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Posted in doc2doc feedback at Mon, 01 Sep 2014 08:04:25

AnneG

Posts: 360
Joined: 18 Mar 2014

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

diabetic dementia.

Posted in Diabetes at Sat, 30 Aug 2014 08:46:54

neuromedicine

Posts: 588
Joined: 23 May 2012

Recently we getting patient with diabetes to developed dementia feature in early age than degenerative dementia. Any process of diabetes that induce degeneration or it is only vascular.so what are the role of diabetes to develop. Diabetic dementia. Pl contribute and discuss.

Case to diagnose

Posted in Neurology at Sat, 30 Aug 2014 08:40:16

neuromedicine

Posts: 588
Joined: 23 May 2012

I am not sure about the forum category.

 

Symphoms which occur for about 3 years:

- all began with abdominal pain located on the lefs side and  sharp pain below the ribs - ultrasonography negative, gastroscopy negative, no signs of Helicobakter

- heart echo and EKG negative, but echo showed no mitral vave proplapse which was found when the patient was 15 years old

- lack of vitamin B was diagnosed, injections didn't help

- next USG has shown adrenal hyperplasia and slightly enlarged liver

- protuberance discs in the thoracic (not sure about this translation, but i hope you know what i mean)

- rehab doesn't help

- dizziness, weakness, sleepiness

- stabbing pain on the right side at the height of the liver just below the ribs

- heartburn (does not depend on eating or drinking)

- no problems with blood pressure

 

I wonder what the diagnosis is. At least I'd like to have an advice for further proceeding.

 

Diabetic neuropathy.

Posted in Diabetes at Sat, 30 Aug 2014 08:50:10

neuromedicine

Posts: 588
Joined: 23 May 2012

It is very critical to diagnosis ,to establish pathogenesis and to treat this patient. Some patient's develops neuropathy without overt diabetes. We could not diagnosed some patient by NCS as in small fibre neuropathy. In pathogegesis , _metabolic, ischaemic , reduction of trophic factor has important role.we treat patient mostly by symptomatically. How we diagnoses early , how we modify the disease process and is any disease modifying drugs with other symptomatically managed drugs.vascular theory going forward in this over metabolic theory.sometimes PVD has good association. How we overcome all the aspect of this disorder.pl share.

Is it time to take another look at shaken baby syndrome?

Posted in Medicolegal at Sat, 30 Aug 2014 06:28:48

Skipper

Posts: 22
Joined: 04 Apr 2013

Over a decade ago several women were sent to prison having being found guilty of murdering their child/children. Frequently the evidence of Prof Roy Meadows was critical in securing the conviction - he described a triad of signs that he absolutely insisted characterised shaken baby syndrome. Since then he has been utterly discredited and faced censure by the GMC.

The most experienced Neuropathologist in the UK Dr Squier gave evidence for the prosecution  in a case where a woman was convicted of SBS. Several years later she appeared for the Defence for the same woman at her appeal, the woman was released. Dr Squier completely changed her view about SBS and feels sure that many people now in prison for murdering their children are innocent. Subsequently she has been ostracised by medical colleagues, Police and Judges - for a fascinating interview see this link:

http://www.dailymail.co.uk/femail/article-1382290/At-half-parents-tried-shaken-baby-syndrome-wrongly-convicted-expert-warns.html

Is it time to wake up to the new understanding of children's brain development and function?

Are senior Doctors afraid to change their views and leave their comfort zone?

kirked

 

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

Posted in News & media at Tue, 02 Sep 2014 02:14:19

ashi

Posts: 10
Joined: 28 Feb 2009

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.

What's your diagnosis? Pigmentation and confusion.

Posted in General clinical at Tue, 02 Sep 2014 11:12:21

Maxim

Posts: 179
Joined: 14 Dec 2010

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?

Good Samaritan Acts

Posted in Medicolegal at Tue, 02 Sep 2014 13:03:12

NandaKar

Posts: 44
Joined: 24 Nov 2012

I gave a presentation a few days ago about 'Legal Aspects of Emergency Care' to a group of senior Doctors. I explained that in the UK there is no legal duty for anyone to step forward and assist but that the medical authorities say there is a moral/professional duty to help as best one can in the circumstances. Despite this one Physician was adamant he would not help in any Trauma type situation because he is not trained in trauma care. I countered this by saying that one does not need special knowledge in trauma care because anyone giving First Aid (whether Doctor, Nurse, First Aiders) always approaches with the same process A B C etc.

I am one of extremely few lawyers who have undertaken the ATLS course (but do not for one minute suggest I have any expertise or ability nor would I dream of declaring my participation in the course in any emergency) but A B C D etc was drilled in repeatedly. Therefore if one comes across an accident or medical emergency of any type one can best help by this approach.

The Consultant would not have it at all. He said 'what about if I move the unconscious pt from a burning car and cause (or worsen) a spinal injury'. My response (as a medical lay man) was quite simply if the car is on fire and the pt is unconscious you either leave them to die in the fire or get them out despite the concomitant risk of making injuries worse. A court will not find against anyone moving the pt where there is no choice.

I was pretty astonished at his attitude and also dissapointed. We have discussed Good Samaritan acts a number of times but I remain curious about Doctors current understanding and approach to such acts.

kirked

NB Please do not think I am bragging or trying to inflate my ego because I did the ATLS course - I fully recognise I was a guest participant and undertook it for my own interest. Whilst I received a pass in the exam it means nothing in reality.

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

Posted in General clinical at Tue, 02 Sep 2014 09:53:31

Abi Blumenthal

Posts: 10
Joined: 27 Jun 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 

Trapped lingual frenulum

Posted in General clinical at Mon, 01 Sep 2014 13:05:15

johnmck

Posts: 42
Joined: 14 Feb 2009

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

 

Ashya King case: breakdown of communication?

Posted in News & media at Tue, 02 Sep 2014 10:24:12

Pat Harkin

Posts: 50
Joined: 26 May 2010

For those outside the UK the news over the last few days has been dominated by the case of Ashya King: a five year old boy with a brain tumour who has been removed from hospital by his parents against medical advice. Ashya and his siblings are now in Spain where his parents were hoping to raise funds for private medical treatment. 

The parents have been arrested and face extradition back to the UK. They are in Madrid while Ashya and his siblings are in Malaga. You can see much fuller coverage of the story here: http://www.bbc.co.uk/news/uk-england-29009883

Social media has been a big factor with Ashya's father and brother posting videos explaining their actions and how they are caring for him - countering statements from the police. 

What are your thoughts on this case and how the authorities have acted and what the UK hospital could have done? There have been similar cases of parents disagreeing with doctors but few have been so dramatic. 

what caused this cardiac arrest?

Posted in Cardiology at Sun, 31 Aug 2014 12:49:39

Maxim

Posts: 179
Joined: 14 Dec 2010

Its almost the end of august and the time when our newest qualified doctors have been in post for about a month. One of this brigade is my cousin and he has just been to see me this afternoon to discuss this case -which to be fair I struggle with. Here are the details he recounts

95 year old lady admitted with urosepsis treated appropriately and apparently getting better,  noted to be in AF on admission, echo shows good lv function

seen on the ward round on wednesday - no concerns

seen on thursday ward round- nursing staff report poor urine output, BP stable Heart rate 105bpm , ecg requested by ward team

 

5pm  Thursday - ecg seen and shows heart rate of 80bpm, T waves appear tall and tented

The new F1s are unable to acquire a venous or an arterial gas and call the oncall SHO

SHO attends 40 mins later also has difficulty and calls the reg. no urine output still . bladder scan shows bladder is empty

reg attends at around 8:30, obtains venous blood and asks for a CXR

CXR shows pulmonary oedema and bloods return with a potassium of 6.6. Whilst they are trying to treat all of this patient has cardiac arrest and cannot be resuscitated.

 

When asked my F1 cousin can not recall the blood pressure, serum creatinine, eGFR or lactate but is sure that the ecg did not show any ischaemic change.

My first thoughts were that this is an ischaemic event either cardiac or intrabdominal. Any other thoughts?

sadian

Investigative reporting; garbage in = garbage out. Raising the bar.

Posted in General clinical at Mon, 01 Sep 2014 07:49:58

Odysseus

Posts: 4137
Joined: 24 Feb 2009

Part of my work is reporting sleep studies but these are only for my own patients now. Formerly I also used to report on patients unknown to me but I found the work tedious and unfulfilling. Yesterday I spent several hours doing reports in patients of mine and noticed how much more detailed and specific my reports were compared        with "unseen" patients. This reminded me of what we called "Unseens" in Latin exams where you were given text to translate that was unfamiliar to you. They were akin to walking through fog for a while until you could make out the terrain. 

Which brings me to investigations in general. In my opinion, the quality of the report depends in the quality of the information provided. Indeed, in more complex cases I even enclose a letter attached to the request so that the radiographer knows exactly where I am coming from. Talking to the doctor doing the test in person, particularly after the result is available, is for me, invaluable. I do this often with PET scans. 

My thesis is therefore, "Garbage in = garbage out". The corollary is "The more you put in, the more you get out".

This is a bit of hyperbole of course and is not to diminish reporting which is done to the best  with the information provided.

I have always taken the trouble to include useful information on all investigations I request; even pathology tests.

Finally, if you know why you are going into a room and what you are looking for, the more you will see. Walk in with no clues and you may see little.

What do you think. What do you do? Do you agree?

I believe we can improve what we do by following this maxim.

Odysseus

Doctors aren't supposed to die and certainly not in the saddle

Posted in General at Tue, 02 Sep 2014 10:12:34

Pat Harkin

Posts: 50
Joined: 26 May 2010

I saw a patient  last week I have been treating for about fifteen years. He has severe ischaemia heart disease with a defibrillating pacemaker which has shocked him on many occasions. I never take his attendances at my rooms for granted. 

Land yet he saw me again last week looking glum. He had visited his much beloved GP on the Friday only to hear that his doctor had died suddenly the next day. He had been going to that doctor for 38 years and I had corresponded to that doctor probably for more than fifteen years. My patient had always thought he'd go first. He felt this was unfair. The Fates had cheated on him.

I wrote a letter of condolence to the doctor's partner. But somehow I felt about as lost as my patient. Doctors aren't supposed to die. 

My late father who was a GP went to work one morning with chest pain. His first patient who could see he was in a sweat, said, "You sure look crook, Doc" and had the common sense to take him up to the local chest hospital where he was told he had a myocardial infarction. He survived only to die in intractable heart failure about fifteen years later. His end was miserable and  cruel. 

I  knew one GP who took the afternoon off and hanged himself.  When I was a student, our director of anaesthetics was found at his desk on Monday  morning, dead with a drip still running. 

Yes, I have seen many colleagues younger and older die. My male boss in thoracic medicine died of breast cancer having discovered a lump in his breast on a ward round while his peer, also my boss perished defending his house in a brushfire. I have seen many a suicide, deaths from heart disease and breast cancer.

i once saw a psychiatrist who, on discovering a metastasis in his cervical spine, took an overdose of methadone. He was brought into  the casualty department I was working in, and saw him resuscitated. It was aweful. 

Another psychiatrist much loved and respected by colleagues, took his life with a gun on a park bench where there'd be less mess.

Yes, doctors are above pathology and fly above humanity, inviolate, untouchable, erudite and immortal. 

Vale, noble colleague. You served your patients well.

I'm back in the saddle again....

Totin' my old 44.

Odysseus

CV / LinkedIn / Web Profiles and telling lies

Posted in Medicolegal at Sat, 30 Aug 2014 13:25:24

DuaneF

Posts: 1446
Joined: 09 Dec 2011

Last month Fraud Prevention officers sent a guide to all University students in the UK warning them of the consequences of not telling the truth on their job application, CV or web profile like LinkedIn. It cites an example of one man who altered his Degree Certificate from a 2:2 to a 2:1. He was given 12 weeks in prison.

In my organisation we have a very clever Forensic Computer programme (to run on job applicants) with parameters which seek out information about the individual from many places and databases. It also visits Facebook, LinkedIn etc. Twice we have picked up information at odds with the info supplied by the application and in both cases they had exaggerated their employment history and detected discrepancies in their qualifications. Some people don't seem to realise that nowadays just a basic internet search can catch them out.

What is your own experience? Have you come across blatant lies or exaggerations? e.g. Making gaps in employment disappear by just altering the dates slightly? Has someone given the impression their job carries far more responsibility or experience than it does in reality? Is it generally accepted that an applicant will obviously present themselves in the best possible light so a little exaggeration is expected? 

kirked

 

scrotal scan in young child

Posted in Radiology at Sun, 31 Aug 2014 09:23:54

Odysseus

Posts: 4137
Joined: 24 Feb 2009

This infant shows a definite scrotal pathology. Can you spot it?

 

Joe

2.5 biological parents!

Posted in General clinical at Mon, 01 Sep 2014 14:43:18

John D

Posts: 3188
Joined: 01 Feb 2010

BBC News reports a girl with 3 biological parents where she had genes from her parents and mitochondria from another lady. It is quite intriguing to think whether such genetic diversity would serve the variation of the human pool in general or not. I would like to learn your opinion whether this would help reduce the risk of genetic disorders or not. My first thoughts would go for diseases with possible mitochondrial inheritance, and whether a mother can avoid that her baby inherits her disease by acquiring mitochondria from someone else.

Tier 4 dependent, want to apply for ct1?

Posted in Careers at Sat, 30 Aug 2014 10:53:33

John D

Posts: 3188
Joined: 01 Feb 2010

Hi , I am tier 4 dependent , want to apply for ct1/ct2 this year in round 1 or 2 , I wanted to know how to contact ukba and ask them my eligibility for labour market test ? Am I eligible for round 1 or only for round 2 as dependent tier 4 ? And criteria of not more than 18 months experience is applied to the speciality one is applying for or in general no more than 18 months experience ? Please reply thanks .

chronic atrial fib

Posted in Cardiology at Tue, 02 Sep 2014 01:49:51

Dr.Chid

Posts: 614
Joined: 21 Feb 2012
i have a case female  incidentally discovered her chronic atrial fib(normal lab value and echo) as a screen with pasthistory of hypertension on betablocker and ccb with occasionally lower limb oedema most likely adverse effect of ccb the questions are 1st shoud she take anticoagulation
2nd is betablocker good for her blood pressure and chronic atrial fib as she has 61 old
3rd what is the alternative therpay for her essentail hypertension
thank u 

Does the world need a new inhaled insulin?

Posted in Diabetes at Sun, 31 Aug 2014 21:40:23

John D

Posts: 3188
Joined: 01 Feb 2010

We are about to find out.  After an epic failure in sales, Pfizer pulled Exubera from the market in 2006 with an estimated US$2,000 million.  Afrezza is the new kid on the block approved by the FDA for both type 1 and type 2 diabetes.  Why try again?  Because patients really want an inhaled insulin option.  The two major patient barriers to Exubera were a large and unwieldy, dispenser and dosing in unfamiliar mgs rather than the universal units.  The new dispenser is small and has been described as whistle-shaped and the vials come is 4 and 8 unit sizes.  There remains the problem of inhaling a foreign substance and the inertia of clinicians who are quite content with using insulin injections.  There will also be a premium in cost that insurance companies may be reluctant to cover.

Should we be recommending plant-based diets to people with or at risk for diabetes?

Posted in Diabetes at Mon, 01 Sep 2014 10:35:03

Dr.Chid

Posts: 614
Joined: 21 Feb 2012

Adapted from Cardiolgy News report on the AADE meeting  by SHARON WORCESTER

The Adventist Health Study-2 (AHS-2), for example, demonstrated that a plant-based eating pattern – defined as ad libitum whole grains, legumes, fruits, and vegetables, and avoidance of all animal products, added oils, and high-fat foods – reduced the incidence of type 2 diabetes. The prospective cohort study involving more than 96,000 adults demonstrated that body mass index and the incidence of diabetes increased in tandem with the amount of animal products in the diet, according to Meghan Jardine, who reviewed the recent literature on plant-based nutrition in a poster presented at the annual meeting of the American Association of Diabetes Educators.


 

The prevalence of type 2 diabetes among nonvegetarians, semivegetarians, pescovegetarians, lacto-ovovegetarians, and vegans in that study was 7.6%, 6.1%, 4.9%, 3.2%, and 2.9%, respectively, and BMI for each of those groups was 28.8, 27.3, 26.3, 25.7, and 23.6 kg/m2, respectively, said Ms. Jardine, a registered and licensed dietician, certified diabetes educator, and diabetes education coordinator at Parkland Health and Hospital System, Dallas.

AHS-2 also demonstrated increased longevity in those who followed a plant-based eating pattern, with men living 9.5 years longer and women living 6.1 years longer than their meat-eating counterparts (JAMA 2013;173:1230-8).

In addition, a National Institutes of Health study demonstrated that a low-fat vegan diet led to significantly greater improvements in glycemic and lipid control than did a conventional diabetes diet in patients with type 2 diabetes.

Hemoglobin A1c levels in 49 patients on the low-fat vegan diet improved from 8.06 to 7.65 at 74 weeks, but while the levels in 50 patients on the conventional diabetes diet initially improved from 7.93 to about 7.7 at 11 weeks, at 74 weeks they had increased to 7.94 (Diabetes Care 2006;29:1777-83).

Among the other findings that Ms. Jardine mentioned were those from "a remarkable study" in which 17 of 21 patients with sharp, burning pain characteristic of distal polyneuropathy experienced complete pain relief after initiating a low-fat, high-fiber, vegan diet along with a daily 30-minute walk, and findings from several studies that have suggested that plant-based eating preserved renal function.

Moreover, a plant-based eating pattern has been shown to reverse coronary artery disease and improve magnesium intake (which reduces insulin resistance), and the high fiber intake associated with plant-based eating improves glucose control and decreases mortality from circulatory, digestive, and inflammatory disease, she said.

Two recent studies demonstrated that meat consumption substantially increases the risk of type 2 diabetes. Even just a half serving per day increase was associated with a 48% increase over 4 years in one study (JAMA Intern. Med. 2013;173:1328-35).

Ms. Jardine noted that the Academy of Nutrition and Dietetics position is that "appropriately planned vegetarian diets, including total vegetarian or vegan diets, are healthful, nutritionally adequate and may provide health benefits in the prevention and treatment of certain disease," and that such diets have been found to be "highly acceptable in diverse populations with various disease states" (Diabetes Educ. 2010:36:33-48).

She warned that patients with diabetes who are on medications and who begin to follow a plant-based eating pattern should be instructed about how to recognize and treat hypoglycemia, as adjustments to medications that lower glucose, blood pressure, and cholesterol may be needed.

Do more, and lose weight

Posted in General clinical at Mon, 01 Sep 2014 11:23:52

AnneG

Posts: 360
Joined: 18 Mar 2014

The Chicago tribune reports on a BMJ article suggesting that by changing one's commute to a more active modality, one can lose weight.  Actually, the study says that commuters who do not drive to work are more likely to be thin, which is not the same thing.  There must be a hundred confounders in this study, but in the end it's no real surprise that those people who do more exercise are likely to be thinner.

Catching the bus or train seems to beat driving - the walk to the bus stop is worth every step, it is suggested.

The next study will look at the correlation between how much people eat, and their thin-ness, I suspect.

 

 

More e-cigarette Use in US 'Non-smoking" Students

Posted in Respiratory medicine at Mon, 01 Sep 2014 11:01:51

DundeeChest

Posts: 1433
Joined: 15 Apr 2010

The BMJ reports that 3 times more non-smoking students are using e-cigarettes in 2013 than 2011.  Should we be worried?  

Some reports suggest that eCigarettes are not a 'gateway' to smoking actual cigarettes, but this study shows that more young people now intend to start smoking, as the prevalence of eCigarette smoking increases.  

I heard John Britton talk at the Summer BTS in July - he was convinced that eCigarettes should be prescribable, available free on the NHS, and by being skeptical we are preventing smokers from quitting.  But if we're helping smokers quit at the expense of starting up even more....?

Vyvanse dosing

Posted in General clinical at Mon, 01 Sep 2014 08:30:20

Adhddoc

Posts: 9
Joined: 19 Jun 2014

There seems to be disagreement in the literature if Vyvanse 20 is equivalent to 5mg of ritalin or 10mg of ritalin. Any thoughts?

he point where

Posted in General clinical at Tue, 02 Sep 2014 12:37:08

vironicanica

Posts: 1
Joined: 02 Sep 2014
 
 
I just got the game and when I went into the options that allows us to change the keys, it pops up a warning telling us what 
 
to not change. I repetitively pressed the "enter" key to close the warning pop-up. When the pop-up disappeared, I noticed 
 
that I was still pressing "enter" to the point where, on the first column, it said "delete" then on the second column: 
 
--------- 
 
A friend of mine didn't have that happen to him but for me, it basically removed the enter key and all I can do on the 
 
Stepmania is move the keys up and down, I cant access any of the listed in order to change what was removed or edited. 
 
I tried uninstalling the game various times but nothing really happened, I also tried scanning through my laptop and I found 
 
nothing that would help me recover the "enter" key.