < 0.03). Higher HbA1c, lipids, and C-reactive protein and reduced kidney function also were associated with a 1.1- to 1.5-fold increased risk for mortality (3.45 × 10−6 < P < 0.03) after adjusting for confounding factors.

CONCLUSIONS Even in this high-risk group, vascular calcification and known CVD risk factors provide useful information for ongoing assessment. The use of cholesterol-lowering medication seemed to be protective for mortality.

COMMENT:  We have known from prior studies that the protective effect of statins is not solely attributable to their lipid lowering effect.  This intriguing study suggests that this benefit may extend to overall mortality in persons with type 2 diabetes.  the data presented suggest that we should consider a further look at the effect of statins on mortality in type 2 diabetes.

Are we attributing too many side effects to statin use?

Posted in Diabetes at Mon, 21 Jul 2014 20:43:18

diabetesMD

Posts: 664
Joined: 15 Apr 2011

What proportion of symptomatic side effects in patients taking statins are genuinely caused by the drug? Systematic review of randomized placebo-controlled trials to aid individual patient choice.

Eur J Prev Cardiol. 2014 Apr;21(4):464-74. doi: 10.1177/2047487314525531. Epub 2014 Mar 12. (Review)

OBJECTIVE: Discussions about statin efficacy in cardiovascular prevention are always based on data from blinded randomized controlled trials (RCTs) comparing statin to placebo; however, discussion of side effects is not. Clinicians often assume symptoms occurring with statins are caused by statins, encouraging discontinuation. We test this assumption and calculate an evidence-based estimate of the probability of a symptom being genuinely attributable to the statin itself.

METHODS: We identified RCTs comparing statin to placebo for cardiovascular prevention that reported side effects separately in the two arms.

RESULTS: Among 14 primary prevention trials (46,262 participants), statin therapy increased diabetes by absolute risk of 0.5% (95% CI 0.1-1%, p = 0.012), meanwhile reducing death by a similar extent: -0.5% (-0.9 to -0.2%, p = 0.003). In the 15 secondary prevention RCTs (37,618 participants), statins decreased death by 1.4% (-2.1 to -0.7%, p < 0.001). There were no other statin-attributable symptoms, although asymptomatic liver transaminase elevation was 0.4% more frequent with statins across all trials. Serious adverse events and withdrawals were similar in both arms.

CONCLUSIONS: Only a small minority of symptoms reported on statins are genuinely due to the statins: almost all would occur just as frequently on placebo. Only development of new-onset diabetes mellitus was significantly higher on statins than placebo; nevertheless only 1 in 5 of new cases were actually caused by statins. Higher statin doses produce a detectable effect, but even still the proportion attributable to statins is variable: for asymptomatic liver enzyme elevation, the majority are attributable to the higher dose; in contrast for muscle aches, the majority are not.

COMMENT: This is an interesting paper that postulates that many, if not most, of the symptoms that patients and their physicians attribute to statin administration occur as frequently in the placebo groups in controlled clinical trials.  It raises the question of whether or not we are depriving people of the potential benefit of statins by attributing minor musculoskeletal symptoms to the drugs.

 

Incretin-based drugs do not appear to cause pancreatitis

Posted in Diabetes at Mon, 21 Jul 2014 20:32:50

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Incretin Based Drugs and Risk of Acute Pancreatitis in Patients With Type 2 Diabetes: Cohort Study

Abstract

Objectives. To determine whether the use of incretin based drugs, compared with sulfonylureas, is associated with an increased risk of acute pancreatitis.

Design. Population based cohort study.

Setting. 680 general practices in the United Kingdom contributing to the Clinical Practice Research Datalink.

Participants. From 1 January 2007 to 31 March 2012, 20,748 new users of incretin based drugs were compared with 51,712 users of sulfonylureas and followed up until 31 March 2013.

Main Outcome Measures. Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals for acute pancreatitis in users of incretin based drugs compared with users of sulfonylureas. Models were adjusted for tenths of high dimensional propensity score (hdPS).

Results. The crude incidence rate for acute pancreatitis was 1.45 per 1000 patients per year (95% confidence interval 0.99 to 2.11) for incretin based drug users and 1.47 (1.23 to 1.76) for sulfonylurea users. The rate of acute pancreatitis associated with the use of incretin based drugs was not increased (hdPS adjusted hazard ratio: 1.00, 95% confidence interval 0.59 to 1.70) relative to sulfonylurea use.

Conclusions. Compared with use of sulfonylureas, the use of incretin based drugs is not associated with an increased risk of acute pancreatitis. While this study is reassuring, it does not preclude a modest increased risk, and thus additional studies are needed to confirm these findings.

COMMENT: A nice addition to the growing body of literature that reduces concerns about pancreatitis as a complication of incretin-based drugs use.

Re: Should minimum staffing levels for doctors be introduced?

Posted in General at Mon, 21 Jul 2014 19:10:13

ynnek

Posts: 1
Joined: 21 Jul 2014
Hi, I'm looking for a English speaking doctor for a one week all paid for visit to Shenzen China. Reason; A Chinese friend who studied at Preston Uclan, has opened a medical centre in China,and is looking for input from the West. I know this nowhere near describes this oppertunity, but if you feel any sort of interest, please contact and I can put you in touch with my friend.

Re: Can a minimalist educational intervention reduce cardiovascular events in persons at risk?

Posted in Diabetes at Mon, 21 Jul 2014 16:00:31

diabetesMD

Posts: 664
Joined: 15 Apr 2011

There is one assumption in your post that is incorrect.  That is, that the revolution of manufactured foods occurred without research.  The manufactured food industry spends billions on research; they just do not publish it in the New England Journal or the BMJ. Nevertheless, there is a large body of research on how to make manufactured foods both irresistible and cheap.  You may wish to read Michael Moss' book-Salt Sugar Fat: How the Food Giants Hooked Us for a terrifying review of how effective this research and marketing strategy has been.  Of course, that has been made obvious by the obesity epidemic.  However, if we are to effectively counter the massive trend toward eating manufactured foods and the demise in cooking from ingredients, we need to become knowledgeable advocates.  Let me take two US examples: corn and milk subsidies.  Because of corn subsidies corn is cheap and overproduced.  One byproduct of this is the ubiquitous replacement of sucrose with the less expensive high fructose corn syrup, felt by many experts to be responsible for much of the obesity associated with sugared soft drinks.  The milk subsidies again resulted in the overproduction of milk and its chief byproduct cheese.  As cheese literally was filling up storage caves throughout the US, the manufactured food industry figured out ways to add this now cheap filler to hundreds of products, the most famous and successful of which are Lunchables eaten by millions of kids.  While I agree that we must now focus on how to reverse this trend, I do not believe that the solutions will be easy or always obvious.  As I have posted before it took us decades to make smoking socially unacceptable.  It is not possible or advisable in my view to make obesity socially unacceptable.  So we first must define our message that will probably need to be the importance of a healthy diet especially in children rather than focusing on obesity, per se.  We then must define socially acceptable means to make “good” foods cheap and manufactured foods expensive.  This is especially true because in many cases the rate of obesity and poor eating habits are highest among the poor and uneducated who have the least flexibility in their food choices.  I welcome your and others examples of successful social strategies to improve eating habits.

Re: Why are there fewer female academics?

Posted in General clinical at Mon, 21 Jul 2014 13:06:08

sken

Posts: 628
Joined: 13 Oct 2009

Perhaps folk would do well to read the latest JRSM on this subject. It seems thatfemale medical students now constitute about 53% of the student body. In 2012 of those holding Lecturer posts 42.3 % were women , if not exactly 50% at least not showing a phenomenal underrepresentation.

The disparity emerges as one moves up the hierarchy  to 30.1% of Readers/Senior Lecturers and 15.1% of Professors.

Some of this later disparity could be historical - the male preponderance of professors have not yet retired in sufficient numbers. There is aso an issue around specialty. Bearing in mind the female emphasis in General Practice there is under-representation of this in the academic world with only 5% of academic staff being GPs. 

For those of us who see the academic world as different , but not necessarily better , we perhaps approach the question from a different direction. What is it about the academic life that discourages women - and perhaps they are making the right choices at the moment ? The answer in part must come from surveys of those Lecturers - what if they really do prefer patient centred medicine. Is that such a bad thing or is there prejudice? The very time when they would be "in the market" for the next stage could well be the favoured time for starting a family - how often is that  a factor?

Re: Poll archive

Posted in doc2doc feedback at Mon, 21 Jul 2014 12:58:34

AnneG

Posts: 293
Joined: 18 Mar 2014

Should doctors who mistreat or neglect patients be prosecuted?

Yes - as long as doctors who make genuine errors do not face prosecution: 154 votes (67%)

No - blaming people does not work: 75 votes (335)

Is there a link between negative media coverage and patient complaints?

Posted in General clinical at Mon, 21 Jul 2014 11:48:25

AnneG

Posts: 293
Joined: 18 Mar 2014

A report by Plymouth University, commissioned by the General Medical Council, has looked into why the number of complaints against doctors has risen, from 5,168 complaints in 2007 to 10,347 in 2012.

The report does not find one single cause for the increase but it said that negative press coverage of doctors could be "chipping away" at their reputation resulting in more people making "me too" complaints to the GMC. It says the "sustained diet of negative coverage, conforming to a few stereotyped models, may feed the increase in complaints by contributing to a highly critical backdrop against which medical consultations are now experienced."

The report also points to social media as providing an outlet for people to discuss their complaints about doctors and "more access to information about how to seek redress." Other factors may include the higher public profile of the GMC and a less deferential attitude of patients towards doctors. 

What do you think?

Re: Ownership of drugs

Posted in News & media at Mon, 21 Jul 2014 11:17:57

rcdeacon

Posts: 142
Joined: 21 Aug 2011

I thought we encouraged immediate removal/destruction of opiates after a number of people were burgled when the family went to the funeral. ie most illegal opiates regrettably come from   initially legitimate sources.

For Motorport/the outdoors and far away we probably prefer Ketamine or Methoxyflourane  ie the latter being inhalational  can be administed by non docs but caution in confined spaces..

Statin Use and Cognitive Decline in the Elderly

Posted in Diabetes at Sun, 20 Jul 2014 19:21:59

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Statin Use but Not Metabolic Syndrome Is Associated with Cognitive Decline in the Elderly: The Sydney Memory and Ageing Study

Program: Abstracts - Orals, Poster Preview Presentations, and Posters
Session: PP15-Lipids, Lipoproteins, Dyslipidemia & Fatty Liver Disease
Translational

Sunday, June 22, 2014: 11:15 AM-11:30 AM

W178 (McCormick Place West Building)


Poster Board SUN-0841

Katherine Samaras, MBBS, PhD, FRACP1, John D Crawford, PhD2, Elizabeth Blanchard, BMSc3, Nicole Kochan, PhD4, Julian N Trollor5, Henry Brodaty4 and Perminder Sachdev2
1Garvan Institute of Medical Research, Sydney NSW, Australia, 2University of New South Wales, Randwick, Australia, 3Garvan Institute of Medical Research, Darlinghurst, NSW, Australia, 4University of New South Wales, Kensington, Australia, 5University of New South Wales, Randwick

The cardiovascular (CV) risk factors of diabetes, hyperlipidemia and hypertension are associated with cognitive decline and are dementia risk factors. Metabolic syndrome (MS) describes clustering of these risks factors; it is unclear whether MS adversely affects cognition. Further, there is controversy whether statin use may impair cognition. We examined if Metabolic Syndrome (MS) and statin use were associated with greater cognitive decline in the elderly over 4 years.

Methods: Participants were drawn from the Sydney Memory and Aging Study, a longitudinal population-derived cohort recruited from the electoral roll (70-90 years at baseline), assessed at baseline, 2 and 4 years, as described.1 Global cognition was measured by neuropsychological testing in five domains (memory, processing speed, language, visuospatial and executive function), to form a composite normalized Z-score, as described.2 MS was defined using IDF criteria.1 Medical history and use of statin therapy and type were documented. Data on 677 participants were analyzed by repeated measure ANCOVA, with covariates (age, sex, years education, smoking, English/non-English speaking background and apolipoprotein E e4 genotype [APOEe4]).

Results:

Mean ± SD age at baseline was 78.3 ± 4.6 years, 47% males, BMI 27.1 ± 4.9 kg/m2, fasting glucose 5.6 ± 1.1 mmol/L. Baseline prevalences of MS, statin-use and diabetes were 54%, 52% and 11%, respectively.

Baseline global cognition was similar between participants with and without MS (-0.65 ± 1.3 v -0.52 ± 1.3, p=0.13). Metabolic syndrome was not associated with any greater decline in global cognition (p=0.97), nor with any domain decline score for memory, language, processing speed, visuospatial or executive function. Results were similar when subjects with diabetes were excluded.

Baseline global cognition was similar between statin-users or not (-0.58 ± 1.3 v -0.59 ± 1.3, p=0.92). Statin-use was not associated with any greater decline in global cognition over 4 years (p=0.25), however significantly greater decline in memory was observed (-0.27±0.04 v. -0.07±0.05, p=0.001). Statin-use was not associated with any greater 4-year decline in language (p=0.51), processing speed (p=0.85), visuospatial (p=0.75) or executive (p=0.96) functions. To examine whether CV risks may interact with statin-use to heighten the decline in memory, interactions were sought in models of statin use and CV or dementia risk factors (including covariates). None was found with diabetes, heart disease, stroke, smoking or APOEe4 carriage.

Conclusion: In this large cohort of community-dwelling well-elderly, statin-use was associated with greater decline in memory at 4 years, but no other cognitive domain. Metabolic syndrome was not associated with accelerated cognitive decline. The impact of metabolic risk and its treatment on cognition in the elderly requires greater interrogation.

COMMENT:  One must always be careful about drawing conclusions from an abstract.  However, this presentation at the International Congress of Endocrinology/Endocrine Society meeting has received considerable press response so I felt that it was worthwhile to post the abstract in its entirety.  It does contain considerable good news.  There was no association between cognitive decline and the metabolic syndrome.  Also the title is a bit misleading in that statin use was not associated with global cognitive decline only with an increased loss of memory function.  This, of course, is not a trivial finding, but one wonders if this is a fixed decline or just the effect of the statin, per se, that would be reversed by stopping the statins.  An important question that I hope the investigators address.

 

Efficacy and Safety of Dulaglutide Added Onto Pioglitazone and Metformin Versus Exenatide in Type 2 Diabetes

Posted in Diabetes at Sun, 20 Jul 2014 19:07:12

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Efficacy and Safety of Dulaglutide Added Onto Pioglitazone and Metformin Versus Exenatide in Type 2 Diabetes in a Randomized Controlled Trial (AWARD-1). Diabetes Care. 2014 May 30.

OBJECTIVE: To compare the efficacy and safety of dulaglutide, a once weekly GLP-1 receptor agonist, with placebo and exenatide in type 2 diabetic patients. The primary objective was to determine superiority of dulaglutide 1.5 mg versus placebo in HbA1c change at 26 weeks.

RESEARCH DESIGN AND METHODS: This 52-week, multicenter, parallel-arm study (primary end point: 26 weeks) randomized patients (2:2:2:1) to dulaglutide 1.5 mg, dulaglutide 0.75 mg, exenatide 10 mug, or placebo (placebo-controlled period: 26 weeks). Patients were treated with metformin (1,500-3,000 mg) and pioglitazone (30-45 mg). Mean baseline HbA1c was 8.1% (65 mmol/mol).

RESULTS: Least squares mean +/- SE HbA1c change from baseline to the primary end point was -1.51 +/- 0.06% (-16.5 +/- 0.7 mmol/mol) for dulaglutide 1.5 mg, -1.30 +/- 0.06% (-14.2 +/- 0.7 mmol/mol) for dulaglutide 0.75 mg, -0.99 +/- 0.06% (-10.8 +/- 0.7 mmol/mol) for exenatide, and -0.46 +/- 0.08% (-5.0 +/- 0.9 mmol/mol) for placebo. Both dulaglutide doses were superior to placebo at 26 weeks (both adjusted one-sided P < 0.001) and exenatide at 26 and 52 weeks (both adjusted one-sided P < 0.001). Greater percentages of patients reached HbA1c targets with dulaglutide 1.5 mg and 0.75 mg than with placebo and exenatide (all P < 0.001). At 26 and 52 weeks, total hypoglycemia incidence was lower in patients receiving dulaglutide 1.5 mg than in those receiving exenatide; no dulaglutide-treated patients reported severe hypoglycemia. The most common gastrointestinal adverse events for dulaglutide were nausea, vomiting, and diarrhea. Events were mostly mild to moderate and transient.

CONCLUSIONS: Both once-weekly dulaglutide doses demonstrated superior glycemic control versus placebo and exenatide with an acceptable tolerability and safety profile.

COMMENTS: Dulaglutide is a promising new GLP-1 receptor agonist that can be given weekly.  The data presented suggest that it is more effective than the formulation of exenatide used in this study.  The study did not examine the comparative effectiveness of dulaglutide versus the long acting exenatide formulation, Bydureon.

Insights into the psychosocial aspects of diabetes-the DAWN2 study

Posted in Diabetes at Sun, 20 Jul 2014 18:53:52

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Personal Accounts of the Negative and Adaptive Psychosocial Experiences of People With Diabetes in the Second Diabetes Attitudes, Wishes and Needs (DAWN2) Study

Diabetes Care June 27, 201

Abstract

OBJECTIVE The authors wished to identify the psychosocial experiences of diabetes both negative accounts of diabetes and positive, adaptive ways of coping from the perspective of the person with diabetes.

RESEARCH DESIGN AND METHODS The participants were 8,596 adults (1,368 with type 1 diabetes and 7,228 with type 2 diabetes) in the second Diabetes Attitudes, Wishes and Needs (DAWN2) study. Initially qualitative data were responses to open-ended survey questions about successes, challenges, and wishes for improvement in living with diabetes and about important experiences. Emergent coding was developed with multinational collaborators that identified thematic content about psychosocial aspects. The κ measure of inter-rater reliability was 0.72.

RESULTS Analysis identified two negative psychosocial themes: 1) anxiety/fear, worry about hypoglycemia and complications of diabetes, depression, and negative moods/hopelessness and 2) discrimination at work and public misunderstanding about diabetes. Two psychosocial themes demonstrated adaptive ways of coping with diabetes: 1) having a positive outlook and sense of resilience in the midst of having diabetes and 2) receiving psychosocial support through caring and compassionate family, friends, health care professionals, and other people with diabetes.

CONCLUSIONS The personal accounts give insight into the psychosocial experiences and coping strategies of people with diabetes and can inform efforts to meet those needs and capitalize on strengths.

COMMENT:  The DAWN investigators continue to add important and useful insights into our understanding of the psychosocial aspects of having diabetes and patient coping mechanisms.  This information is useful for both educators and clinicians as they deal with this complex illness.  An understanding of these complex emotions and coping mechanisms is essential for the development of successful long-term strategies to help people with diabetes cope with the disease.

 

final nice guidance on statins released

Posted in Cardiology at Sun, 20 Jul 2014 14:20:49

sadian

Posts: 1142
Joined: 17 Jun 2011

we have discussed the draft nice guidance on statins before that suggests reducing (potentially) the threshold for statin prescription to a 10% 10 year CV risk (currently 20% 10 year risk).

The final guideline is just published

http://www.bmj.com/content/349/bmj.g4694

and sticks with this threshold giving an estimated number needed to treat of 77 people to avoid one death/stroke/non-fatal MI after 3 years.

What do you think?

sadian

 

Re: Abnormal ECG?

Posted in Cardiology at Sun, 20 Jul 2014 14:16:28

sadian

Posts: 1142
Joined: 17 Jun 2011

I agree with JohnD.

For an aswer based  completely on your  image only  - these are J waves or j point deflections and can be seen as normal variants in young adults.

 

sadian

Re: Should HIV-negative gay men take antiretrovirals?

Posted in General clinical at Sun, 20 Jul 2014 11:32:19

sken

Posts: 628
Joined: 13 Oct 2009

Difficult. Free condoms to help prevent STI are I think already accepted in some quarters. Trying to keep HIV negative gay men negative has potential large cost savings and could help slow down overall disease spread. In the UK our health care philosphy seems to be increasingly that we must target resources to combatting lifestyle risks and that it is an imposition on individuals to go beyond gently suggesting lifestyle changes. 

A second problem with this suggestion is that it has long been unacceptable to act as though HIV is more likely to affect gay men rather than those sometimes referred to as "straight" . So perhaps prophylaxis should be offered to everyone on contact with a new sexual partner. 

And of course resources should as usual be diverted away from those whose disease could be seen as occurring through no fault of their own in accordance with the opinions expressed by much of the media.

Re: Would you order an unnecessary test/procedure if a patient insisted on it?

Posted in General clinical at Sun, 20 Jul 2014 11:07:21

bjf

Posts: 83
Joined: 12 Feb 2013
The test was not unnecessary, foresight or hindsight! The important elements in his presenting history were miscontextualised, giving the impression that investigating the particular set of symptoms were unnecessary . "Headaches" can be enough justification for going all out with investigations no matter how flavored by other incidental red-herrings in the history . I've learnt to respect 'headaches' as benign sounding symptoms full of surprise revelations The choice of plain xray or/and something more techy will be guided by predictive capabilities, relevance, availability, access, funds, local protocols, judgement or sometimes even mere 'hearts and guts' Basil jide fadipe. Justin fadipe centre. West Indies

Re: Should retired doctors be employed in medical training?

Posted in General clinical at Sun, 20 Jul 2014 09:50:14

Poltor

Posts: 216
Joined: 29 May 2013

What goes around comes around.

Re: Treatment as a punitive exercise

Posted in General clinical at Sun, 20 Jul 2014 09:47:07

Poltor

Posts: 216
Joined: 29 May 2013

It's all about paternalism, isn't it?

Those 'doing it' know more than those to whom it's being done, and therefore know 'better'.

Re: Would you like to own the organisation you work for?

Posted in News & media at Sun, 20 Jul 2014 09:45:03

Poltor

Posts: 216
Joined: 29 May 2013

We already do - so what?

I have been very disillusioned by the King's Fund for years - they inhabit the highest ivory towers in the land, and appear to have little idea of what's going on on the ground, let alone what should go on.

 

This is yet another attempt to dress up privatisation. No way, sunshine!

Re: Citizens of MH17, Vale.

Posted in News & media at Sat, 19 Jul 2014 12:11:09

Carolin

Posts: 1044
Joined: 16 Aug 2012

what a terrible tragedy ! Our thoughts are with the innocent people who died and their families, of course very mich with the many doctors who died (Dutch AIDS expert Joep Lange being one of them).

It was reported there were 4 Germans on board, but I really feel that nationalities don´t matter here. It could have been any plane - Lufthansa flew exactly the same course until thursday and only changed flight routes after.

I expect we´ll get full information soon ( or at least some!) to show who´s responsible. This won´t bring back the dead.

Re: This is not hyperkalemia

Posted in General clinical at Sat, 19 Jul 2014 12:06:31

alphi

Posts: 3
Joined: 09 Aug 2010

Left axis, RV5/V6 + SV1 machts with Sokolov criteria. T wave are asymmetrical , not symmatrical as it happens in ischemic cardiopathy  

Re: How to get an open letter published

Posted in BMJ at Sat, 19 Jul 2014 08:48:40

John D

Posts: 3082
Joined: 01 Feb 2010

tjaard,

Doc2Doc is the message board of the BMJ.  It is not a back door to the letters page of that Journal.    In message 2 of this thread David Payne, the Digital Editor of the BMJ, advised how to submit a letter for publication. I suggest you follow his advice.

But my own advice would be that if you have any hope of being accepted, do not send a three page, thousand word letter.  Read the BMJ Letters pages; see the length of letters that are accepted and follow that style.

John