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The most viewed discussions on doc2doc this month

Fears of the Spread of a new Respiratory Virus

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

John D

Posts: 3632
Joined: 01 Feb 2010

One of the serious health hazards of Globalization is the spread of the viral infections. Wendy Barclay Professor at Imperial College London, comments about viral infections are very valuable. “We will never be able to eradicate viruses, but by understanding them better, we can develop new vaccines, antiviral agents and good strategies to minimise their harmful impact”

Read more here about fears of the spread of a new respiratory virus.http://www.bbc.co.uk/news/health-21442519

"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: 3632
Joined: 01 Feb 2010

This morning's news is full of the announcement that Mr Hunt is now planning to enforce 7 day working on consultants (without reduction in mon-fri services) threatening the BMA to agree this or he will impose new contracts without them. http://www.bbc.co.uk/news/health-33542940

i can only begin to tell you all how my blood began to boil at this announcement and I'm sure we can all see so many problems involved but what can be done about it? Or is this simply another time where the BMA will roll over and play dead on our behalf? Is this another nail in the NHS coffin?

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

Posted in Cardiology at Mon, 27 Jul 2015 19:44:21


Posts: 10
Joined: 09 Nov 2014
A 36 year old Asian male has a chief complaint of nausea/vomiting and generalized weakness. He also endorses muscle cramps  and a history of intermittent fevers at home. He is a non-smoker, denies excess alcohol use, and denies substance use.
He has a past medical history of:
• Extra-pulmonary TB 
• HIV diagnosed September 2014
On examination of the paient:
• The only physical exam findings of significance are mild tachycardia (HR-110s-120s)  and mild hypoxemia (SpO2-92-93%)
• Only abnormal test result is creatinine of 1.4
EKG revealed:
Echo was ordered, which revealed:
1. What is the diagnosis?
2. How best to treat this?
3. Is there any role for surgery?

Evidence of severe bipolar disorder online

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


Posts: 571
Joined: 23 Aug 2013

Twice now, I've seen well-known contributors on message boards a thousand miles from this one whose posts start to show evidence of severe bipolar disorder.   In one, they became manic, posting about their superpowers in the Galaxy.    Inevitably, they came down the other side into depression and suicidal thoughts.    That person survived and posts still, I think because they were known to have bipolar, and their state was recognised by carers, although I know they lived alone.

Now another person, on another site, has suddenly posted that their life is a struggle, they feel sad all the time, lonely, unloved, ugly and old, and that they wish they didn't exist.    I paraphrase but use their words.

I have no duty of care towards this person, who is a pseudonym on a message board, but we are all human beings.     I have notified the MsB's moderators, in case they know who this person is and can inform a carer, but I'm not hopeful of that.   I see this as like a phone call to the Samaritans, but I have not idea how they deal with such calls, or what to say to this potentially suicidal person that might help them.

Any ideas?


Philosophy of Coffee & Personality

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


Posts: 571
Joined: 23 Aug 2013

In a recent post in the BBC, philosopher Berman discusses the different types of coffee and what do they tell about us. He further illustrates on the mindset beyond tea-ism & coffee-ism comparing them to Eastern & Western philosophies.

I cannot help but wonder, why do people try to decipher personality through coffee and other mundane daily activities. I have my worries about the conclusions that stem from interesting associations.

What should doctors wear at work?

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

John D

Posts: 3632
Joined: 01 Feb 2010

BMJ Careers has published an article on doctors' attire. With the demise of the white coat in the 1990s and ties in the early 2000s for infection control reasons, some doctors in the UK have struggled with what to wear at work. Can anything come close when it comes to the practicality white coats with big pockets offer?

Should doctors dress differently to patients? To other hospital  staff?

What do you wear?

Clinical Quiz

Posted in Diabetes at Thu, 30 Jul 2015 09:35:03

John D

Posts: 3632
Joined: 01 Feb 2010


35 years old patient presented with palpitation muscle cramps and weakness after consumption of a large amount of Cola drink , ECG is shown above, what is the diagnisis ?

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

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


Posts: 571
Joined: 23 Aug 2013

In the latest What your patient is thinking piece from The BMJ, an anonymous author describes their experience seeing more than 12 doctors in two emergency departments over 15 hours before being admitted with psychosis.

On sleep deprivation the author writes: "A deferred decision equals more questioning, which means more sleeplessness and growing desperation."

On noise: “The staff could see it was comforting for someone to play a single song on repeat. What they couldn’t understand was the sinister meaning that had for me.”

“I’m sure you wanted me to hear the sounds of pain just the other side of that curtain.”

On history taking: “If a doctor asks questions in a blank, detached way, it feels very frightening.

“The best communicators use calm and clarity; they treat the distressed person as a person. Paramedics are often good at this.”

Are there protocols in your emergency department for people experiencing psychosis? Is it always possible to follow them?

As this is based on a patient-authored piece, The BMJ will be inviting patients to comment here. Please bear this in mind when responding.

Do your patients show you medical selfies?

Posted in BMJ at Mon, 27 Jul 2015 12:21:20


Posts: 1527
Joined: 25 Jan 2009

Dermatology, orthopaedics, and plastic surgery trainees have written a piece about patients taking pictures of their injuries, dressings, etc to show their doctors.

The authors point out that dedicated medical illustration units are not always available (especially in general practice) and that if patients take and choose to present their own clinical photographs ("medical selfies"), data protection issues are avoided.

They use burns as an example of when medical selfies are helpful, and write that the benefits include patient empowerment and consistency in management.

What do you think about patients showing you medical selfies? In which clinical situations might they be most useful?

Coping with silly comments

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


Posts: 571
Joined: 23 Aug 2013

As soon as I become or may become a patient , I am faced with the "doctors make bad / awkward patients etc... " comments. There is no let up in retirement. My rejoinder to a nurse on a recent trip to the hospital was a good-natured "Doctors bad? You ought to see what some nurses are like!" The need to comment on docs as bad patients even pre-empts concern about what might be the matter as I found out in the supermarket today. 

My present plan for my next admission when challenged in this way will be a simple "I agree - and I will be showing you just why we have this reputation...." Has anyone any better suggestions ?

So far as I know there is no good evidence behind this reputation . Perhaps it stems from the challenge of looking after someone who may know more than the carer , perhaps doctors ask questions and in the heart of hearts of carers good patients do NOT do that whatever the pamphlets say. Perhaps it is simply schadenfreude. 

It is all very well coping with these comments if one is reasonably well - elective surgery - but what if one is sick? If I chose to seek medical advice (something I would not do very readily) I would find it irksome to know that I would be cast as another neurotic doctor or be told I should have come much sooner - probably true ,and perhpas I should not be so selfish as to spoil the gloating self-righteousness of the carer..... I have been a patient a number f times and know just what a difference it makes to be accepted for what I am and feel we are all on the same side.

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

A 35 year old patient presented to the emergency department complaining of one episode of syncope while walking. He does not remember details of the episode, but he mentioned full recovery only a couple of minutes after the event.

He reported no known diseases, no smoking, drinking or drug use. His family history included an older brother who died suddenly while sleeping at age 38.

On physical examination the heart rate was 66 bpm, BP was 140/92 mmHg, respiratory rate 14, temperature 36.2oC. SatO2:97%.

Lungs were clear.

Heart auscultation a systolic murmur (++/4) was noted on the left sternal border.

The ECG showed LV hypertrophy. On echocardiogram a hypertrophic cardiomyopathy (HCM) with a septal thickness of 35 mm was found. The aortic outflow gradient had a peak of 45 mmHg. Aortic and mitral valves were normal. LV ejection fraction was normal.

When Should Aspirin Be Used for Prevention of Cardiovascular Events?

Posted in Diabetes at Mon, 27 Jul 2015 20:43:36


Posts: 746
Joined: 15 Apr 2011

When Should Aspirin Be Used for Prevention of Cardiovascular Events?

JAMA. 2014;312(23):2503-2504. doi:10.1001/jama.2014.16047.

Verbatim Excerpts

In pooled data from about 200 trials among patients with known vascular disease, aspirin was shown to have long-term benefits in preventing major vascular events.  These trials demonstrated that among those with known vascular disease there is net benefit, reducing the risk of major vascular events by more than 20% exceeding the modest bleeding risks when aspirin is taken at a low dose daily. Higher doses do not increase the beneficial effects but increase the risk of bleeding. Thus, aspirin is recommended at a dose of 75 mg to 100 mg per day for longer-term secondary prevention of cardiovascular events in patients with known vascular disease. Aspirin also has utility in the setting of vascular procedures such as percutaneous coronary interventions, reducing the risk of restenosis, and is recommended for several months up to a year after the procedure.

Given the beneficial effects of aspirin during acute events, following procedures, and in the secondary prevention of major vascular events among patients with cardiovascular disease (CVD), it was logical to ask whether this inexpensive drug could prevent the first myocardial infarction or stroke among persons who have yet to manifest vascular disease. Primary prevention trials for this question are especially challenging given the continued reduction in the incidence of important outcomes and require very large study populations followed up for many years.

Beginning in the 1980s several large-scale trials were undertaken to address this question, starting with 2 trials among male physicians, the British Doctors’ Trial and the Physicians’ Health Study. These studies, along with a handful of other primary prevention trials among more than 100 000 study participants, have generally shown more modest reductions of major vascular events compared with secondary prevention (12% for major vascular events and 22% for secondary prevention) and reductions in myocardial infarction and transient ischemic attack risk, and some have demonstrated a reduced risk of ischemic stroke.  In the vast majority of the primary prevention trials, the overall risk level of CVD events was very low.  In the primary prevention setting, there are limited data among those at higher risk. There is also a paucity of data in Asian populations, in which hemorrhagic stroke risk (one of the important adverse effects of aspirin) tends to be higher than in Western populations, and thus this population is of particular interest.

In this issue of JAMA, Ikeda and colleagues7 report the results of the Japanese Primary Prevention Project (JPPP). The JPPP clinical trial studied the effect of once-daily, low-dose (100 mg), enteric-coated aspirin compared with no aspirin for preventing atherosclerotic events in 14 658 Japanese patients 60 years or older with hypertension, dyslipidemia, or diabetes.

The study, which had planned to follow up participants for 6.5 years, was stopped early due to futility. After a median follow-up of 5 years, there was no significant difference in the rate of the composite primary end point of total number of major atherosclerotic events (nonfatal myocardial infarction, nonfatal stroke, CVD death), with a cumulative composite event rate of 2.77% in the aspirin group and 2.96% in the no aspirin group (hazard ratio [HR], 0.94 [95% CI, 0.77-1.15]). There were reductions in pre-specified secondary end points of myocardial infarction and transient ischemic attack, but increased risk of serious bleeding events. These results are consistent with those of other primary prevention trials, except that in JPPP the overall risk of intracranial hemorrhage appeared higher in the studied Asian population than in Western populations. In fact, in this population, there were more fatal and nonfatal hemorrhagic strokes than myocardial infarctions.

Aspirin primary prevention trials have become increasingly challenging to conduct. There is wider use of a number of prevention medications such as antihypertensive agents and lipid-lowering drugs, as well as other preventive measures that collectively result in fewer events than expected, as seen in JPPP. In addition, aspirin may be started in some patients who develop evidence of vascular disease before developing a major outcome. This selective drop-in may be even more of an issue in an unblinded study. In JPPP, nearly 10% of patients in the no aspirin group began using aspirin by the end of the study. Also, self-reported adherence with taking aspirin was only 76% among those who attended study visits. There was also a substantial rate of loss to follow-up, and it is possible that those who experienced events could have been lost to follow-up at a higher rate than those without events. This could have reduced the overall observed event rate. Although these issues present challenges for the conduct of long-term trials, they reflect the real practice of medicine in the 21st century.

The JPPP study adds to the body of evidence that helps refine the answer to the question of when aspirin should be used to prevent vascular events. Decision making involves an assessment of individual risk-to-benefit that should be discussed between clinician and patient. However, at present the choice of aspirin remains clear in several situations. Aspirin is indicated for patients at high short-term risk due to an acute vascular event and those undergoing certain vascular procedures; patients with any evidence of vascular disease should be given daily aspirin. On the other hand, patients at very low risk of vascular events should not take aspirin for prevention of vascular events, even at low dose.

However, some individuals who do not have overt vascular disease will have risk levels that approach those of patients with CVD (such as patients with multiple risk factors). It remains likely that there is some level of risk of CVD events that would result in a positive trade-off of benefit and risk for the use of aspirin, but the precise level of risk is uncertain. This is in part because most populations studied have been at very low risk. Patients at higher than average risk are being studied in 3 ongoing trials of aspirin in primary prevention. The ASCEND study involves aspirin for patients 40 years and older with type 1 or 2 diabetes; the ARRIVE study is testing aspirin in middle-aged and older patients who are at higher risk based on the presence of multiple CVD risk factors; and the ASPREE study is testing aspirin in individuals older than 70 years. Information from these studies will help refine guidelines that currently reserve aspirin for higher-risk patients. Findings from these studies, with additional data about risks and other potential long-term benefits, such as reducing the risk of colorectal and other cancers, will prove helpful for clinical decision making involving the role of aspirin for primary prevention.

COMMENT: This is a nice summary of where we are to date on the use of aspirin in primary and secondary prevention of cardiovascular events.  Basically the data show that modest doses of aspirin (75-100 mg/daily) are beneficial in the secondary prevention of cardiovascular events.  Additionally in western populations prophylactic use of aspirin also have modest benefits.  However, the risk of aspirin in the primary prevention of cardiovascular events in Asian populations appears to cause more harm than benefits because of this population’s risk of hemorrhagic strokes as reported from the Japanese Primary Prevention Project as reported in this same issue of JAMA.  There remains uncertainty regarding at what cardiovascular risk does the primary prevention benefit of prophylactic aspirin therapy outweigh the risks.  The results of three ongoing studies should clarify this question.

Should your psychiatrist track your mobile phone?

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


Posts: 1027
Joined: 13 Oct 2009

In a recent post at Harvard Magazine, named your phone knows how you feel? the author discusses the data received from mobile phones and how they can help map the emergence/recurrence of psychiatric disorders.

I am partial towards privacy. However, the author makes a good point about objective measures in psychiatric assessment. I wonder whether you'd be happy to compromise your privacy for your mental health or not.


MERS in Manchetser, UK

Posted in Public health at Mon, 27 Jul 2015 18:56:04


Posts: 1403
Joined: 07 Sep 2009

The emergency department at Manchester Royal Infirmary was closed this afternoon following the admission of two patients with suspected Middle Eastern respiratory syndrome coronavirus (MERS-CoV).

The Guardian reports that a hospital spokesperson confirmed the patients have been isolated and the hospital has now re-opened.

WHO data show there have been 186 confirmed cases of MERS (185 in the Republic of Korea and one in China) and 36 deaths from the coronavirus to date. 

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

Circle of Willis, Islets of Langerhans, Golgi apparatus are a few names of great physicians who discovered these parts of our bodies. The nomenclature follows naming diseases and syndromes after their discoverers eg Asperger Syndrome, Alzheimer's Disease, Bilharziasis, Paget's Disease, Sydenham Chorea, Huntigton's Disease, Parkinson's Disease, 

The myriad of names given in tribute to great doctors and discoverers is a great honour, but it seldom describes the case at hand and is non-descriptive of the organ/disease in charge. Some names are coupled with terrible diseases eg Hodgkin lymphoma.j

I wonder whether it would be a good idea to start using more descriptive names to these organelles and diseases.

Clinical Quiz

Posted in General clinical at Mon, 27 Jul 2015 22:40:44


Posts: 431
Joined: 29 Jul 2010


35 years old patient presented with palpitation muscle cramps and weakness after consumption of a large amount of Cola drink , ECG is shown above,

what is the diagnisis ?

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

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

Changing email account for login

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


Posts: 1403
Joined: 07 Sep 2009

Hi, I have recently changed jobs and can no longer access the email account that I used when I signed up, I cannot find a way of changing this for my profile, nor a way of changing my login password.

Could you please guide me through the process?

Thank you,


Transgender Youth Don't Have Hormone Abnormalities

Posted in News & media at Mon, 27 Jul 2015 18:13:20

Mukhtar Ali

Posts: 992
Joined: 14 Nov 2010

Sex hormone levels in transgender youth are consistent with the gender they were assigned at birth, a new study finds.


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

Posted in Cardiology at Wed, 29 Jul 2015 12:55:22


Posts: 10
Joined: 09 Nov 2014

There is emerging evidence that endovascular therapy (EVT) for acute ischemic stroke significantly improved functional outcomes (without compromising safety) in patients with acute ischaemic stroke due to anterior circulation, large artery occlusion, compared with standard therapy.A recent spate of multiple trials have shown this, as did a pooled analysis-


It has also received endorsement from national societies and guidelines-


It may lead to a paradigm shift about the way acute stroke care is delivered-especially with expanding availability of this modality.

However some caveats to ponder-


Anyone have real-life experience with this therapy?

H1N1 Vaccine and Narcolepsy link Discovered

Posted in News & media at Mon, 27 Jul 2015 18:06:00

Mukhtar Ali

Posts: 992
Joined: 14 Nov 2010

Researchers have found a clue to the cases of narcolepsy seen after H1N1 infection and vaccination.


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


Posts: 1027
Joined: 13 Oct 2009

The ramifications of consent to surgery continue to interest me. In recent years I have come across 2 very competent surgeons who have used the phrase "I will operate if you beg me to". Fair enough one of these was for indicated but not-in-a-hurry problem but the other was for fairly gross and incapacitating disease (not malignant but likely to have an increasingly unfavourable out come). 

I contrast this with a slightly more gung-ho approach of a junior doctor who told someone I was accompanying that there was a cataract in her eye (attending the clinic for other reasons and subjected to regular eye inspection) and she could be put on the list with a view to surgery within 6 weeks and it was essentially a fairly minor procedure. This hit the patient like a bolt from he blue - junior doc could be brilliiant picking up something missed by others in a clinic not geared to cataracts etc....- but clearly a matter for some thought rather than just jumping on to an operating list.

But this idea of "I will operate if you really cannot cope" worries me . Clearly patients must not be led to think unrealistically about surgery and its benefits , but begging (does one have to provide a selection of gifts as a supplicant ?) alters the whole doctor / patient relationship and puts us back 40-50 years. It is presumably something to do with self-image - after all if the surgeon operates badly he is still culpable - but what about the patient who feels rejected : could the surgeon be responsible for a bad outcome there?

For me , speaking from a moderately knowledgeable base , the decision is relatively easy - seek the best technician with a reliable anaethetist and know about the expectations and limitations of the procedure involved . But I can see that for others this idea of "begging" will be decidedly offputting , although perhaps focusing the mind of those who see surgery will provide an answer which is unlikely.

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.


FDA Approves Stomach Balloon for Weight Loss

Posted in Public health at Thu, 30 Jul 2015 19:15:01

Mukhtar Ali

Posts: 992
Joined: 14 Nov 2010

By Kristin J. Kelley

Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM

The FDA has approved a balloon that helps obese patients lose weight by filling part of the stomach and triggering feelings of fullness. The ReShape Integrated Dual Balloon System is indicated for adults who have at least one obesity-related condition (e.g., diabetes, hypertension, hyperlipidemia) and for whom diet and exercise hasn't worked.

The balloon — which is inserted into the stomach via the patient's mouth and then filled with saline — is only intended to be used for up to 6 months. Patients should still adhere to a supervised diet and exercise plan during and after use of the device.

In a randomized trial of over 300 obese patients, those who received the balloon lost an average of 6.8% of their total body weight (14 pounds) in 6 months versus 3.3% (7 pounds) among those who didn't receive it.

Side effects include gastric ulcers, indigestion, abdominal pain, and vomiting. Myocardial infarction, infection, and severe allergic reactions are rare. The device shouldn't be used in patients who've had bariatric or gastrointestinal surgery.

FDA news release (Free)