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Posted in Neurology at Wed, 22 Oct 2014 19:45:25

Mukhtar Ali

Posts: 856
Joined: 14 Nov 2010

Is there any modifiable risk factor for dementia . Day by day patient of dementia gradually increases so we prevent or halt the process of development of dementia. Non modifiable risk factors such as age, sex ,genetic . pl discuss.

The Ebola Frontline

Posted in Public health at Fri, 24 Oct 2014 13:18:46


Posts: 537
Joined: 18 Mar 2014

This isn't from  MSF's Frontline Blogs page, but from the pages of the Observer, in the Sunday newspaper's magazine section, about the work at the centres run by the US charity, Samaritan's Purse  in Monrovia and by MSF in Sierra Leone .  You can read the whole report at:  http://www.theguardian.com/society/2014/aug/24/ebola-the-frontline-liberia-sierra-leone

It includes several interviews, with a doctor, a public health specialist, a nurse, one who has lost their entire family to Ebola and to a survivor, their first in Monrovia.   I'd like to copy here the last, becauue I think it encapsulates the predicament of so many in West Africa.    May I introduce you to Harrison Sakela?


The survivor


'I decided to treat her myself: I bought some medicine and a drip': Harrison Sakela, Liberia.

‘I decided to treat her myself: I bought some medicine and a drip’: Harrison Sakela, Liberia. Photograph: Carilla Doe

Harrison Sakela, Liberia
I kept hearing the word “Ebola” but I hadn’t seen what the illness could do to a human body until my mother got sick. She had travelled to a funeral in Sierra Leone and met someone who had it. I was teaching a class, like any normal day, when I was told that she was unwell, so I went to see her in Sierra Leone and it was obvious that something was very wrong.

I decided to treat her myself: I bought some medicine and a drip. I spent about three days trying to help her but she wasn’t responding. At the last stage, she wouldn’t look people in the face. She was toileting every two to three minutes. She refused to eat food. It took her two weeks to die.

Within a week of coming back from Sierra Leone, I began feeling very weak. My head was hurting, I had a fever. I was not even able to cross the road. A Samaritan’s Purse health facility worker saw me and asked me to come to the centre. I agreed straight away and tested positive for Ebola that day. I had severe diarrhoea and was very weak, but I never vomited blood like others had. A week later they tested my blood. It came back negative for Ebola and they discharged me. I came out and I am all right. Now I am the Ebola ambassador.

I have lost five family members to Ebola: my mother, father, sister, niece and my niece’s daughter. I have no one now, so I’ve decided to stay on at the treatment centre and work here as a security guard.

Most people in my community are ready to accept me again, although some people are saying that the Liberian government is giving me money to say that Ebola is real. Ebola is real. I have experienced it. The people of West Africa need to stop denying it exists

To support the work of Médecins Sans Frontières or Samaritan’s Purse, please visit: msf.org.uk and samaritans-purse.org.uk


What's your diagnosis: a previously healthy and active man losing the ability to live independently

Posted in General clinical at Thu, 23 Oct 2014 12:36:14


Posts: 537
Joined: 18 Mar 2014

The case below was published in the BMJ a few years ago. What's the most likely diagnosis?

A 55 year old man was brought to see his general practitioner by his wife. She said that he had been healthy and active when younger, but that his ability to function independently had declined over the previous few years to the point where she was now helping him with all activities of daily living. If she did not help or prompt him, he did not wash or dress himself and would sit on the sofa all day doing nothing.

He had no history of physical illness, but he had experienced bouts of depression for many years and had developed obsessive-compulsive behaviours over the past 15 years. These included picking up litter in the street and arranging his belongings in lines. On questioning about illness in the family, he said that he thought his mother had been diagnosed with Alzheimer’s disease in her 40s.

On examination, he had occasional involuntary movements in his arms. Examination of the limbs was otherwise normal. He was fully oriented and scored 26/30 on the mini-mental state examination.



Time Capsule

Posted in General at Fri, 24 Oct 2014 19:38:10

Mukhtar Ali

Posts: 856
Joined: 14 Nov 2010

The original work and concept of Time capsule is a very good idea and appreciable effort, but here I request every user to add your choice pic, documents etc. for building an imaginary time capsule that will in one or other way reflect our thinking process and feelings about the society we live in and the world around us.

The Wikipedia article about Time Capsule will help you to expand your idea about time capsule.


Thanks a lot for your contributions.


Posted in Medical education at Fri, 24 Oct 2014 20:19:55

Mukhtar Ali

Posts: 856
Joined: 14 Nov 2010

Holidays for me  on Thursday, the benefit of age. My holiday  reading will include be 'Being Mortal' by Atul Gawande. I think various books, ,apart from text books, have influences how I have  practiced medicine. Recently  the Ben Goldacre books have influenced me. I think Atul Gawande's book will affect how I practice in my last few months as a Partner and how I will work if I do locums.

I recommend this book to all.

Where was WHO in Ebola outbreak?

Posted in General at Mon, 20 Oct 2014 18:53:32

Mukhtar Ali

Posts: 856
Joined: 14 Nov 2010

Aid workers ask where was WHO in Ebola outbreak?


Should the NHS be liberated from political control?

Posted in News & media at Fri, 24 Oct 2014 18:00:55

John D

Posts: 3297
Joined: 01 Feb 2010

The NHS is set to be a key battleground in the 2015 general election. At the recent party conferences both the Conservatives and Labour made bold promises on the NHS, and Labour, in particular, is keen to position itself as the saviour of the health service. 

A recent news story in the Times alleged that senior Tory aides thought that former health secretary Andrew Lansley's reorganisation of the NHS was a "huge strategic error" with no one in the government, including David Cameron, having a "clue what [Lansley] was embarking on."

So, with these revelations (which aren't really that surprising) in mind is it time for politicians to leave the NHS be and let the NHS manage itself? Or do politicians provide accountability - we can vote them out if we're not happy with the way the health service is managed? 

Unfading Shadow of Ebola

Posted in Public health at Wed, 22 Oct 2014 19:54:07

John D

Posts: 3297
Joined: 01 Feb 2010

At least 3,700 children in Guinea, Liberia and Sierra Leone who have lost one or both parents to Ebola this year face being shunned, the UN children's organisation has said.


Which medical innovation has changed your practice the most?

Posted in General clinical at Wed, 22 Oct 2014 21:45:35


Posts: 786
Joined: 13 Oct 2009

As I've mentioned before on these boards I write quite a few obituaries for the BMJ and I'm currently researching a very eminent radiologist who did a lot of research on contrast media, pioneering a new type of solution that caused fewer allergic reactions in patients and also caused a lot less pain on injection, meaning that patients did not move around so much when being X-rayed. It made me think what an impact that must have made for both radiologists and their patients.

An article in the New England Journal of Medicine highlights the contribution of two doctors, Alim-Louis Benabid, a neurosurgeon and Mahlon DeLong, a neurologist whose research deep brain stimulation and its translation into clinical practice has brought amazing benefits to around 100,000 patients with Parkinson's disease and neurological conditions.

So, which medical innovation - treatment, drug, new pathway of care - has made the most difference in your practice? 

Medical students asking intimate questions

Posted in Medical ethics at Thu, 23 Oct 2014 14:33:11


Posts: 235
Joined: 14 Dec 2010

I am a fifth year Medical student and last week I clerked a patient with anal SCC. In hindsight I thought I should have asked the patient about potential risk factors such as receptive anal sex, however I also felt this was quite intrusive and asking the patient intimate questions about risk factors that wouldn't affect the management and outcome would cause potential unnecessary embarrassment for the patient with no benefit other than satisfying my own clinical curiosity.
If this was an STI clinic or I suspected the patient had HIV I wouldn't hesitate to ask about sexual partners, so wondered why this case should be different? 

Is it appropriate for Medical students to ask probing and intimate questions even if it's clinically relevant or should it be the responsibility of the senior clinician to ask to prevent potential recurrent embarrassment for the patient?


Should smoking be banned in public parks?

Posted in Respiratory medicine at Fri, 24 Oct 2014 18:50:00


Posts: 32
Joined: 10 Nov 2013

The London health commission has launched a report looking at improving the health of the capital and one of its more eye-catching recommendations is that boroughs should increase the number of smoke-free public spaces, including parks, green spaces and Trafalgar Square. Policing such a ban would be tricky and it seems a bit draconian. I wouldn't often quote Forest (smokers' rights organisation) but one of its spokesman was quoted saying that if people don't like the smell of smoke they should just move - I would have to agree with this.

Other recommendations (out of 64) include:

  • It also says that London Transport should spend a fifth of its advertising budget on encouraging Londoners to to walk 10,000 steps, inlcuding walking up the stairs and escalators at Tube stations. 
  • Boroughs should be supported in attempts to introduce minimum pricing of alcohol of 50p a unit
  • Fast food outlets should be restricted to within 400m of schools
  • a £1bn, five-year programme of investment in GPs' premises

Feeding Birds: A Humane Gesture

Posted in General at Wed, 22 Oct 2014 02:50:37


Posts: 4354
Joined: 24 Feb 2009

Feeding birds is a humane  act  and an immemorial  popular custom of  every society. For many, it is a thing of joy, the joy of inner and soul.

Are you bird enthusiasts?

Thanks for your input.

Feeding the birds:

Of course my heart is open to the birds

whose song may lift my soul both night and day.

Cheering better with their song than words

Could ever bring  happiness into play.

In feeding the birds I hope to attract

the small ones that twitter and tweet in tune.

I'm hoping the kindness in this small act

may cause my little feathered friends to croon.

My plan worked as well as any plan does

the garden is now full of pretty birds

but also attracts some far larger crows

and from our neighbours  some rather harsh words.

Into my feeders I fit a large scoop

and clean the car daily, it takes off the poop.


New cardiology clinical champions

Posted in Cardiology at Fri, 24 Oct 2014 09:15:32


Posts: 1
Joined: 24 Oct 2014
Doc2doc is sad to say goodbye to our cardiology clinical champion Sadian, who has decided to step down after providing sterling service on the message boards over the last few years. Hopefully Sadian will still visit doc2doc from time to time.
However, we're very excited to welcome four (yes four!) replacements who have a great breadth and range of experience.
I'm introducing them with their screen names so you know who they are online: 
  • Mbittencourt, a cardiologist based in Brazil who has particular interest in CT; 
  • Heart Matters, a trainee cardiologist from the West Midlands in the UK with interest in interventional cardiology; 
  • Heartfelt, a cardiologist in New York who is conducting research into bleeding-anemia-transfusions and thrombolytics;
  • Heart Doc, a consultant cardiologist from Essex, UK who has subspecialty interest in devices and heart failure.
They will begin posting clinical questions and contributing to the main messageboards over the next few weeks and I'm sure all the regular posters will make them feel welcome. I'm really excited to have such a dynamic and diverse team. 

What constitutes poetry when in blank verse; lineated prose or real art?

Posted in General at Tue, 21 Oct 2014 20:35:07


Posts: 4354
Joined: 24 Feb 2009

As a lover and writer of poetry (Greek word), I question what constitutes poetry when it is devoid of metre, rhyme or any other conceit so typical for example of poetry before the twentieth century. 

The Greeks wrote poetry in abundance and generally with strict rules abou metre but not usually rhyming. 

Modern verse is often devoid of any internal structure which I think is often a way an unskilled poet disguises a lack of talent. 

Is blank verse just prose in lines? If you had to tell a Martian what characterises poetry and moreover, modern poetry, what would you say ?

Compact and bizarre language in my opinion is not a sine qua non of poetry 

I have my opinions which I will keep til later. While not decrying blank verse, I decry blank poetry. 

Poetry to me should be like origami. But I will say no more now.

I have written poetry in English and French, including in alexandrines, even at school; each is a different clay, each a different firing. I have not mastered Greek enough to do so. 

Perhaps we should have a poetry competition eg a poem of no more than twenty lines on something of your choice.

We may have discussed this topic before and if so, forgive me, but I think we may yet bring fresh coal to the fireplace. If we think more about things non-medical, I think we can think more about things medical. 


Is paying UK GPs 55 £ for diagnosing dementia a good idea?

Posted in Neurology at Wed, 22 Oct 2014 10:03:28


Posts: 537
Joined: 18 Mar 2014

Awoke this morning to hear that GPs are going to have a six month trial of being paid 55 pound for every new case of dementia that they diagnose. This seems to me to be wrong on many levels. If dementia were a disease that could be cured  then I would have no problem in making more diagnoses of dementia and 'curing' them. There is now medication for dementia. One of the problems is that to me the medication usually does not often  work and never cures.

There are many down sides to the patient and not many up sides to a person diagnosed with dementia.

Imagine you are old, living reasonably in a nursing home and your GP diagnoses you with dementia. You will probably have to move to a dementia home , where all the patients have dementia.

Fuming into my coffee prior to this morning's Surgery.

I assume that it is just another Government silly idea. I doubt that the Civil Servant or Political Aide who thought up the idea will be sacked, but in my opinion he or she should be. I hope it is not a politically motivated idea to discredit GPs and thus the NHS and make all who can afford to go private, go private and watch the NHS crumble.

Almost makes me glad I am retiring.

Almost but not quite.

How stupid an people be?

Posted in General clinical at Thu, 23 Oct 2014 12:23:06


Posts: 235
Joined: 14 Dec 2010

I learned today of  two related patients ,one of whom is Hep C +ve, sharing razors!!

Appopriate investigations & education  courtesy of a colleague

What's your diagnosis? Recurrent fever after a holiday in Turkey.

Posted in General clinical at Fri, 24 Oct 2014 20:18:15


Posts: 2
Joined: 24 Jun 2009

The case below was published in the BMJ in 2011. I'll post the answer in a few days.

In early October 2010, a 64 year old man presented to our hospital in Switzerland with chest pain, fever, and night sweats, which had been present since his return from holiday three weeks earlier. He had been on holiday in Turkey from July to mid-September. On further questioning he reported an episode of diarrhoea and sickness associated with fever shortly after returning home to Switzerland. During his stay in Turkey he had eaten fresh food, including meat and dairy products. Furthermore, he had experienced a myocardial infarction and had undergone angiography and insertion of a bare metal stent on 4 September while in Turkey.

Previously he had been treated with a calcium channel blocker and an angiotensin II receptor antagonist because of high blood pressure. On admission, aspartate aminotransferase at 79 U/L (reference range 11-36), alanine aminotransferase at 86 U/L (10-37), γ glutamyltransferase at 192 U/L (11-66), alkaline phosphatase at 238 U/L (0-129), and C reactive protein (CRP) at 25.4 mg/L (0-10) were all slightly raised.

Stenosis of the right coronary artery was seen on angiography and another stent was inserted. Over the next seven days he developed recurrent fevers, which were accompanied by chills and temperatures as high as 39.5°C. Ten of 13 aerobic blood cultures taken at three to 10 days after presentation grew very small Gram negative rods two and a half to three days after incubation. Bloods taken during this time showed a normal white cell count and slightly decreased haemoglobin of 130 g/L (140-180).

An abdominal ultrasound showed an enlarged spleen and mild hepatosteatosis. Computed tomography of the chest and abdomen and transoesophageal echocardiography were performed to look for a source of infection, but all were uninformative.

Reflecting on failure in psychiatry exam

Posted in Psychiatry at Wed, 22 Oct 2014 08:56:14


Posts: 786
Joined: 13 Oct 2009

A recent blog post in the Royal College of Psychiatrists, discussed the journey of a trainee who could not make it in the final exam. It is reflection about the whole process. I wrote this blog post. So, I will be grateful to learn your opinion whether you would like to comment here or on the RCPsych website.

Antipsychotics for ADHD

Posted in Psychiatry at Tue, 21 Oct 2014 14:13:17


Posts: 23
Joined: 24 Apr 2012

A recent blogpost by Dr Claudia Gold MD, discusses the use of Risperidone atypical antipsychotic in cases of ADHD. The author stated that the results of adding antipsychotic treatment  the usual stimulant + parenting technique has better results than treatment as usual.

I wonder what are your thoughts of prescribing antipsychotics for children with ADHD.


Reducing Alcohol drink drive limit in Scotland

Posted in Medicolegal at Fri, 24 Oct 2014 22:33:26


Posts: 786
Joined: 13 Oct 2009
The Scottish Justice Minister is proposing to reduce the Alcohol Drink Drive Limit from 80mcg/100mls to 50mcg/100mls. He wants to have this new limit in place for Christmas because that is the time when drink drive campaigns are reinforced.
Across Europe and throughout the world Alcohol Drink Drive Limits vary and some countries apply different rules to experienced and non experienced drivers. For example in the Netherlands the limit is 50 but for drivers who have less than five years since passing their driving test it is reduced to 20. In Italy the limit is 51 but is reduced to Zero for those with less than three years driving experience. 
Some countries have a drink drive tolerance of zero, for example:
Hungary, Estonia, Russia, Brazil, Romania, Georgia, Barbados, Nepal.
The European Parliament has put forward proposals to harmonise alcohol blood limit levels throughout Europe. They also propose a zero level for novice and professional drivers. 
Is it 'simplest' to just have a zero drink drive level? Is it realistic? Will it catch the persistent offenders who drink and drive or others with very small residual alcohol levels?
The following link gives Alcohol Drink Drive limits for pretty much every country (it certainly seems reputable):

New plan for the NHS

Posted in News & media at Thu, 23 Oct 2014 09:18:52


Posts: 537
Joined: 18 Mar 2014

What do you think of the five-year plan for the NHS unveiled by six national bodies - NHS England, Public Health England, Monitor, the NHS Trust Development Authority, Care Quality Commission and Health Education England. 

The report calls for extra funding and changes to the way the NHS is run, such as hospitals employing GPs. You can see the review here: http://www.england.nhs.uk/2014/10/23/nhs-leaders-vision/

How do you think the NHS needs to change to meet the needs of 21st century healthcare?



Seven Day working weak?

Posted in General clinical at Fri, 24 Oct 2014 12:30:48

John D

Posts: 3297
Joined: 01 Feb 2010

I note UK politicians are pushing the seven day working week and am wondering whether there is any rationale or logic  other than allowing politicians to sleep better?  Most countries on the planet earth seem to think 5 days is enough. I am not sure how many politicians function 7/7 but suspect the total is 0%. While it is good to have  input from utter imbeciles and politiicans occasionally it is a shame when either group creates policy? NZ is still five days and I note our triage services/phone lines are evolving quite well. Obviously we still charge after hours and it is interesting the number of things that can thus wait to monday or  morning.  What other countries  are ever likely to follow the UKs lead??

Doctors are to be recruited on the basis of values as well as skills

Posted in Careers at Wed, 22 Oct 2014 15:00:57


Posts: 537
Joined: 18 Mar 2014

A story on the BMJ Careers site reports that doctors should be recruited on their values, as well as their skills. 

From next autum students enrolling on healthcare courses at universities in England will have to demonstrate values such as respect and dignity, commitment ot quality of care, compassion and everyone counts. Health Education England has said that trusts should recruit staff on the same basis, although it will not be mandatory. 

How doctors would demonstrate such values is a moot point...! 


Patients who love to talk

Posted in General clinical at Fri, 24 Oct 2014 13:50:08


Posts: 537
Joined: 18 Mar 2014

I have to admit that when I go to see a doctor (either for myself or my children) I like to chat (colleagues won't be surprised at this). Often it's a way of getting over either embarassment or nervousness (whatever I see the doctor for I always think they're going to tell me I've only got six months to live). I also think a little bit of me wants the doctor to know that I'm intelligent and someone s/he can engage with on an equal basis. 

Do you like to have chatty patients? Do you think that it helps the relationship and aids your diagnosis? 

William Kayley, a regular BMJ blogger from the US (hence the use of the word 'folks'), wrote this on the subject:

"I've had several visits recently with folks who love to chat - and that's great - and from at least one of those chats I learned the extent to which the patient's primary health concern was really about the health of another family member. It's wonderful to spend a lot of time with folks, and to be thought of as 'that patient, caring doctor.'"

He sounds lovely! I wish my GP (v miserable) was more like him. 




Are you active everyday?

Posted in General at Fri, 24 Oct 2014 22:21:38


Posts: 786
Joined: 13 Oct 2009

The head of Public Health England wants people to be active every day and is urging people to hold meetings standing up, or while walking. GPs prescribing exercise is not what he wants - he wants them to be working iwth patients to encourage them to be more active. We need to build activity into our everyday, so eschewing the car for two feet or two wheels, and the lift for the stairs.

I would say that I'm active pretty much every day as I walk my children to school most days (20 mins walk) but then I do spend a lot of my working day sitting around. 

GPs have been urged in the past to carry out consultations standing up but what about hospital doctors - are you active?