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Re: Clinical question of the week: What should we do about sugar-sweetened beverages?

Posted in Diabetes at Fri, 31 Jul 2015 21:03:32


Posts: 1032
Joined: 13 Oct 2009

Interesting that Tesco is taking active steps to stop stocking some of the  the high sugar drinks that have been on  their shelves and to sell more with low sugar content. Good for Tesco ! The governement should back this initiative.

Requesting legal advice: whistleblowing and political abuse of psychiatry

Posted in Medicolegal at Fri, 31 Jul 2015 16:18:43

Jorge Ramirez

Posts: 19
Joined: 09 Jan 2015

Dear members doc2doc,

My story is summarized in this release to the public opinion by the league of users from Caprecom (Valle del Cauca, Colombia). 


For users proficient in the Spanish language, I recommend this post by No Gracias:  Loca de Rebeldía

I recently commented here about physician suicide, whistleblowing, human rights, and other topics.

I think that all cases involving the reprisals of whistleblowers are complex and difficult. I have read some posts here on doc2doc about whistleblowing and how it should be effective. There are many recommendations for whistleblowers which are described throughly with great detail in the website of Brian Martin (bmartin.cc) - without doubts, the website of Brian was my best resource for effective whistleblowing. After all the events that happened to me during the last two years (i.e., whistleblowing reprisals), I just know one big thing [that's the reason why I'm writing this post (*)]: I can't resist only by myself, I need support and advice, 

Roddick John. The key to effective whistleblowing is interprofessional collaboration BMJ 2009; 339 :b3055



(*) The parable of the Fox and the Hedgehog. Hat tip: James C. Coyne.


Posted in Respiratory medicine at Fri, 31 Jul 2015 16:07:06


Posts: 1032
Joined: 13 Oct 2009

Check electrolytes and creatinine, calcium and FBC. SXR abdo. Clearly physical examination but may be of limited value and peritoneal aspirate. Consider "non-dialysed" related causes (including hernial orifices). If a pyrexia might need abx but  take sample first (probably blood cultures as well) and discuss choice  with local renal unit or microbiologist.

Re: Medical Drones? They Could Be Flying Soon!

Posted in General clinical at Fri, 31 Jul 2015 12:33:07


Posts: 1558
Joined: 09 Dec 2011

In Response to Re: Medical Drones? They Could Be Flying Soon!:[QUOTE]

To be used as a sample transport, the drone would need to be autonomous. Presently, drone flying regs in the UK insist that the pilot has the tone in line of sight at all times and no more than 500metres away.     No doubt autonomous drones will happen but not yet, and not legal.  See self driving cars.

A gun in a hobby drone!   I've been silent recently, but when the President of the United States is as concerned as I am about arms in America, I am entitled to say, what madness is this?



There you go again John!


Any small opportunity to Bash Guns you take with pride.   This post was about Drones,  I suggest you might avail yourself of the services of an Optometrist!    There is a senator in my home state who is trying to Ban Garden tools,  The common Machete, for brush clearing, and he lost all traction to do so.  I use chain saws, Mahetes, and axes to clear my woods of shrubs, vines, and firewood, so this senator is really lost his logic bearing for sure.   Although I do support your disdain for drones, they are too small to be detected by radar, and seen by planes, so they are in effect more dangerous than guns, by a large margin!



Posted by John D[/QUOTE]


Is it autism or neurodiversity?

Posted in Psychiatry at Fri, 31 Jul 2015 11:36:40


Posts: 573
Joined: 23 Aug 2013

The depiction of autism in 'Rainman' by Dustin Hoffman, and the various presentations of Autism Spectrum Disorder (ASD) in media including 'Mary & Max', 'I am Khan' and many talks on TED from Silberman's the forgotten history of autism, to King's talk about her experience with the freeing power of autism to Chung talking about the Dx of autism to the multitude of books by Temple Grandin, an argument seems to emerge.

The concept of neurodiversity seems to emerge, where autism seems to be a manifestation of a different way of thinking. It would be dangerous to assume normality on all cases of autism, but a very few cases of highly functioning persons with autism, may beg for the question. Whether one is seeking neurotypicality or adaptation and functioning.

Re: Important Medical Law Cases

Posted in Medicolegal at Fri, 31 Jul 2015 10:55:29


Posts: 1032
Joined: 13 Oct 2009

Many thanks - Intubating a lively 2 year old in his cot - not sure that many would have been overkeen to go ahead. Might have required an anaesthetist depending on expertise of the SHO and registrar and considerable sedation . And would simple intubation have been enough ? Bronchoscopy?  Recognising that there was a very real problem here and urgent review to plan ahead for the next episode - yes.

Leaving a clinic to attend a possible (not definite) crisis is always difficult. Looking back now it is difficult to believe how often folk might be involved in more than one activity at a given time eg clinic and on-call were typical examples. Bleep batteries dead - whose responsibility ? What had happened to the consultant - again we are tlking about an age when it was more acceptable for a consultant to be an absent landlord.

Personally , I would have felt there was enough here to be proactive and that a potential crisis should have been recognised - but negligence? Probably now but perhaps not then. Just how often does this chain of events happen - is it something with which one expect to be within a junior doctor's competence and experience?

Re: FDA Approves Stomach Balloon for Weight Loss

Posted in Public health at Fri, 31 Jul 2015 09:37:59


Posts: 1032
Joined: 13 Oct 2009

Golly - just why does everything take so long in medical care? Time and again we hear of "new" drugs or treatments which have been around for decades. I remember - must have been about 30 years ago - looking into these balloons and whether one could devise a way of adjusting pressures endoscopically. Perhaps progress in this instance has been hampered by a shortage of obese patients....

The forthcoming paradigm of psychiatry

Posted in Psychiatry at Fri, 31 Jul 2015 08:20:14


Posts: 573
Joined: 23 Aug 2013

In an inspirational TED talk Dr Thomas Insel speaks 'Towards a new understanding of mental illness'. It seems that in the next couple of decades might look brighter in terms of evidence-based diagnosis.

I wonder whether you think this would be feasible.

Re: Clinical Quiz

Posted in Diabetes at Fri, 31 Jul 2015 00:01:51


Posts: 432
Joined: 29 Jul 2010


Glass cola.jpg


Published Reports described individuals with severe hypokalemia related to chronic extreme consumption  

( 4 - 10 liters per day ) of Cola . Diarrhea caused by heavy consumption of Fructose is also a contributing factor to the diuretic effect of caffeine

A physiological response to hypercapnia, blood potassium as well as calcium helps offset acidosis, which is consistent with chronic severe consumption of carbonated beverages





Re: Thrombectomy for stroke-flash in pan or game-changer?

Posted in Cardiology at Thu, 30 Jul 2015 21:34:09


Posts: 1032
Joined: 13 Oct 2009

I had a quick look at some of these very helpful references , but could not see comment on the tricky question of informed consent. About a year ago there was a case report on this very question in Clin Med (I could dig out the referece if anyone interested). Essentially it was just highlighting this very problem when looked at from the patient's angle : not the best time to have to make such a choice. Uncertainty about the best treatment does not help , but there may never be a clear answer. My next of kin know that where there is doubt I would go for the chance of recovery with optimal function even if there was a higher overall mortality. She could then make the decision if I could not communicate adequately (always assuming we have completed a proxy doct covering healthcare which we are doing). The decision also depends on the practical issues of which interventionist is around etc...

But what hope is there that Joe Public will have ever thought through these options beforehand ? How was consent obtained in these trials? Perhaps easier in a trial than in normal clinical life?

What's in a Newborn's Temporary Name? Possible Trouble

Posted in Medical ethics at Thu, 30 Jul 2015 20:01:36

Mukhtar Ali

Posts: 992
Joined: 14 Nov 2010
Using a distinct temporary first name that incorporated the mother's first name reduced wrong-patient electronic orders by 36%.

Newborns must be given an immediate temporary first name, which most often is “Babyboy” or “Babygirl.” These nondistinct names can be a source of medical errors and misidentification.

In one center's NICU, interventionists created a distinct first name for newborns that incorporated the mother's first name. For example, in the case of a fictional mother named Wendy Jackson, a daughter would be temporarily named “Wendysgirl Jackson” rather than “Babygirl Jackson.” For multiple births, a number was added in front of the distinct name (e.g., “1Wendysgirl,” “2Wendysgirl”). To assess the effectiveness of this naming convention, researchers evaluated the incidence of wrong-patient errors during the 1-year period before and after the intervention. Errors were captured using an automated tool that probed the medical record for orders that were retracted and reordered (RAR).

RAR events declined by 36% during the first year after implementing the intervention (odds ratio, 0.64). Use of the distinct first name was particularly beneficial in reducing RAR events in orders placed by house staff (OR, 0.48) and in orders concerning male infants (0.39).


Social Media and Mental Health

Posted in Public health at Thu, 30 Jul 2015 19:23:21

Mukhtar Ali

Posts: 992
Joined: 14 Nov 2010

Adolescents who spend a great deal of time on social networking sites are more likely to report mental health issues, according to a new study.


Re: Should we get rid of names of discoverers from our organelles?

Posted in Medical ethics at Thu, 30 Jul 2015 14:07:19


Posts: 460
Joined: 14 Dec 2010

Jeffrey Aronson wrote a good article about this in the BMJ last year. He summarised the main arguments for and against eponyms in Medicine. 

BMJ 2014;349:g7586 doi: 10.1136/bmj.g7586 (Published 16 December 2014).

My own answer would be definitely to keep them and this would apply even if, the person is later found to have done 'bad things'.  Reiter is an example where the eponym has recently been expunged from usage.  I would argue that we should always try to learn about the names enshrined in these eponyms and to be aware of and learn from bad things that were done.  We can't, or shouldn't, try to rewrite history.

Anyone with any sense should realise that diseases, structures and processes first described decades or centuries ago may now have a very different profile which keeps changing and it's incumbent on all clinicians to keep up to date with current knowledge, at least in their own field.

There's a danger that we come to think Medicine is only about now and is just a product of the most recent guideline, dictats or even financial statement.  This is probably not accidental but our current clinical practice arises from an unbroken lineage of  people, advances and lessons with an unbroken line extending back and, we hope, forwards. 

Appreciation of how we got here is rapidly being lost in medical education; many students and new doctors look blank when even names such as Osler is mentioned (while talking about 'coeliac's disease as if Dr Coeliac described it!).  It's clearly not necessary for a formal history of Medicine to be taught routinely but our most valued teachers and mentors extend well beyond those who are still alive.  The lessons from even those who are long deceased are often still valuable today.  Other sciences, the humanities and the law celebrate and learn from their histories and we should do the same.


Re: Consent

Posted in doc2doc feedback at Thu, 30 Jul 2015 10:28:48


Posts: 1032
Joined: 13 Oct 2009

John D - I think we have all come across these folk. Expressed in our current society view that if something is as risky as that then it would not be allowed . No wonder painting the high risks are not taken on board., But patients who really do seem impervious to option appraisals I think are relatively rare and there is an obligation on behalf of the surgeon to be sure that there are clear indications (witness the problems surrounding cosmatic surgery).  I think these are different from attempts to pass outcome measures entirely over to the patient and there is a difference between getting the patient to request surgery and making him/her beg for it.

 Nor should Informed consent be used as an excuse for not operating : adverse outcomes should not be overstated. A mortality of 5% should not be portrayed as one of 20%. Some people may not waken after an anaesthetic or have a heart attack during it  , but that should not be portrayed as a routine risk and a reason to refuse to operate. One of my big grouses before retirement was thae way in which surgeons tried to avoid operating as they became older. It seemed to stem from a feeling of not wishing to put head above parapet rather than just idleness. As I think I have commented before , it is depressing as a physician to be looking after patients medically but with indications - sometimes strong indications - for surgery. I was never sure just how far one could go in saying "Your mother/father needs surgery but they won't go ahead".** I am of course only talking about surgery within my own specialty where I am reasonably confident about indications.

**I think I usually ducked and probably said something about anaesthetic risks ....

Re: "Enforced" 7 day working - has Mr Hunt really lost it?

Posted in General clinical at Wed, 29 Jul 2015 16:44:27

John D

Posts: 3633
Joined: 01 Feb 2010

My deep cynicism about this e-petitionidea has been confirmed.    Origuinally, it wa set up so that if 10,000 signatures were obtained, the Giovernment would respond, and if 100,000 would be considered for a debate in Parliament - high bars to get over, when for instance one on fracking has only 500 to date.  I can't see how many the one asking for a no-confidence debate on Hunt, but the last I saw was neraly 200,000!

So, the Gov has 'considered' it - basicly tolld everyone who siogned it to F-off.  here is the entiore tesxt of their reply, inaccurate (=lying), and near libellous as it is:

The Government has responded to the petition you signed – “To debate a vote of no confidence in Health Secretary the Right Hon Jeremy Hunt”.

Government responded:

The Government is committed to delivering seven day services to make sure that patients get the same high quality, safe care on a Saturday and Sunday as they do on a week day.

Many people do not realise that if you are admitted to hospital on a weekend, you have a 16% greater chance of dying. The Government wants to change this so that everyone can be confident that they will receive the same level of care whatever day of the week they are admitted to an NHS hospital. 

NHS consultants already provide an outstanding service and show great dedication to ensuring patients get the best outcomes. But the Government has a duty to make sure the system is set up in a way which makes it as easy as possible for hospitals to organise their resources to maximise patient safety across every day of the week.

To understand more about the possible issues for staff contracts, last year the government asked the independent pay review bodies for NHS staff - The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) and the NHS Pay Review Body (NHSPRB) for their observations and recommendations about how the reform of employment contracts could help support the delivery of seven day services in England.

The reports were published this month. They identified that a major barrier to seven day services is a decade old contractual right in the consultants’ contract negotiated by their union representatives in 2003 that allows senior doctors to refuse to work non-emergency work in the evenings, at nights and at weekends. No junior doctor, nurse or other clinical group has any such right. Other senior public sector professionals who work in services required to keep the public safe, such as police officers, firemen and prison governors, do not have this opt out either.

Whilst the vast majority of consultants work tirelessly for their patients, the opt out allows individuals to charge employers hugely expensive payments which are much higher than national contract rates (up to £200 an hour). The average earnings for a hospital consultant are already in the top 2% in the country at £118,000, and these inflated payments can make it difficult for hospitals to provide the weekend cover they know patients need. 

The report endorsed the removal of the opt out, as well as broadly supporting other changes to the consultant contract that would ensure the right level of cover is available every day of the week; not just Monday to Friday.

Under the new plans, doctors will still continue to receive a significantly higher rate for working unsocial hours and there will be a contractual limit (not an expectation) of working a maximum of 13 weekends a year.

By the end of the Parliament, the Government hopes that the majority of consultants, in line with existing practice for nurses, midwives and junior doctors, will be on reformed contracts, working across seven days, to deliver a better service to patients. Hospitals like Salford Royal and Northumbria that have instituted seven day services have already seen improvements in patient care and staff morale.

These new plans will mean that doctors working in some of the toughest areas in the NHS, such as A&E and obstetrics, will at last be properly rewarded and there will be faster pay progression for all consultants early on in their career. Under the new proposals, the highest performing consultants could be able to receive up to £30,000 a year in bonus payments, on top of their base salary.

Of course, improving weekend care requires more than just ensuring greater consultant presence. That's why the government is also addressing issues such as access to weekend diagnostic services, provision of out of hospital care to facilitate weekend discharges, and adequate staffing cover amongst other clinical groups,. But NHS leaders and the independent pay review bodies are clear that increasing the presence of senior clinical decision makers at weekends is vital, and that the consultant opt out remains a barrier to organising broader support services and staff rotas.

The Government feels it is under an obligation to the public to do all it can to make NHS care at the weekend as safe as during the week through the delivery of seven day services this Parliament and that is what it will continue to do.

Click this link to view the response online: https://petition.parliament.uk/petitions/104334

The Petitions team
UK Government and Parliament

Re: Changing email account for login

Posted in doc2doc feedback at Wed, 29 Jul 2015 13:54:49


Posts: 1403
Joined: 07 Sep 2009

Hi Adrian, please could you email me on smalik@bmj.com with the old and new email addresses and I'll try to help you.

Re: What should doctors wear at work?

Posted in Careers at Wed, 29 Jul 2015 08:43:51

John D

Posts: 3633
Joined: 01 Feb 2010

I hate colour coding.    When used for drugs labels it can be a source of serious error, and for theatre wear is no substitute for proper organisation.   A theatre manager of my parish tried to institute colour coded hats.    When there were none of my rank available and I wore a different one, I was disciplined in public for my 'error'.   Badly is how I felt and how the policy succeeded.

How are we to know who is who?   Again in theatre, the WHO process starts with a briefing meeting in which the first item is introductions all round, of name and positionby each in turn.  On the ward, and to the conscious patient anyone should introduce themselves by name and purpose.  It' s simple courtesy.

As to how we should dress, this has been considered many times and I did a meta-analysis some years ago.  Jeans and surprisingly clogs were out,  and when asked to compare models patients preferred a formal style.   But when they had interacted with doctors in both formal and  casual wear, the personal style, their "bedside manner" contradicted any impression made by their clothing.   If you area good doctor, it doesn't matter what you wear!


Re: Fears of the Spread of a new Respiratory Virus

Posted in General at Wed, 29 Jul 2015 08:24:12

John D

Posts: 3633
Joined: 01 Feb 2010

Reasonable precautions by that hospital's A&E, given the lethal prognosis of MERS but surely no need for panic.  So far, like bird flu, transmission to and between humans is difficult.   The  history of these patients' infection has, rightly, not been made public but I'll bet recent travel to the Middle East features in it.


Re: Should your psychiatrist track your mobile phone?

Posted in Psychiatry at Wed, 29 Jul 2015 07:55:29


Posts: 1032
Joined: 13 Oct 2009

your phone knows how you feel? ". Interesting - mine is almost permanently swithched off (only use it to make an occasional call or connect to internet when I am away).Does this reflect my mental state in retirement?

Re: Philosophy of Coffee & Personality

Posted in Psychiatry at Tue, 28 Jul 2015 14:00:43


Posts: 573
Joined: 23 Aug 2013

In Response to Re: Philosophy of Coffee & Personality:[QUOTE]

There may be other good reasons for doing those things in various settings but trying to assess personality from the descriptions and preferences seems a bit far fetched.

Posted by Maxim[/QUOTE]

Thanks Maxim,

I hope for a day when we get rid of this type of conclusions.

Re: Evidence of severe bipolar disorder online

Posted in Psychiatry at Tue, 28 Jul 2015 13:57:09


Posts: 573
Joined: 23 Aug 2013

Sometimes, there are posts that are glaringly suggestive of mental illness. In the case mentioned by John D, if the person is not speaking metaphorically or bluffing, it might be suggestive of an illness. This brings me to the basic role of a physician which is to treat the patient at hand. I guess it would be out of great compassion that a doctor would love to treat whosever he can help. However, doctors are not entitled to eradicate illness, stalk patients and read their posts to help them. Doctors cannot prevent illness, or protect the society. To the best, of my knowledge, this would be the role of police and social services to protect from dangers.

I am not sure whether it would be OK to report to the police on such posts or not.

Re: What your patient is thinking: Psychiatric assessments—how much is too much?

Posted in Psychiatry at Tue, 28 Jul 2015 13:47:29


Posts: 573
Joined: 23 Aug 2013

The tradition of a distant 'blank slate' psychiatrist may be backdated to the psychoanalytic era. There was  no emphasis on the evidence to adopt such posture apart from philosophically intriguing concepts. The I protracted psychiatric assessment is probably due to the Meyerian (following Adolf Meyer) model of psychobiology (biopsychosocial assessment). Psychiatry seemed to thirve on buzz words like 'holistic approach'. It is almost always difficult to argue with a doctor that nocturnal eneuresis is irrelevant to dementia, or that frequent job changing is not a precursor of PTSD.

I might be a bit of a radicalist. I think the psychiatric assessment needs a lot of reform, where it should adhere to the bio-medical model, and delegate the rest of psycho-socio-spiritual to other disciplines.

Re: Coping with silly comments

Posted in BMJ at Tue, 28 Jul 2015 13:29:27


Posts: 573
Joined: 23 Aug 2013

This cliche folows a long stream of stereotypes that can help treating doctors to cast blame on patients not doctors for any problem. I tend to agree with sken, may be because some doctors need to ave good understanding about what is going on. May be because doctors are sophisticated. I wonder whether it would be easier to treat a lawyer, an engineer, a pharmacist, or not.

There is no thing such as 'bad patient'. However, there is 'incompetent doctor'.

Re: Clinical question of the week: HCM part 1

Posted in Cardiology at Tue, 28 Jul 2015 07:34:28


Posts: 20
Joined: 04 Sep 2014

Part 2:

Which of the following criteria below does not indicate increase risk of sudden death in patients with HCM?

Re: Clinical question of the week: HCM part 2

Posted in Cardiology at Tue, 28 Jul 2015 07:28:55


Posts: 20
Joined: 04 Sep 2014

Part 1 of the question is here: http://doc2doc.bmj.com/forums/open-clinical_cardiology_clinical-question-of-week-hcm-part-1-1