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Poll archive

Posted in doc2doc feedback at Mon, 21 Jul 2014 12:58:34

AnneG

Posts: 301
Joined: 18 Mar 2014

I love the new poll feature, its a great way to see what everyone thinks on some of these issues. What do people think of creating a page with all the previous poll results on?

Would you order an unnecessary test/procedure if a patient insisted on it?

Posted in General clinical at Sun, 20 Jul 2014 11:07:21

bjf

Posts: 83
Joined: 12 Feb 2013

A feature in this week's BMJ looks at the Choosing Wisely campaign - a movement that was founded in the United States by the American Board of Internal Medicine (ABIM) to urge doctors to stop carrying out  unnecessary, wasteful and potentially harmful tests and procedures.

The campaign has come up with lists of common procedures which it believes are over used. The list includes: 

  • Imaging for low back pain
  • Imaging for headaches
  • Antibiotics for upper respiratory tract infections
  • Preoperative testing in low-risk patients
  • Antipsychotics in older patients
  • Artifical nutrition in patients with advanced dementia or cancer

The feature quotes a statistic from a survey by the ABIM Foundation which found that 53% of doctors would order an unnecessary test or procedure if a patient insisted on it.

Doctors said that they would order the test to avoid a malpractice suit, to be safe, for reassurance or to keep the patient happy. 

Why are there fewer female academics?

Posted in General clinical at Mon, 21 Jul 2014 13:06:08

sken

Posts: 633
Joined: 13 Oct 2009
A recent story in BMJ Careers highlights that women are under-represented in medical academics. 
 
Do you think that Sally Davies and Jonathan Grant are right to be concerned about the number of women in academia?  Is it fair to assume that some medical areas will be under-researched because of a lack of women in academia.
 
Jane Dacre also makes the interesting point that medical school selection panels may be unconsciously biased against women. I wonder if any of the Doc2Doc community had experienced this first hand? 

The Indignity of Death

Posted in Medical ethics at Tue, 22 Jul 2014 23:18:49

MHMQ786

Posts: 3
Joined: 09 Jun 2013

 

The Indignity of Death

(The reflections of a fourth-year medical student on a medical elective abroad)

 

That moment is fearsome;

When the body trembles under the weight of death.

The eyes fix, the pupils dilate.

These Doctors have seen it before,

More frequently than they can recall.

 

This is the departure of the soul.

 

A flight with an unpredictable take-off.

It can start with red herrings;

Something so simple, like no air.

And when you notice the drowning:

The swimming in and out of consciousness,

The training kicks in.

The reflexive actions occur with little thought.

 

They try to preserve it,

To stop the soul from leaking away.

Sometimes it works, but this time it does not.

 

She dies on that narrow metal trolley.

 

Her cut-up dress baring the bruises on her chest –

The remnants of chest compressions.

Her face is slack, turning blue and dulled.

 

The team step back with a sigh.

Whether it is relief or resignation, it is hard to tell.

Then they watch and wait;

Waiting for the flat line to mark the finality of death.

 

She is alone,

In a cold, clinical place of healing.

Yet it failed to heal in this instance.

It is pitiful – her loneliness, her nakedness.

 

The paperwork is filled, the red tape adhered to.

Her husband is then told of her departure.

His wizened face is emotionless –

Perhaps he, too, has become accustomed to death like these Doctors.

 

But for me, it is beyond tragic.

This lonely, undignified death scares me.

I never want to lose this fear.

 

I never want death to become an insignificant part of life.

 

I stand in my corner and pray for her soul,

And pray for mine too,

As they take the shell of my fellow human away.

-----


Question for current Doctors: do you ever really get used to death? Does it stop affecting you or is that just a professional facade we all must hide behind?

Ownership of drugs

Posted in News & media at Mon, 21 Jul 2014 11:17:57

rcdeacon

Posts: 142
Joined: 21 Aug 2011

Really one for kirked. For years we used to tell patients that ward staff had no legal right to confiscate a patient's drugs with a view to destroying them , although it was common practice and ther some strong safety arguments behind the practice.

The problem now emerging is what happens to the drugs when the patient dies. Presumably the family can inherit ownership , however inadvisable medically. Is the concept of legal ownership for the lifetime of the person for whom the drugs were prescribed ? Are there certain drugs where the possession would be illegal?

I can give a couple of concrete examples. Firstly , one well-known newspaper columnist commented that after her mother's distressing death she kept many/most of her mother's drugs as an insurance policy for when she herself became terminally ill. Surely if these included opiates , there should have been adequate checks to cover the amount remaining and continued possession would have been illegal? But what about the Distalgaesic ?  The latter is much readily available now but one reason for its near withdrawal was that it seemed to be more effective for ending life than simple paracetamol - and this has been borne out by subsequent experience.

The second example is that of someone who obtains barbiturates via the internet - the legal problem with that is one of possession . The medical problem is that of keeping a medicine in the frig for years , particularly one in solution. Not just that it may "go off" but that it is not a very secure place as regards others.

I think one of the knock on effects of the  discussion around assisted dying ( which I happen to support for the terminally ill) , there are folk out there who have anxieties about what may happen to them  and I have concerns about folk storing medicines of this type. But what else can they do if doctors are not prepared to engage them in a dialogue - I heard a cancer specialist last night saying he had never been asked to shorten someone's life. Must have a hearing problem ?

Should minimum staffing levels for doctors be introduced?

Posted in General at Mon, 21 Jul 2014 19:10:13

ynnek

Posts: 1
Joined: 21 Jul 2014

The National Institute for Health and Clinical Excellence has published new staffing guidance for nurses which sets out "red flag" events which may indicate when staffing levels are unsafe. The events include patients not being provided with basic care such as pain relief or help going to the bathroom.

The guidance does not set out any specific ratios but said that if a single nurse was caring for more than eight patients it might be a signal that safe care could not be provided. 

At their annual conference in May junior doctors called for doctor numbers to be increased to 3.3 per 1000 population, to meet the Organisation for Economic Cooperation and Development average, and for minimum doctor staffing levels to be introduced in UK hospitals. According to data from the World Bank the UK currently has 2.8 doctors per 1000 people compared to 3.8 in Germany, 3.7 in Spain and 3.2 in France. 

What do you think? Should miminum staffing levels be introduced?

Is there a link between negative media coverage and patient complaints?

Posted in General clinical at Tue, 22 Jul 2014 18:24:52

Poltor

Posts: 220
Joined: 29 May 2013

A report by Plymouth University, commissioned by the General Medical Council, has looked into why the number of complaints against doctors has risen, from 5,168 complaints in 2007 to 10,347 in 2012.

The report does not find one single cause for the increase but it said that negative press coverage of doctors could be "chipping away" at their reputation resulting in more people making "me too" complaints to the GMC. It says the "sustained diet of negative coverage, conforming to a few stereotyped models, may feed the increase in complaints by contributing to a highly critical backdrop against which medical consultations are now experienced."

The report also points to social media as providing an outlet for people to discuss their complaints about doctors and "more access to information about how to seek redress." Other factors may include the higher public profile of the GMC and a less deferential attitude of patients towards doctors. 

What do you think?

final nice guidance on statins released

Posted in Cardiology at Wed, 23 Jul 2014 22:08:03

Dr. K. Ashutosh

Posts: 3207
Joined: 27 Mar 2012

we have discussed the draft nice guidance on statins before that suggests reducing (potentially) the threshold for statin prescription to a 10% 10 year CV risk (currently 20% 10 year risk).

The final guideline is just published

http://www.bmj.com/content/349/bmj.g4694

and sticks with this threshold giving an estimated number needed to treat of 77 people to avoid one death/stroke/non-fatal MI after 3 years.

What do you think?

sadian

 

Should HIV-negative gay men take antiretrovirals?

Posted in General clinical at Sun, 20 Jul 2014 11:32:19

sken

Posts: 633
Joined: 13 Oct 2009

The World Health Organization has recently changed its guidelines, saying that men who have sex with men and are HIV negative should consider taking antitretroviral drugs alongside the usual HIV prevention measures. 

The change has come because, despite big strides in tackling AIDS and HIV over recent years, vulnerable groups, such as gay men and sex workers, are falling behind. The IpRex study found that taking a daily pill reduced the rate of new HIV infections by 44%. There has been concern previously that people taking a pill would be more likely to engage in risky behaviour, that is having multiple partners and ignoring safe sex practices. However, the IpRex study found that this was not the case.

The PROUD study, conducted in the UK, is also looking at what impact a daily pill has on infection rates. 

Abnormal ECG?

Posted in Cardiology at Thu, 24 Jul 2014 14:14:59

AnneG

Posts: 301
Joined: 18 Mar 2014

Hi all,

 

Sorry to bother you, I'm not a doctor but work in Healthcare... Anyway cutting the story short our new Obs Machines come with 3 Lead ECG...

So keen to practise to learn how to use the equipment we had a practise on each other... One of the ECG's I have enclosed as a weblink to the photo,

 

It shows a little notch I've not seen before (3 lead of person in 20's with no known cardiac history)

http://i1368.photobucket.com/albums/ag165/dgurd025/Mobile%20Uploads/image_zps4434a256.jpg

any idea how serious?

 

thanks

Yes, Cheetos, Funnel Cake, and Domino's Are Approved School Lunch Items

Posted in Diabetes at Thu, 24 Jul 2014 12:00:35

sken

Posts: 633
Joined: 13 Oct 2009

Yes, Cheetos, Funnel Cake, and Domino's Are Approved School Lunch Items

http://www.motherjones.com/environment/2014/07/school-lunch-conference-cheetos

I thought that I would post this to show what we are up against.

At exactly 10 a.m. on Monday, hundreds of school cafeteria professionals ran hooting and clapping down an escalator into an exhibition hall that looked like a cross between a mall food court and the set of Barney. Pharrell blared over loudspeakers. The Pillsbury Doughboy was on hand for photo ops, as was Chester the Cheetah (the Cheetos mascot) and a dancing corn dog on a stick. Attendees queued up to be contestants in a quiz show called "Do You Eat Smarter Than a Fifth-Grader?" and flocked toward trays groaning with every kind of kid food one could imagine: tater tots, PB&Js with crusts preremoved, toaster waffles with built-in syrup, and endless variations on the theme of breaded poultry: chicken tenders, chicken bites, chicken rings, chicken patties, and, of course, chicken nuggets.

The conference's sponsors include PepsiCo and Domino's.

I was at the annual conference of the School Nutrition Association (SNA), the professional group that represents the nation's 55,000 school food workers, and the biggest draw of the event—the exhibition hall—had just opened for business. More than 400 vendors vied for the attention of the conference's 6,500 attendees, who had descended on the Boston Convention and Exhibition Center with one main goal: to find new foods to serve at their schools.

Many of the vendors were household names: Sara Lee, Kraft, Perdue, Uno, and Pizza Hut, to name a few. Among the corporate sponsors who collectively put up about $200,000 to help stage the affair were Domino's Pizza, PepsiCo, Tyson, General Mills, and AdvancePierre Foods, which bills itself as "the No. 1 provider of fully-cooked protein and assembled sandwiches to school systems across the country."

To be sure, you won't find most of the items on exhibit in supermarkets or restaurants. That's because they are specially made to conform to the new federal school nutrition standards, some of which took effect July 1. There are fruit and vegetable requirements; limits on calories, sodium, and saturated fats; and a mandate that all grain foods served at school must be at least 51 percent whole grain.*  The rules—which I'll cover in more detail in a subsequent post—are contentious, and the SNA opposes some of them. Politico's Helena Bottemiller Evich reported that after first lady Michelle Obama spoke out in favor of the rules, organizers told the White House that its senior adviser for nutrition policy, Sam Kass, would not be allowed to speak at the conference.

Politics aside, the vendors were armed with newly formulated products designed to conform to the rules. At the Kraft booth, a rep gushed about the virtues of the company's new flavored cream cheeses, available in milk chocolate, dark chocolate, and caramel, "with half the calories of Nutella." She told me they were designed as dips for fruits with the new produce rule in mind. "Nowadays, it's the only way to get kids to eat anything that's good for them," she said.

Indeed, the exhibitors' guiding principle seemed to be something like: "Whatever you do, don't tell them it's healthy." I watched as a Sara Lee rep promised a cafeteria director from Louisiana that her students wouldn't be able to detect the whole-grain flour in her company's chocolate muffin. The PepsiCo booth stocked a flyer (below) informing attendees that newly formulated Cheetos fit with the guidelines. When I sampled a vitamin-fortified, low-cal Slush Puppy, the rep asked me, "Doesn't that taste just as good as a regular slushy?" (It didn't.) A food service company rep promised me that his funnel cake was "plenty sweet," even though it fit within the calorie limits. (It was.)

While the exhibitors were eager to show off their products' nutritional stats, few offered actual ingredients lists. When I asked the rep at the Uno pizza booth why ingredients weren't included on his nutrition information sheet, he told me the list wouldn't fit on the page.

One ingredient in Domino's school lunch pizza was silicone dioxide, otherwise known as sand.

"Don't the school nutritionists ask you what's in this?" I asked. Nope, he said. Most of them just wanted to know whether the product met the legal guidelines. He offered to email me the list later. When he did, I learned that Uno's Whole Grain Low Sodium Sweet Potato Crust Pepperoni Pizza contained nearly 50 ingredients, including sodium nitrite, which has been linked to cancer. I also persuaded the Domino's rep to email me a list of ingredients in his company's specially formulated school pizza, SmartSlice. It was also nearly 50 items long, and included silicone dioxide, otherwise known as sand.

After wandering through most of the 180,000 square feet of exhibits, I came across an earnest gray-haired woman in the back of the cavernous room selling frozen "pulses"—mostly lentils and chickpeas—to stir into soups and sauces. I was the only one at her booth. Had she noticed that everyone seemed drawn to the big-name foods up front? She responded that she hoped attendees would consider fortifying their name-brand meals with some of her lentils. "If you add a pulse product to a potato salad, it steps up the nutrition," she offered hopefully.

But the attendees would have to find her first, and that would be a tall order: Corporations such as PepsiCo and General Mills had rented out multiple exhibit spaces ($2,400 to $2,600 a pop) in the high-traffic front and central aisles of the exhibit floor. Some big booths even had café-style seating areas where attendees chatted as they gobbled up samples. "You have to go in the far corners to find the more interesting stuff," says Steve Marinelli, who runs the food program for a rural Vermont school district and told me he was having trouble locating the wholesome foods he wanted. "Someone was selling this really cool hummus, but you really had to look hard to find it."

The lentil lady didn't stand a chance.

 

Can a minimalist educational intervention reduce cardiovascular events in persons at risk?

Posted in Diabetes at Tue, 22 Jul 2014 13:39:33

Maxim

Posts: 143
Joined: 14 Dec 2010

Participation in a Lifestyle Change Program Is Associated with Reduced Incidence of Cardiovascular Disease in a Large National Health Care System

ADA Scientific Sessions 2014

Lifestyle change programs can reduce weight and cardiovascular disease (CVD) risk factors, but there is little understanding of their impact on CVD in real world settings. The VA is the largest integrated healthcare system in the US, and its MOVE! program has had over 400,000 participants since 2005. We used national VA databases to identify patients eligible for MOVE, and we defined baseline as first MOVE visit for participants or first visit with a weight recorded after Jan 1, 2005 for nonparticipants. 1,394,322 eligible patients without CVD at baseline were identified, among whom 152,863 (11%) were participants. Patients were 92% male and 76% white, mean age 52 years and BMI 32. Participants decreased weight by -0.9% and -0.6% at 12 months and 3 years, while nonparticipants increased weight by 0.2% and 0.7% (each p<0.001). Incident CVD was identified with ICD-9 and procedure codes for coronary artery disease, CAD, cerebrovascular disease, CBD, peripheral vascular disease, PVD, and heart failure, HF. In multivariable Cox proportional hazards models adjusting for demographic and clinical factors including age, race, gender, BMI, and baseline comorbidities such as diabetes, MOVE participation was associated with lower incidence of total CVD (hazard ratio 0.83, 95% CI 0.77-0.89), as well as CAD (HR 0.84, 0.77-0.90), CBD (HR 0.81, 0.72-0.91), and HF (HR 0.77, 0.72-0.82), but not PVD (HR 0.94, 0.83-1.06). In 512,268 patients with available data, the association with CVD was attenuated, but not eliminated, after further adjustment for systolic blood pressure, HDL cholesterol, non-HDL cholesterol, and random plasma glucose (HR 0.88, 95% CI 0.80-0.96). Conclusions: The VA’s MOVE program demonstrates that lifestyle change can be achieved in a large scale healthcare setting - a model strategy for combating obesity and chronic disease nationally - and participation is associated with reduced development of cardiovascular disease.

COMMENT:  Again this is an abstract to be taken with caution.  Nevertheless, it is one of a very few studies looking at the effectiveness of large-scale, minimal interventions.  We are talking about a program that consists primarily of baseline and follow up measurements of cardiovascular risk factors and a series of ten lectures.  It is encouraging indeed to see how effective it was.

Examining the morbidly obese abdomen; plumbing the depths

Posted in General clinical at Tue, 22 Jul 2014 11:00:03

sken

Posts: 633
Joined: 13 Oct 2009

I often see obese and morbidly obese patients and wonder should I examine their abdomens as I usually do a full physical examination at the first visit, being a specialist physician.  Indeed I often order abdominal ultrasounds in these folk for this and other reasons as I think it is so easy to miss an abnormality.

Which brings me to the point;

1. Is there any point examining the abdomen in a morbidly obese patient?

2. If you do an abdominal ultrasound, does physicial examination add anything?

My own opinion is that you can find things on examination which may not be apparent on an ultrasound and this examination can direct the ultrasonographer to areas of interest. The ultrasonographer here is usually not a radiologist but the radiologist can be called in to look at areas of interest and check the result. 

Odysseus

Efficacy and Safety of Dulaglutide Added Onto Pioglitazone and Metformin Versus Exenatide in Type 2 Diabetes

Posted in Diabetes at Sun, 20 Jul 2014 19:07:12

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Efficacy and Safety of Dulaglutide Added Onto Pioglitazone and Metformin Versus Exenatide in Type 2 Diabetes in a Randomized Controlled Trial (AWARD-1). Diabetes Care. 2014 May 30.

OBJECTIVE: To compare the efficacy and safety of dulaglutide, a once weekly GLP-1 receptor agonist, with placebo and exenatide in type 2 diabetic patients. The primary objective was to determine superiority of dulaglutide 1.5 mg versus placebo in HbA1c change at 26 weeks.

RESEARCH DESIGN AND METHODS: This 52-week, multicenter, parallel-arm study (primary end point: 26 weeks) randomized patients (2:2:2:1) to dulaglutide 1.5 mg, dulaglutide 0.75 mg, exenatide 10 mug, or placebo (placebo-controlled period: 26 weeks). Patients were treated with metformin (1,500-3,000 mg) and pioglitazone (30-45 mg). Mean baseline HbA1c was 8.1% (65 mmol/mol).

RESULTS: Least squares mean +/- SE HbA1c change from baseline to the primary end point was -1.51 +/- 0.06% (-16.5 +/- 0.7 mmol/mol) for dulaglutide 1.5 mg, -1.30 +/- 0.06% (-14.2 +/- 0.7 mmol/mol) for dulaglutide 0.75 mg, -0.99 +/- 0.06% (-10.8 +/- 0.7 mmol/mol) for exenatide, and -0.46 +/- 0.08% (-5.0 +/- 0.9 mmol/mol) for placebo. Both dulaglutide doses were superior to placebo at 26 weeks (both adjusted one-sided P < 0.001) and exenatide at 26 and 52 weeks (both adjusted one-sided P < 0.001). Greater percentages of patients reached HbA1c targets with dulaglutide 1.5 mg and 0.75 mg than with placebo and exenatide (all P < 0.001). At 26 and 52 weeks, total hypoglycemia incidence was lower in patients receiving dulaglutide 1.5 mg than in those receiving exenatide; no dulaglutide-treated patients reported severe hypoglycemia. The most common gastrointestinal adverse events for dulaglutide were nausea, vomiting, and diarrhea. Events were mostly mild to moderate and transient.

CONCLUSIONS: Both once-weekly dulaglutide doses demonstrated superior glycemic control versus placebo and exenatide with an acceptable tolerability and safety profile.

COMMENTS: Dulaglutide is a promising new GLP-1 receptor agonist that can be given weekly.  The data presented suggest that it is more effective than the formulation of exenatide used in this study.  The study did not examine the comparative effectiveness of dulaglutide versus the long acting exenatide formulation, Bydureon.

What's your favourite holiday destination?

Posted in General at Thu, 24 Jul 2014 14:07:50

DuaneF

Posts: 1428
Joined: 09 Dec 2011

I'm off on my holidays soon (Italy since you were asking...) so my impending trip (and the amazing weather we're having here in the UK) has got me thinking about favourite destinations: both places you've been and like to have been.

Here are the top places I've visited

1. Zanzibar - I spent a few days on this island paradise about 14 years ago and would love to go back. The sea was clear, the sand was pure white and we found a fabulous beach bar.... Happy memories! The capital, Stonetown, is also really interesting and has a fabulous night-time fish market. 

2. The Lake District - breathtaking and unspoilt. Wonderful views.

3. Corsica - we had our honeymoon here so it gets a special mention!

4. Dumfries and Galloway - like Cornwall but with a fraction of the visitors

5. Laos - waterfalls, temples, great food and people.

6. Ile de Re, France - I've spent a few lovely holidays here with my family

Places I would like to go:

1. Canada - I fancy kayaking in the lakes

2. Norway - I'm not sure I would enjoy the herring but I like the idea of white nights in the summer 

3. Greek islands - particularly Santorini

4. Australia - just because I've never been

5. Brazil - the World Cup whetted my appetite! 

 

So doc2doc-ers - what are your top holiday destinations/memories?

Should we be considering a new primary care paradigm for the care of people with chronic diseases?

Posted in Diabetes at Mon, 21 Jul 2014 22:49:53

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Effects of Nurse-Managed Protocols in the Outpatient Management of Adults With Chronic Conditions: A Systematic Review and Meta-analysis

Ann Intern Med. 2014;161(2):113-121. doi:10.7326/M13-2567

Abstract

Background: Changes in federal health policy are providing more access to medical care for persons with chronic disease. Providing quality care may require a team approach, which the American College of Physicians calls the “medical home.” One new model may involve nurse-managed protocols.

Purpose: To determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia.

Data Sources: MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL from January 1980 through January 2014.

Study Selection: Two reviewers used eligibility criteria to assess all titles, abstracts, and full texts and resolved disagreements by discussion or by consulting a third reviewer.

Data Extraction: One reviewer did data abstractions and quality assessments, which were confirmed by a second reviewer.

Data Synthesis: From 2954 studies, 18 were included. All studies used a registered nurse or equivalent who titrated medications by following a protocol. In a meta-analysis, hemoglobin A1c level decreased by 0.4% (95% CI, 0.1% to 0.7%) (n = 8); systolic and diastolic blood pressure decreased by 3.68 mm Hg (CI, 1.05 to 6.31 mm Hg) and 1.56 mm Hg (CI, 0.36 to 2.76 mm Hg), respectively (n = 12); total cholesterol level decreased by 0.24 mmol/L (9.37 mg/dL) (CI, 0.54-mmol/L decrease to 0.05-mmol/L increase [20.77-mg/dL decrease to 2.02-mg/dL increase]) (n = 9); and low-density-lipoprotein cholesterol level decreased by 0.31 mmol/L (12.07 mg/dL) (CI, 0.73-mmol/L decrease to 0.11-mmol/L increase [28.27-mg/dL decrease to 4.13-mg/dL increase]) (n = 6).

Limitation: Studies had limited descriptions of the interventions and protocols used.

Conclusion: A team approach that uses nurse-managed protocols may have positive effects on the outpatient management of adults with chronic conditions, such as diabetes, hypertension, and hyperlipidemia.

COMMENT:  For those of us who follow the health services research literature, this is not a surprising study.  However, it comes at a time when we in the US are wringing our hands over the predicted shortfall of 65,000 primary care physicians by 2020.  So the study generates the questions should we be considering a new paradigm in chronic disease care that includes nurses?

 

Should doctors become managers?

Posted in Careers at Thu, 24 Jul 2014 14:24:09

kirked

Posts: 1548
Joined: 08 Oct 2010

A recent discussion at a UK conference highlighted the dearth of doctors in management positions. Una O'Brien, permanent secretary at the Department of Health in England, said that the UK was unusual in that very few doctors were in senior leadership positions but "interestingly in practically every other country in the world this is the norm."

One chief executive said that doctors might be put off becoming managers because pay and security is worse for managers than it is for doctors. Clinicians also tend to think that only by being involved in patient care can they "make a difference." 

However, Mark Newbold, chief executive of Heart of England NHS Foundation Trust, said: "You get to a point where there is only so many times you can sit around with other doctors, drinking coffee and criticising the way the place is being run without saying, 'Well actually maybe we should put our money where our mouth is and have a go at it.' And that's how I got into it."

Do you think the NHS would improve if more doctors were in senior managerial positions? What is the experience of overseas doctors?

Statin Use and Cognitive Decline in the Elderly

Posted in Diabetes at Sun, 20 Jul 2014 19:21:59

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Statin Use but Not Metabolic Syndrome Is Associated with Cognitive Decline in the Elderly: The Sydney Memory and Ageing Study

Program: Abstracts - Orals, Poster Preview Presentations, and Posters
Session: PP15-Lipids, Lipoproteins, Dyslipidemia & Fatty Liver Disease
Translational

Sunday, June 22, 2014: 11:15 AM-11:30 AM

W178 (McCormick Place West Building)


Poster Board SUN-0841

Katherine Samaras, MBBS, PhD, FRACP1, John D Crawford, PhD2, Elizabeth Blanchard, BMSc3, Nicole Kochan, PhD4, Julian N Trollor5, Henry Brodaty4 and Perminder Sachdev2
1Garvan Institute of Medical Research, Sydney NSW, Australia, 2University of New South Wales, Randwick, Australia, 3Garvan Institute of Medical Research, Darlinghurst, NSW, Australia, 4University of New South Wales, Kensington, Australia, 5University of New South Wales, Randwick

The cardiovascular (CV) risk factors of diabetes, hyperlipidemia and hypertension are associated with cognitive decline and are dementia risk factors. Metabolic syndrome (MS) describes clustering of these risks factors; it is unclear whether MS adversely affects cognition. Further, there is controversy whether statin use may impair cognition. We examined if Metabolic Syndrome (MS) and statin use were associated with greater cognitive decline in the elderly over 4 years.

Methods: Participants were drawn from the Sydney Memory and Aging Study, a longitudinal population-derived cohort recruited from the electoral roll (70-90 years at baseline), assessed at baseline, 2 and 4 years, as described.1 Global cognition was measured by neuropsychological testing in five domains (memory, processing speed, language, visuospatial and executive function), to form a composite normalized Z-score, as described.2 MS was defined using IDF criteria.1 Medical history and use of statin therapy and type were documented. Data on 677 participants were analyzed by repeated measure ANCOVA, with covariates (age, sex, years education, smoking, English/non-English speaking background and apolipoprotein E e4 genotype [APOEe4]).

Results:

Mean ± SD age at baseline was 78.3 ± 4.6 years, 47% males, BMI 27.1 ± 4.9 kg/m2, fasting glucose 5.6 ± 1.1 mmol/L. Baseline prevalences of MS, statin-use and diabetes were 54%, 52% and 11%, respectively.

Baseline global cognition was similar between participants with and without MS (-0.65 ± 1.3 v -0.52 ± 1.3, p=0.13). Metabolic syndrome was not associated with any greater decline in global cognition (p=0.97), nor with any domain decline score for memory, language, processing speed, visuospatial or executive function. Results were similar when subjects with diabetes were excluded.

Baseline global cognition was similar between statin-users or not (-0.58 ± 1.3 v -0.59 ± 1.3, p=0.92). Statin-use was not associated with any greater decline in global cognition over 4 years (p=0.25), however significantly greater decline in memory was observed (-0.27±0.04 v. -0.07±0.05, p=0.001). Statin-use was not associated with any greater 4-year decline in language (p=0.51), processing speed (p=0.85), visuospatial (p=0.75) or executive (p=0.96) functions. To examine whether CV risks may interact with statin-use to heighten the decline in memory, interactions were sought in models of statin use and CV or dementia risk factors (including covariates). None was found with diabetes, heart disease, stroke, smoking or APOEe4 carriage.

Conclusion: In this large cohort of community-dwelling well-elderly, statin-use was associated with greater decline in memory at 4 years, but no other cognitive domain. Metabolic syndrome was not associated with accelerated cognitive decline. The impact of metabolic risk and its treatment on cognition in the elderly requires greater interrogation.

COMMENT:  One must always be careful about drawing conclusions from an abstract.  However, this presentation at the International Congress of Endocrinology/Endocrine Society meeting has received considerable press response so I felt that it was worthwhile to post the abstract in its entirety.  It does contain considerable good news.  There was no association between cognitive decline and the metabolic syndrome.  Also the title is a bit misleading in that statin use was not associated with global cognitive decline only with an increased loss of memory function.  This, of course, is not a trivial finding, but one wonders if this is a fixed decline or just the effect of the statin, per se, that would be reversed by stopping the statins.  An important question that I hope the investigators address.

 

Can India build 5.2m toilets by the end of August?

Posted in BMJ India at Wed, 23 Jul 2014 21:48:49

Dr. K. Ashutosh

Posts: 3207
Joined: 27 Mar 2012

Earlier this month India's ministry of drinking water and sanitation said that it would build 5.2m public toilets by the end of August (yes, this August!) Some 60% of Indians practise open defecation (that's a polite way of saying that they c**p in the open) and a World Bank report said that stunting in Indian children was linked to malnourishment caused by open defecation.

It's an ambitious target but is it one that is likely to be met - and is building toilets alone enough to solve the problem of open defecation? 

Do statins have an independent effect on mortality in type 2 diabetes?

Posted in Diabetes at Mon, 21 Jul 2014 20:58:38

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Contributors to Mortality in High-Risk Diabetic Patients in the Diabetes Heart Study

Diabetes Care July 2, 2014  

Abstract

OBJECTIVE Not all individuals with type 2 diabetes and high coronary artery calcified plaque (CAC) experience the same risk for adverse outcomes. This study examined a subset of high-risk individuals based on CAC >1,000 mg (using a total mass score) and evaluated whether differences in a range of modifiable cardiovascular disease (CVD) risk factors provided further insights into risk for mortality.

RESEARCH DESIGN AND METHODS We assessed contributors to all-cause mortality among 371 European American individuals with type 2 diabetes and CAC >1,000 from the Diabetes Heart Study (DHS) after 8.2 ± 3.0 years (mean ± SD) of follow-up. Differences in known CVD risk factors, including modifiable CVD risk factors, were compared between living (n = 218) and deceased (n = 153) participants. Cox proportional hazards regression models were used to quantify risk for all-cause mortality.

RESULTS Deceased participants had a longer duration of type 2 diabetes (P = 0.02) and reduced use of cholesterol-lowering medications (P = 0.004). Adjusted analyses revealed that vascular calcified plaque scores were associated with increased risk for mortality (hazard ratio 1.31–1.63; 3.89 × 10−5 < P < 0.03). Higher HbA1c, lipids, and C-reactive protein and reduced kidney function also were associated with a 1.1- to 1.5-fold increased risk for mortality (3.45 × 10−6 < P < 0.03) after adjusting for confounding factors.

CONCLUSIONS Even in this high-risk group, vascular calcification and known CVD risk factors provide useful information for ongoing assessment. The use of cholesterol-lowering medication seemed to be protective for mortality.

COMMENT:  We have known from prior studies that the protective effect of statins is not solely attributable to their lipid lowering effect.  This intriguing study suggests that this benefit may extend to overall mortality in persons with type 2 diabetes.  the data presented suggest that we should consider a further look at the effect of statins on mortality in type 2 diabetes.

Insights into the psychosocial aspects of diabetes-the DAWN2 study

Posted in Diabetes at Sun, 20 Jul 2014 18:53:52

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Personal Accounts of the Negative and Adaptive Psychosocial Experiences of People With Diabetes in the Second Diabetes Attitudes, Wishes and Needs (DAWN2) Study

Diabetes Care June 27, 201

Abstract

OBJECTIVE The authors wished to identify the psychosocial experiences of diabetes both negative accounts of diabetes and positive, adaptive ways of coping from the perspective of the person with diabetes.

RESEARCH DESIGN AND METHODS The participants were 8,596 adults (1,368 with type 1 diabetes and 7,228 with type 2 diabetes) in the second Diabetes Attitudes, Wishes and Needs (DAWN2) study. Initially qualitative data were responses to open-ended survey questions about successes, challenges, and wishes for improvement in living with diabetes and about important experiences. Emergent coding was developed with multinational collaborators that identified thematic content about psychosocial aspects. The κ measure of inter-rater reliability was 0.72.

RESULTS Analysis identified two negative psychosocial themes: 1) anxiety/fear, worry about hypoglycemia and complications of diabetes, depression, and negative moods/hopelessness and 2) discrimination at work and public misunderstanding about diabetes. Two psychosocial themes demonstrated adaptive ways of coping with diabetes: 1) having a positive outlook and sense of resilience in the midst of having diabetes and 2) receiving psychosocial support through caring and compassionate family, friends, health care professionals, and other people with diabetes.

CONCLUSIONS The personal accounts give insight into the psychosocial experiences and coping strategies of people with diabetes and can inform efforts to meet those needs and capitalize on strengths.

COMMENT:  The DAWN investigators continue to add important and useful insights into our understanding of the psychosocial aspects of having diabetes and patient coping mechanisms.  This information is useful for both educators and clinicians as they deal with this complex illness.  An understanding of these complex emotions and coping mechanisms is essential for the development of successful long-term strategies to help people with diabetes cope with the disease.

 

Are we attributing too many side effects to statin use?

Posted in Diabetes at Mon, 21 Jul 2014 20:43:18

diabetesMD

Posts: 664
Joined: 15 Apr 2011

What proportion of symptomatic side effects in patients taking statins are genuinely caused by the drug? Systematic review of randomized placebo-controlled trials to aid individual patient choice.

Eur J Prev Cardiol. 2014 Apr;21(4):464-74. doi: 10.1177/2047487314525531. Epub 2014 Mar 12. (Review)

OBJECTIVE: Discussions about statin efficacy in cardiovascular prevention are always based on data from blinded randomized controlled trials (RCTs) comparing statin to placebo; however, discussion of side effects is not. Clinicians often assume symptoms occurring with statins are caused by statins, encouraging discontinuation. We test this assumption and calculate an evidence-based estimate of the probability of a symptom being genuinely attributable to the statin itself.

METHODS: We identified RCTs comparing statin to placebo for cardiovascular prevention that reported side effects separately in the two arms.

RESULTS: Among 14 primary prevention trials (46,262 participants), statin therapy increased diabetes by absolute risk of 0.5% (95% CI 0.1-1%, p = 0.012), meanwhile reducing death by a similar extent: -0.5% (-0.9 to -0.2%, p = 0.003). In the 15 secondary prevention RCTs (37,618 participants), statins decreased death by 1.4% (-2.1 to -0.7%, p < 0.001). There were no other statin-attributable symptoms, although asymptomatic liver transaminase elevation was 0.4% more frequent with statins across all trials. Serious adverse events and withdrawals were similar in both arms.

CONCLUSIONS: Only a small minority of symptoms reported on statins are genuinely due to the statins: almost all would occur just as frequently on placebo. Only development of new-onset diabetes mellitus was significantly higher on statins than placebo; nevertheless only 1 in 5 of new cases were actually caused by statins. Higher statin doses produce a detectable effect, but even still the proportion attributable to statins is variable: for asymptomatic liver enzyme elevation, the majority are attributable to the higher dose; in contrast for muscle aches, the majority are not.

COMMENT: This is an interesting paper that postulates that many, if not most, of the symptoms that patients and their physicians attribute to statin administration occur as frequently in the placebo groups in controlled clinical trials.  It raises the question of whether or not we are depriving people of the potential benefit of statins by attributing minor musculoskeletal symptoms to the drugs.

 

Incretin-based drugs do not appear to cause pancreatitis

Posted in Diabetes at Mon, 21 Jul 2014 20:32:50

diabetesMD

Posts: 664
Joined: 15 Apr 2011

Incretin Based Drugs and Risk of Acute Pancreatitis in Patients With Type 2 Diabetes: Cohort Study

Abstract

Objectives. To determine whether the use of incretin based drugs, compared with sulfonylureas, is associated with an increased risk of acute pancreatitis.

Design. Population based cohort study.

Setting. 680 general practices in the United Kingdom contributing to the Clinical Practice Research Datalink.

Participants. From 1 January 2007 to 31 March 2012, 20,748 new users of incretin based drugs were compared with 51,712 users of sulfonylureas and followed up until 31 March 2013.

Main Outcome Measures. Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals for acute pancreatitis in users of incretin based drugs compared with users of sulfonylureas. Models were adjusted for tenths of high dimensional propensity score (hdPS).

Results. The crude incidence rate for acute pancreatitis was 1.45 per 1000 patients per year (95% confidence interval 0.99 to 2.11) for incretin based drug users and 1.47 (1.23 to 1.76) for sulfonylurea users. The rate of acute pancreatitis associated with the use of incretin based drugs was not increased (hdPS adjusted hazard ratio: 1.00, 95% confidence interval 0.59 to 1.70) relative to sulfonylurea use.

Conclusions. Compared with use of sulfonylureas, the use of incretin based drugs is not associated with an increased risk of acute pancreatitis. While this study is reassuring, it does not preclude a modest increased risk, and thus additional studies are needed to confirm these findings.

COMMENT: A nice addition to the growing body of literature that reduces concerns about pancreatitis as a complication of incretin-based drugs use.

Similarities between old age and AIDS

Posted in Medical ethics at Wed, 23 Jul 2014 09:37:30

sken

Posts: 633
Joined: 13 Oct 2009

The present view that is pushed is that old age is not a disease in itself - but perhaps we should see it in the same light as HIV infection which is not a disease in itself , but predisposes sufficiently to AIDS to be considered  as such. In some ways old age is worse than simple HIV infection - it is not preventable , is relatively untreatable and has a fairly remorseless progression to death . It is also an increasing and  major threat to the community not yet suffering. 

As with AIDS there is an increasing emphasis among those at risk to make some preparation for how they would like to be treated when the later stages emerge , eg advance decisions etc... Amongst those of us who are ageing discussions emerge which the medical profession seems unwilling or unable to handle.

Should trainee doctors be allowed to opt out of the European working time directive?

Posted in General clinical at Thu, 24 Jul 2014 12:57:08

AnneG

Posts: 301
Joined: 18 Mar 2014

The government has said that it wants to encourage more junior doctors to opt out of the European working time directive which states that trainees can work for a maximum of 48 hours a week.

A taskforce reported in April that the directive had had an adverse effect on training in some specialties, particularly in acute medicine and surgery. It said that doctors were working unpaid to ensure that they had sufficient access to training. 

Mark Porter, chairman of BMA Council, said: "Having the right degree of flexibility in the system is important, but we must not create a culture in which doctors feel presured into opting out of the 48-hour weekly limit that protects patients."