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Re: Comment: The Ebola Frontline

Posted in Public health at Tue, 07 Jul 2015 16:36:47

Mukhtar Ali

Posts: 979
Joined: 14 Nov 2010

New cases continue to arise and the recent Ebola cases reported in Liberia are further evidence that this Ebola outbreak is not over. However, over the last year progress has been made in establishing systems and tools that allow us to respond rapidly and effectively. Thanks to the diligence and dedication of tens of thousands of responders, scientists, researchers, developers, volunteers, and manufacturers, we are better off than we were a year ago.


Re: Clinical question of the week: nausea, vomiting and generalised weakness

Posted in Cardiology at Tue, 07 Jul 2015 16:34:24


Posts: 1
Joined: 07 Jul 2015
Dear Colleague, From these overall data, that we face, a patient suffering with Tuberculosis on the background of immunodeficiency. It can be assumed that such a combination is formidable miliary tuberculosis. The general condition of our patient due to severe intoxication (fever, nausea and vomiting of central origin, high levels of creatinine). In addition to ECG, there are signs of pericarditis. Ultrasound unknown * support (picture does not open), but we can assume the presence of fluid in the pericardium. Muscle cramps are likely to be related to treatment of tuberculosis. These drugs cause a deficiency of magnesium and vitamin B6. Treatment should include: - Treatment of tuberculosis, - Intravenous desintoxication therapy; - Preparations magnesium and B6 (combined means). – If the jugular vein will increase - puncture of pericardium is indicated. I’m Ready to discuss this interesting case. Sincerely, Dr.Viktor

Re: MRCOG Part 1 sample question from OnExamination: Total blood volume

Posted in General clinical at Tue, 07 Jul 2015 14:03:26


Posts: 1
Joined: 27 Jan 2015
The body weight as well increases to same proportions.

The rise of PTSD

Posted in News & media at Tue, 07 Jul 2015 10:54:13


Posts: 1817
Joined: 08 Oct 2010
I heard a radio interview today with a woman who claimed giving birth left her with Post Traumatic Stress Disorder (PTSD). It made me think of the rise of this disorder in popular conscience and its ubiquity. There are so many legal cases now where PTSD features in so many ways.  Consider the former soldier on a shooting spree. His defence is he has PTSD from combat. A surviving victim claims PTSD as she thought she would die. Witnesses with PTSD from the horror of the attack. Officers responding claim PTSD due to the gunfight. Emergency workers claiming PTSD due to the horrific injuries and distress they dealt with. 
Should PTSD excuse or partially excuse a criminals actions? Should it be used in mitigation at sentencing? Is it an attempt to evade responsibility? Witnessing such events is distressing but are we less able to cope with them? Or is it only right that we recognise people's distress who witnessed the events? Should Paramedics, Nurses, Policemen be able to use PTSD or are such sexperiences part and parcel of the job?
PTSD was recognised as a medically distinct phenomenon in 1980, with the publication of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Disorders. 
The DSM classifies PTSD as an anxiety disorder, describing it as an extreme reaction to “an event outside the range of usual human experience and that would be markedly distressing to almost anyone,” and that creates intense fear, terror and helplessness involving a threat to oneself or others.  It says the traumatic event is persistently re-experienced with avoidance of stimuli associated with the trauma or numbing of general responsiveness and persistent symptoms of increased arousal.
There are few objective markers for diagnosis. Psychiatrists say it can be easy to simulate or exaggerate and when compensation is the objective there is an incentive to do so. I do not suggest PTSD does not exist but suspect it is being used as a catch all for a whole range of purposes. There is even 'Malinger PTSD' described in the US by Forensic Psychiatrists evaluating former servicemen. 
Interested in folks view.

Re: It is time to break the silence on physician suicide.

Posted in News & media at Tue, 07 Jul 2015 05:04:42

Jorge Ramirez

Posts: 16
Joined: 09 Jan 2015

1. Regarding the biochemistry of mental disorders:

Matthew S. Lebowitz and Woo-kyoung Ahn. Effects of biological explanations for mental disorders on clinicians’ empathy PNAS 2014 111 (50) 17786–17790; published ahead of print December 1, 2014, doi:10.1073/pnas.1414058111

Healy David. Serotonin and depression 2015; 350 :h1771

2. About venlafaxine and paroxetine:


3. About "doing extensive tests and recommending appropriate nutrients..."

- What kind of tests and dietary supplements do you recommend?

- Does the evidence support these types of diagnostic and therapeutic interventions?

- Too much medicine?


4. Professor Peter C Gøtzsche writes about some bizarre events in the 2015 Maudsley Debate ”This house believes that the long term use of psychiatric medications is causing more harm than good.”

..."We could stop 98% of psychotropic drug use without deleterious effect” (which I have documented in my upcoming book), and this was changed into “We could stop almost all psychotropic drug use without deleterious effect.”...


5. Psychiatry is probably causing more harm than good when physicians are labelled - without sufficient evidence - with a mental disorder according to the DSM-V definitions, sometimes coercive methods are used for this purpose, ranging from subtle coercion (e.g., referral to a psychiatrist by the employer) to forced administration of psychotropic drugs (please read: http://davidhealy.org/pharmaceutical-rape/) with involuntary placement into a mental hospital. I believe that it is also important to discuss the role of psychiatry in the investigations to determine the fitness to practise of doctors. 
http://www.bmartin.cc/dissent/documents/#psychiatry - https://iatroskalos.wordpress.com/2013/07/10/repeated-allegations-about-my-mental-health-at-walsall/

More harm than good?



In Response to Re: It is time to break the silence on physician suicide.:[QUOTE]

I am a GP in Dublin with a big  interest in the biochemistry of mental health.

Doctors by nature  tend to be industrious, push themseles more than most,  and if they get depressed they usually get very depressed indeed. Biochemically they are undermethylated (too little CH3 molecules in the brain). Many  respond  to antidepressants but they may need a high dose eg 300 mg venlafaxine. At that level the drugs have serious side effects so many of them spend time out of work and may  also spend time in a mental  health hospital.  

By doing extensive tests and recommending appropriate nutrients (individualised  doses of vitamins,minerals, essential fatty acids, amino acids and other biochemicals) it is usually  possible to get them on to a lower dose of medication but some will have to stay on a little  medication for the foreseeable future.

I have seen a few  consultants  from UK who were very depressed indeed. One was a registrar initially and had OCD as well as depression. She could not study because of her mood and difficulty in concentration. I got her down to paroxetine 20 mg  from 60 mg.  She recovered over many months, passed her membership and is now doing well  as a consultant.

It is frightening that so many doctors die so young  when they could be well but British psychiatrists do llittle more than they did 30 years ago. I went to Sydney in 2006 to learn all about this  type of treatment. If you are interested there is a course for doctors  quite soon in  California  for 4 days.Details  are at www.walshinstitute,.org. There is a yearly course in Australia too -details at www.biobalance.org.au.

Posted by Ardfert[/QUOTE]


Re: I need the Dr Suggestion regarding the Health!

Posted in General clinical at Mon, 06 Jul 2015 19:25:52

John D

Posts: 3613
Joined: 01 Feb 2010

I have sent this student a personal message of sympathy and suggested he seeks advice from his local doctor again.    This thread is closed.

John the Moderator

Re: What your patient is thinking: Excuse me doctor, I can still hear you

Posted in BMJ at Mon, 06 Jul 2015 16:00:11

John D

Posts: 3613
Joined: 01 Feb 2010

Perhaps it's worthwhile linking this thread to the " New guidance: being open and honest when things go wrong." page of the GMC's website.    Their new guidelines on the best response to mistakes and when things go wrong should be applied  in this situation too.



Re: Where do you stand on e-cigarettes?

Posted in Public health at Mon, 06 Jul 2015 15:28:27

John D

Posts: 3613
Joined: 01 Feb 2010

Nicotine replacement treatments break the link betwen a dummy in the mouth and the fix.  Maybe that is why it's hard to show that it is effective.   But if a smoker cannot stop fixing, and can replace their fag by an e-cig, then Good, I say.   BUt under the same regulations as 'real' fags.

This stuff is being sold in multiply scented, flavoured, coloured and glamourised forms, clearly, obviously and blatently to capture the new young market.  That is Bad, and shosuld be controlled, along with the nicotine content.

Let the tobacco barons go off and market their poisons to organic gardeners to control thier aphids.


Re: When should we be silent?

Posted in BMJ at Mon, 06 Jul 2015 14:55:16


Posts: 1545
Joined: 09 Dec 2011

In Response to Re: When should we be silent?:[QUOTE]

Duane - Quite right. Hero was the wrong word. But then I see anyone prepared to live/work in New York in the summer - or depths of winter - as something of a hero (or should it be something of the misbegotten).... Equally I feel responding to the Tunisia problem in a like manner to the Twin Towers was inappropriate and not only on account of scale.. I doubt whether terrorism will ever go away and in one way I see it as an expression that mankind can see something as so important that it transcends the normal rules. One man's terrorist can also be another person's hero. We must learn to live with terrorism and try to understand what drives it  : ideally  not defeat it , but make it unnecessary. This means confronting extreme religious beliefs of whatever type but there are other driving forces as well. I suspect the best we are likely to achieve is to localise it but that may be very difficult in this day and age.

Posted by sken[/QUOTE]


Your quite right,

I agree,  and  Terrorism is difficult to control, although not impossible.  I served 8 years in the U.S Army, and I can attest to the fact that it is possible to eliminate terrorism In your country, or locally if the political will exists to use the Military!   The Military has the tools and power to do the job, it is just lacking the political power of Politicians with Spines!



Live clinical case scenario - tonight at 7pm BST

Posted in General clinical at Mon, 06 Jul 2015 14:52:08


Posts: 3
Joined: 27 Apr 2015

Hey guys,


After a few months of putting together the various pieces I'm trialling a live clinical case scenario tonight at 7pm BST. It'll rely on the audience participating to take a collaborative history, suggest/interpret investigations and reach a diagnosis together.


Things will likely go wrong, given this is the first time, but I just wanted to give it a go and then take any feedback you guys provide to refine it for the next time.


Anyway you can watch on my website www.geekymedics.com/live at 7pm


Would love you guys to stop by and provide any feedback here afterwards :)




Lewis Potter

Re: How many of your patients opt out of MMR?

Posted in General clinical at Mon, 06 Jul 2015 12:50:34


Posts: 1389
Joined: 07 Sep 2009

News from The BMJ:

"California has ended vaccine exemptions on the basis of religion or personal belief. Under the new law, signed by Governor Jerry Brown on 30 June, unvaccinated children in the state will not be allowed to attend school, day care programs, and nurseries, unless they have a medical reason, such as an allergy, for not receiving a vaccination. Previously, just two other US states, West Virginia and Mississippi, limited exemptions to medical reasons."

Re: Med school finals sample question from OnExamination: Amiodarone for AF

Posted in Finals help! at Mon, 06 Jul 2015 10:53:09


Posts: 41
Joined: 07 Apr 2015

The correct answer is thyroid function.


Amiodarone is a drug which is used to control a variety of cardiac dysrhythmias including ventricular and supraventricular tachycardias and atrial fibrillation.

Its use is limited by its significant side effect profile, predominantly hepatic dysfunction and drug-associated hepatitis (for which baseline and regular liver function should be assessed) and respiratory complications including pneumonitis and pulmonary fibrosis. For this reason, a baseline chest x ray should be carried out and this should be repeated at least annually to ensure no deterioration.

If the patient experiences respiratory symptoms they should be investigated promptly with plain films initially and further investigated with high resolution CT scanning of the chest and pulmonary function testing including diffusion studies. Baseline pulmonary function testing is not mandatory prior to starting treatment and there is no benefit in regular assessment of the peak expiratory flow rate. Discontinuation of the drug when respiratory symptoms occur is advisable as pulmonary fibrosis is often not reversible and stopping the drug may prevent further deterioration in function.

Amiodarone also has the potential to cause some significant eye-related side effects including the deposition of corneal microdeposits which can impair visual acuity and may cause night-time glare and significantly reduce a patient's ability to drive. This is called whorl keratopathy and often is reversible on cessation of the drug. Approximately 10% of patients taking amiodarone complain of some form of visual discolouration, predominantly a bluish tinge to vision. Other visual manifestations have also been reported including optic atrophy, non-ischaemic neuritis, papilloedema and various visual field defects, none of which are dosage dependent and are occasionally partly reversible on cessation of the drug. It is not necessary to establish baseline visual acuity or fields prior to starting treatment.

Amiodarone is also occasionally indicted in the development of a peripheral neuropathy with decreased peripheral sensation and also occasionally with tremor. There is no need to perform nerve conduction studies prior to starting therapy and rarely is it needed during therapy if symptoms develop.

Amiodarone is an iodine-containing drug very similar in chemical structure to thyroxine. Both hyperthyroidism and hypothyroidism have been reported in many patients taking this drug, although this is often subclinical and detected on biochemical monitoring. It is very important to establish a baseline thyroid profile prior to starting treatment and often amiodarone is avoided in those with thyroid dysfunction. Usually measurement of both free thyroxine (T4) and tri-iodothyronine (T3) are monitored, as well as thyroid stimulating hormone (TSH) as T4 estimation alone is not sufficient to detect dysfunction.

Try more OnExamination sample med school finals questions here

Re: Question of the week: How well do TV dramas portray mental illness?

Posted in Psychiatry at Mon, 06 Jul 2015 10:27:50

Laura Glenny

Posts: 6
Joined: 19 May 2015

This is also makes an interesting read, how films often portray diabetes mellitus inaccurately: http://student.bmj.com/student/view-article.html?id=sbmj.h3291

Stephanie Hill talks about Panic Room, The Experiment, and Hansel's "sugar sickness" in Hansel and Gretel: Witch Hunters

Re: Medical Electives! Pakistan? Uganda? Turkey? Malaysia? Where??!

Posted in Student BMJ at Mon, 06 Jul 2015 10:22:45

Laura Glenny

Posts: 6
Joined: 19 May 2015

I would also recommend reading this article on how to make the most of your medical elective: http://student.bmj.com/student/view-article.html?id=sbmj.h2161

Hope this helps to answer some of your questions!

Re: Poll archive 29/6/15-6/7/15

Posted in doc2doc feedback at Mon, 06 Jul 2015 10:18:34


Posts: 1389
Joined: 07 Sep 2009

Have you ever blown the whistle (made a protected disclosure) at work? (53 votes)

Yes: 27 votes (50.9%)

No I would never do it: 12 votes (22.6%)

No but I'm thinking about it: 14 votes (26.4%)


Posted in Respiratory medicine at Sun, 05 Jul 2015 12:58:11


Posts: 1001
Joined: 13 Oct 2009

By NNI I mean the number needed to investigate to establish the diagnosis in question. I would not want to take some of our "guideline-backed" treatments with NNT of 50 or over and I am becoming increasingly wary about this NNI which is much in the news at the moment. 

For cancer - and what else is of such concern - the going rate seems to be 3% positive and this seems unrelated to influence on outcome. For some tests , looking at outcome measures , a prevention of death from the disease concerned of 0.1 % is considered good enough for some.

Put in practical trems , the 3% pick-up means that 97% will also be put through expensive and often inconvenient and uncomfortable tests , often with red herrings in the form of other disorders being found. One used to look at a figure of 5% (ie 1: 20 risk , 95% probable that everything will be OK) as about right for a discussion with the patient.  Would I volunteer to mention symptoms at  a 3% risk ? I have serious doubts in view of what the GP will be obliged to recommend . Watchful waiting is not encouraged , so that is something to be taken on one's own initiative before seeking advice. Would I be influenced by better information on outcome ? Very probably. 

Our obsession with early diagnosis will always mean a better outcome with diseases ranging from cancer to dementia is something which needs to quantified. Of course it may be relevant , but how often ?

Heartthrobs and Rosacea

Posted in Public health at Sat, 04 Jul 2015 15:54:32

Mukhtar Ali

Posts: 979
Joined: 14 Nov 2010


Industry 'must do more' to Improve Urinary Catheters

Posted in Public health at Sat, 04 Jul 2015 15:36:35

Mukhtar Ali

Posts: 979
Joined: 14 Nov 2010

A leading researcher says industry must "wake up and invest more" in urinary catheters.

Mandy Fader, professor of continence technology at the University of Southampton, says their design has changed "very little" in 80 years.


Re: Happy 4th Of July to All Doc to Doc Members...

Posted in General clinical at Sat, 04 Jul 2015 15:16:31


Posts: 1545
Joined: 09 Dec 2011

In Response to Re: Happy 4th Of July to All Doc to Doc Members...:[QUOTE]


I must pop your balloon of the Great American Melting Pot, and instead suggest that the USA is a Great Pot Pourri, a mixture of elements that have not as yet melded together into one Nation.   Any more than any other.   Nation.

Only recently we have seen the severe chasms that rift American society, and the remarkable way that hereditary dynasties that the USA fought its War of Revolution to be rid of have attained the highest office in the land.   Not since the Pitts, Elder and Younger, were Prime Ministers have such families arisen in the UK.  

But now, less seriously, I must sympathise with Americans, who must peer against evening sunlight to mKe out the celebratory fireworks!  Guy Fawkes was much more considerate to foment the Gunpowder Plot, the foiling of which in November so enlivens our  late autumn skies, as the pyrotechnics display to perfection against near black night.   No hot punch and Firework Toffee for you, Duane!  What food and drink will help you celebrate the Fourth?


Posted by John D[/QUOTE]


Alas no one can pop my Baloon,  Indeed I am an American, Relentless, driven by high ideals, and well heeled in The Military Arts!   America is both a Melting pot, and a Potpurri, perhaps we are more, time will tell how great we will become, but I can only say how great we are!   

As to food and drink,  I plan to have a BBQ,  My wife and I celebrate by cooking on the grill, like so many other Americans,  I will make Steak Marinated in my special recipe, Pork cutlets,  Chicken marinated in Dixie lime and sweet sauce,  along with a healthy salad, and Potatoe salad.  I also drink fresh coffee,  Gevalia brand, Ice tea,  and  a fruit salad for desert.   Quite far from the puritan turkey and stuffing of so many  paintings, but surely an american BBQ is as Iconic as english Earl Grey Tea.



Re: A splenic lesion

Posted in Radiology at Sat, 04 Jul 2015 10:06:29


Posts: 44
Joined: 11 Feb 2009

Splenic abscess

Re: Any idea what placebo is?

Posted in General at Sat, 04 Jul 2015 09:21:59


Posts: 1001
Joined: 13 Oct 2009

One could see a placebo as something viewed from the patient response as opposed to the scientific. A knock-on from this is whether the NHS should fund "non-proven" treatments - but when we look at what we do fund perhaps we should consider funding something that simply has making patients feel (with the emphasis on feel)  better. Of course there has to be a degree of deception in one form or another and just giving a treatment as a placebo - "there is nothing in these blue tablets , safe to take etc... " may not work as well as giving them with a "new treatment , free of side effects which some folk have found very helpful". The "laying on of hands" - or whatever - clearly requires a degree of belief of one form or another.

Belief in a response , conditioning , empathetic prescribing may all contribute to a placebo effect - and possibly the patient choosing and paying for the treatment. There is a single major drawback in using this form of treatment as first line - the patient may be missing out on much needed necessary treatment but cases of real disasters seem few and far between. 

Would I take a placebo? Well , I have been swallowing glucosamine (paid for by me)  on a daily basis for some years. Would I accept acupuncture ? Probably not - but had an enthusiast on the unit who used it pre-endoscopy , and we tried lavender oil on the pillow at one time and foot rubbing as one of our nurses had a side line in these activities : the benefit being that these might help more patients to opt out of or settle for less sedation for a one-off procedure. 

Perhaps the bigger threat facing NHS treatment is in pushing treatments where we have a "We believe" approach to a point where we push treatment until the NNT number  exceeds the NNH . Antidepressants , anxiolytics and statins etc...  come to mind. I also remember how hurt one of my colleagues in supportive psychotherapy felt when she claimed that her patients felt better after a session of treatment  and I pointed out that they might also have felt better if she had given them a bunch of £5= notes.

Any reason not to retract?

Posted in Anaesthesia at Sat, 04 Jul 2015 00:29:59

Jorge Ramirez

Posts: 16
Joined: 09 Jan 2015

The effect of dabigatran plasma concentrations and patient characteristics on the frequency of ischemic stroke and major bleeding in atrial fibrillation patients: the RE-LY Trial (Randomized Evaluation of Long-Term Anticoagulation Therapy). J Am Coll Cardiol. 2014 Feb 4;63(4):321-8. doi: 10.1016/j.jacc.2013.07.104. Epub 2013 Sep 27.

This question thread is also open via:

- ResearchGate: 
https://www.researchgate.net/post/Any_reason_not_to_retract2#55971fe961432591358b45da [accessed Jul 3, 2015].

- Twitter:

I previously requested (2014) four retractions of publications of the RE-LY trial:

- New England Journal of Medicine (n=1): No response.

- Lancet (n=2): Refused to retract the two publications of the RE-LY study (without explaining their decision).

- Heart (n=1): no answers yet.

I have also requested the retraction of a clinical practice guideline concerning acute coronary events and a pharmacoeconomic evaluation of dabigatran and rivaroxaban (Colombia).


1. Dabigatran Investigation. http://www.bmj.com/investigation/dabigatran. The BMJ 2014.

2.  Re: Concerns over data in key dabigatran trial. http://www.bmj.com/content/349/bmj.g4747/rr/778288

3. A message to people responsible for abandoned or misreported trials: you will be published or retracted.

4. Should doctors use Twitter? http://bit.ly/1GV7yHj doc2doc.


P.S. I apologize for my mistake of posting this question on the wrong category (i.e., open anesthesiology - I cannot edit the category of the question).

Re: Has the legal system gone bananas?

Posted in General clinical at Sat, 04 Jul 2015 00:14:10


Posts: 1545
Joined: 09 Dec 2011

Yes John The legal system has gone bananas,  


This man should not be paying with anything but his own life!  His life should have been taken already.

justice is fleeting in our modern world.



Re: New Scientist? Or Daily Mail?

Posted in General clinical at Fri, 03 Jul 2015 18:51:16


Posts: 1001
Joined: 13 Oct 2009

Research into CFS will make little progress until we can resolve the entities involved. The main common characteristics seems to be a denial of the possibility of psychological factors and a common hatred of the medical profession along with a lack of energy.

Yet amongst these patients there is a group where many of us feel there is an underlying poorly defined physical component along with a very distressing level of symptoms . The first step in any useful trial of treatment aimed at a cure will be to find an objective way of identifying this group.and it is these where the trials of treatment may be most helpful. But lumping all patients together to obtain numbers for a trial may well be unhelpful  The clues may come from those patients with hep C or connective tissue disorders etc... where fatigue of a similar type can be a factor and which hopefully these days are picked up during screening tests for CFS. 

As for the others we can but see how best to help and to give them time and use  such programmes as may help - and take the flak about how useless we are.

individualized type 2 diabetes education program on clinical outcomes during Ramadan

Posted in Diabetes at Fri, 03 Jul 2015 16:56:00


Posts: 741
Joined: 15 Apr 2011

Impact of an individualized type 2 diabetes education program on clinical outcomes during Ramadan

BMJ Open Diab Res Care 2015;3:e000111 doi:10.1136/bmjdrc-2015-000111

Verbatim Abstract

Objective To determine if individualized education before Ramadan results in a safer fast for people with type 2 diabetes.

Methods Patients with type 2 diabetes who received care from participating clinics in Egypt, Iran, Jordan and Saudi Arabia and intended to fast during Ramadan 2014 were prospectively studied. Twelve clinics participated. Individualized education addressed meal planning, physical activity, blood glucose monitoring and acute metabolic complications and when deemed necessary, provided an individualized diabetes treatment plan.

Results 774 people met study criteria, 515 received individualized education and 259 received usual care. Those who received individualized education were more likely to modify their diabetes treatment plan during Ramadan (97% vs 88%, p<0.0001), to perform self-monitoring of blood glucose at least twice daily during Ramadan (70% vs 51%, p<0.0001), and to have improved knowledge about hypoglycemic signs and symptoms (p=0.0007). Those who received individualized education also reduced their body mass index (−1.1±2.4 kg/m2 vs −0.2±1.7 kg/m2, p<0.0001) and glycated haemoglobin (−0.7±1.1% vs −0.1±1.3%, p<0.0001) during Ramadan compared those who received usual care. There were more mild (77% vs 67%, p=0.0031) and moderate (38% vs 19%, p<0.0001) hypoglycemic events reported by participants who received individualized education than those who received usual care, but fewer reported severe hypoglycemic events during Ramadan (23% vs 34%, p=0.0017).

Conclusions This individualized education and diabetes treatment program helped patients with type 2 diabetes lose weight, improve glycemic control and achieve a safer fast during Ramadan.

COMMENT:  While the results are unsurprising, they are nevertheless a significant contribution to our understanding of the role in individualized patient education in preventing diabetes adverse events during the religious fasting associated with observation of Ramadan.  Whereas the data were collected in clinics in Muslim countries, the results may be most useful in non-Muslim countries where physicians may be less familiar with the rituals of Ramadan and their potential risks to persons with diabetes.