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The most viewed discussions on doc2doc this month

It is time to break the silence on physician suicide.

Posted in News & media at Sun, 22 Nov 2015 09:45:10


Posts: 1178
Joined: 13 Oct 2009

There is an increasing trend of reports concerning doctors that committed suicide. (1,2)

Widespread corruption and wrongdoings involving the American Association of Addiction Medicine (ASAM) and Physician Health Programs (PHPs) have been denounced by different sources as a key factor involved in the abuse, hopelessness, and suicide of our colleagues.(3) ASAM and PHPs are coercing physicians into 12-steps recovery programs, an intervention not supported by the evidence, but "spiritual recovery" and irrational prescription of active pharmacological principles (e.g., suboxone).(4) The creation of "addiction medicine" as a medical specialty is also part of this problem and far away to be the solution.

One thing is for certain. When society gives power of diagnosis and treatment to individuals within a group schooled in just one uncompromising model of addiction with the majority attributing their very own sobriety to that model, they will exercise that power to diagnose and treat anyone and everyone according to that model. The birth of Addiction Medicine as an ABMS accepted discipline is sure to be a success for the drug and alcohol testing and 12-step treatment industry, but its spawn is sure to be an inauspicious mark on the Profession and Guild of Medicine and a bane of society for years to come." ―Michael Lawrence Langan.(5)

I am concerned about the insufficient information about physician suicide in countries outside the United States (considering that there is also not enough information about this matter in the US). In Colombia, a statistical report by the national institute of legal medicine, reported eight cases of suicides of doctors and other healthcare professionals in 2011.(6) However, this report does not provide specific details about these eight cases of suicide. A more recent publication by the National Institute of Legal Medicine (2013) unfortunately does not report the number of suicides among doctors and other healthcare professionals in Colombia. I knew two colleagues in Colombia that committed suicide but the circumstances, motives, and predisposing factors remain hidden behind a wall of silence.      

If we continue keeping the silence involving the suicide of our colleagues, it will be very difficult for us to prevent  the suicide of our patients, as well as effectively supporting families suffering by the suicide of one of their loved ones.


1. Google News (search query: "physician suicide"): https://goo.gl/vp72Ub

2. Pamela Wibble. Physician suicide 101: Secrets, lies and solutions. 

3. Michael L. Langan. Category: Physician Suicide.

4. [(Chaos) x (Suboxone + J Addict Med + Am Soc Addict Med + Like Minded Docs + Addiction Medicine + Spiritual Interventions + 12 Step Recovery Programs + Drug Testing)]

5. Re: Drug policy: we need brave politicians and open minds BMJ 2014.

6. Comportamiento del suicidio en Colombia, 2011. Instituto Nacional de Medicina Legal.

Aphantasia: a real disorder or a fantasy?

Posted in Psychiatry at Thu, 26 Nov 2015 08:16:33


Posts: 1
Joined: 26 Nov 2015

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.

Is it autism or neurodiversity?

Posted in Psychiatry at Fri, 20 Nov 2015 14:59:48


Posts: 1178
Joined: 13 Oct 2009

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.

ECG Question

Posted in Cardiology at Tue, 24 Nov 2015 22:13:28


Posts: 475
Joined: 29 Jul 2010

ECG below obtained from 45 years old patient presented with dizziness and palpitations

what is the diagnosis ?


Do doctors have a special way of thinking?

Posted in General clinical at Fri, 20 Nov 2015 15:08:28


Posts: 6
Joined: 18 Nov 2015

Thinking is classified sometimes as scientific thinking, heuristic thinking, arithmetic thinking, algebraic thinking, logical thinking, but how about medical thinking. A book named How doctors think by Jerome Groopman, discusses the way doctors think. He challenges the notion that doctors have scientific thinking, and adopts a confrontative approach to the linear dichotomous model of algorithmic thinking. He highlights that doctors do use heuristics, and that thinking outside the box can be helpful.

I wonder whether you have a theory of how doctors arrive at their decisions, and conclusion and whether it is purely scientific or following guidelines or whether it is affected by biases.

Homeopathy will be banned.

Posted in General clinical at Fri, 20 Nov 2015 17:32:12


Posts: 194
Joined: 21 Aug 2011

The controversial treatment of homeopathy which has partial presence of NHS, may be banned from the GPs as BBC report states. I have my concerns about homeopathy, as NHS Choices states that it has no effect while the treatment is available in private practice and some areas elsewhere. In the light of lack of evidence of efficacy, I wonder why it is still present and not banned.

MCS - Court ruling allows withdrawal of treatment

Posted in News & media at Wed, 25 Nov 2015 17:39:41


Posts: 1659
Joined: 09 Dec 2011
In a significant court ruling a 68 year old woman in a 'minimally conscious state' is to have treatment including fluids and food withdrawn enabling her to die. She has had Multiple Sclerosis for 23 years and her daughter, family and medical team supported the application to the court. Her doctors gave evidence in support of a legal declaration that continuing to live as she is would not be in her “best interests”. The judge concluded that although Mrs N now has no capacity to decide for herself and no real awareness of her condition, her past life and views made it clear she would have found the prospect of continuing to live in her current state “grotesque".
Previously courts have only made such decisions in cases involving patients with no prospect of recovery who are in a coma or vegetative state. But, every case is assessed and decided on its own facts. The Judge in this case said:
"I am left with little doubt that Mrs N would have been appalled to contemplate the early pain, increasing dependency and remorseless degeneration that has now characterised her life for so long. I have no difficulty in accepting the family’s view that she would not wish to continue as she is. More than that, she would have wished to have discontinued her treatment some considerable time ago. There will undoubtedly be people who for religious or cultural reasons or merely because it accords with the behavioural code by which they have lived their life prefer to, or think it morally right to, hold fast to life no matter how poor its quality or vestigial its nature. Their choice must be respected. But choice where rational, informed and un coerced. This is the essence of autonomy. It follows that those who would not wish to live in this way must have their views respected too"
It is worth noting that one previous case for a similar declaration was sought. It was the first occasion in this country in which an application for the withdrawal of ANH had been made in respect of a person in a minimally conscious state - WvM (2011), the declaration was refused.
Campaigners who oppose assisted dying said the ruling could put vulnerable sick or disabled people at risk. Peter Saunders, director of Care Not Killing said: “This case demonstrates judicial mission creep whereby judges, through subjective application of vague and ambiguous legal precedent, are able to shape and remake the law. In so doing they erode legal protection for vulnerable people and give an invitation to those who wish to rid themselves of a financial or emotional care burden to push the envelope even further.” 
I could not disagree more with Mr Saunders. This case demonstrates clearly that such decisions are taken with great care, and that every case is individual and that no blanket ruling emerges. A case such as this concerns one individual woman, it would not put any vulnerable or disabled people at risk. This is about autonomy not forced withdrawal of treatment.

Nuremberg legacy 70 years on

Posted in News & media at Sat, 28 Nov 2015 15:00:49


Posts: 1178
Joined: 13 Oct 2009

70 years ago on the 20th November 1945 the major architects and enforcers of the holocaust were put on trial in Nuremberg. Leaders of a sovereign nation were, for the first time, tried for crimes so serious they amounted to crimes against humanity (a new term in the legal lexicon). A year later 23 Nazi Doctors and administrators had to account for their crimes. Their hideous abuse of human beings veiled as ‘experiments’ which led to so much death, injury and suffering were so cruel that  initial reports were disbelieved.

It is remarkable the trials happened at all.  It was Churchill’s wish that as Nazi officials were found they should be executed without trial by an officer of Major or above. However on 22nd October 1944 Churchill wrote ‘in the blessed air above El Alamein’ a letter to Roosevelt noting that on major war criminals Stalin ‘took an unexpectedly ultra-respectable line. There must be no execution without trial; otherwise the world will say we were afraid to try them’. There were flaws.  For example the Soviet prosecutor had ample experience conducting show trials and he cited the Hitler-Stalin pact as evidence of German aggression against Poland. The tribunal also applied the tu quoue principle. But, nonetheless defendants could appoint legal counsel, were able to mount a defence as they saw fit, had full access to all evidence, could call witnesses and have them extensively cross examined by counsel. The trials’ were conducted with far more fairness than any individual received under the Nazi’s.   

Crucially, the Nuremberg trials established – to legal standards - an irrefutable and detailed record of the Nazi regime’s crimes such as the holocaust at precisely the time when many Germans were eager to forget or claim complete ignorance.

Today, the most relevant legacy are the “Nuremberg principles”. Confirmed in a UN General Assembly resolution in 1948, they firmly established that individuals can be punished for crimes under international law. Perpetrators could no longer hide behind domestic legislation or the argument that they were merely carrying out orders

The strongest impact should have been on the development of international criminal law, but this was largely frozen out by the Cold War. With the re-emergence of international tribunals investigating war crimes and genocide in the former Yugoslavia and Rwanda in the 1990s, the legacy of Nuremberg proved a powerful argument for establishing the International Criminal Court in 1998. The Rome Statute includes many principles developed in 1945.

But laws however expertly drafted cannot prevent war. Crimes are committed by individuals, not abstract entities, and individuals must be held accountable to deter future crimes. The Nuremberg legacy established that no one is above the law, and that no head of state or military leader can hide behind their title to commit abuses; that some crimes are so grave as to affect and endanger all of humankind, and therefore it is in the interests of all countries to ensure that those responsible are punished. But, we know all too well that not all countries are held accountable for political reasons. The Statute has not been ratified by important major powers, such as the United States of America, Russia, India, China and Israel.

The trial of Nazi Doctors and the trial court's formulation of the Nuremberg Code, with its absolute requirement of informed consent, is usually presented as the trial's major medical ethics and human rights law accomplishment (which subsequently led to The Helsinki Declaration).


Dermatology revision

Posted in General clinical at Thu, 19 Nov 2015 22:52:48


Posts: 475
Joined: 29 Jul 2010

This patient developed this skin condition suddenly, after emotional reaction

What is called ?

2003-09-17 Goose bumps.jpg

Fructose consumption and metabolic syndrome

Posted in Diabetes at Wed, 25 Nov 2015 11:39:20


Posts: 792
Joined: 15 Apr 2011

Isocaloric Fructose Restriction and Metabolic Improvement in Children with Obesity and Metabolic Syndrome

Obesity (2015) 00, 00–00. doi:10.1002/oby.21371

Verbatim Abstract

Objective: Dietary fructose is implicated in metabolic syndrome, but intervention studies are confounded by positive caloric balance, changes in adiposity, or artifactually high amounts. This study determined whether isocaloric substitution of starch for sugar would improve metabolic parameters in Latino (n527) and African-American (n516) children with obesity and metabolic syndrome.

Methods: Participants consumed a diet for 9 days to deliver comparable percentages of protein, fat, and carbohydrate as their self-reported diet; however, dietary sugar was reduced from 28% to 10% and substituted with starch. Participants recorded daily weights, with calories adjusted for weight maintenance. Participants underwent dual-energy X-ray absorptiometry and oral glucose tolerance testing on Days 0 and 10. Biochemical analyses were controlled for weight change by repeated measures ANCOVA.

Results: Reductions in diastolic blood pressure (25 mmHg; P50.002), lactate (20.3 mmol/L; P<0.001), triglyceride, and LDL-cholesterol (246% and 20.3 mmol/L; P<0.001) were noted. Glucose tolerance

and hyperinsulinemia improved (P<0.001). Weight reduced by 0.960.2 kg (P<0.001) and fat-free mass by 0.6 kg (P50.04). Post hoc sensitivity analysis demonstrates that results in the subcohort that did not lose weight (n510) were directionally consistent.

Conclusions: Isocaloric fructose restriction improved surrogate metabolic parameters in children with obesity and metabolic syndrome irrespective of weight change.

COMMENT: One more piece of evidence that fructose has metabolic effects separate from its caloric content.  These data are consistent with the observation that high fructose corn syrup consumption is associated with the metabolic syndrome.


Blunt trauma abdomen with pancreatic laceration

Posted in General clinical at Wed, 25 Nov 2015 13:23:49


Posts: 554
Joined: 04 Jul 2010

Back after a long hiatus. I'm presently specializing in surgery and we had this patient admitted under us last thursday.

A 23 year old male patient presented to the emergency with a history of blunt trauma abdomen 4 days back. He was riding a motorcycle (without helmet of course) when he skidded and fell down. He was previously admitted at an outside facility where he was managed conservatively. When he presented to us, he was conscious, alert and cooperative, without any significant external injuries. He had no pallor, jaundice, cyanosis, clubbing or edema. His pulse was 118/min, BP-122/70 mmHg, RR – 26/min and was afebrile. His abdomen was distended, tense and tender. Hepatic dullness was not obliterated and IPS was absent. His chest X-ray and straight X-ray abdomen did not show any significant abnormality. He had CT scan of the whole abdomen done two days after the injury which showed grade III hepatic laceration involving segment VII and VIII and laceration of the pancreas at the body along with hemoperitoneum. We did not have access to emergency ultrasound so an abdominal tap was done which revealed presence of blood. The visiting surgeon was informed and a decision was taken to undertake emergency laparotomy for the patient. Then there was a sudden significant development in the patient. His SpO2 in room air was found to be 83%. It debated whether to do a repeat X-ray or to do a pleural tap. It was decided to do b/l pleural tap which revealed b/l hemothorax.


The patient was taken to the operation theatre and before laparotomy, b/l chest drains were put in. About 500 ml of blood came from each drain following the SpO2 rose to 97%. We then proceeded to laparotomy. The abdomen was opened by midline incision. On opening, the abdomen, blood was seen within the abdominal cavity which was sucked out. There was an estimated 2 liters of blood within the abdominal cavity. On exploring, the infracolic compartment was found to be normal. A 10 cm laceration was seen in the antero-superior surface of liver with a parenchymal depth of 1 cm. there was no active bleeding from it was decided to leave it as such. There was extensive saponification in the supracolic compartment . The lesser sac was entered by dividing the gastrocolic ligament. On entering the lesser sac, dark coloured serous fluid came out which was sucked out. there was extensive saponification along the body of the pancreas and the pancreas was highly friable. The exact site of the pancreatic laceration could not be identified. The spleen and the duodenum was found to be normal. It was decided to put a drain in the lesser sac and close the abdomen. A feeding jejunostomy was done to maintain nutrition in the post-operative period as possible pancreatic fistula was anticipated.  

The patient is presently in 4th post-op day with a high leucocyte count – 21000/mm3 and the output from the drain in the lesser sac is about 75ml in 24 hrs. Both the chest drains have become non-functional but the patient is having tachyapnea. He is scheduled for a CT thorax and upper abdomen after 2 days. Feeding through FJ has been started.


Trainee doctors' strike - the consultants' situation

Posted in News & media at Fri, 20 Nov 2015 13:32:32


Posts: 1178
Joined: 13 Oct 2009

Everyone in the UK and NHS will know by now that the trainee doctors have voted with an overwhelming majority to take strike action.    Although Secretary of Health Hunt is being urged to invoke ACAS (Advisory, Conciliation and Arbitration Service - a Government, but intended to be apolitical strike resolution department), which would postpone industrial action.   BUt he seems to be being equally urged by his political masters to adopt a macho stance, in the belief that a strike by doctors will loose them their enormous public support.

We shall see whta will happen, but in the event of a total walk out by trainees, as planned, what should the non-trainee doctors of the UK do?   I expect that plans are being made to cancel non-urgent work of all sorts, relatively easy for surgeons, except in cancer, less so for the physicians, most of whose admissions are urgent, and impossible for the obstetricians.   But will there be enough consultants an SAS doctors to cover the wards?    And what if Trusts try to bring in locums or retired doctors to keep lists and clincis going?  

In the past, industrial action in industry was notorious for 'chalk-line' disputes, about what was or was not the job of a group of workers.  I have no doubt that Trusts, driven by the wind of the economy, and the whips of politics, will attempt to keep as much going as possible, above and beyond what the doctors might consider essential.

Please tell us here what is happening in your part of the NHS.  We have debated anonymity on Doc2doc, and this is a time when that anonymity frees you to be as honest and open as you wish.   The strike dates are:

  Emergency care only – 8am, Tuesday 1 to 8am, Wednesday 2 December 2015

  −  Full walkout – 8am to 5pm, Tuesday 8 December 2015

 −  Full walkout – 8am to 5pm, Wednesday 16 December 2015


What's going to happen in your hospital or surgery?




why digital is not working

Posted in General clinical at Fri, 27 Nov 2015 10:18:02


Posts: 1178
Joined: 13 Oct 2009

The hospitals in UK have already been fully electronic. Patient records, drug charts etc. are fully electronic. But it seems not so useful. Nurses still have too much paperwork to do. Operations are not starting on time, sometimes even cancelled, due to staffing/patient/equipment issues. So what is the true problem and what is the right solution? Any ideas?


Confidentiality vs Information Disclosure

Posted in Medicolegal at Tue, 24 Nov 2015 10:43:37


Posts: 528
Joined: 14 Dec 2010

Mr and Mrs A, have been married for 5 years and in their late 30's. Mrs A is sub-fertile due to fibroids. Superoverulation was attempted but no ova were collected. Mrs A is also HIV +, but is stable. Her husband, who has tested negative, knows her status, but apart from the HCPs caring for her, no one else knows

She is advised by the Fertility clinic to seek an egg donor. Her younger sister, who has two children of her own, is prepared to donate an egg to her. Mrs A is close to her sister and they worship at the same church, so see each other reguarly.

The clinicians caring for her at the Fertility Centre are divided on the question of whether or not Mrs A's siter has a righ to know her sister's HIV status? Mrs A is admant that her sister is not told, particualry as she recognises that the IVF treatment proposed has probably only a 10% chance of success in her case.

Discuss the ethical and legal issues

SPRINT trial Should we lower systolic targets.

Posted in Psychiatry at Sat, 28 Nov 2015 23:04:59


Posts: 27
Joined: 04 May 2015

SPRINT trial was stopped early [ after 3.26 years] because it was found that having a systolic target of 120 rather than 140 lowered rate of heart failure , deaths from cardiovascular causes and all causes of mortality but increased rate of renal failure and syncope.

My natural inclination is 'primum non nocere/ firstly do no harm'. But this trial probably should make me more inclined to treat hypertension more aggressively.

Between 1969 and 2013, the age-standardized death rate per 100 000 decreased from 1278.8 to 729.8 for all causes (42.9% reduction)

Posted in Diabetes at Mon, 23 Nov 2015 13:57:45

John D

Posts: 3844
Joined: 01 Feb 2010

Temporal Trends in Mortality in the United States, 1969-2013

JAMA. 2015;314(16):1731-1739. doi:10.1001/jama.2015.12319.


Importance  A systematic and comprehensive evaluation of long-term trends in mortality is important for health planning and priority setting and for identifying modifiable factors that may contribute to the trends.

Objective  To examine temporal trends in deaths in the United States for all causes and for 6 leading causes.

Design, Setting, and Participants  Joinpoint analysis of US national vital statistics data from 1969 through 2013.

Exposure  Causes of death.

Main Outcomes and Measures  Total and annual percent change in age-standardized death rates and years of potential life lost before age 75 years for all causes combined and for heart disease, cancer, chronic obstructive pulmonary disease (COPD), stroke, unintentional injuries, and diabetes mellitus.

Results  Between 1969 and 2013, the age-standardized death rate per 100 000 decreased from 1278.8 to 729.8 for all causes (42.9% reduction; 95% CI, 42.8%-43.0%), from 156.8 to 36.0 for stroke (77.0% reduction; 95% CI, 76.9%-77.2%), from 520.4 to 169.1 for heart disease (67.5% reduction; 95% CI, 67.4%-67.6%), from 65.1 to 39.2 for unintentional injuries (39.8% reduction; 95% CI, 39.3%-40.3%), from 198.6 to 163.1 for cancer (17.9% reduction; 95% CI, 17.5%-18.2%), and from 25.3 to 21.1 for diabetes (16.5% reduction; 95% CI, 15.4%-17.5%). In contrast, the rate for COPD increased from 21.0 to 42.2 (100.6% increase; 95% CI, 98.2%-103.1%). However, during the last time segment detected by joinpoint analysis, death rate for COPD in men began to decrease and the declines in rates slowed for heart disease, stroke, and diabetes. For example, the annual decline for heart disease slowed from 3.9% (95% CI, 3.5%-4.2%) during the 2000-2010 period to 1.4% (95% CI, −3.4% to 0.6%) during the 2010-2013 period (P = .02 for slope difference). Between 1969 and 2013, age-standardized years of potential life lost per 1000 decreased from 1.9 to 1.6 for diabetes (14.5% reduction; 95% CI, 12.6%-16.4%), from 21.4 to 12.7 for cancer (40.6%; 95% CI, 40.2%-41.1%), from 19.9 to 10.4 for unintentional injuries (47.5%; 95% CI, 47.0%-48.0%), from 28.8 to 9.1 for heart disease (68.3%; 95% CI, 68.1%-68.5%), and from 6.0 to 1.5 for stroke (74.8%; 95% CI, 74.4%-75.3%). For COPD, the rate for years of potential life lost did not decrease over this time interval.

Conclusions and Relevance  According to death certificate data between 1969 and 2013, an overall decreasing trend in age-standardized death rate was observed for all causes combined, heart disease, cancer, stroke, unintentional injuries, and diabetes, although the rate of decrease appears to have slowed for heart disease, stroke, and diabetes. The death rate for COPD increased during this period.

COMMENT: Sometimes in our busy lives we need to be reminded that what we do every day truly does make a difference.  Consider yourself reminded.

Cardiology Quiz

Posted in Cardiology at Fri, 27 Nov 2015 23:23:30


Posts: 475
Joined: 29 Jul 2010

42 years old patient presented with headache and dizziness one hour after he woke up in the morning, the ECG shown was taken in the A& E  at the same time

1/ What is the diagnosis ?

2 /What is the  differential diagnosis ?



Confidentiality vs Information Disclosure

Posted in Medical ethics at Mon, 23 Nov 2015 22:06:18

Tom Axon

Posts: 2
Joined: 12 May 2014

Mr and Mrs A, have been married for 5 years and in their late 30's. Mrs A is sub-fertile due to fibroids. Superoverulation was attempted but no ova were collected. Mrs A is also HIV +, but is stable. Her husband, who has tested negative, knows her status, but apart from the HCPs caring for her, no one else knows

She is advised by the Fertility clinic to seek an egg donor. Her younger sister, who has two children of her own, is prepared to donate an egg to her. Mrs A is close to her sister and they worship at the same church, so see each other reguarly.

The clinicians caring for her at the Fertility Centre are divided on the question of whether or not Mrs A's siter has a righ to know her sister's HIV status? Mrs A is admant that her sister is not told, particualry as she recognises that the IVF treatment proposed has probably only a 10% chance of success in her case.

Discuss the ethical and legal issues

Can changes in the microbiota caused by lactobacillus change incretin secretion-proof of concept

Posted in Diabetes at Sat, 21 Nov 2015 22:34:24


Posts: 792
Joined: 15 Apr 2011

Intake of Lactobacillus reuteri Improves Incretin and Insulin Secretion in Glucose Tolerant Humans: A Proof of Concept

Published online before print June 17, 2015, doi: 10.2337/dc14-2690 Diabetes Care June 17, 2015


OBJECTIVE Probiotics can modify gut microbiota and alter insulin resistance and diabetes development in rodents. The authors hypothesized that daily intake of Lactobacillus reuteri increases insulin sensitivity by changing cytokine release and insulin secretion via modulation of the release of glucagon-like peptides (GLP)-1 and -2.

RESEARCH DESIGN AND METHODS A prospective, double-blind, randomized trial was performed in 21 glucose tolerant humans (11 lean: age 49 ± 7 years, BMI 23.6 ± 1.7 kg/m2; 10 obese: age 51 ± 7 years, BMI 35.5 ± 4.9 kg/m2). Participants ingested 1010 b.i.d. L. reuteri or placebo over 4 weeks. Oral glucose tolerance and isoglycemic glucose infusion tests were used to assess incretin effect and GLP-1 and GLP-2 secretion, and euglycemic-hyperinsulinemic clamps with [6,6-2H2]glucose were used to measure peripheral insulin sensitivity and endogenous glucose production. Muscle and hepatic lipid contents were assessed by 1H-magnetic resonance spectroscopy, and immune status, cytokines, and endotoxin were measured with specific assays.

RESULTS In glucose tolerant volunteers, daily administration of L. reuteri increased glucose-stimulated GLP-1 and GLP-2 release by 76% (P < 0.01) and 43% (P < 0.01), respectively, compared with placebo, along with 49% higher insulin (P < 0.05) and 55% higher C-peptide secretion (P < 0.05). However, the intervention did not alter peripheral and hepatic insulin sensitivity, body mass, ectopic fat content, or circulating cytokines.

CONCLUSIONS Enrichment of gut microbiota with L. reuteri increases insulin secretion, possibly due to augmented incretin release, but does not directly affect insulin sensitivity or body fat distribution. This suggests that oral ingestion of one specific strain may serve as a novel therapeutic approach to improve glucose-dependent insulin release.

COMMENT: The metabolic effects of changes in the microbiota are a hot topic right now.  For good reason, differences in microbiota may be retated to obesity, for example.  in this proof of concept study the canges in microbiota resulting from lactobacillus ingestion resulted in increased incretin secretion and subsequent insulin secretion in normal indiviuals.  Obviously we are a long way from any therapeutic recommendations, but such studies are opening up a whole new area of research.

Were cardiovascular deaths related to insulin dose in the ACCORD trial?

Posted in Diabetes at Sat, 21 Nov 2015 22:51:07


Posts: 792
Joined: 15 Apr 2011

Insulin Dose and Cardiovascular Mortality in the ACCORD Trial

Published online before print October 13, 2015, doi: 10.2337/dc15-0598 Diabetes Care October 13, 2015


OBJECTIVE In the ACCORD trial, intensive treatment of patients with type 2 diabetes and high cardiovascular (CV) risk was associated with higher all-cause and CV mortality. Post hoc analyses have failed to implicate rapid reduction of glucose, hypoglycemia, or specific drugs as the causes of this finding. We hypothesized that exposure to injected insulin was quantitatively associated with increased CV mortality.

RESEARCH DESIGN AND METHODS The authors examined insulin exposure data from 10,163 participants with a mean follow-up of 5 years. Using Cox proportional hazards models, we explored associations between CV mortality and total, basal, and prandial insulin dose over time, adjusting for both baseline and on-treatment covariates including randomized intervention assignment.

RESULTS More participants allocated to intensive treatment (79%) than standard treatment (62%) were ever prescribed insulin in ACCORD, with a higher mean updated total daily dose (0.41 vs. 0.30 units/kg) (P < 0.001). Before adjustment for covariates, higher insulin dose was associated with increased risk of CV death (hazard ratios [HRs] per 1 unit/kg/day 1.83 [1.45, 2.31], 2.29 [1.62, 3.23], and 3.36 [2.00, 5.66] for total, basal, and prandial insulin, respectively). However, after adjustment for baseline covariates, no significant association of insulin dose with CV death remained. Moreover, further adjustment for severe hypoglycemia, weight change, attained A1C, and randomized treatment assignment did not materially alter this observation.

CONCLUSIONS These analyses provide no support for the hypothesis that insulin dose contributed to CV mortality in ACCORD.

COMMENT: Insulin resistance is associated with increased atherosclerosis and causes hyperinsulinemia in normal individuals.  Therefore, there is some rationale for hypothesizing that exogenous insulin would result in increased atherosclerosis.  The problem with that syllogism is that there are no studies that demonstrate a relationship between cardiovascular mortality and death from cardiovascular disease and insulin dose.  The ACCORD study is the ideal place to look at this since the intensively treated patients had increased cardiovascular mortality.  Again we find, howover, no association with insulin dose and cardiovascular death.


The latest CDC data on e-cigarette use in the US.

Posted in Diabetes at Sun, 22 Nov 2015 23:45:00


Posts: 792
Joined: 15 Apr 2011


 Electronic Cigarette Use Among Adults: United States, 2014

Key findings

Data from the National Health Interview Survey

In 2014, 12.6% of adults had ever tried an e-cigarette even one time, with use differing by sex, age, and race and Hispanic or Latino origin. About 3.7% of adults currently used e-cigarettes, with use differing by age and race and Hispanic or Latino origin. Current cigarette smokers and former smokers who quit smoking within the past year were more likely to use e-cigarettes than former smokers who quit smoking more than 1 year ago and those who had never smoked. Among current cigarette smokers who had tried to quit smoking in the past year, more than one-half had ever tried an e-cigarette and 20.3% were current e-cigarette users. Among adults who had never smoked cigarettes, 3.2% had ever tried an e-cigarette. Ever having used an e-cigarette was highest among never smokers aged 18–24 (9.7%) and declined with age.

COMMENT:  Even though a UK committee recently concluded that e-cigarettes were safer than smoking tobacco cigarettes and may be useful for smoking sensation, I find the data on young non-smokers troublesome.  We need to monitor their use carefully. 

How should we determine the relative weight of patient factors in determining glycemic goals?

Posted in Diabetes at Mon, 23 Nov 2015 18:46:15


Posts: 792
Joined: 15 Apr 2011

Clinical Assessment of Individualized Glycemic Goals in Patients With Type 2 Diabetes: Formulation of an Algorithm Based on a Survey Among Leading Worldwide Diabetologists

Diabetes Care October 30, 2015


OBJECTIVE Over the past few years diabetes glycemic guidelines increasingly have stressed the need to adjust glycemic targets based on parameters pertaining to individual patient characteristics and comorbidities. However, the weight and value given to each parameter will clearly vary depending on the experience of the provider, the characteristics of the patient, and the specific clinical situation.

RESEARCH DESIGN AND METHODS To determine if there is current consensus on a global level, we conducted a survey among 244 key worldwide opinion-leading diabetologists. Initially, the physicians were to rank the factors they take into consideration when setting their patients' glycemic target according to their relative importance. Subsequently, six clinical vignettes were presented, and the experts were requested to suggest an appropriate glycemic target. The survey results were used to formulate an algorithm according to which an estimate of the patient's glycemic target based on individualized parameters can be computed. Three additional clinical cases were submitted to a new set of experts for validation of the algorithm.

RESULTS A total of 151 (61.9%) experts responded to the survey. The parameters “life expectancy” and “risk of hypoglycemia from treatment” were considered to be the most important. “Resources” and “disease duration” ranked the lowest. An algorithm was constructed based on survey results. Presenting three new cases to 57 leading diabetologists who suggested glycemic targets that were similar to those calculated by the algorithm validated it.

CONCLUSIONS The resultant suggested algorithm is an additional decision-making tool offered to the clinician to supplement clinical decision-making when considering a glycemic target for the individual patient with diabetes.

COMMENT: An interesting exercise that may be useful in helping clinicians weigh various clinical factors in determining the glycemic goals for individual patients.


Coke’s Chief Scientist, Who Orchestrated Obesity Research, Is Leaving

Posted in Diabetes at Wed, 25 Nov 2015 20:08:17


Posts: 792
Joined: 15 Apr 2011


Coca-Cola’s top scientist is stepping down after revelations that the beverage giant initiated a strategy of funding scientific research that played down the role of Coke products in the spread of obesity.

Rhona S. Applebaum, Coke’s chief science and health officer, helped orchestrate the establishment of a nonprofit group known as the Global Energy Balance Network. The group’s members were university scientists who encouraged the public to focus on exercise and worry less about how calories from food and beverages contribute to obesity.

Coca-Cola spent $1.5 million last year to support the group, including a $1 million grant to the University of Colorado medical school, where the nonprofit group’s president, James O. Hill, a prominent obesity researcher, is a professor.

Coke’s financial ties to the group were first reported in an article in The New York Times in August, which prompted criticism that the soft drink giant was trying to influence scientific research on sugary drinks.

The university returned the money to Coca-Cola this month after public health experts raised concerns.

Dr. Applebaum, a food scientist with a Ph.D. in microbiology, had been Coke’s chief scientific and regulatory officer since 2004. In that role she helped lead the company’s efforts to work with scientists as a way to counter criticism about sugary drinks.

At one food industry conference in 2012, Dr. Applebaum gave a talk outlining Coca-Cola’s strategy of “cultivating relationships” with top scientists as a way to “balance the debate” about soft drinks.

A spokeswoman for Coca-Cola said on Tuesday that Dr. Applebaum, 61, had made the decision to retire in October and that her retirement “has been accepted and the transition is underway.” The company declined a request for an interview with Dr. Applebaum.

Coca-Cola has said that while it offered financial support for the Global Energy Balance Network, the company had no influence on the group or the scientific research it produced. But reports show that Dr. Applebaum and other executives at Coke helped pick the group’s leaders, create its mission statement and design its website, findings first reported this week by The Associated Press.

The A.P. also published a series of emails between Dr. Hill of the University of Colorado and Coke executives that revealed the initial strategy of the Global Energy Balance Network. Before the G.E.B.N. was created, Dr. Hill proposed publishing research that would help the company fend off criticism about its products by shifting the blame for obesity to physical inactivity

COMMENT: It’s a start.



universal screening for hypercholesterolemia in children,

Posted in Careers at Wed, 25 Nov 2015 23:38:47


Posts: 475
Joined: 29 Jul 2010

Abstract :-

During the last 50 years, it has become evident that atherosclerosis originates in childhood. Although cardiovascular disease (CVD) events are rare in children, autopsy data and imaging studies have documented subclinical disease in association with measurable risk factors during childhood. When present at a young age, risk factors track into adulthood and have been associated with a moderate to high risk of future CVD. As such, the ability to identify this vulnerable population creates the opportunity to prevent the development of risk factors and future CVD events with effective management of genetic and acquired risk factors. In 2011, the National Heart, Lung, and Blood Institute Expert Panel published comprehensive guidelines summarizing the current evidence and providing developmentally appropriate recommendations for screening, treatment, and follow-up ofchildren and adults younger than 21 years at risk for premature CVDs such as myocardial infarction and stroke. In addition to screening individuals with a family history of hypercholesterolemia and/or premature CVD, the Expert Panel recommended universal screening of all children between 9 and 11 years of age and then again between 17 and 21 years of age. Although the recommendation for universal screening, regardless of general health or the presence/absence of risk factors of CVD, is not without controversy, this review serves to create awareness among healthcare providers, elected officials, and the lay public about the burden of CVD, the opportunity for prevention, and the benefits of early and effective therapeutic intervention with lifestyle changes and lipid-lowering medications.

  Ref:-       2015 Jan;108(1):7-14. doi: 10.14423/SMJ.0000000000000219.

According to my searches openions are controversial, some authers found that both screening and early intervention in the pediatric population will identify individuals not previously recognized at risk of premature  coronary artery disease and stroke and reduce the incidence of later morbidity and mortality

Opponents of universal screening believe that there is no adequate evidence to show that interventions based on abnormal lipid screening results in youth will be more effacious than interventions later in the disease process

Reimbursing patients for financial loss

Posted in News & media at Sat, 28 Nov 2015 23:07:00


Posts: 27
Joined: 04 May 2015
PULSE posed this question last week which I thought was quite interesting:
'One of my GP partners arranged a prescription for an antibiotic to treat an ongoing UTI. He later realised that he had misread the MSU sensitivities, and the infection was resistant to that antibiotic. By then, the patient had had the item dispensed, and she asked if the practice would reimburse her the wasted prescription fee. How should we respond?'
Varying views were received on the rapid responses. Inconvenience and financial loss can work both ways!