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The most viewed discussions on doc2doc this month

Should e-cigarettes be allowed inside hospitals?

Posted in General at Thu, 26 Feb 2015 18:22:04


Posts: 266
Joined: 29 May 2013

The ban on smoking inside NHS buildings in long standing and well accepted, but on a few occasions recently I've noticed staff and patients using e-cigarettes inside hospital buildings.

Evidence into the use of e-cigarettes is still being generated - the reduction in transferrance of tar and some of the other harmful pathogens seems accepted. Likewise the fact that there is no second hand smoke to affect those around the "smoker". But do they truely help smokers give up? Do children and teenagers see e-cigarettes in use and model their behaviour, chosing to take up smoking from observing the adults around them?

I wondered what people's opinions are on should their use be allowed inside hospital buildings? Do your trusts already have policies in place?


Feeding Birds: A Humane Gesture

Posted in General at Sat, 28 Feb 2015 14:32:19

Mukhtar Ali

Posts: 902
Joined: 14 Nov 2010

Feeding birds is a humane  act  and an immemorial  popular custom of  every society. For many, it is a thing of joy, the joy of inner and soul.

Are you bird enthusiasts?

Thanks for your input.

Feeding the birds:

Of course my heart is open to the birds

whose song may lift my soul both night and day.

Cheering better with their song than words

Could ever bring  happiness into play.

In feeding the birds I hope to attract

the small ones that twitter and tweet in tune.

I'm hoping the kindness in this small act

may cause my little feathered friends to croon.

My plan worked as well as any plan does

the garden is now full of pretty birds

but also attracts some far larger crows

and from our neighbours  some rather harsh words.

Into my feeders I fit a large scoop

and clean the car daily, it takes off the poop.


Is it OK for doctors to accept gifts from patients?

Posted in General at Sat, 28 Feb 2015 16:16:33


Posts: 1112
Joined: 16 Aug 2012

BMJ Careers recently published an interesting article about accepting gifts from patients. Are gifts simply tokens of gratitude or are ulterior motives at play for perceived benefits like tests, referrals, etc any time patients demand them. Do you feel embarrassed accepting gifts from patients? Would you feel worse refusing them? How about a gift with monetary value >£100?

Clinical question of the week: What are the next steps for this woman with diabetes? Part 1 of 2

Posted in Diabetes at Fri, 27 Feb 2015 22:29:46

Joey Rio

Posts: 919
Joined: 13 Apr 2011

This case is about a retired, 57 year old lady who has had type 2 diabetes and hypertension for about 8 years. Her father also had type 2 diabetes and died of a heart attack at home at the age of 75 years. She is a former high level tennis player.

At the age of 47 she severely injured her right knee. Two years later and after three unsuccessful  knee surgeries, she was given a full right knee prosthesis so she might be able to walk again without the help of any external orthopaedic devices. So, she suddenly went from having an athletic lifestyle to a sedentary one. This resulted in the development of depression, weight gain of about 10 kg over 4 years, and type 2 diabetes mellitus at the age of 46 years. She came to my university office  to get a second opinion about two  issues: her diabetic metabolic control, and her uncontrolled hypertension.

  • Hello Dr. Joey Rio: How  are you?

  • Hi. What brings you here? I have already read the report of your doctor , and have also seen your blood reports.

  • Well doc, I can walk now, have started losing weight slowly (now BMI 28) and find my new home to be in a very relaxing neighborhood!

  • Before we move ahead let me do a complete physical exam on you and an ECG


She had a BP of 165/95 mmHg, ++ bilateral pedal oedema (slightly larger at the right side), and a pretty normal retinal exam. Recent fasting plasma glucose results were 240 and 236 mg/dL.  Uric acid 7 mg/dL. The rest of the lab tests, ECG included, were normal. I ordered more tests and requested she comes back in three weeks.


Before we move ahead with this case, what  tests do you think I ordered next?


Other colleagues opinions about the below options for this Poll are welcomed.



End of life care - Doctors religious beliefs

Posted in General at Sat, 28 Feb 2015 15:20:22


Posts: 343
Joined: 14 Dec 2010
I didn't see this survey when it was published originally in Journal of Medical Ethics (in 2010) but just came across it whilst searching for something else.  The Guardian reported it with the headline Atheist Doctors 'more likely to hasten death' (not a very good headline once one reads the survey).
With 'end of life' care does it matter that the Doctor is religious? Will his particular religion affect the way he gives end of life care? Does any particular religion have a greater influence of end of life care than another?
Would you ask your Doctor his religious/spiritual beliefs if he was to care for you at the end of life? 

MOOCs - Have you tried them?

Posted in General at Tue, 24 Feb 2015 19:41:06


Posts: 546
Joined: 23 Aug 2013

Massive Open Online Courses

Has anyone undertaken any MOOC courses? They started about 2008 but took off in 2012 and have become the modern equivalent of correspondence courses. The subject areas are vast with anything from Finance and Business, to Greek Philosophy to learning Spanish. I have undertaken one course in History of Art and found it well presented with very good study materials including video and audio presentations. They offer a large number of students the opportunity to study high quality courses online with prestigious universities, normally at no cost. Harvard, MIT, Georgetown, Oxford, Cambridge and about 700 other Universities worldwide are offering courses. Interestingly the drop out rate is high – independent study requires commitment and discipline but nevertheless Universities are ploughing millions of dollars/pounds into MOOCs. Most courses are free, some have a low cost and some charge a small fee for a certificate. Below I have listed 3 sites which offer MOOCs on a not for profit basis:


EdX is a non-for-profit provider, created by Harvard and MIT (Massachusetts Institute of Technology) universities. Today partners include the Australian National University, TU Delft (the Netherlands), and Rice, Berkeley and Georgetown universities in the US. EdX also offers ID verified certificates of achievement, for a minimum feeEdX offers interactive online classes and MOOCs from the world's best universities. Online courses from MITx, HarvardX, BerkeleyX, UTx and many other universities. Topics include biology, business, chemistry, computer science, economics, finance, electronics, engineering, food and nutrition, history, humanities, law, literature, math, medicine, music, philosophy, physics, science, statistics and more. EdX is a non-profit online initiative created by founding partners Harvard and MIT.MOOCs - Massive Open Online Courses.


MOOEC, launched in November 2013, offers free courses and lessons in English supported by Pier online, the University of Queensland ITCE, Griffith University GELI, Queensland University of Technology, Goldcoast TAFE and many non-government provider. The courses offer English language learning all levels.


In 2012 the Open University launched FutureLearn, partnering with more than 20 UK and international universities and other institutions such as the British Council, the British Library and the British Museum.

Apart from having undertaken one course I have absolutely no connection to these sites but just thought others (perhaps recently retired like Pat) might be interested in taking a course purely for their own pleasure.

NB. There are many other sites about MOOCs in addition to those highlighted above - a simple Internet search will throw up many many more.




Would you imitate your patient's accent?

Posted in Medical ethics at Sat, 28 Feb 2015 12:28:47


Posts: 1
Joined: 23 Aug 2012

I've noticed one colleague who tends to automatically copy the patient's accent in order to facilitate communication. When I had a discussion with the doctor he stated that he names it mirroring. He does it for two reasons. First, he imitates the accent to build rapport with the patient so as to have some familiarity. Second, he uses local terminology to make it easier for the patient to understand him.

I wonder whether you find this a necessary communication skill or a manifestation of pretention that may be perceived by the patient as derogatory sign or an expression of lack of authenticity

Any info on the induction and refresher scheme?

Posted in Careers at Wed, 25 Feb 2015 12:30:59


Posts: 2
Joined: 25 Feb 2015

Hi everyone,

I am UK born and bred but trained as a GP in Canada. I am in my mid 50's.

To get GMC registration, I would need to do the Induction and Refresher scheme. It will be expensive (over £1000 for the exam fees) and then 3-6 months retraining away from home.

I don't need to work financially so I'm not sure what to do. I have been back in the UK for 2 years and only hear the bad side of working for the NHS as a GP, mainly from the press. I would like to hear from anyone working as a GP for their opinion.

Has anyone done the course? Is it worth me doing this?

Thanks in advance, all view points welcome.

MRCP Part 1 Question of the Day from BMJ OnExamination - Burkitt's lymphoma

Posted in General clinical at Wed, 25 Feb 2015 09:41:47


Posts: 1141
Joined: 07 Sep 2009

Try today's Question of the Day from BMJ OnExamination and test your knowledge

Questions include exam themes similar to the January 2015 MRCP Part 1 exam

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

Posted in Psychiatry at Wed, 25 Feb 2015 09:41:00


Posts: 1141
Joined: 07 Sep 2009

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.

Smoking Banned in Cars!

Posted in Respiratory medicine at Fri, 27 Feb 2015 16:58:38


Posts: 11
Joined: 15 Feb 2013


MPs in England voted overwhelmingly to ban smoking in cars last week.  

A landmark piece of legislation, or the epitome of the nanny state?

GMC registration

Posted in Careers at Wed, 25 Feb 2015 10:14:41

Abi R

Posts: 17
Joined: 18 Nov 2013

Hello Friends

I am a medical graduate from a EU university, graduated in 2006.

Since graduating i moved to UK, and looked after my uncles business.

Now i want to go into medical practice, can some one please advise my chances and the options i have to start my career.

Will GMC accept my application, or how should i approach them??

What kind of training i can start.

Any advise is most appreciated>

Thank you


Risks of NSAIDs following myocardial infaction

Posted in Diabetes at Thu, 26 Feb 2015 10:49:01


Posts: 883
Joined: 13 Oct 2009

Association of NSAID Use With Risk of Bleeding and Cardiovascular Events in Patients Receiving Antithrombotic Therapy After Myocardial Infarction

JAMA. 2015;313(8):805-814. doi:10.1001/jama.2015.0809.

Verbatim Abstract

Importance  Antithrombotic treatment is indicated for use in patients after myocardial infarction (MI); however, concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) could pose safety concerns.

Objective  To examine the risk of bleeding and cardiovascular events among patients with prior MI taking antithrombotic drugs and for whom NSAID therapy was then prescribed.

Design, Setting, and Participants  Using nationwide administrative registries in Denmark (2002-2011), we studied patients 30 years or older admitted with first-time MI and alive 30 days after discharge. Subsequent treatment with aspirin, clopidogrel, or oral anticoagulants and their combinations, as well as ongoing concomitant NSAID use, was determined.

Exposures  Use of NSAIDs with ongoing antithrombotic treatment after first-time MI.

Main Outcomes and Measures  Risk of bleeding (requiring hospitalization) or a composite cardiovascular outcome (cardiovascular death, nonfatal recurrent MI, and stroke) according to ongoing NSAID and antithrombotic therapy, calculated using adjusted time-dependent Cox regression models.

Results  We included 61 971 patients (mean age, 67.7 [SD, 13.6] years; 63% men); of these, 34% filled at least 1 NSAID prescription. The number of deaths during a median follow-up of 3.5 years was 18 105 (29.2%). A total of 5288 bleeding events (8.5%) and 18 568 cardiovascular events (30.0%) occurred. The crude incidence rates of bleeding (events per 100 person-years) were 4.2 (95% CI, 3.8-4.6) with concomitant NSAID treatment and 2.2 (95% CI, 2.1-2.3) without NSAID treatment, whereas the rates of cardiovascular events were 11.2 (95% CI, 10.5-11.9) and 8.3 (95% CI, 8.2-8.4). The multivariate-adjusted Cox regression analysis found increased risk of bleeding with NSAID treatment compared with no NSAID treatment (hazard ratio, 2.02 [95% CI, 1.81-2.26]), and the cardiovascular risk was also increased (hazard ratio, 1.40 [95% CI, 1.30-1.49]). An increased risk of bleeding and cardiovascular events was evident with concomitant use of NSAIDs, regardless of antithrombotic treatment, types of NSAIDs, or duration of use.

Conclusions and Relevance  Among patients receiving antithrombotic therapy after MI, the use of NSAIDs was associated with increased risk of bleeding and excess thrombotic events, even after short-term treatment. More research is needed to confirm these findings; however, physicians should exercise appropriate caution when prescribing NSAIDs for patients who have recently experienced MI.

COMMENT:  The American Heart Association first recommended against NSAID use in people with prior myocardial infarction in 2007.  In 2012 Danish investigators found that 44% of persons with acute myocardial infarction were taking NSAIDs and that the risk of death or recurrent myocardial infarction with NSAID use was increased for at least 5 years.  In this follow up study, 34% of such patients had been prescribed a NSAID and that there was an associated risk with such use for as little as three days.  We need to get this message out folks. It has been eight years since the initial concern was raised and the labeling of the NSAIDs does contain warnings about their use in persons with cardiovascular disease; perhaps it is time to add stronger labeling.

German nurse jailed for life for murdering patients

Posted in Respiratory medicine at Sat, 28 Feb 2015 18:03:32


Posts: 883
Joined: 13 Oct 2009

“German nurse jailed for life for murdering patients

Prosecutors at the district court of Oldenburg said he had been bored and had wanted to practise his - as he himself described them - "excellent" resuscitation skills. If his first attempt at resuscitation was successful, they said, he would sometimes make a second attempt.”





Of course, this has been in the news here for quite a while – the most shocking aspect is probably that he probably killed more than a hundred patients and that colleagues who started to suspect sth didn´t speak out earlier.

Do you think this is a single case and are we all watchful enough ?

New UK driving offence - Driving whilst impaired by drugs

Posted in General clinical at Fri, 27 Feb 2015 17:07:44


Posts: 883
Joined: 13 Oct 2009
On the 2nd March 2015 a new law will come into effect which introduces offences for drug driving.  The current drug driving legislation requires the presence of drugs and evidence of impairment which is often difficult for the police to prove.  The new law will work on the same principles as the drink driving offences with’ specified levels and excess will result in prosecution. the offence will carry a mandatory disqualification and a maximum of 6 months imprisonment.
The police will use a drug screening device (DSD) to establish the presence of drugs.  These can test up to 6 drugs in a single test of a person’s saliva.  These is only one DSD approved so far and it is only approved for Cannabis presence. The DSDs are not 100% accurate and therefore cannot be used as evidence in a court case.  They can give false readings both positive and negative and are affected by eating and drinking prior to the test which is why manufacturers of the DSD recommend that there should be a 10 minutes delay after eating or drinking.
The Crime and Courts Act 2013 created a new limits-based offence of drug-driving by inserting a new section 5A in the Road Traffic Act 1988. Under the Act, a driver can be convicted if “the proportion of the drug in” his or her “blood or urine exceeds the specified limit for that drug”.
Clonazepam, 50 µg/L
Diazepam, 550 µg/L
Flunitrazepam, 300 µg/L
Lorazepam, 100 µg/L
Methadone, 500 µg/L
Morphine, 80 µg/L
Oxazepam, 300 µg/L
Temazepam, 1000 µg/L
Illicit drugs
Benzoylecgonine, 50 µg/L
Cocaine, 10 µg/L
Delta–9–Tetrahydrocannabinol (Cannabis and Cannabinol), 2 µg/L
Ketamine, 20 µg/L
Lysergic Acid Diethylamide (LSD), 1 µg/L
Methylamphetamine – 10 µg/L
Methylenedioxymethaphetamine (MDMA – Ecstasy), 10 µg/L
6-Monoacetylmorphine (6-MAM – Heroin and Morphine), 5 µg/L
There are still a number of concerns about whether the limits accurately reflect the different speeds at which the drug breaks down in the blood, but the assurances have been provided that the limits include these variations. Yesterday I heard an interview with a medical expert who was clearly concerned that it could be very difficult to prove exactly how much medication had been taken and how to accurately prove impairment due to drivers' varying metabolism.
A defence has been introduced under S5 A(3) which states that if a drug is prescribed for medical or dental reasons and taken in accordance with any directions by the Doctor, Dentist or consultant and also the manufacturers instructions.  The drugs must also be being used legally ie not prescribed to another.
Until more devices are approved which can measure accurately the levels the police will still be required to do the impairment test which is currently mandatory for driving whilst unfit through drugs.
There will similar offences of “being in charge ” and failing to supply specimens which will carry similar penalties. 
Greater Manchester Police have already said they will not be enforcing the new law from monday. Chief Insp Mark Dexter stated "We have taken the decision, in GMP, not to make use of the legislation whilst we satisfy ourselves that the legal and procedural issues involved in prosecuting these cases can properly withstand legal scrutiny. We are mindful that if we get this wrong then a significant amount of court time and public money could be wasted. There are issues that have not been resolved".
It is not clear at present what impact this legislation will have upon Doctors when patients try to use a medical defence.

Idiopathic pulmonary fibrosis - ask your questions via TweetChat today #IPFchat

Posted in Respiratory medicine at Wed, 25 Feb 2015 10:55:38


Posts: 1461
Joined: 15 Apr 2010

Max Pemberton and Toby Maher are hosting a tweetchat about IPF now.

Search #IPF on twitter, or register on TweetChat to join

Divorce among medics

Posted in General at Sat, 28 Feb 2015 18:19:20


Posts: 883
Joined: 13 Oct 2009

New research from the US shows physicians & surgeons are less likely to divorce than nurses, healthcare executives, and lawyers, but as likely to divorce as dentists and pharmacists.

The study didn't account for medic-medic marriages but suggests that female medics have a substantially higher prevalence of divorce than male medics which may be attributable to hours worked.

Do the results of the study reflect your experience/the experience of doctors you know?

sodium thiopental

Posted in Anaesthesia at Fri, 27 Feb 2015 12:01:41

John D

Posts: 3446
Joined: 01 Feb 2010

Hello I am not an anaesthetist,


but I wanted to ask a question.


I have a concern about a friend who  is considering ending his life.




He  has 20 mg of powdered sodium thiopental which he plans to take orally


And some anti throwing up medicine. He wouldnt die from this right.? I saw this is an


I.v drug on google, so he'll be ok, right? Thank you for your help.




Thank you

Home nebulisers for COPD - not always the answer.

Posted in Respiratory medicine at Wed, 25 Feb 2015 10:27:29


Posts: 1461
Joined: 15 Apr 2010

This study in BMJ Open Respiratory looks at real life experiences of COPD patients with nebulisers.  


Patients always want nebulisers, as they associate them with getting better in hospital.  But we know they aren't any more effective than inhalers, particularly multidosing via a spacer.


The study shows that patients struggle with all sorts of aspects of home nebuiliser use.  

Do you routinely hand out nebulisers to your COPD patients?  Or do you have them locked away in a fort knox like store room?



Get old medical articles

Posted in General at Thu, 26 Feb 2015 17:26:45

John D

Posts: 3446
Joined: 01 Feb 2010

Hello every body
Is there any way to get old medical articles that are not available online
For example a service that scans these articles and send them by mail

Medicolegal Case Report - Gastroenterology

Posted in General at Sat, 28 Feb 2015 22:27:37


Posts: 1768
Joined: 08 Oct 2010

This Judgement was handed down in 2010 but concerned events within the month of December 1999. It is not at all unusual for cases to take this long but it cannot be good for the Doctors involved to have this hanging over them, nor the family of the deceased. The only people comfortable with such unnecessary foot dragging are the lawyers who receive payment however long it takes and however expensive it becomes. Today and tomorrow I will aim to publish here the whole case in segments. There are bits and pieces that need amending and a very large amount of legal theory which will not concern Doctors reading this. Please feel free to comment on any part of it as we go along.

In December 1999 Mr A developed an itchy rash on his arms/legs/trunk along with Jaundice.  On 7 December 1999, having sought  medical  attention at Portrush  Medical  Centre for a blood sample, his general practitioner Dr Logue diagnosed inflammation/bile duct stones or a serious malignant state. Consequently the plaintiff telephoned Professor Roy Spence (Professor Spence) who arranged an appointment at the outpatients' clinic at the Ulster Independent Clinic (UIC) on 9 December 1999. The deceased had previously been under the care of Professor Spence in 1996 with rectal bleeding when a diagnosis of diverticulitis was made.  Professor Spence alleged in evidence that on examination in 1999 the deceased looked unwell, jaundiced and had an enlarged liver. He said that obstructive jaundice can be caused, inter alia, by cancer of the head of the pancreas, gallstones in the bile duct (these two causes accounting for about 90% of jaundice in middle aged men) and the remaining 10% include a stricture of the bile duct which can be benign or malignant. In the event it proved to be the case that Mr A  did have a malignant stricture of the bile duct namely a cholangiocarcinoma (hereinafter described as "CC").

Professor Spence thereafter remained in overall charge of Mr A’s care between 9 December 1999 and 17 December 1999 overseeing his care as an inpatient at the UIC and coordinating the investigation of his condition by various other experts, He was sufficiently concerned that he immediately arranged the patient's admission to UIC. An ultrasound scan was carried on the evening of 9 December 1999 by a radiologist Dr Crothers and subsequently on 10 December 1999, a CT scan of the abdomen on 13 December 1999 was performed by Dr Crothers. According to the note made by Dr Crothers, this revealed a dilated common hepatic duct with marked intra hepatic biliary dilatation on both lobes of the liver. The head of the pancreas was reasonably well visualised and no obvious mass was identified. Even though the head of the pancreas did not seem to be a difficulty, he stated that USS is not an infallible guide to the condition and so the CT scan was arranged.

Professor Spence then referred Mr A to Dr Collins, Consultant Gastroenterologist at the Royal Victoria Hospital (RVH). Dr Collins considered that an ERCP was necessary to define the cause of the obstructive jaundice which he duly performed on 14 December 1999. According to Dr Collins the ERCP confirmed a stricture in the upper common hepatic duct involving the bifurcation of the left and right hepatic ducts. It was his contention that the most likely diagnosis was that of a hilar cholangiocarcinoma tumour.  It was Dr Collins' evidence that due to the tightness of the stricture only small biliary stents for the purpose of drainage could be inserted namely a 5 and 7 French stent in the right hepatic duct. He was unable to drain the left side due to the stricture. Both the need for an ERCP and the manner in which it was carried out were matters of dispute in this case. It was the plaintiff's contention that infection occurred into the biliary tree at the time of the ERCP when the drainage was not provided. The infection worsened in the absence of appropriate treatment causing the consequences which led to his death according to the plaintiff's case. The condition of Mr A after the ERCP procedure was a matter of contention in this case, with the defendants alleging that nothing of undue concern arose until 21/22 December 1999 whereas the plaintiff alleges that matters of concern were ignored from a much earlier stage. Dr Collins asserted that he had discussed the ERCP findings with Dr Ellis, a consultant interventionist radiologist before conversing with a surgeon, Mr Diamond.

Following the ERCP, Professor Spence consulted the only hepato-biliary surgeon at that time in Northern Ireland namely Mr Diamond of the Mater Hospital who saw the Mr A on 15 December 1999. Mr Diamond asserted that, having had the benefit of the deceased's UIC notes records and scans and subsequently Dr Collins' opinion (and thus that of Dr Ellis ) on the ERCP findings his view that the lesion was an inoperable type IV hilar CC tumour. He recommended palliation through the insertion of drains placed by a trans-hepatic approach using  percutaneous trans-hepatic cholangiography. This classification and conclusion was challenged by the experts on behalf of the plaintiff who broadly asserted that it was a type 3A tumour on the universally acknowledged Bithmus scale which was operable. Save for the visits to the RVH for the CT scan on 13 12 99 and the ERCP on 14 December 1999, the deceased remained a patient in the UIC between 10 December 1999 and 17 December 1999. The UIC is an independent hospital with charitable trust status, which opened in 1979. Patients are referred by their GP for consultant care in the clinic. It is not a clinic equipped to carry out ERCP/PTC procedures and does not have an Intensive Care Unit (ICU). The competence of the consultants and nursing staff from that clinic was an issue in the case. In 1999 UIC did not employ  medical  staff and the patient care was consultant led. If illness arose, the consultant in charge was contacted directly and overnight a consultant was on call.   Between 17 December 1999 and 24 December 1999 Mr A was a patient in the RVH. Subsequent to the ERCP Mr A underwent PTC procedures carried out by Dr Ellis on both 17 December 1999 and 20 December 1999 . The delay between the ERCP on 14 December 99 and the first PTC was a matter of contention between the parties.

On 17 December 1999 an initial cholangiogram demonstrated obstruction of the right main hepatic duct extending into the origins of the anterior and posterior sectoral ducts. There was also occlusion of the left main duct. A metal stent was placed into the right ductal system and an external drain placed on the left. It was impossible according to Dr Ellis initially to get a stent through the lesion on the left side and therefore an external drain was placed on the left side for drainage. Over the next 24-48 hours it was a matter of dispute as to how much, if any, bile Mr A's external drain produced and thus how successful the PTC had been.  On 20 December 1999 a further metal wall stent was placed across the tumour to achieve drainage from both sides of the liver. This second metal stent was placed across the left hepatic duct stricture into the first metal stent in a T configuration rather than the usual Y configuration because it had proved impossible to put a parallel metal stent on the left side. The aim was to place the stent on the left side across the blockage so that it could drain into the right stent and then drain down into the intestine. It was the defendants' case that these PTCs did achieve some measure of drainage from both lobes of the liver.  It was the plaintiff's case that this procedure had a number of errors and did not drain well or at all. It was contended that the bile, unable to escape through that stent on the left side, escaped into the peritoneal cavity through the puncture site at the liver causing peritonitis. The plaintiff's case was that the deceased deteriorated thereafter. There thus had been inadequate ERCP management with no alternative method of drainage for 3 days, no recognition of post ERCP symptoms followed by inadequate biliary drainage at the PTCs on 17 and 20 December 1999. The plaintiff further contended this condition was not treated until 23 December 1999, despite clear signs of infection, with aggressive intravenous fluids and antibiotics i.e. 9 days after the original ERCP. The plaintiff's evidence was that the defendants at various stages ignored symptoms such as the deceased suffering severe abdominal pain, fever, rigors, lack of appetite, nausea and passing black tarry stools all of which were indiciae of infection, peritonitis, septic shock, pancreatitis, multi-organ failure etc.

The nature and degree of a number of allegedly rancorous verbal exchanges between the plaintiff and  medical  staff and nurses at the RVH during this period was a matter of much dispute during the case and included an allegation by Mrs A that Dr Collins had assaulted and falsely imprisoned her on 24 December 1999. According to the defendants it was only from 22 December 1999 onwards that more serious symptoms started to emerge in the light of a report from the bacteriology department showing that his blood cultures revealed an ecoli gram negative rod infection. His condition deteriorated on 23 December 1999. An intensive care opinion was obtained and the matter discussed with the specialists in the renal department of BCH but neither haemodialysis nor immediate transfer to the ICU was required at that time according to the defendants. A central venous line was inserted by an anaesthetist. An unfolding pattern of non improving blood pressure and poor urinary output emerged. The treatment the Mr A received from  medical  and nursing staff in the RVH, and in particular the events surrounding 23 and 24 December 1999 were much in dispute during the trial. Following the breakdown in relations between Mrs A and  medical  and nursing staff at the RVH and with Dr Collins in particular on 24 December 1999, Mr A was transferred to the High Dependency Unit of the Belfast City Hospital under the care of Professor Spence. He remained at the BCH between 24 December 1999 and his death on 30 December 1999. The reasoning behind the transfer and the  medical  advisability of doing so was a matter of contention. On arrival at BCH it is clear that Mr A at that stage was suffering from deteriorating renal function, hypotension, poor urinary output, sepsis and his abdomen was distended. He was given fluid intravenously, drugs and antibiotics to deal with the very low blood pressure and to stabilise his condition. Once again the treatment that was given to the deceased at this time was a matter of dispute between the parties. The defendants contend that initially he improved somewhat but by 26 December 1999, Dr McNamee, a nephrologist at BCH, found him to be confused with continued renal failure. On 28 December 1999 an ultrasound scan and CT scan were performed. Dr McNamee's assertion was that this was to fulfil the need to try and search for the on-going sepsis. The defendants' case was that a CT guided drainage procedure was undertaken and bile stained fluid was aspirated. It was Mrs A’ assertion that the purpose of this procedure was in fact to replace a metal stent which she alleged had been voided per rectum by the deceased on the 27 December 1999 in her presence and that of a nurse and that this procedure contributed to his demise.  It soon became clear however that the deceased was suffering multi organ failure. Over the few days in the BCH he underwent haemodialysis for his renal failure but despite the support of therapy and continued antibiotics his condition deteriorated as his jaundice worsened and his coagulation deteriorated. On 28 December 1999 Professor Spence considered that owing to rapid deterioration he was not fit for a general anaesthetic to undergo any surgical procedure for example to perform peritoneal toilet. Following discussions with the surgeons, nephrologists and an anaesthetist it was agreed that his continuing care should be palliative. Mr A died on 30 December 1999.

A post-mortem examination was undertaken by Professor Crane on 31 December 1999. Professor Crane's report, and his evidence evinced his view that there was an infiltrating CC in the area of the bifurcation of the common hepatic duct. He alleged he sought the view of a histopathologist at the RVH, Dr Sloane, to confirm the presence of a CC tumour. This was a source of complaint from Mrs A who challenged not only Dr Sloane's role and the independence of the post-mortem but suggested Dr Collins had tried to influence the outcome. According to Professor Crane, histologically there was acute haemorrhagic pancreatitis with widespread destruction of the glandular tissue and foci of fat necrosis. Professor Crane concluded that following stent insertion, Mr A developed septicaemia, which was further complicated by renal failure and it was these conditions that were eventually responsible for his death.







Head transplant

Posted in Medical ethics at Thu, 26 Feb 2015 10:35:35

John D

Posts: 3446
Joined: 01 Feb 2010

Despite the rapid advances in transplant mmedicine and in re-attaching the nerves of severed limbs, and even spinal cord tracts, most people think that to transplant a head is still in Science Fiction.  But an Italian surgeon, Sergio Canavero, has proposed a project to achieve this by 2017.   He thinks that procedures to encourage restoration of spinal cord function are sufficient, and that tissue cooling and revival techniques will protect the brain.    He is far from being the leader of a wide group of transplant surgeons, but will be speaking at a major conference in Annapolis in June this year.

But who will be the subject of these operations?   Canvero suggests that brain dead donors should be used first, wholly as expertimental subjects, but who could be to object of a successful technique?   People with extensive metastatic cancer or debilitating neurological disease?  People with severe body image problems, like those who want a limb amputated, with multiple traumatic limb loss, people with severe multi-joint arthritis or just old people?

Canavero is right to start a debate, as this will eventually be a possibility, but is his timeline still science fiction?


Is a smoking ban in parks and outdoor spaces a good idea?

Posted in General clinical at Fri, 27 Feb 2015 20:49:44


Posts: 1141
Joined: 07 Sep 2009

Possibly even more contentious than the thread about smoking in cars ...

A Head to Head article in The BMJ asks whether a smoking ban in UK parks and outdoor spaces is a good idea.

Arguing 'Yes' are Ara Darzi and Oliver P Keown from the Institute of Global Health Innovation. They say, "Extending antismoking legislation in the United Kingdom to encompass a ban in parks and squares is an opportunity to celebrate the great beacon of healthy living, clean air, and physical activity our green spaces are designed for. And, crucially, it is an opportunity to support our population—young and old—to make healthier lifestyle choices easier." 

And they imply the smoking reduction trends unofficially observed in cities where such bans are in place (New York City,Hong Kong, Toronto)  speak for themselves.

Arguing 'No' is public health professor Simon Chapman from the University of Sydney. He writes, "In a 2013 review I worked on, the only studies we found were of real world or simulated outdoor exposure in crowded settings such as bar patios, beer gardens, and bus shelters. No studies looked at exposure in parks or on beaches—almost certainly because researchers with any knowledge of airborne exposures would appreciate that such exposures would be so small, dissipated, and transitory as to be of no concern."

He adds, "In Australia, daily smoking prevalence is now only 12.8% and is highly likely to keep falling. This has been achieved without the unethical coercion of smokers."

Which argument do you support?


Poll about smoking in cars

Posted in General clinical at Fri, 27 Feb 2015 20:28:49


Posts: 1141
Joined: 07 Sep 2009

The thread Smoking Banned in Cars is too interesting to go without a poll

Dietary cholesterol consumption no longer of concern

Posted in Cardiology at Sat, 28 Feb 2015 05:27:38

heart doc

Posts: 9
Joined: 07 Sep 2014
An expert panel in the US on healthy eating has published its dietary recommendations this week in a 570 page report. 'Current evidence suggests that there is no appreciable relationship between heart disease and dietary cholesterol consumption'. They have also concluded that 3 to 5 cups of coffee per day can form part of a healthy balanced diet http://www.medscape.com/viewarticle/840328?nlid=77207_1985&src=wnl_edit_medn_card&uac=103682HR&spon=2 Crazy advice or welcome evidence based challenge to dogma? .....You decide