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Shit people say to women doctors

Posted in BMJ at Fri, 22 May 2015 17:01:11

nicudoc16

Posts: 1
Joined: 22 May 2015

The Tumblr blog Shit People Say to Women Directors is a collection of stories about sexism in the film industry. The BMJ is inviting people to write about their experiences of sexism in medicine on this thread in order to expose some of the barriers women doctors are facing.

Let us know your stories. 

News updates: The unfading shadow of Ebola

Posted in Public health at Fri, 22 May 2015 14:51:40

Mukhtar Ali

Posts: 957
Joined: 14 Nov 2010

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

http://www.bbc.com/news/world-africa-29424919

MRCPsych Question of the Day from OnExamination: Which antidepressant to use?

Posted in Psychiatry at Sat, 23 May 2015 23:38:02

Jorge Ramirez

Posts: 5
Joined: 09 Jan 2015

A 64-year-old lady with a moderate depressive illness currently treated with an SSRI presents with increasing fatigue. Her plasma sodium is found to be 122 mmol/L.

POISE-2Trial and Pre operative care guidelines

Posted in Cardiology at Sun, 24 May 2015 12:00:56

sken

Posts: 951
Joined: 13 Oct 2009

What should be the pre operative prescription, if any, to reduce CV events close to surgery in high risk patients?

Recent recommendations say:

Continue beta-blockers, ASA and statins if in use. Do not start if not in use.

In short, mostly keep doing your regular stuff, nothing else for most cases. Then, what should be the role of a GP, internist or cardiologist in the routine pre-op care?

'All UK final year medical students should sit the same exam, says Future Forum...' Really?

Posted in Student BMJ at Fri, 22 May 2015 16:32:55

Maxim

Posts: 415
Joined: 14 Dec 2010
An article published in this months Student BMJ outlines how it has been raised by the future forum (a consultation group for the NHS) that finals should be standardised across all UK medical schools. This has been raised because there are concerns of the preparedness of graduates and an inconsistency in the competency in graduates entering foundation training.
The article also outlines how apparently the National Training Survey published in 2011 by the GMC showed that 24% of foundation year doctors did not feel adequately prepared for their first job.

I wonder why this issue has come about. It seems ludicrous to think that medical students are not being assessed to the same degree in their final exam as the whole point of the GMC guidelines is so that this type of concern does not raise its head. The whole point of Tomorrows Doctors is to make sure that all graduates are equipped with the same skills in the same way. How are the finals all of a sudden causing this?
The point being raised about 24% of new F1s not feeling prepared I believe has nothing to do with how they are tested for their finals. Surely confidence is acquired not throught the sitting of exams but through the practice of clinical skills on willing patients?
I do not think that by simply making the final paper the same for all medical schools is somehow going to make them feel either more confident or more like doctors. Creating an exam such as the one suggested by the Future Forum is allied to the idea of there only being one exam board that is allowed to set GCSEs or A levels instead of the current system of OCR and Edexcel etc. That idea I likewise believe to be foolish.

What is everyones opinion on this matter?? Would a one exam system be better?

Here is the link to the article: http://student.bmj.com/student/view-article.html?id=sbmj.e600

Clinical question of the week: what's causing this change in mental state?

Posted in Psychiatry at Sat, 23 May 2015 15:37:21

Mukhtar Ali

Posts: 957
Joined: 14 Nov 2010

A thirty six year old female has been receiving treatment for a psychiatric disorder. She has been in remission for a while. During the summer, she went to the beach. She suffered nausea and vomiting. She became quite irritable, her speech became sluggish, her gait became unsteady, she became unable to focus, and her hands became shaky. She was unwilling to go to the A&E. Her spouse became worried and immediately took her home but  forgot to bring her medication. Due to nausea, she was unable to eat well. Her husband switched every meal to big bowls of soup with plenty of juice and other fluids. Eventually, her spouse managed to convince her to seek medical advice. On the next appointment, the doctor was unable to pin point what happened.

Why are trainees not choosing general practice?

Posted in Careers at Sun, 24 May 2015 22:56:39

rayhope

Posts: 16
Joined: 12 Apr 2009

BMJ Careers recently published this piece on why fewer doctors in training are choosing careers in general practice.

The authors, from the National Medical Director's Clinical Fellow Scheme, surveyed 428 trainees from the  Yorkshire and East of England Deaneries in 2014.

The reasons trainees choose general practice, as suggested in the article:

Broad clinical range

Continuity of care

Work life balance

Flexible

Length of training

Job security

Challenging

 

The reasons they don't choose general practice:

Not exciting

Want to specialise

Want to work in a team

Want to work in acute care

Too much non-clinical work

Dislike GP rotation

Dislike brief consultation

Uncertainty with system

 

How can general practice be made more attractive to doctors in training?

Any idea what placebo is?

Posted in General at Mon, 25 May 2015 14:12:24

John D

Posts: 3545
Joined: 01 Feb 2010

Hi guys. I am a 16-year old student and one of my homework’s in science class is placebo effect. Can anyone tell me what it means please? I have been searching about it in the net and there are so many things that came out. I don’t know what it really means now. I would really appreciate your answers. Thank you so much.

Have you ever fallen asleep on the job?

Posted in General at Fri, 22 May 2015 18:00:33

Mukhtar Ali

Posts: 957
Joined: 14 Nov 2010

Just spotted this article on BuzzFeed about junior doctors falling asleep on duty: "Doctors are defending their gruelling jobs by sharing pictures of themselves asleep at work. A blog post from earlier this month that criticized a medical resident in Mexico for sleeping on the job has led to a social media movement with doctors defending their long hours and need for rest."

Here are some of the pictures:

 

tutoblogx.blogspot.mx

 

Embedded image permalink

Paola Perez‏@pao_perezf (via twitter)

 

Embedded image permalink

 

MechiFiu‏@MechiFiu (via Twitter)

 

Medical student finals sample question from OnExamination: hyoscine

Posted in Finals help! at Sun, 24 May 2015 21:13:49

Pat Lush

Posts: 513
Joined: 27 Jul 2011

A 23-year-old woman comes to the clinic complaining of severe menstrual cramps. She has been taking maximal doses of ibuprofen and paracetamol to little effect.

You decide to try a course of hyoscine tablets.

A typical case of FUO... does anyone has any suggestions or answers!! Please help.

Posted in General clinical at Fri, 22 May 2015 20:40:41

tagreed

Posts: 9
Joined: 20 Mar 2009

Patient origin: Indian

Age/ Gender: 61 years/ Male

Chief complaint: Patient complained of persistent fever at night since past 2 months. Lot of coughing at night.
 
History of present illness:

Fever: Since past 2 weeks persistent fever with sweating at night. Fever subsides with sweating at night. Fever increases in evening, in between 4-7 pm and subsides at around 1-2am at night. Fever subsides, on taking anti-pyretics.

Cough: Coughing is there whole day...but increased at night, causing sleep disturbance. Cough is with little discharge which was white in colour.  No yellow color.   Cough: feel better after taking ambrolite cough syrup.

 
After 2-3 weeks of illness..patient showed to general physician... He gave antibiotics for 2 weeks...and ordered for blood test... Malaria tests...typhoid tests,  Blood tests revealed anaemia..lymphocytosis.
 
 Patient is already taking antihypertensive and antidiabetic medication. Blood pressure is controlled ...sugar is fluctuating.


 Patient was also experiencing heaviness in abdomen after eating food ...so his doctor ordrd for Ultrasound abdomen. It showed liver and spleen enlargement.
 

So...after giving antibiotics for 1 week. Antimalarial were given for 5 days. No effect was observed 
 Antiallergics have also been given for 15 days.


CT scan chest: showed normal lungs but upper abdomen and mediastinal lymph nodes enlargement.
 

Then CT scan abdomen was prescribed....which showed coeliac and portal lymph node enlargement.

Then anti- tubercular drugs were prescribed. 

EUS FNAC: showed normal lymph nodes. No granuloma, No lymphoma.
 And liver ...kidney function tests are also normal.

Nausea started after starting wid Anti- Tubercular Drugs (ATT). Although appetite was normal throughout.

 

Now fever has increased to 101 deg celsius. 

Weight loss: Slight 3-4 kgs.

Lymph node biopsy also showed No lymphoma, cancerous cells. No granuloma.

Now, what to do!! absolutely clueless.. :(
 

Nepal Earthquake and Looming Dangers

Posted in Public health at Sun, 24 May 2015 15:29:32

Mukhtar Ali

Posts: 957
Joined: 14 Nov 2010

Natural disasters and calamities inflicted by Nature cannot be avoided but have to be endured with great patience and immense courage. In such miserable circumstances the first effective step is to mobilize all available resources for immediate and quick response with an emphasis on provision of food, shelter and first aid medicine. Rehabilitation stands second in number in the phases of repair and recovery from losses. The looming dangers of preventable diseases are of great concern in the earthquake hit areas.

http://www.bbc.com/news/uk-32583422

"there is lot of discussion about Sglt2inhibitors in forums, which has an edge Cana. or Dapaglifazone? "

Posted in Cardiology at Sun, 24 May 2015 03:10:45

diabetesMD

Posts: 739
Joined: 15 Apr 2011
Dear Diabetes spl, It will be nice if you can clarify whether Cana.or Dapaglifazone is better. How? and. Why?share your experience and thoughts. Dr Valluri Ramarao DNB (fam -med)

How long should the prison term be for wrong diagnosis?

Posted in General clinical at Sun, 24 May 2015 11:04:56

Maxim

Posts: 415
Joined: 14 Dec 2010

Others may have noted that a Dutch doctor (a neurologist) was sentenced to 3 years in prison for making wrong diagnoses and that prosecutors think this is too lenient. There is also the problem of whether the doctor himself had brain damage following a car accident. But is the doctor the prime culprit if the system has allowed him to continue to work and does it really help to send someone to prison in this way ? Just think twice before a patient insists on a label or if you suggest someone has Alzheimer's a little too readily. The mis-diagnoses included MS and Alzheimer's - both of which we are pressurised to make earlier and earlier sometimes in the face of less than convincing evidence. 

Of course precise details would be very relevant.

It is time to break the silence on physician suicide.

Posted in News & media at Fri, 22 May 2015 17:35:25

Jorge Ramirez

Posts: 5
Joined: 09 Jan 2015

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.

References

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

2. Pamela Wibble. Physician suicide 101: Secrets, lies and solutions. 
http://www.kevinmd.com/blog/2014/11/physician-suicide-101-secrets-lies-solutions.html

3. Michael L. Langan. Category: Physician Suicide.
http://disruptedphysician.com/category/physician-suicide-2/

4. [(Chaos) x (Suboxone + J Addict Med + Am Soc Addict Med + Like Minded Docs + Addiction Medicine + Spiritual Interventions + 12 Step Recovery Programs + Drug Testing)]
http://disruptedphysician.com/2015/01/30/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.
http://www.bmj.com/content/349/bmj.g7603/rr

6. Comportamiento del suicidio en Colombia, 2011. Instituto Nacional de Medicina Legal.
http://www.medicinalegal.gov.co/documents/10180/34616/6-F-11-Suicidio.pdf/6b2966e7-cbcb-4618-a3c3-af5cd111629e

Philosophy of Coffee & Personality

Posted in Psychiatry at Sun, 24 May 2015 10:54:51

Maxim

Posts: 415
Joined: 14 Dec 2010

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

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

Trust and doctors charged with Corporate manslaughter

Posted in Medical ethics at Sat, 23 May 2015 10:56:58

John D

Posts: 3545
Joined: 01 Feb 2010

The CEO and a consultant anaesthetist from the Tunbridge Wells NHS Trust were in court recently, charged with corporate manslaughter and "gross negligence" manslaughter respectively, after the death of a mother from bleeding after a Caesarian Section.   http://www.kentonline.co.uk/maidstone/news/hospital-trust-and-doctor-due-36063/

"Corporate manslaughter" became a new legal entity after the "Spirit of Free Enterprise" ferry disaster, when it was found that company policies and practices had caused many deaths, but that the Law then required a person the be charged with actual negligence or manslaughter.      The 2007 Act has been applied in several cases since, but this is the first hospital to be so charged.

The case continues.

John

 

Head of New Hospital New Zakho Kurdistan

Posted in General clinical at Sat, 23 May 2015 04:08:34

rast

Posts: 1
Joined: 23 May 2015

Good afternoon everyone.

Im searching for a medical professional from the UK to help start a Brand New Hospital In New Zakho Kurdistan.

This is not a recruitment drive nor is an agency!!!!!!!

The Chairman of Rast who is Building the city has a desire to improve standards and with the help of the right person to assist with Design layout and organisation structure this could be the start of something good for the region.

Please email me for more details!! or send a resume if directly interested.

https://www.facebook.com/newzakho

 

Best Wishes

Rast

How much exercise is enough?

Posted in Diabetes at Sun, 24 May 2015 02:22:39

diabetesMD

Posts: 739
Joined: 15 Apr 2011

Gretchen Reynolds recently reviewed two studies examining the benefits of varying the duration and intensity of exercise for the New York Times.

The Right Dose of Exercise for a Longer Life http://nyti.ms/1D0fPH8

She opens the article with a cute analogy: “Exercise has had a Goldilocks problem, with experts debating just how much exercise is too little, too much or just the right amount to improve health and longevity.” She then describes the results of two new, large-scale studies addressing these questions, both published recently in an April edition of the JAMA. Internal Medicine.  I summarize these finding below.

The current broad guidelines from governmental and health organizations call for 150 minutes of moderate exercise per week to build and maintain health and fitness, but the scientific basis for this recommendation is shaky to say the least.  There is no doubt that any amount of exercise is beneficial.  Nevertheless, quantitating how much is needed to achieve maximal benefit and how intense does it need to be has proved to be difficult.  Additionally, we do not know at what point too much or too intense exercise becomes harmful.

In the broader of the two studies, researchers with the National Cancer Institute, Harvard University and other institutions gathered and pooled data about people’s exercise habits from six large, ongoing health surveys, winding up with information about more than 661,000 adults, most of them middle-aged.  The data were stratified by their weekly exercise time, from those who did not exercise at all to those who worked out for 10 times the current recommendations or more (meaning that they exercised moderately for 25 hours per week or more).  Then they compared 14 years’ worth of death records for the group.  They found that, unsurprisingly, the people who did not exercise at all were at the highest risk of early death.  Those who exercised a little, not meeting the recommendations but doing something, lowered their risk of premature death by 20 percent.  Those who met the guidelines precisely, completing 150 minutes per week of moderate exercise, enjoyed greater longevity benefits and 31 percent less risk of dying during the 14-year period compared with those who never exercised.

The maximal benefit, however, was achieved by those who tripled the recommended level of exercise, working out moderately, mostly by walking, for 450 minutes per week, or a little more than an hour per day. Those people were 39 percent less likely to die prematurely than people who never exercised.

The subset of individuals engaging in 10 times or more the recommended exercise dose gained about the same reduction in mortality risk as people who simply met the guidelines. They did not gain significantly more health benefit, but neither did they increase their risk of dying young.

The other new study of exercise and mortality reached a somewhat similar conclusion about intensity. While a few recent studies have intimated that frequent, strenuous exercise might contribute to early mortality, the new study found the reverse.

In this study, Australian researchers analyzed health survey data from over 200,000 Australian adults, determining how much time each person spent exercising and how much of that exercise qualified as vigorous, such as running instead of walking, or playing competitive singles tennis versus a sociable doubles game.

As in the previously described study, they found that meeting the exercise guidelines substantially reduced the risk of early death; this was true even when the exercise was moderate, such as walking.

However, adding occasional vigorous exercise, demonstrated an additional reduction in mortality. Those who spent up to 30 percent of their weekly exercise time in vigorous activities were 9 percent less likely to die prematurely than people who exercised for the same amount of time but always moderately, while those who spent more than 30 percent of their exercise time in strenuous activities gained an extra 13 percent reduction in early mortality, compared with people who never broke much of a sweat. Again the study did not demonstrate any increase in mortality, even among those few people completing the largest amounts of intense exercise.

Klaus Gebel, a senior research fellow at James Cook University in Cairns, Australia, who led the second study concluded that anyone who is physically capable of activity should try to “reach at least 150 minutes of physical activity per week and have around 20 to 30 minutes of that be vigorous activity,” Additionally more exercise does not seem to be unsafe.

 

Lack of physician trust haunts the Chinese health care system

Posted in Diabetes at Sat, 23 May 2015 03:12:01

diabetesMD

Posts: 739
Joined: 15 Apr 2011

Comments on the Perspective entitled

Lessons from the East — China's Rapidly Evolving Health Care System

by David Blumenthal, M.D., M.P.P., and William Hsiao, Ph.D.

N Engl J Med 2015; 372:1281-1285April 2, 2015DOI: 10.1056/NEJMp1410425

As my readers know I have been involved in diabetes care in China for nearly three years.  We have two inpatient centers in Hangzhou and Ningbo.  Therefore I read with great interest this article about the evolution of China’s health care system.  My first experience with the system was in 1979 when I went to China with a group of US health policy staff.  As the article states, the advances in the health of the Chinese people was very impressive.  Using local “barefoot doctors” with as little of six weeks of training the focus was on public health.  When I returned in 2012, China was, of course, an entirely different country and the health care system was modern and well equipped.   However, I am taken by how skeptical the patients are especially when using insulin was suggested.  At first, I attributed this to a cultural needle phobia.  However, this article has convinced me that the source is quite difference.  Let me quote the key paragraph:

“Third, physician professionalism may be underappreciated as a foundation for effective modern health care systems. The inculcation of professional norms during and after training and the existence of professional institutions that reinforce these norms certainly do not guarantee that professionals will act only in the interest of their patients and the public. But there seems little question that the lack of a widely shared tradition of professionalism has complicated China's efforts to create a health care workforce that its leaders and the public trust to do the right thing.”

Quite simply the Chinese public does not trust its physicians.  In a recent survey when patients were asked directly if they trusted their physicians, 66% said no.  This is a potentially disastrous situation for the treatment of diabetes and other chronic conditions that now threaten to consume the Chinese health care system.  When we started our programs in China we focused on patient-centered care, patient education and continuity of care.  It appears that this is a winning strategy to develop trust.  Now we have enough experience and patient data to examine the effects on outcomes and patient satisfaction.  Our patient satisfaction scores are consistently high.  We hope to begin to analyze our outcomes and success in developing continuity of care in the near future.

Rethinking how we deliver primary care in the 21st century

Posted in Diabetes at Sat, 23 May 2015 03:59:26

diabetesMD

Posts: 739
Joined: 15 Apr 2011

Health Care 2020: Reengineering Health Care Delivery to Combat Chronic Disease

American Journal of Medicine April 2015Volume 128, Issue 4, Pages 337–343

Abstract

Chronic disease has become the great epidemic of our times, responsible for 75% of total health care costs and the majority of deaths in the US. Our current delivery model is poorly constructed to manage chronic disease, as evidenced by low adherence to quality indicators and poor control of treatable conditions. New technologies have emerged that can engage patients and offer additional modalities in the treatment of chronic disease. Modifying our delivery model to include team-based care in concert with patient-centered technologies offers great promise in managing the chronic disease epidemic.

COMMENT: I recommend this thoughtful article that presents evidence that the American (and most other) health care system will be increasing focused on the treatment of chronic diseases and that it is woefully designed to treat them.  The opening paragraph sets the scene:

“Chronic disease represents the major driver of illness and health care utilization in the US, and its prevalence in the population is increasing. In 2010, chronic disease was responsible for 7 of every 10 deaths in the US and accounted for over 75% of total health care costs.1, 2 In just a 5-year span, from 2005 to 2010, the prevalence of chronic disease increased from 46% to 47% of the US population, equivalent to an additional 8 million Americans, and by 2020 it is projected to increase by an additional 16 million, comprising 48% of the population.3 It is noteworthy that over half of these individuals, or approximately 81 million of the US population, will have multiple chronic conditions.4 Total cost of health care also has increased steadily over this period, and it is estimated that two-thirds of this escalation is due to the increased prevalence of chronic disease.”

The authors then goes on to provide evidence of the current system’s poor performance:

“Although chronic disease represents the leading cause of death in the US, 40% of all premature death is due to behaviors amenable to change. Maximizing disease outcomes will therefore require the necessary time and expertise needed for a careful assessment and modification of lifestyle factors.15 In the primary care setting, the median length of a physician visit is <15 minutes, during which a median of 6 topics will be covered, leaving little if any time to formally assess and address the root causes of many chronic diseases, including poor nutrition and physical inactivity.”

The remainder of the manuscript describes a number of evidence-based changes that have the potential to effectively address the issue including a complete change in the patient care paradigm with closer integration of other health care providers and the increased use of self-management technologies.  This thoughtful article is well worth your time to read.

Reevauating the use of metformin in the presence of renal impairment

Posted in Diabetes at Sun, 24 May 2015 01:37:39

diabetesMD

Posts: 739
Joined: 15 Apr 2011

Using metformin in the presence of renal disease

BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h1758 (Published 14 April 2015) Cite this as: BMJ 2015;350:h1758

This editorial encourages the increased use of metformin in persons with renal impairment and points out the discrepancies among various guidelines.  In the opening paragraph the authors state:

“In January, the electronic Medicines Compendium (eMC) updated the Summary of Product Characteristics for Glucophage (metformin), approved by the UK Medicines and Healthcare Products Regulatory Agency (MHRA). The summary states that “Metformin may be used in patients with moderate renal impairment, stage 3a (creatinine clearance [CrCl] 45-59 mL/min or estimated glomerular filtration rate [eGFR] 45-59 mL/min/1.73 m2) only in the absence of other conditions that may increase the risk of lactic acidosis . . . If CrCl or eGFR fall <45 mL/min or <45 mL/min/1.73 m2 respectively, metformin must be discontinued immediately.”  This is reiterated in the patient information leaflet.”  Additionally they point out that the guidelines for use in renal disease are even more restrictive for generic metformin (making no sense at all) and points out the state of our confusion, viz. “Renal failure or renal dysfunction (creatinine clearance <60 ml/min)” is a contraindication to use."

The initial confusion with the use of metformin resulted from a misunderstanding about the difference between two biguanides, phenformin and metformin.  Phenformin was associated with an unacceptable incidence of lactic acidosis and was removed from the US market.  However, the incidence of lactic acidosis with metformin is much less and virtually always occurs in patients who have contraindications to the drug.  This is because phenformin enters the mitochondria where lactic acid is made at therapeutic concentrations, whereas metformin only does so at concentrations above its therapeutic range resulting from a decreased excretion  such as in heart, liver or (severe) renal failure.  The new NICE guidelines nicely balance the risks and benefits of using metformin in the presence of renal disease.

“Guidelines from the UK National Institute for Health and Clinical Excellence (NICE) suggest that metformin dose should be reviewed at an eGFR of 45 and stopped at an eGFR of 30.”  The benefits and safety of metformin have been studied for 50 years.  Nevertheless, we still see confusion about its use in the presence of renal disease.  I would urge that based upon more recent studies we reevaluate its use in moderate renal impairment.

                                                            

Foreign Body Ingestion From Grilling?

Posted in General clinical at Mon, 25 May 2015 13:32:46

John D

Posts: 3545
Joined: 01 Feb 2010

Has anyone else ever seen a case of accidental foreign body (FB) ingestion from outdoor grilling? Just curious, because the other day I had a patient present to my ED (A&E) with acute, severe abdominal cramps and diffuse pain; nausea and vomiting approximately 3 hours after a cookout where the patient ate chicken grilled on an ordinary BBQ grill. Upon ruling out food poisoning (relatively short duration to symptoms; no one else afflicted) abdominal plain-films and then CT were ordered which showed an opaque, relatively small and thin metallic object in the stomach at the entrance to the duodenum. Apparently, though not too frequently encountered, is the mechanism whereby which a person ingests a metal bristle--from a grill-cleaning brush--that got stuck to cooking meat which was then eaten. Although one might think that the FB would be noticed through chewing before swallowing it, the small size of these grill bristles makes unnoticed ingestion a possibility. In this case STAT endoscopy located the FB embedded in the mucosa which was able to be easily removed without complications. After the endoscopy the patient's course was uneventful, spending just one day inpatient for observation and then discharged.

I had never--in my 17 year tenure in the ED--seen a case of this phenomenon before and figured it must be quite rare. But just this morning I happened to see a news story about this very subject which stated that it occurs more often than one might suspect. Have you ever seen a case(s) like this before? Heard about it? Seen it in the literature? Comments?

Screening for Type 2 Diabetes Mellitus: A Systematic Review for the U.S. Preventive Services Task Force

Posted in Diabetes at Mon, 25 May 2015 09:34:54

Maxim

Posts: 415
Joined: 14 Dec 2010

Screening for Type 2 Diabetes Mellitus: A Systematic Review for the U.S. Preventive Services Task Force

Ann Intern Med. Published online 14 April 2015 doi:10.7326/M14-2221

Verbatim Abstract

Background: Screening for type 2 diabetes mellitus could lead to earlier identification and treatment of asymptomatic diabetes, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT), potentially resulting in improved outcomes.

Purpose: To update the 2008 U.S. Preventive Services Task Force review on diabetes screening in adults.

Data Sources: Cochrane databases and MEDLINE (2007 through October 2014) and relevant studies from previous Task Force reviews.

Study Selection: Randomized, controlled trials; controlled, observational studies; and systematic reviews.

Data Extraction: Data were abstracted by 1 investigator and checked by a second; 2 investigators independently assessed study quality.

Data Synthesis: In 2 trials, screening for diabetes was associated with no 10-year mortality benefit versus no screening (hazard ratio, 1.06 [95% CI, 0.90 to 1.25]). Sixteen trials consistently found that treatment of IFG or IGT was associated with delayed progression to diabetes. Most trials of treatment of IFG or IGT found no effects on all-cause or cardiovascular mortality, although lifestyle modification was associated with decreased risk for both outcomes after 23 years in 1 trial. For screen-detected diabetes, 1 trial found no effect of an intensive multifactorial intervention on risk for all-cause or cardiovascular mortality versus standard control. In diabetes that was not specifically screen-detected, 9 systematic reviews found that intensive glucose control did not reduce risk for all-cause or cardiovascular mortality and results for intensive blood pressure control were inconsistent.

Limitation: The review was restricted to English-language articles, and few studies were conducted in screen-detected populations.

Conclusion: Screening for diabetes did not improve mortality rates after 10 years of follow-up. More evidence is needed to determine the effectiveness of treatments for screen-detected diabetes. Treatment of IFG or IGT was associated with delayed progression to diabetes.

Comments: As discussed in the accompanying editorial Screening for Hyperglycemia: The Gateway to Diabetes Prevention and Management for All Americans the case for screening a wider portion of the population for pre-diabetes (impaired fasting glucose or IGT) has become stronger as studies are completed demonstrating the benefit of intensive lifestyle or pharmacologic intervention on both the conversion from pre-diabetes to diabetes and the reduction of cardiovascular risk factors.  The cost of treating diabetes represents 25% of the Medicare expenses.  There are over 80 million people in the US with pre-diabetes and over 90 per cent do not know that they have it.  I concur with the authors of the editorial that we need to expand diabetes screening in a manner similar to the current ADA recommendations http://care.diabetesjournals.org/content/25/suppl_1/s21.full

 

A systematic review of acute ischemic stroke treatment

Posted in Diabetes at Mon, 25 May 2015 03:53:13

diabetesMD

Posts: 739
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Acute Stroke Intervention: A Systematic Review

JAMA. 2015;313(14):1451-1462. doi:10.1001/jama.2015.3058.

VERBATIM ABSTRACT

Importance

Acute ischemic stroke is a major cause of mortality and morbidity in the United States. We review the latest data and evidence supporting catheter-directed treatment for proximal artery occlusion as an adjunct to intravenous thrombolysis in patients with acute stroke.

Objective

To review the pathophysiology of acute brain ischemia and infarction and the evidence supporting various stroke reperfusion treatments.

Evidence Review

Systematic literature search of MEDLINE databases published between January 1, 1990, and February 11, 2015, was performed to identify studies addressing the role of thrombolysis and mechanical thrombectomy in acute stroke management. Studies included randomized clinical trials, observational studies, guideline statements, and review articles. Sixty-eight articles (N = 108 082 patients) were selected for review.

Findings

Intravenous thrombolysis is the mainstay of acute ischemic stroke management for any patient with disabling deficits presenting within 4.5 hours from symptom onset. Randomized trials have demonstrated that more patients return to having good function (defined by being independent and having slight disability or less) when treated within 4.5 hours after symptom onset with intravenous recombinant tissue plasminogen activator (IV rtPA) therapy. Mechanical thrombectomy in select patients with acute ischemic stroke and proximal artery occlusions has demonstrated substantial rates of partial or complete arterial recanalization and improved outcomes compared with IV rtPA or best medical treatment alone in multiple randomized clinical trials. Regardless of mode of reperfusion, earlier reperfusion is associated with better clinical outcomes.

Conclusions and Relevance

Intravenous rtPA remains the standard of care for patients with moderate to severe neurological deficits who present within 4.5 hours of symptom onset. Outcomes for some patients with acute ischemic stroke and moderate to severe neurological deficits due to proximal artery occlusion are improved with endovascular reperfusion therapy. Efforts to hasten reperfusion therapy, regardless of the mode, should be undertaken within organized stroke systems of care.

Comments

This systematic review reinforces the key role of rapid administration of IU rtPA in reducing the morbidity of acute ischemic stroke.  It should be particularly useful for residents and fellows who will be dealing with acute stroke.  The review also provides evidence that when possible, mechanical thrombectomy in select patients with acute ischemic stroke and proximal artery occlusions has demonstrated substantial rates of partial or complete arterial recanalization and improved outcomes compared with IV rtPA or best medical treatment alone in multiple randomized clinical trials