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The most viewed discussions on doc2doc this month

Charging drunks at A&E

Posted in News & media at Sat, 23 Aug 2014 08:19:13

sken

Posts: 688
Joined: 13 Oct 2009

Northern Ireland's health minister Edwin Poots has mooted the possibility of charging A&E patients who turn up drunk or high on drugs. 

Between April to June this year the 12-hour A&E waiting time target was missed more than 700 times. Responding to this, Poots said: "The United Kingdom has a great prinicple of healthcare, free at the point of need to all who need it, irrespective of their ability to pay for it.

"I think it is a wonderful prinicple but I think on occasions it is absued and we sometimes need to look at how we can make sure that abuse doesn't take place," he said. 

What do you think? Thin end of the wedge or sensible idea? 

 

Should I have commercial rights in my own body?

Posted in Medicolegal at Mon, 25 Aug 2014 09:01:04

rcdeacon

Posts: 149
Joined: 21 Aug 2011
Last month a Canadian Court ruled (as a preliminary matter and not the actual issue of the case in question) that human tissue removed from the body for diagnostic medical tests is 'personal property' that belongs to the hospital where the procedure was performed. This decision may have important legal ramifications that affect the biotech industry and genetic research community outside of Canada.
 
The question who owns my body, or parts of my body? has long been a matter of much discussion and debate and courts have steered clear of deciding personal ownership because of (principally) its likely commercial implications. One of the best examples of using specimens from patients commercially is of course the Henrietta Lack story.
 
HeLa is a human epithelial adenocarcinoma cell line that was derived from biopsy specimens of a 31-year old patient named Henrietta Lacks who was being treated for cervical cancer at The Johns Hopkins University Hospital in 1951. The specimens were obtained without her knowledge or consent. HeLa cells were the first human cells to be stably cultured for research and are the world’s most commonly used human cells.
 
In spring 2013, a research team in Germany posted the full genome sequence of a HeLa cell line in a public database. The posting of the data triggered strong reactions from many, but most importantly from the Lacks family. The data were removed from public view. At the same time, a second HeLa genome sequence paper was under consideration for publication. In response, the NIH worked with the Lacks family to establish a process to make HeLa cell whole genome sequencing data available for biomedical research. NIH-funded researchers who sequence HeLa cell lines will be expected to deposit their data into NIH’s database of Genotypes and Phenotypes (dbGaP) and requests for access to the data will be subject to a special review and approval process involving the HeLa Genome Data Access Working Group of the Advisory Committee to the Director.
 
Since Henrietta's cells were taken in 1951 they have been massively used throughout the world for numerous medical reasons - probably most significantly in developing the Salk vaccine. The companies utilising the cell line have made billions of dollars commercially but her descendants have (as yet not received any financial recompense).
 
The Law and ethics of ownership of my body or anything taken from it requires setting down clearly and coherently but I am just asking a rather simplistic question at first which I hope will stimulate a good discussion.
 

Should doctors be forced to apologise to patients when they get things wrong?

Posted in News & media at Mon, 25 Aug 2014 10:09:14

John D

Posts: 3170
Joined: 01 Feb 2010

The BBC reports that the General Medical Council is considering forcing doctors to apologise to patients if they have made a mistake.

The GMC's chief executive, Niall Dickson, told the BBC: "If we are to maintain that trust [between doctor and patient], in the small number of serious cases where doctors fail to listen to concerns they should be held to account for their actions."

The GMC has also said that doctors who fail to raise concerns about another colleague's performance should also face tougher sanctions.

Is forcing someone to say "sorry" the right way to go about things? I know when I ask my chldren to apologise to each other for some slight it never sounds terribly sincere and I'm not sure if makes the injured party feel any better. A doctor who is sincere in their contrition would surely have voiced it without any coercion.

Exciting opportunity for a cardiologist on doc2doc

Posted in Cardiology at Wed, 27 Aug 2014 17:43:04

bright09

Posts: 4
Joined: 05 May 2014

Doc2doc is looking for a cardiology clinical champion. The role involves posting ideas and content onto the relevant doc2doc discussion forums, answering clinical questions and signposting tools and studies that would be useful to primary and secondary care clinicians.

The ideal candidate should have a strong cardiology background - senior trainee or higher - and be an enthusiastic user of social media and networks. The role is a good way of learning more about the work of journals, as well as keeping on top of developments in your field.

The role attracts a small honorarium and would take up no more than one to two hours per week.

To apply please send a CV and covering letter detailing how you would develop the role, giving three examples of relevant clinical discussions that you would post on the site. 

For more information and to apply please email: agulland@bmj.com

Does it matter if hospitals raise as much money as possible from private patients?

Posted in General clinical at Sun, 24 Aug 2014 16:15:59

yoram chaiter

Posts: 2057
Joined: 03 Mar 2009

A news story in the Guardian reports that private patient income has increased by up to 40% since the Coalition goverment lifted the cap on the number of private patients hospitals can treat. Under the Health and Social Care Act hospitals can now raise up to 49% of income from private patients. 

According to the news story University College Hospital Trust's private patient income has gone from £7.3m in 2010-11 to £10.3m in 2013-14; the Royal Brompton's income increased from £24.3m to £33.6m over the same period and Papworth Hospital's income went from £4.9m to £6.4m. 

If private patients are not treated at the expense of NHS patients does it matter if hospitals raise money in this way? Or will this create a two-tier NHS? The Royal Brompton - based in expensive Chelsea - is understandably a mecca for private patients but what about hospitals in less well-heeled areas? 

Man killed as e-cigarette explodes

Posted in General at Tue, 26 Aug 2014 11:32:18

Mukhtar Ali

Posts: 817
Joined: 14 Nov 2010

Since January, nine fires involving e-cigarettes have been recorded on Merseyside.

http://www.bbc.com/news/uk-england-merseyside-28701515

Should charities ditch their fighting talk?

Posted in General at Thu, 28 Aug 2014 00:43:39

Odysseus

Posts: 4110
Joined: 24 Feb 2009

BMJ columnist Margaret McCartney takes charities such as Cancer Research UK to task for their use of military metaphors when talking about disease. 

Advertisements feature phrases such as "Cancer! We're coming to get you" and "Oi! Cancer! You. Me. Outside. Now." The journalist John Diamond, who died of cancer, wrote: "My antipathy to the language of battles and fights has ... everything to do with a hatred of the sort of morality which says that only those who fight hard against their cancer survive it or deserve to survive it - the corollary being that those who lose the fight deserve to do so."

I have been taken to task on this forum for using military metaphors and have vowed to avoid it but it can be a tough trap to avoid. What do you think? Does talk of fighting a disease help patients? 

Does it matter if hospitals raise as much moneyas possible from car parking?

Posted in General clinical at Wed, 27 Aug 2014 13:32:38

sken

Posts: 688
Joined: 13 Oct 2009

The latest pre-election, crowd-pleasing wheeze from the Tories is to say that hospitals should not charge for car parking.

Anyone who has served on hospital or probably any other committees will know that it is fatal to the progress of the meeting if there is an agenda item about car parking.    Every single person will have a whole shedload to say, then to repeat, and positions are inflexible.  So I have no doubt this thread will run and run.

My view, as inflexible and repetitive as anay, is that every other car park in a city centre is payable.    Unless the hospital makes a similar charge, its car park will fill up with shoppers.  Some years ago, before my hospital made a charge, the car park was listed by the City Council for  "convenient Christmas parking"!    The only exceptions are the supermarkets, and they expect you present a till receipt to escape a charge.

Sure, hospitals could put barriers and ticket booths on the exits to ther car parks, staffed by people with their finger on the boom trigger, to charge anyone who cannot present a 'hospital ticket' of some sort.  But the Gov. isn't offereing to right this enormous wrong by funding that capital and continuing cost.      A supermarket can do so by 0.5p on the cost of a tin of beans, but that's not how health budgets work, Mr.Cameron, much as you would like it to.

But, tell us, Cousins, do you pay to park at American hospitals, the epitome of the non-state-funded health system?  

John

Are we raising a feral generation?

Posted in General at Tue, 26 Aug 2014 02:38:25

Odysseus

Posts: 4110
Joined: 24 Feb 2009

http://www.abc.net.au/news/2014-08-23/crap-australian-parents-raising-a-generation-of-spoilt-brats/5691638

As one who teaches medical students and who has grandchildren, I believe this above post has some merit. I think we are degenerating as a society and poor parenting has a lot to do with it.

What thinketh thee?

Odysseus

What is your pet hate?

Posted in General clinical at Wed, 27 Aug 2014 09:35:46

AnneG

Posts: 348
Joined: 18 Mar 2014

1. My first pet hate is patients who continue to wax lyrical as I listen to their chest. It is as if my auscultatory skills are so astute that I can continue listening for the intricate sounds of the inner chest while they continue uninterrupted. 

2. Second pet hate is patients whose phone goes off during the consultation and they don't know how to turn it off or silence it and it is hidden in a bag containing the kitchen sink.

3. Third pet hate is when I see a patient, explain all the tests and give them the forms and they then lose them all.

4. Fourth pet hate is when patients ring me from the ward about a problem without going through the nursing chain of command.

5. When visiting a patient in a hospital bed who keeps their TV blaring on.

6. Patients who come into my consultation room for a consultation with others without introducing me to them. It is a case of 20 questions. 

7. Lawyers who just want "five minutes" on the phone but it turns out to be a cross-examination about something you wrote three years ago and more complex than the Dreyfus Affair. 

I have several other pet hates possibly unique to Australian medicine and includes patients about to go on a three month cruise who expect me to charge them a fee with no out of pocket expenses (Medicare fee only). 

We probably have done this before so please foregive me if so. It is just that I have had a few today.

What is your pet hate?

Odysseus

 

"Young blood turns back time"

Posted in Medical ethics at Mon, 25 Aug 2014 09:31:35

rcdeacon

Posts: 149
Joined: 21 Aug 2011

An article under the above name appears in this weeks New Scientist (23/8/14, P.8)  http://www.newscientist.com/article/mg22329831.400-young-blood-to-be-used-in-ultimate-rejuvenation-trial.html   It reviews animal experiments that show that a plasma factor Growth Differentiation Factor 11 (GDF11)  can reverse the effects of aging.    Following up on this Prof.Tony Wyss-Coray PhD, a neurophysiologist at Stanford is to give GDF11 to some patients with Altsheimers to see if their condition is reversed.

 Why is it necessary to 'experiment' on those poor people, when a far, far bigger experiment is going on continuously?    In the Uk about 8,000 blood transfusions are given every day, donated by 1.6 million donors.  No blood is given as whole blood these days; the red cells are seperated and resuspended in a salts and sugar solution.   The plasma is either frozen and then thawed to be used as 'fresh frozen plasma' (FFP), or is seperated into many different factors for highly specific treatments.   At least 2 million donations are given in the UK every year, and the Blood Transfusion Service keeps scrupulous records of what is given to who.   Surely the patients given blood or FFP should first be investigated for signs of rejuvenenation, before we experiment on people who may be unable to give informed consent? 
 
  Have the investigators read the Helsinki Declaration recently?  Especially Paragraph 24, "For a research subject who is legally incompetent, physically or mentally incapable of giving consent or is a legally incompetent minor, the investigator must obtain informed consent from the legally authorized representative in accordance with applicable law. These groups should not be included in research unless the research is necessary to promote the health of the population represented and this research cannot instead be performed on legally competent persons."
 
John

Clinical question: What advice would you give this so-called "pre-diabetic" patient?

Posted in Diabetes at Thu, 28 Aug 2014 08:25:34

Joey Rio

Posts: 875
Joined: 13 Apr 2011
This clinical question comes from one of our diabetes specialists, Joey Rio.
 
Dr Johnstone is a happily married retired academic physician, epidemiologist and statistician, who was referred to my university diabetic and hypertension clinic. He is a 78-year-old upper middle class retired physician and was diagnosed as having pre-diabetes about four years ago. He has a 40% carotid plaque in his right common carotid artery and 25% at his left common carotid artery. He has no angina symptoms. His treadmill test was normal six months ago.
 
He has a BMI of 28. He follows a healthy diet, walks 30 to 40 min three times a week, and does muscle anaerobic exercise once a week. For the last three and a half years he had microalbuminuria but is now non-albuminuric.
 
He is on aspirin 100 mg/day, Atorvastatin 20 mg because of a previous LDL Cholesterol of 130 mg;dL which is now 85 mg/%.and Metformin 500 mg extended release by night. He complains of muscle pain and bouts of impotence.
 
He also takes amlodipine 5 mg by night only. His eGFR has been stable for the last five years at 65 ml/min.
 
Six months ago he had 24-hour arterial blood pressure monitoring which showed a mean daytime systolic BP of 139 mmHg, with a night time BP drop of 12%. Diastolic BPs were unremarkable: no patholological hypotensions or hypertensive peaks!
 
HBA1C levels have been stable at the level of 6.1% for the last four measurements. He has done no fasting glycaemias for the last three years.
 
 
 
 
 

GP's telephoning hospital to clarify referral guidelines

Posted in General clinical at Tue, 26 Aug 2014 20:22:30

Maxim

Posts: 176
Joined: 14 Dec 2010

If a GP telephoned the hospital to clarify referral guidelines of a specific patients symptoms how would the hospital feel about this?  If it is unclear from reading clinical guidelines.  This particular bit of medical knowledge is not specialist but may be not that common.

The GP could of course discuss this with a GP colleague.  But I think to get the most accurate answer would be to phone the hospital.

Any thoughts on this please? Is this done very much/ at all ?

 

Trapped lingual frenulum

Posted in General clinical at Thu, 28 Aug 2014 08:18:28

John D

Posts: 3170
Joined: 01 Feb 2010

Last weekend when attending Manchester Pride as a volunteer Doctor I saw a patient who had his lingual frenulum trapped between his lower front teeth due apparently due to the excessive ardour of his partner . Has any body come accross this before ?

I reduced this digitally after injecting lidocaine. Full function was achieved immediately . Formal follow up was not possible but the patient was advised to return if they had problems & they had not represented themself

 

Would you recommend mind mapping in your practice?

Posted in Psychiatry at Thu, 28 Aug 2014 03:18:50

Sidhom

Posts: 411
Joined: 23 Aug 2013

Mind maapping is a concept that emerged from the discipline of pop psychology that was popularised by Tony Buzan. The main theory is that it resembles the way the mind thinks!  Many people find it a helpful tool. I wonder would you recommend to your patients who suffer mild cogntive impairement, early dementia or other excutive difficulties e.g. frontal lobe syndrome, type II schizophrenia.

The Ebola Frontline

Posted in Public health at Sun, 24 Aug 2014 16:28:45

John D

Posts: 3170
Joined: 01 Feb 2010

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

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

 

The survivor

 

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

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

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

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

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

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

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

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


 

WHO urges tougher action on e-cigarettes

Posted in News & media at Wed, 27 Aug 2014 17:46:55

Robo49

Posts: 59
Joined: 02 Sep 2009

The World Health Organization has published a wide-ranging report on the burgeoning e-cigarette market, calling for e-cigarettes to be banned in enclosed public places.

It also urges restrictions on the advertising of e-cigarettes and the banning of unproven health claims about them. 

WHO also says that e-cigarettes with fruit, sweet and alcohol flavours should also be banned until "it can be proved they are not attractive to children and adolescents." 

"E-cigarettes have been marketed in almost 8000 different flavours, and there is concern they will serve as a gateway to nicotine addiction and, ultimately, smoking, particularly for young people," says WHO.

The report also found insufficient evidence to determine whether e-cigarettes help smokers give up conventional cigarettes. "Therefore, WHO currently recommends that smokers should first be encouraged to quit smoking and nicotine addiction by using a combination of already-approved treatments."

The UK government has said that it will not ban e-cigarettes in public places. What do you think? Do e-cigarettes help people give up smoking? Should they be banned in public places?

 

Russian stem cell treatment results in death

Posted in General clinical at Mon, 25 Aug 2014 20:48:47

Odysseus

Posts: 4110
Joined: 24 Feb 2009

I have seen occasional patients who naively believes that stem cell treatment will be the panacea for their ills which are not amenable to conventional medicine.

I personally don't want errant stem cells inhabiting my body unless their are of proven benefit and well behaved. 

This case demonstrates the pitfalls of this therapy or was it just bad luck?

http://www.abc.net.au/news/2014-08-25/rogue-operators-charge-thousands-ineffective-stem-cell-treatment/5695360

Odysseus

Older Adults Commonly Overscreened for Cancer

Posted in General at Sat, 23 Aug 2014 12:09:55

Mukhtar Ali

Posts: 817
Joined: 14 Nov 2010

By Kelly Young

Two studies in JAMA Internal Medicine delve into the topic of overscreening older adults for cancer.

In the first, researchers calculated 9-year mortality risk for roughly 27,000 people aged 65 and older who completed the National Health Interview Survey. For participants with a 9-year risk of 75% or higher:

  • 55% of men had a PSA test within 2 years;
  • 38% of women had a mammogram within 2 years;
  • 31% of women had a Pap test within 3 years;
  • 41% of men and women had colorectal cancer screening within 5 years.

In the second study, researchers simulated "recommended screening" for colorectal cancer (colonoscopies at ages 65 and 75), shorter screening intervals, and screening beyond age 75 among average-risk 65-year-old Medicare beneficiaries. Recommended screening translated to a net benefit of 64.5 quality-adjusted life-years (QALYs) gained per 1000 beneficiaries. When screenings were done after age 75, QALYs declined. When the screening interval was shortened from 10 to 5 years, there was a gain of 0.7 QALYs per 1000 beneficiaries, but the cost per additional QALY gained was $711,000.

A commentator recommends that clinicians change the way they speak with older patients about cancer screening, noting that "assessment of life expectancy should inform individual decision making."

JAMA Internal Medicine article on screening patients with limited life expectancies (Free abstract)

JAMA Internal Medicine article on colorectal cancer screening simulation (Free abstract)

JAMA Internal Medicine commentary (Subscription required)

Background: NEJM Journal Watch General Medicine summary on overscreening for prostate cancer (Free)

Breast is best - but are we doing enough to support it?

Posted in General clinical at Thu, 28 Aug 2014 08:08:36

John D

Posts: 3170
Joined: 01 Feb 2010
Apologies to the doc2doc community but I've been rather quiet on the forums recently thanks to a new arrival to our family. This article (http://www.bbc.co.uk/news/health-28851441, http://www.theguardian.com/commentisfree/2014/aug/23/breastfeeding-may-be-natural-but-not-easy ) which was in the news thus week is therefore very close to my heart at present.
 
It has been known for some time and is well publicised that "breast is best" for babies. The health benefits to mother and baby are extensive and for baby seem to extend through into adult life. However, breast feeding is not easy and does not appeal to all mothers, hence campaigns over recent years to incentivise mothers to breast feed. 
 
After the birth of our daughter I've been through a very rocky time regarding feeding and I'm not ashamed to admit there have been tears and tantrums from both mother and daughter along the way. I've kept telling myself breast is best and thats therefore what I wanted to do, after all I preach it to so many parents at work, ideally should put my own teaching into practice. 
 
We spent 2 days in hospital after delivery where I'm disappointed to say that feeding support was rather limited, and we only got to see the "infant feeding advisor" at 48 hours as we wee being discharged home. Once back in ether community, our community midwife visited on day 3 & 5 for about 15 mins each visit, where she had a set checklist of tasks including checks on mine and baby's welfare & health. "How is breast feeding going?" "I'm not sure..." "Keep at it, you'll get the hang of things". 
 
By the end of the first week I was in pain and ready to give up. If things were going to continue I needed more support. I tried the midwife, but as a colleague was off sick she couldn't come back until day 12. I tried NCT (a volunteer charity organisation) but their support group was unfortunately shut for the school holidays, and so in desperation I paid for a private "lactation consultant" to come out and spend 2 hours with us at home, observing a feed and giving hands on support. 
 
Now, at 4 weeks post delivery, we are doing much better and the feeding and my mood are much improved.  After lots of hard work we've done it without the need for formula (although a small piece of research from the US showed that limited formula use can actually improve breast feeding rates in the longer term http://pediatrics.aappublications.org/content/early/2013/05/08/peds.2012-2809.abstract)
 
I seem to have rambled but coming back to the point - breast is best, and there is such pressure to breast feed but such limited support to facilitate that. With such a balance is it any wonder than women who intend to breast feed but are unable to have such high depression rates? 
 
But with limited resources in thee modern NHS how can we better support breast feeding in those crucial early days? Surely with such proven health benefits, women should not be having to fall back on charity and even paid private support to succeed with breast feeding. What is the way forward 

DNAR - practical aspects

Posted in General clinical at Wed, 27 Aug 2014 18:38:38

sken

Posts: 688
Joined: 13 Oct 2009

A very elderly retired colleague and friend of many years (but it could be anyone and seems reasonable discussion for doc2doc) may need hospital admission on an emergency basis. He has a very real , but increasingly limited ,quality of life but - as is often forgotten - further illness, even if not major , might change all that. He has no wish to live other than in his own home but that is becoming increasingly under threat (already has a number of carers of various types). I am sure everyone has the picture. He is also deeply religious.

I tried to have a discussion with him about DNAR (easier for me than for the family) and made little progress , the answer being "Only if it will be successful". I think he is influenced a bit by having seen a patient on the LCP being refused food and drink even when hungry and thirsty.  "Ending it all" has crossed his mind but he scarcely has that option now and has religious objections anyway.

It is midnight , he has just been admitted with a small stroke and being a bit deaf and now with mild dysphasia and mild confusion , I am interested to know what the admitting doctor would write in the notes about resus.and how a decision would be reached.  I know what he would have trusted me to make the appropriate decision as his doctor in years gone by , but now that type of trust is outdated . The family have plenty of common sense but all live at a distance and might well not be available for discussion. 

I am interested to know how thoughtful folk tackle these issues - I am not really expecting a definitive answer ! 

 

Sheepdogs or robots?

Posted in General clinical at Thu, 28 Aug 2014 07:58:44

John D

Posts: 3170
Joined: 01 Feb 2010

Odysseus , I am not sure whether it has been in your news , but in the UK it seems that careful computer analysis of dog movements means that it is becoming feasible to think about replacing sheepdogs with robots. Just why anyone would want to do this I cannot imagine. 

It all seems to have a remarkable analogy with some of modern medicine?

As one old shepherd said "It is not just the movements but also the way the dog looks at the sheep and what happens on eye contact".

What's your diagnosis? Pigmentation and confusion.

Posted in General clinical at Wed, 27 Aug 2014 16:01:03

AnneG

Posts: 348
Joined: 18 Mar 2014

The case below appeared in the BMJ's endgames section a few years ago. I will post a link to the answer soon.

A previously well 51 year old Cypriot woman presented to the emergency department with a five day history of vomiting. She reported no diarrhoea, fever, or abdominal pain. She had no unwell contacts or recent foreign travel. Her medical history included recently diagnosed depression and a review by dermatologists two years previously for generalised darkening of her skin. Her dentist had biopsied an area of discoloration on her gums.

On examination, her pulse was 100 beats/min, temperature 37.9°C, and blood pressure 107/63 mm Hg. She was dehydrated and had mild epigastric tenderness. Initial blood tests showed a haemoglobin concentration of 118 g/L (normal range 120-152 g/L), white cell count of 2.8×109/L (4.1-10×109/L), neutrophil count of 1.2 mm3(2.5-7.5 mm3), sodium concentration of 131 mmol/L (135-145 mmol/L), potassium concentration of 4.4 mmol/L (3.5-4.5 mmol/L), corrected calcium concentration of 1.98 mmol/L (2.15-2.61 mmol/L), alanine transaminase concentration of 92 U/L (64-83 U/L), alkaline phosphatase concentration of 56 U/L (<55 U/L), bilirubin concentration of 7 µmol/L (0.2-1.3 µmol/L), and C reactive protein concentration of 45 mg/l (<1 mg/l).

The patient was admitted to a general medical ward and overnight became confused, disorientated, and agitated. Observations showed that her heart rate had changed to 110 beats/min, her blood pressure was 98/55 mm Hg, and her temperature had increased to 38°C. Her Glasgow coma scale score was 12, and she had developed brisk reflexes and bilateral extensor plantar responses. Her arterial blood gas showed a pH of 7.29, pO2 of 12.7 kPa, pCO2 of 2.8 kPa, base excess of −15 mmol/L, chloride concentration of −109 mmol/L, and bicarbonate concentration of −10 mmol/L. Her plasma glucose concentration was 1.1 mmol/L.

What is your diagnosis? And what course of treatment would you pursue?

Mantoux conversion in the absence of disease; what to do?

Posted in Respiratory medicine at Thu, 28 Aug 2014 06:25:44

Odysseus

Posts: 4110
Joined: 24 Feb 2009

As one who no longer treats TB patients, I am interested in the current guidelines about the treatment of those with Mantoux conversion or QuantiFERON Gold Assay positive patients who, after thorough examination etc have no evidence of tuberculosis.

INAH for six monts was the treatment but I am interest in what sound evidence was there for this and how many patients you would have to treat to prevent one developing TB. I have seen patients with INAH peripheral neuropathies and liver abnormalities. 

Sometimes dogma becomes fact when it is but dogma and not based on anything solid. 

Over to you experts....

What do you recommend?

Odsseus

cadiogenic shock

Posted in Anaesthesia at Thu, 28 Aug 2014 08:14:56

John D

Posts: 3170
Joined: 01 Feb 2010

how can we start anaesthesia for cardiogenic shock for vent support and what are the maintanance drugs for anaethesia on vent