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Re: SCE Endocrinology and Diabetes practice question from OnExamination: What are the side effects of exenatide?

Posted in Diabetes at Tue, 28 Apr 2015 09:59:06


Posts: 8
Joined: 07 Apr 2015

The correct answer is: Risk of pancreatitis


Acute pancreatitis has been reported in 89 patients treated with exenatide up to September 2007.

The majority of cases (87 out of 89) have occurred in the USA.

Many of the patients who developed pancreatitis had co-existent risk factors for the development of pancreatitis such as alcohol excess, gallstones or hypertriglyceridaemia.

However, despite this, the Food & Drug Administration (FDA) indicated that they felt there was an association between exenatide and the development of pancreatitis in some cases.

Consequently, the FDA advised that patients commencing exenatide should be advised to 'seek medical care promptly if they have unexplained persistent severe abdominal pain, which may be accompanied by vomiting'.

Other recognised side effects of exenatide include gastrointestinal disturbance such as:

  • nausea
  • vomiting
  • diarrhoea, and
  • bloating.

Headache, dizziness and injection site reactions are also recognised side effects.

Weight loss is a benefit of treatment not a side effect.

Hypoglycaemia occurs rarely in patients treated with exenatide in addition to metformin (incidence of 4.5-5.3% compared with 5.3% in placebo treated patients).

If exenatide is used in combination with a sulphonylurea, or both metformin and a sulphonylurea, then the incidence of hypoglycaemia is much higher (14-36% compared with 3% in the placebo group).


  1. Buse JB, Henry RR, Han J, et al. Effects of exenatide (exendin-4) on glycemic control over 30 weeks in sulfonylurea-treated patients with type 2 diabetes. Diabetes Care.2004;27(11):2628-35.
  2. DeFronzo RA, Ratner RE, Han J, et al. Effects of exenatide (exendin-4) on glycemic control and weight over 30 weeks in metformin-treated patients with type 2 diabetes.Diabetes Care. 2005;28(5):1092-100.
  3. Kendall DM, Riddle MC, Rosenstock J, et al. Effects of exenatide (exendin-4) on glycemic control over 30 weeks in patients with type 2 diabetes treated with metformin and a sulfonylurea. Diabetes Care. 2005;28(5):1083-91.

MRCP part 2 practice question from OnExamination: SLE medication

Posted in General clinical at Tue, 28 Apr 2015 09:57:13


Posts: 8
Joined: 07 Apr 2015

A 65-year-old woman with SLE is diagnosed with class IV SLE nephritis.

The renal physician plans to start her on i.v. methylprednisolone (1 gm/day for three days) followed by oral prednisolone 1 mg/kg/day, and fortnightly i.v. cyclophosphamide.

Re: Poll archive

Posted in doc2doc feedback at Tue, 28 Apr 2015 09:53:35


Posts: 1267
Joined: 07 Sep 2009

Should more doctors stand for election as members of parliament? (95 votes)

Yes: 74 votes (77.9%)

No: 21 votes (22.1%)

Re: Diminished Capacity and Criminal Law

Posted in BMJ at Tue, 28 Apr 2015 09:41:16


Posts: 1783
Joined: 08 Oct 2010

In Response to Re: Diminished Capacity and Criminal Law:[QUOTE]


This must make most clinicians (and lawyers) uncomfortable.  It presumably comes within the concept of capacity legally.  The default position in clinical practice is to assume that capacity exists until it can be shown that it is impaired.  The general tests for capacity here would presumably have to to show that the criteria applied specifically to his ablility to instruct counsel and to follow proceedings.  Surely, it is for a judge to appoint psychiatric assessors to make these judgements and, as you say, for the process to be transparent.  We are not told who made the judgements and it what circumstances.

I can't see how the claim that he is 'no threat to the public' is connected to the judgement about dementia but there may have been some other reason for that.  I would regard any future involvement in The Lords or other aspect of law-making as a distinct threat to the public.  I couldn't possibly say if some active politicians don't fall into the same category.

Lord Janner has to be considered innocent until proved guilty but dementia of the severity that precludes trial is essentially irreverrsible and if, like Saunders, Lord Janner later makes a miraculous recovery, a charge of perverting the cause of justice might be added.

I had in the back of my mind something about another type of judicical process by which a judge could somehow review the evidence in the absence from court of the defendant.  Is that the case or have I also begun to lose it? 


Posted by Maxim[/QUOTE]

Many thanks Maxim,

The threat to the public aspect of the DPP decision refers to the matter that if no prosecution goes ahead would the accused be likely to commit further offences of the type alleged? In this case the answer is no, because the dementia is such that he would not be in any position to abuse. On that specific point I am in agreement. Janner must of course be considered innocent unless and until he is found guilty - but it is clear to see that the DPP was satisfied that the evidential burden had been met (when assessed at three different times in the preceding thirty years) but factors such as mismanagement, incompetence or cover up prevented a trial taking place when it should have done. Over the last decade there have been cases where elderly men with Dementia have been prosecuted and imprisoned for the same type of offences - it is not surprising that people think 'the establishment' are covering up in this case.

Newspapers have stated that Janner was signing legal documents regarding his financial affairs and was in correspondence with the House of Lords up until over a matter of weeks before the DPP published her decision - he cannot have Dementia so bad he cannot be tried but perfectly capable of managing his own financial affairs. As you rightly say, if he suddenly makes a remarkable recovery there would certainly be some very serious legal questions asked.

As regards the medical experts, two were appointed by the cPS and two by the defence. I don't doubt that the Doctors formed their opinions in good faith but people are rightly skeptical post Saunders, Pinochet et al.

One possibility that the DPP did not put forward - and I believe she should have - would be a trial of facts. While Janner would not be standing trial and could not be found guilty or not guilty, a Judge could hear in open court the allegations and charges, hear the evidence and make a finding on whether the crimes alleged had taken place. At least that way the alleged victims would have an opportunity to state their case and a historical record would be determined. In my view the DPP should have done this, and could still do this. There is concern that victims will be less willing to come forward when famous or well placed people are accused of sexual abuse - a trial of facts would surely be preferable.

Overall, this case has been managed very badly for thirty years. Police officers say they were told by the powers that be not to pursue an MP (likewise with Cyril Smith), alleged victims not treated with decency, the CPS not vigorously managing their case and finally seeming to give Janner a get out of jail free card. Perhaps the full public inquiry which has been started will get to the truth.


Re: Clinical question of the week: ST elevation without obstructive coronary disease

Posted in Cardiology at Tue, 28 Apr 2015 05:50:08

dr v n srivasta

Posts: 6
Joined: 16 Oct 2013

I agree with Dr Chid

Do you think this advertisement is unethical?

Posted in Medical ethics at Mon, 27 Apr 2015 21:08:21

John D

Posts: 3515
Joined: 01 Feb 2010

We take the Daily Telegraph in our house (Know your enemy, I say) and like others it has a Saturday Colour supplement.  This full page ad appeared this last weekend.


As you can see, it's for a Hilton Hotels "Weekender" short holiday package, and invites you "Get, set, go! Make a fast getaway"     On a scooter, dressed for the beach, without helmets.

There have been so many holiday makers maimed or killed, hiring scooters on holiday and, inexperienced or drunk, falling off.    I thought that a responsible newspaper like the Telegraph would have let this one by only in a moment of inattaention.   But no!

"this was an independent advertisement designed, paid for and placed by the company concerned ... you will appreciate that we are presented with thousands of advertisements in the course of a year and it simply isnt possible to check ... We do our best to ensure they appear to be legal, decent, honest and truthful.", said the Telegraph's Enquiries Desk.   In other words, we were only obeying orders.

Who else might see the error of Hilton's ways?  Ah, the Advertising Standards Authority.  Which thanked me for my complaint and will get back to me within ten working days.   Dammit!  That foolish young man and his girl could be dead and buried in ten days!

Complain to Hilton Hotels, you say?   Gladly, if you will give me a contact that isn't "Reservations/ Meetings & Groups/ Investor Relations/ Hotel Questions/ Travel Agent/ etc.etc."

Do you think I'm an interfering old fool?    I think that a hotel company that encourages reckless and, in this country, illegal use of a motor bicycle, should be shown the error of their ways.


Over 75 and DNR

Posted in BMJ at Mon, 27 Apr 2015 20:15:42


Posts: 925
Joined: 13 Oct 2009

One of our newspapers (not one I would buy) has a main feature on the front page about an apparently new policy to ask those >75 about their views on DNAR. Provided this is introduced as a topic and not a decision to be made irrespective of the illness , I cannot see a great objection , apart from the obvious one that reminding anyone that they might die is seen as totally outlandish. Of course it would be wrong to try to obtain a clear decision unless clinically indicated but as a discussion point there is much to be said for it and after 75 there is an increased risk of acute hospital admission in a state where it could well be difficult to engage in constructive discussion.

Inevitably the response has been pretty over-the-top. The woman at the counter had also seen the headline and said she remembered a book where the elderly were killed off to provide food for the hungry and this seemed to be the first step in that direction..... 

DOI  >75

PS Just had 2 weeks windsurfing in Tobago + fair amount of reading. "I'll see myself out , thank you" is a good short read. A collection of essays (Warnock , Will Self and others) giving some views on end-of-life with quite an emphasis on what the elderly think - or at least the thinking elderly.

Re: Killer Krokodil Hits The Streets With A Vengeance!

Posted in General clinical at Mon, 27 Apr 2015 11:32:19


Posts: 389
Joined: 14 Dec 2010

I agree with John D that it's important for the profession to keep these things clinical.  The jokey tabloid names for lethal drugs can distort the real nature of such drugs and we should counter these fashions whenever possible.

Even 'ordinary' compounds used for genuine clinical reasons can cause  devastating tissue necrosis when extravasated.  8.4% sodium bicarbonate and 50% dextrose are two of the worst offenders and we still see these problems even with apparently good iv access.  pH and osmolarity are probably the mechanisms in the absence of infection.

Addicts will always find ways to do themselves serious damage but we also need to remind inexperienced staff of similar dangers in their own practice and that the use of these concentrated preparations is rarely, if ever, necessary.

Free clinical examination (OSCE) guides with HD video demonstrations

Posted in General clinical at Mon, 27 Apr 2015 11:15:00


Posts: 1
Joined: 27 Apr 2015

Hey guys,

I'm Lewis, a junior doctor in the UK. I founded www.geekymedics.com which is a free medical student revision resource. I've been producing lots of clinical examination guides, with associated videos and thought it might be useful to people preparing for clinical exams. I'd also love to hear your feedback.

The examination guides are located here http://geekymedics.com/category/osce/

Hopefully you guys find it a valuable resource :)



Re: Liverpool CCG "rethinks" funding for homeopathy

Posted in News & media at Sun, 26 Apr 2015 15:22:48


Posts: 1512
Joined: 09 Dec 2011

In Response to Re: Liverpool CCG "rethinks" funding for homeopathy:[QUOTE]

Really, Poltor, do tell!   References, proper trials, please.

On the other hand,  Mathie and Clausen's meta-analysis, in the January issue of Homeopathy http://www.ncbi.nlm.nih.gov/pubmed/25576265 could only find, " some very limited evidence that clinical intervention in animals using homeopathic medicines is distinguishable from corresponding intervention using placebos"

If that is the best that a Homeopathic journal can find, then the whole "discipline" should be discarded.  



If you're going to hit me with Kant, I surrender!



Posted by John D[/QUOTE]


Surely a Doctor as intelligent as you must have had reason to travel the  cerebral voyage through Kant's Critique of Pure Reason?   I read Kant for relaxation after a day of calculating downwind hazards associated with chemical or nuclear hazards.     In any event,  I hope the NHS does not cover Homeopathy.    I believe it to be Quackery!



Re: Should surgical training include involvement in a clinical trial?

Posted in General clinical at Sun, 26 Apr 2015 07:26:52

John D

Posts: 3515
Joined: 01 Feb 2010

A rather pathetic orthopaedic surgeon.  What doctor every sees everything in their specialty, when orthopaedics is so large and medicine changes with time?   I've certainly not seen everything in anaesthesia in thirty-plus years, but I hope I've read about almost everything!

And I hope that Mr.Bicknell is being Devil's Advocate, saying that surgery is such a craft that its practitioners need not know about the science of their specialty.    Surely he will agree that progress in modern surgery has to be based on the evidence of properly conducted trials, and that a fully trained (if not experienced, see above) surgeon should have as part of their professional background a knowledge and experience of trials.



Re: Fancy quizzing a future UK health secretary?

Posted in BMJ at Sat, 25 Apr 2015 22:26:04


Posts: 275
Joined: 29 May 2013

Why will these so-called intelligent people not realise that two factors head the list of damage to the NHS - 1) the Internal Market and the management tiers which it generated, and 2) the stupid idea of 'Efficiency Savings' AKA cuts across the board.

Stopping both of these would allow the NHS to work better at no extra cost!

Re: Doctors who are body builders

Posted in Public health at Sat, 25 Apr 2015 12:19:12


Posts: 389
Joined: 14 Dec 2010

In one sense extreme bodybuilders may indeed be 'not like us'.  I've seen a claim that a significant proportion of the top competitors have a mutation in a gene coding for functional myostatin, the protein that normally stops skeletal muscle growing beyond a certain size.  It's a similar mutation to the one responsible for the dramatic musculature of Belgian Blue, 'double-muscled', bulls.  My attention was drawn to this when the local farmer put an incredible looking (luckily placid) bull in the field next to our house.  The farmer denied emphatically that he'd been giving the animal anabolic steroids! 

Re: MRCGP practice question from OnExamination: Chronic knee pain

Posted in General clinical at Sat, 25 Apr 2015 08:45:57


Posts: 925
Joined: 13 Oct 2009

maxim makes an important point. What I found interesting in this thread is that the evidence is so poor. It should be feasible to do a good study on paracetamol levels in those on regular prescribed paracetamol and look for evidence of outside sources. The problem would be that obtaining informed consent would re-emphasise the need not to take these and so the study could be self-defeating. The guidelines for those considered as "at risk" seem somewhat arbitrary with the dose : kg bodyweight etc... being in the equation.

A similar problem exists with NSAID - I take my long acting prescribed one cautiously and do not double up with my OTC ibuprofen , but there are times when I am tempted.

I doubt whether the test patient in this thread would have been in a major danger zone but at least she would (hopefully) have been wiser if referred to the A&E as an emergency. Presumably the episode would also have been reported as a "significant clinical incident" : how does this system work in general practice?

Re: ECG from the grand round

Posted in General clinical at Sat, 25 Apr 2015 01:18:56


Posts: 712
Joined: 21 Feb 2012

Thank you.


Re: Recurrent Diverticulitis Investigation

Posted in General clinical at Fri, 24 Apr 2015 20:46:37


Posts: 6
Joined: 11 Nov 2013

As a patient with this condtion I do wonder about the wisdom of antibiotic use to treat. So far i have refused them and the condition seems to self limit -although pain ofen persists for a week or two ect. natural yogurt, honey and extra sleep seems to sort it out at the moment. My GP has never referred me for investigation although my sister who lives in a different country has had a scan. She also has accepted some 'bulking agents' but i have decided that it is eventually about stress levels  and life style.

Re: Amantadine for Irritability After Traumatic Brain Injury

Posted in General at Fri, 24 Apr 2015 15:14:34

Mukhtar Ali

Posts: 938
Joined: 14 Nov 2010

Traumatic Brain Injury (TBI) is a feature of fast life style worldwide but the numbers of patients are more in countries with huge population like India, Pakistan, and Bangladesh. The statistic shows that they are usually young people and otherwise with robust heath. The researchers have a good chance to re-evaluate the efficacy of a relatively inexpensive drug call Amantadine freely available, in the TBI patients in India, Pakistan and Bangladesh.

Re: Doctors standing for election as MPs

Posted in Careers at Fri, 24 Apr 2015 13:17:26

P English

Posts: 65
Joined: 29 Jun 2009

Just to point out - many doctors have - mostly unwillingly - become civil servants.

Among the many restrictions this places on their ability to advocate for the populations they serve, this means that if they wish to stand as an MP they must first resign from their posts (though they may be entitled to get their job back again if they're not elected).

Any civil servant doctor would have to take this into consideration.


Re: Performers List problems

Posted in Careers at Fri, 24 Apr 2015 03:52:55

peter lacey

Posts: 5
Joined: 11 Apr 2015

How dare they!  

Re: Comment: The Ebola Frontline

Posted in Public health at Thu, 23 Apr 2015 17:56:21

Mukhtar Ali

Posts: 938
Joined: 14 Nov 2010

Ebola Treatment Shows Promise in Monkey Study

Wednesday, April 22, 2015

WEDNESDAY, April 22, 2015 (HealthDay News) -- An experimental drug being tested on Ebola victims in Sierra Leone has proven effective in treating infected monkeys during laboratory trials, a new study reports.

The antiviral drug, TKM-Ebola, cured three monkeys infected with Ebola, said study senior author Thomas Geisbert, a professor of microbiology and immunology at the University of Texas Medical Branch at Galveston


Patient Feedback important for doctors/hospitals?

Posted in Quality & Safety at Thu, 23 Apr 2015 13:34:12


Posts: 1
Joined: 23 Apr 2015

As a medical service provider, is it important for doctors, hospitals, nurse practitioners to know how the patient felt about the service provided by their doctor, doctor's office, nurses?

Re: Clinical question of the week: 16yo with sexual exhibitionism, dysarthria, and drooling

Posted in Psychiatry at Thu, 23 Apr 2015 12:53:00


Posts: 3
Joined: 07 Aug 2011

Wilson's disease.

Caeruloplasmin, genetic testing.

Screening of relatives.

Does the patient know best?

Posted in Quality & Safety at Thu, 23 Apr 2015 04:16:48


Posts: 1267
Joined: 07 Sep 2009

At 1530 today the International Forum in London is hosting its first formal debate.  Speakers will argue for and against the motion that “the patient knows best”. The audience will get the chance to vote and contribute before and after the argument. 

Speakers for the motion:

1.       David Grayson, Consultant Otolayngologist, Ko Awatea, New Zealand

2.       Paul WicksVice President  of Innovation at PatientsLikeMe.com

3.       Surina Taneja, medical student and member of the debating section, UCLU Medical Society, UK

Speakers against the motion:

1.       Brian Robson, Executive Clinical Director of Healthcare Improvement Scotland

2.       David GilbertDirector of InHealth Associates and writer of futurepatientblog.com

3.       Kirtana Vallabhanenimedical student and member of the debating section, UCLU Medical Society, UK

AdjudicatorsThos Thorogoodstudent debater, and Tessa RichardsSenior Editor/ Patient Partnership, The BMJ

ChairTim BrooksChief Executive, BMJ


You can watch the debate live at 1530 by clicking here



Where do you stand on this?

Re: Poll about smoking in cars

Posted in General clinical at Wed, 22 Apr 2015 17:24:40


Posts: 1
Joined: 22 Apr 2015

smoking kills.............. it should be discouraged no matter where we are.

Re: Watch quality and safety sessions live from the International Forum this week

Posted in Quality & Safety at Wed, 22 Apr 2015 08:51:37


Posts: 1267
Joined: 07 Sep 2009

You can watch these sessions live (for free) today, tomorrow, and Friday