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Clinical question of the week: would you change this man’s anti-diabetic treatment?

Posted in Diabetes at Sun, 22 May 2016 04:12:18

Joey Rio

Posts: 1068
Joined: 13 Apr 2011

A 72 year old male has had type 2 diabetes for six years. He is on metformin extended release 2.0 grs per day. He does not have any major cardiovascular disease. His last two routine HBA1C levels, taken within a four month period by his GP prior to this appointment, were stable at 9.1%.

Aphantasia: a real disorder or a fantasy?

Posted in Psychiatry at Fri, 27 May 2016 15:47:21

Mukhtar Ali

Posts: 1027
Joined: 14 Nov 2010

The BBC Health reported a case of aphantasia; describing a man who cannot visualise or form imagery.The only reference cited is from Cortex journal a letter to the editor named lives without imagery; congenital aphantasia. doi:10.1016/j.cortex.2015.05.019

I wonder how much syndromes can be built on single case reports, and I have my concerns about such labels, and whether these would have any significant clinical implication or not. I am not sure I have encoutnered any case of 'aphantasia' I am a bit curious about your practice whether you met with cases that would qualify to this disorder or not.

Zika and the Rio Games

Posted in General clinical at Fri, 27 May 2016 13:12:42

John D

Posts: 4049
Joined: 01 Feb 2010

International Journal of Infectious Diseases: Unexpected and Rapid Spread of Zika Virus in The Americas - Implications for Public Health Preparedness for Mass Gatherings at the 2016 Brazil Olympic Games

 “Mass gatherings at major international sporting events put millions of international travelers and local host-country residents at risk of acquiring infectious diseases, including locally endemic infectious diseases. The mosquito-borne Zika virus (ZIKV) has recently aroused global attention due to its rapid spread since its first detection in May 2015 in Brazil to 22 other countries and other territories in the Americas. The ZIKV outbreak in Brazil, has also been associated with a significant rise in the number of babies born with microcephaly and neurological disorders, and has been declared a ‘Global Emergency by the World Health Organization. This explosive spread of ZIKV in Brazil poses challenges for public health preparedness and surveillance for the Olympics and Paralympics which are due to be held in Rio De Janeiro in August, 2016. We review the epidemiology and clinical features of the current ZIKV outbreak in Brazil, highlight knowledge gaps, and review the public health implications of the current ZIKV outbreak in the Americas. We highlight the urgent need for a coordinated collaborative response for prevention and spread of infectious diseases with epidemic potential at mass gatherings events.”


What will Zika mean for the 2016 Rio Olympic Games?

Wanting to leave and work abroad in Australia or USA.?

Posted in Careers at Mon, 23 May 2016 08:43:18


Posts: 1
Joined: 23 May 2016


i went to the BMJ careers fair and the guys there made asutralia sound really good only porblem is that my degree was from europe though im a UK citizen,  which australia say you need to do the entrance exams first. Uk graduates dont have that problem. im stuck in a rut here, I want a new challenge and better lifestyle but its hard to choose whether to do the oz exam or suck it up and do all the USMLE  steps and head that way . its a crossroads decision i guess. im not terribly looking froward to doing CMT here at themoment!


anywone made the leap or thinking of it?


Body Integrity Identity Disorder (BIID)

Posted in Psychiatry at Fri, 27 May 2016 19:30:08

John D

Posts: 4049
Joined: 01 Feb 2010

Hi all,


I’m an MA Journalism student in London doing a documentary on Body Integrity Identity Disorder (BIID), also known as Amputee Identity Disorder.


Myself and a colleague are looking to explore the condition in a sensitive and respectful way, while raising public awareness.


We would be forever grateful to anyone willing to be interviewed about it (and is within travelling distance i.e. Britain or Ireland).


Preferably it would mean showing your face on camera but if you would prefer to remain anonymous that’s absolutely okay too.


Please PM me here or leave a comment if you are interested!


Thanks in advance!


Time to abandon three-phase trials?

Posted in BMJ at Sun, 22 May 2016 05:56:21

Jorge Ramirez

Posts: 69
Joined: 09 Jan 2015

Should three-phase trials be abandoned? Andrew V Metcalfe, an associate professor in statistics at the University of Adelaide, asks this in response to the death of a man last month during a drug trial in France.

BBC news health editor James Gallagher described the death in his report as "the bitter price of the new medicines we take for granted." He concludes: "Testing such experimental drugs, at the cutting edge of science, can never be completely risk-free."

Professor Metcalfe, responding to a paper on thebmj.com, argues that biotrial phase I trial of an experimental drug has shown that while the risk may be small the consequences can be tragic. 

Using biometric information such as DNA profiles would shift the emphasis from the estimation of the average effects of a new treatment to the prediction of its effects on specific patients, he concludes.


Book about how to treat sciatica and low back pain with Osteopathy

Posted in General at Tue, 24 May 2016 19:49:26

John D

Posts: 4049
Joined: 01 Feb 2010

Hi everyone! Did you hear about Osteopathic medicine?

Osteopathic medicine provides all of the benefits of modern medicine including prescription drugs, surgery, and the use of technology to diagnose disease and evaluate injury. It also offers the added benefit of hands-on diagnosis and treatment through a system of therapy known as osteopathic manipulative medicine.
So did you hear about one of my latest books called "OSTEOPATHIC TREATMENT OF THE LOW BACK PAIN AND SCIATICA CAUSED BY DISC PROLAPSE" which represents the results of 20 years of treating disc prolapse.

What do you think about Osteopathic medicine? Is it beneficial or not?

You could find more details here:http://medoslibrosalud.com/en/osteopathy/114-osteopathic-treatment-of-the-low-back-pain-and-sciatica-caused-by-disc-prolapse.html


Prescribing Marjuana

Posted in General clinical at Thu, 26 May 2016 00:37:04


Posts: 839
Joined: 21 Feb 2012
Which most closely resembles your views toward physicians prescribing medical marijuana to patients?
1/ There is little clinical evidence to validate marjuana as a medical therapy
2/ Medical marjuana should be considered to alleviate patient suffereing
3/ Patients should be allowed to decide for themselves whether to make use of medical marjuana
4/ Further medical education about marjuana is needed

Magic mushrooms in the news again

Posted in General clinical at Fri, 20 May 2016 11:48:32


Posts: 1694
Joined: 09 Dec 2011

About 2 weeks ago I was listening to a chap who suffered from severe cluster headaches and who found his reserve treatment was a concoction of magic mushrooms when other treatments failed. To-day the news is that they are (or at least the active ingredient psilocybin) seems to be rescue treatment for severe depression when other treatments are failing.

This is just where we need someone like Edzard Ernst to advise and explore. What a pity that the pro-alternative medicine crowd had him sidelined. He really should have known that a post designed to look at the subject was a post to promote it not to explore its basis and viability. Particularly when going totally against the belifs of the heir to the throne.

Of course there may be something in these magic mushroom stories. I still remember some patients taking Digitalis Folia before purer forms of digoxin became the rule. 

In or Out?

Posted in Diabetes at Mon, 23 May 2016 09:58:39


Posts: 1971
Joined: 08 Oct 2010

The UK is currently in the throes of anguishing about whether to opt out of the EU. Some of the arguments seem self-defeating - Osborne a pro-Europe chancellor recently pointed out that house prices might fall by around 20% if we leave....perhaps a good argument for leaving not staying except amongst the relatively affluent and financial elite ?

 The NHS has been featuring strongly , again with an impossibility of knowing true effects. What do people think?


Plantar fasciitis vs metatarsalgia vs other?

Posted in Sport and exercise medicine at Sun, 22 May 2016 13:05:30


Posts: 2
Joined: 19 Aug 2014

Hi all, I badly need some help.

I'm a GP myself, and am unsure where to go from here. I've had pain in the metatarsal heads region bilaterally for about 7 months now. It started off in my left foot when I was running a lot, gradually progressed to the point where I could hardly walk. The pain was sharp, in the ball of my foot and occured on lifting off the ground. I was tender over the distal metatarsal shafts. I saw an orthopaedic surgeon and a physio at the time, the consensus was I either had a metatarsal stress fracture or was about to have one, and we elected not to get any imaging as the treatment was the same regardless - just rest it. I wore a cam boot for a month, during which time I started to get the exact same symptoms in the right foot - just from walking around at work. 

The physio made me orthotics with metatarsal domes which worked up to a point - they relieved the pain initially, but when I started trying to walk a bit more (and I don't mean much - like parking at the far end of the car park rather than at the front door of the supermarket) it all flared up again.

So I saw another physio, on the recommendation of a friend. His assessment was that my plantar fascia was extremely tight, and set about releasing it. I ditched the metatarsal domes at this stage. I rolled my foot on a golf ball every night with great relief.  Over about 2 months things greatly improved to the point where I could walk around normally.

Things went pear-shaped when I tried running again - gentle runs, on flat grass, no more than two or three laps of a football field. Each time I've tried it's caused a flare and I've had to cease all activity.

My last attempt at running was 2 weeks ago, and since then the soft tissues over the plantar fascia have been really swollen and tender, which has never happend before in all of this. The golf ball, which before had nightly relieved my pain, now made things worse. I went back to the physio who did his usual manual stretching and massage, and instead of improving things it's made the inflammation worse. I have a dull burning sensation in my plantar fascia at night, and pain and a crackling sensation in the ball of my foot whenever I lift off the ground.

I'm at the end of my tether. I'm in my 30s and can barely walk. To me the whole thing seems like a mechanical problem, but I'm uncertain as to the exact diagnosis - everything I've read suggests plantar fasciitis causes heel, not metatarsal head, pain; and reliable information on metatarsalgia is hard to find.

I haven't gotten expert help sooner as I know I don't need an operation, and am reluctant to have a steroid injection, so what's an orthopod going to do for me? But I've realised I'm my own worst enemy and have booked an appointment. But any advice as to what might be going on or what I can do in the next month while I'm waiting to see them would be greatly appreciated.

What is your Biggest Issue in communications?

Posted in General clinical at Tue, 24 May 2016 14:40:46


Posts: 4
Joined: 23 May 2016

Hello All,

Looking to see what the biggest administrative/communications issues exist for physicians. I work for a technology startup that actually is working with practices to cut down on patient non-adherence, prior authorization issues among other administrative headaches that happen in the healthcare system. 

We have some pretty great results so far, and are always looking to spread the word. Any issues you find with traditional communications methods? Maybe something we haven't thought of? 


If you're curious, our app is free to use and I'd be happy to chat for 10 mins about setting it up for anyone interested: Just shoot me an email alexis.sheehy@klara.com

Klara Website: goo.gl/b5654q


Doctor needed for Liquid Biopsy

Posted in General at Tue, 24 May 2016 19:53:24

John D

Posts: 4049
Joined: 01 Feb 2010

Hi, I was wondering if there are any Indian doctors here that would see my friend and write him a prescription to undergo Liquid Biopsy tests for Cancer. This is very urgent as he can not find a doctor that will allow.

Antibiotics proscribing not the answer to over-prescribing.

Posted in Radiology at Sat, 21 May 2016 19:21:09


Posts: 206
Joined: 21 Aug 2011

For the past 40 years we have had escalating concerns about the overuse of antibiotics and increasingly we are now heading towards over restriction on prescribing. We will never get it completely right and clearly doctors need some official backing for their trying to refuse (and often upset ) many patients who demand them for the wrong reasons. The recent emphasis on patient responsibility is belated but very welcome.

 But there will be a knock on effect. There will be those - including children - where antibiotics will not be given when that should have done. We may have to live with that but the judiciary is unlikely to see it hat way if a case comes to court. The suggestion of an instant test to detect whether there is a bacterial infection is unlikely to have universal application and has yet to be developed..  There are also some messy areas - is a higher dose more likely to breed resistant bugs ? Is the use of a combination better or worse? Should we really be waging war on common relatively commensal bugs such as Helicobacter pylori , whenever it is found , with a wide range of potent antibiotics - or other common problems such as Campylobacter jejuni and Clostridium when not causing significant disease? There are many borderline conditions where individual patients may feel a beneficial response but one might "get by" without prescribing (think UTI in women). And just what are we meant to do about gonorrhoea with its the rising incidence and drug resistance ? 

Interestingly I gather the veterinary and farming use is far more relevant in the development of resistance to our more specialised antibiotics. But can one envisage vets refusing to treat someone's dog - a child perhaps - but certainly not a pet dog.....

The first step needs to be education of the public - as much as doctors - after all they are the folk with the biggest personal stake in good care. At last there really does seem to be a campaign for this. The second step is to ensure the pharmaceutical industry receives adequate support to seek out new antibiotics rather than just going for more profitable compounds for shareholder profits. And of course a few additional vaccines against some common infections would not go amiss.

7T Sodium Cardiac MRI may be a game changer

Posted in Radiology at Fri, 27 May 2016 08:10:55


Posts: 1319
Joined: 13 Oct 2009

Magnetic resonance imaging (MRI) has come a long way and is still moving forward with new developments being announced almost every day. Before, there was a clear line between CT and MRI, but that black and white concept is fading away. With the introduction of powerful modules and software, there might come a time in the future where it won’t matter which diagnostic method is performed, granted of course if there are specific indications or contraindications. With newer generation CT scanners to lower dosage while increasing quality, but MRI has no serious side effects related to increase in field strength. This is why researchers and clinicians are waiting with open arms for 7T MRI and beyond.

MRI takes advantage of the fact that water is located in all tissues and organs, creating a signal which is then formed into an image. However, many people are unaware that MRI can be used to study other elements, like sodium, phosphorus and others. Sodium is a very important element in the human body. The only isotope that is stable is 23Na, which is the most abundant form. In the human body it regulates blood flow, blood pressure, osmotic pressure and pH. Sodium chloride, more commonly known as table salt, is our main source of sodium. You may have heard or read that salt is bad for your health, but abnormally low levels of sodium can also adversely affect health. The American Heart Association recommends ingesting less than 1,500 mg per day, which is considerably less than their previous number 2,300 mg per day. They explain that because hypertension risk is so high among Americans, 1,500 is the number that exemplifies perfect cardiovascular health. Obviously this number is not for everybody, because competitive athletes, people who work in conditions with elevated temperatures, i.e. those who sweat a lot, will require more sodium intake.


Source: http://bimedis.com/latest-news/browse/97/7t-sodium-cardiac-mri-may-be-a-game-changer



Posted in General clinical at Fri, 20 May 2016 14:23:13


Posts: 3
Joined: 06 May 2016

Because Full HD endoscopes are already on the market, Sony and Olympus decided to team up to take the next logical step. They formed an alliance, Sony Olympus Medical Systems, to develop the best 4K endoscope out there. Their 4K surgical endoscopy system, the Visera 4K UHD (ultra-high definition), combines the collective mass of knowledge and experience of two tech giants, which means that their brainchild is feature-rich, sleek and has extremely high-quality images in a small package.

Keep up with latest trends in the sphere of medicine by reading the article belowhttp://bimedis.com/latest-news/browse/262/4k-endoscopy-with-olympus-visera-4k-uhd--the-wave-of-the-future

The Future of Telemedicine?

Posted in General at Thu, 19 May 2016 15:28:25


Posts: 1
Joined: 19 May 2016

I would love to hear your thoughts!!

Statistics show 66% of all patients who visit an urgent care clinic, or "walk in clinic" have a primary care physician. The question is - WHY are these people going to a "walk in clinic" over visiting their PCP whom they have a relationship with? I believe the answer is simple...convenience and accessibility. People just don't want to wait a week to see their doctor. We expect to do our banking 24/7, shopping 24/7, and now people want their healthcare to be 24/7. I say, let's equip our PCP's with the tools they need to care for their patients remotely to help them fight the battle with retail / urgent clinics and telehealth companies (where no doctor/patient relationship is established). It's time for doctors to get their patients back!!

Question - As a doctor, if you had the option to care for your patients in a way as simple as "SMS texting" and it was done over a HIPAA compliant platform and you got paid, would you do it? If not, why? 

1.2 billion primary care doctor visits happened last year, roughly 700 million of those could have been done remotely. That's 70%!! 

BMJ Open journal club: what impact does audit and feedback have on the role of the community pharmacist?

Posted in General clinical at Mon, 23 May 2016 14:52:47


Posts: 4
Joined: 23 May 2016

Medication-use problems are an issue that policymakers are trying to find more effective solutions for, seeking ways to optimise the role of healthcare professionals in managing these patients. Community pharmacists are now being recognised as a lesser used resource for improving patients' use and understanding of their medications - meaning that revisions are being made to healthcare policies to expand the authority of pharmacists in this way.

Clinical performance of healthcare professionals has been shown to display small improvements when being presented with audit data and feedback of their care. However, there have not been studies done for pharmacists, to evaluate whether the use of audit and feedback could increase pharmacists' provision of services or improve performance on standardised medication-use measures.

This study, by Winslade et al, seeks to evaluate the impact of such performance feedback to community pharmacists on the provision of services and quality of hypertensive and asthmatic patients' medication use. In a randomised, controlled, single-blind trial in 1,833 community pharmacies in Canada, this study used provincial billing data to measure performance, and mailed comparative feedback reported the pharmacy-level percentage of dispensings to patients either non-adherent to antihypertensive medications or those overusing asthma drugs.

The authors found that this comparative pharmacy performace feedback did increase the provision of asthma pharmacy services. However, they did not find that audit and feedback was effective in providing an improvement in managing non-compliance of antihypertensive medication, or in the performance of medication-use measures.

What are your views on audit and feedback? What do you think could improve the management of non-compliance of antihypertensive medication in this setting?


More information about this article:


Objective To evaluate the impact of comparative performance feedback to community pharmacists on provision of professional services and the quality of patients’ medication use.

Design Randomised, controlled, single-blind trial.

Setting All 1833 community pharmacies in the Quebec province, Canada.

Participants 1814 pharmacies not opting out and with more than 5 dispensings of the target medications during the 6-month baseline were randomised by a 2×2 factorial design to feedback first for hypertension adherence (907 control, 907 intervention) followed by randomisation for asthma adherence (791 control, 807 intervention). 1422 of 1814 pharmacies had complete information available during the follow-up for hypertension intervention (706 intervention, 716 control), and 1301 of 1598 had the follow-up information for asthma (657 intervention, 644 control).

Intervention Using provincial billing data to measure performance, mailed comparative feedback reported the pharmacy-level percentage of dispensings to patients non-adherent to antihypertensive medications or overusing asthma rescue inhalers.

Primary and secondary outcome measures The number of hypertension/asthma services billed per pharmacy and percentage of dispensings to non-adherent patients over the 12 months post intervention.

Results Feedback on the asthma measure led to increased provision of asthma services (control 0.2, intervention 0.4, RR 1.58, 95% CI 1.02 to 2.46). However, this did not translate into reductions in patients’ overuse of rescue inhalers (control 45.5%, intervention 44.6%, RR 0.99, 95% CI 0.98 to 1.01). For non-adherence to antihypertensive medications, feedback resulted in no difference in either provision of hypertension services (control 0.7, intervention 0.8, RR 1.25, 95% CI 0.86 to 1.82) or antihypertensive treatment adherence (control 27.9%, intervention 28.0%, RR 1.0, 95% CI 0.99 to 1.00). Baseline performance did not influence results, and there was no evidence of a cumulative effect with repeated feedback.

Conclusions Comparative pharmacy performance feedback increased the provision of asthma pharmacists’ services but did not improve the performance on medication-use measures. Billing data can be used to evaluate the impact of billable services rendered by pharmacists on the quality of patients’ medication use.

Link to the full text version of the paper: http://bmjopen.bmj.com/content/6/5/e010865.full

HIPAA-Compliant Messaging App - would you use?

Posted in Medicolegal at Mon, 23 May 2016 15:01:20


Posts: 4
Joined: 23 May 2016

We have a HIPAA-compliant messaging app made exclusively for use of doctor-patient, pharmacy, lab etc. communications. We've seen increases across the board for more patients seen, more prescriptions being filled, less time spent on the phone. It's pretty remarkable.

If you're curious, our app is free to use and I'd be happy to chat for 10 mins about setting it up for anyone interested: Just shoot me an email alexis.sheehy@klara.com.

How to waste £2.4 bn

Posted in BMJ at Sat, 21 May 2016 22:05:58


Posts: 57
Joined: 04 May 2015

Article in BMJ of 30th April 2016 by Dr Margaret McCarney on the NHS England 56 page  document 'General Practice Forward View.

She makes several salient points.

Spending money on non-evidence based interventions leads to harms: it wastes time and energy. 

Two elephant sized omissions

Lack of cost effectiveness of the Care Quality Commission and the urgent needs to stop doing things that don't work, What about ditching the Health and Social Care Act an stopping unnecessary screening?

I recomend the article

How to misspend £2.4 bn

Posted in BMJ at Sat, 21 May 2016 21:52:51


Posts: 57
Joined: 04 May 2015

NHS England have produced a 56 page article 'General Practice Forward View'. There is comment on this by Dr Margaret McCartney in the BMJ of 30th April 2016. She makes several salient points.

Spending money on non-evidence based interventions leads to multiple harms: it wastes time and energy and disrupts the NHS.

£30 m on acceleration towards a paper free environment, where is he evidence of benefit ?

£45 on increasing online consultations, where is the evidence of benefit ?

... and two elephant sided holes , lack of cost effectiveness of Care Quality Commission.

and the urgent need to stop doing things that don't work, Health and Social Care Act, unnecessary and un proven screening and unnecessary targets.

I only do a few out of hours sessions now. I do worry about General Practice. The almost universal reason that I see patients in OOH is that they could not get a timely appointment with their GP. GP are so busy chasing targets that there is little time left to see ill patients. Prevention may be better than cure . But some times a cure is good and we are all mortal.

Lessons from the rhubarb season

Posted in General at Wed, 25 May 2016 17:21:01


Posts: 1319
Joined: 13 Oct 2009

We are now well into the rhubarb season and those that indulge will be well aware of the potential effect on the gut. A visitor to the UK unused to this could well be classified as having traveller’s diaorrhoea (TD).  Many specialists like to give their special interest an all-inclusive nature. Think psychiatrists and depression or borderline personality disorders.

   By defining TD as 3 or more loose motions daily , we include many folk where this is their “normal” – but once they cross the Channel it becomes a disease. The effect I notice with goodly helpings of rhubarb I have when abroad after consuming many of the varied vegetables on offer – often soaked in copious amounts of oil. And that is apart from all those figs in season. BO 3 X daily : if only – and what about the night time as well… And of course any urgency is likely to affect social functioning so I automatically move to a more severe stage of TD by definition.  Co-incidentally , I may have a change in my gut flora , but that would not be  unexpected. 

  When challenged , those with a particular interest in TD can become incredibly defensive – reminiscent of the psychiatrist who will react with details of patients with severe or psychotic depression to suggestions that minor degrees of being “down-the-dumps” for a short time does not equate with psychiatric disease.


  Perhaps we need to change the definition of TD to one where the disturbance of bowel function is

A. 1. A disturbance beyond the normal bowel habit for the individual ;

2. Not corrected by a bland diet  ;

3. Associated with feeling unwell ;

4. Not responding to 2-6 mgs of loperamide daily ;

or B. . Persisting after return to the UK ,( but needing recognition that any TD may have precipitated the onset of IBS) when a wider differential diagnosis might be relevant.

  C. Any significant features such as pyrexia , blood in the stools etc.. are red flag symptoms requiring a different approach and these travellers should not be dismissed as having a tummy upset and lumped together with those with milder symptoms. And as for the outbreaks of Norovirus on cruise ships , I would see that as something else altogether and remain thankful that I do not feel tempted anyway by embarking on one of those floating “townships” (by now not just floating hotels).

The aim of being more restrictive in our definition of TD is in part to discourage the overuse of antibiotics , prophylactic and recognise the true incidence of TD where these might be effective.


Medical School Scholarship Fundraiser-https://www.gofundme.com/24gkdx8

Posted in General at Sun, 22 May 2016 20:57:22


Posts: 2
Joined: 22 May 2016

Raising money from donors to donate the funds to various university medical school scholarship funds within the U.S.A.

Medical School Scholarship Fundraiser-https://www.gofundme.com/24gkdx8

Posted in General at Sun, 22 May 2016 20:54:20


Posts: 2
Joined: 22 May 2016

Raising money from donors to donate the funds to various university medical school scholarship funds within the U.S.A.

ECG Question

Posted in General clinical at Sun, 29 May 2016 00:56:48


Posts: 839
Joined: 21 Feb 2012

This is the ECG of 18 year old boy signs up to join the army which was taken during routine meical examination, no medical complaint

what is the diagnosis :-


ECG - Question 14 (brugada syndrome)