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David Kerr: The dangers of going to hospital

2 Jul, 12 | by BMJ

David Kerr

Hospitals can be dangerous places. Two things happen to everyone admitted to hospital for more than a few hours—they are put to bed and are fed. Over half a century ago Richard Asher highlighted the obsession hospitals have with beds and the dangers of being confined to bed (BMJ 1947; doi: 10.1136/bmj.2.4536.967). Asher’s description of the dangers of lying in bed still has resonance today—“the blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, and the spirit evaporating from his soul.” In a sense not a lot has changed in that beds are undoubtedly the main currency in discussions with managers.  Hospitals compare themselves by the number of beds under their control and performance is assessed by length of stay—in other words time in bed and doctors are compared by their bedside manner. Richer Asher appreciated the positive effects of going to bed when unwell but riled against the negative impact of overdose—prolonged length of stay which would have resonance with hospital mangers today. more…

Richard Lehman’s journal review – 10 April 2012

10 Apr, 12 | by BMJ

Richard LehmanJAMA  4 Apr 2012  Vol 307
1394    A special dread settles on me this week as I know I am going to have to write about breast cancer screening. But let’s leave the dread question of whole-population mammography for later, and consider the add-on benefit of annual ultrasound or single-screening MRI in selected high-risk women. While the war over breast screening rages unchecked in the letters and a book review in this week’s Lancet, let’s take refuge in this little corner of the battlefield, where at least the fog of war is not too thick and we can count a few weapons and estimate a few casualties. The volunteer combatants are women with dense breasts and at least one factor that increases their risk of breast cancer. The ultimate proof of victory, as in all screening studies, will be a reduction in total mortality. The casualty list should include every woman undergoing biopsy or surgery, because nobody comes away from these things altogether unscathed, be it mentally or physically. This study gives us a casualty list, including the number of enemy killed (breast cancers detected and operated on), but cannot give us any idea of the extent or the cost of victory, because it was run over a three-year period only. Our brave lasses certainly saw their share of action: 2725 over the age of 25 (!) went through annual mammography and ultrasound, and 612 ended up having MRI. During that time 110 had 111 breast cancer events: 33 detected by mammography only, 32 by ultrasound only, 26 by both, and 9 by MRI after mammography plus ultrasound; 11 were not detected by any imaging screen. Enough. We can tell from these figures that the three imaging modalities will pick up most cancers; but the true cost—mentally, physically, and financially—can only be hinted at in a study like this. Only very long-term follow-up will give us a true estimate of overdiagnosis and the degree to which such screening detects cancers which would never progress. But in just these three years, a total of 1272 biopsies were performed—more than ten for each cancer detected. So this high risk group may well see a small reduction in all-cause mortality over the course of their “screening lives,” but it will be purchased at a high cost in medical procedures and anxiety. In fact any woman undergoing this cycle of procedures would be extremely lucky to get away with a single fine-needle biopsy during her life—two or three would be more likely. more…

David Kerr: 2012, technology and all that

4 Jan, 12 | by BMJ Group

David KerrJanuary is the month that heralds the end of procrastination. The New Year is traditionally the time that individuals and organisations look ahead and plan for the future. Among the usual resolutions to do more, eat less, and be more productive, there is also the ubiquitous past-time of predicting the near future. For healthcare the future seems to be focused increasingly on the development and application of technology with a blurring of the distinction between consumer electronics and medical devices.


David Kerr: Consumerism and the lost tribe in diabetes

19 Dec, 11 | by BMJ Group

David KerrBad news makes good press. Last week the main medical news item was the release of the National Diabetes Audit figures for England and it made grim reading. The audit collected data from 152 Primary Care Trusts covering almost 70% of the population of people living with diabetes. The bottom line was that there are an estimated 24,000 excess (i.e. premature) deaths each year associated with diabetes and many of these are preventable. The news was especially bad for people with type 1 diabetes where the excess risk of an early death was increased 2.6 fold compared to the background population and was even higher for young people with the condition. These mortality data follow on from the more general findings highlighting the fact that achieved levels of blood glucose control have not improved for a number of years and are particularly bad for the lost tribe of young people aged 16-24 years with type 1 diabetes. more…

Richard Smith: Hauling the private sector onboard to combat diabetes

12 Dec, 11 | by BMJ Group

Richard SmithThe golden phrase for countering non-communicable disease (NCD) is that we need a “whole of government and whole of society approach.” An important step on that path is obviously for all parties to talk together, and that’s why the International Diabetes Federation for the first time started its biannual conference with a “global diabetes forum,” with the title of “Harnessing the private sector expertise.” How did it go? more…

Rebecca Coombes: UN summit in New York – a view from the sidelines

19 Sep, 11 | by BMJ Group

What’s the mood among delegates on the eve of the UN summit on non-communicable diseases as they gather in hotel bars and the confusion of side events in New York City?

Well, earlier in the day I went on a hike through Central Park with about 50 others in an event organised by the NCD Alliance to publicise that 300 million people are now caught up in the global diabetes epidemic. We waved helium balloons and cars honked in support from 5th Avenue. My walking partner was Allison Schauwecker, a graduate of international relations now working for a company which makes a weekly television show on US cable television for diabetic patients. It pulls in millions of viewers every week. Allison, diagnosed with Type 1 Diabetes when she was 25, carried a small bag of sweets “in case I go low.”  more…

David Kerr: The dark side of insulin

16 Aug, 11 | by BMJ Group

David KerrIt has been a strange few weeks for insulin. This year is the 90th anniversary of its discovery and in everyday clinical practice, insulin still remains “a force of magical activity” as described in a letter to the Times shortly after it was first used in humans. Nowadays, despite a bewildering array of therapies for diabetes in general, the immediate consequences of starting insulin in new onset type 1 diabetes still remains a medical marvel. However, over the past few weeks, insulin has received a rather negative press. more…

Richard Smith: Prevention of diabetes – from impossible to widely available in 30 years

13 Jun, 11 | by BMJ Group

Richard SmithIn the 1980s it was conventional wisdom that type 2 diabetes couldn’t be prevented, said Michael Engelgau of the US Centers for Disease Control and Prevention, when I chatted to him in Changzhi, China last week. The condition was treatable but not preventable. Dr Engelgau went onto to tell me about the thinking that led to the Diabetes Prevention Program, which showed conclusively that type 2 diabetes could be prevented. I found it an intriguing story that illustrates the prejudices and messiness that are the reality of research and which are usually obscured in traditional scientific papers. more…

Siddhartha Yadav: Diagnosing and treating the “Nepalese” microbes

6 May, 11 | by BMJ Group

A large portion of my work as a doctor in Nepal is to treat infections. Even in chronic conditions – COPD, diabetes, malignancy – I find that infectious micro-organisms take the toll more rapidly than the disease itself. It is fascinating how these minute beings have the power to bring human life to a standstill.

Fever without an obvious localising site often presents a diagnostic dilemma here. One of the reasons is that the spectrum of micro-organisms we are dealing with in Nepal is very different from that elsewhere. In a study looking at the etiology of febrile illnesses in adults presented to the Patan Hospital in Kathmandu (Am. J. Trop. Med. Hyg., 70(6), 2004, pp. 670-675), the most common organism isolated was Salmonella enterica (typhi and paratyphi) causing enteric fever. Perhaps this is why some researchers on enteric fever refer to Kathmandu as the “typhoid capital of the world.” more…

Richard Smith: Adding treatment of hypertension to HIV programmes in rural Kenya

17 Mar, 11 | by BMJ Group

Richard SmithThe biggest problem with treating hypertension in rural Kenya is lack of drugs. Health workers are plentiful, and there is an impressive health system—but drugs are scarce.

I learnt this when I visited the hospital in Eldoret, a small city in the West of Kenya, and a close by community clinic. My colleagues and I were the guests of AMPATH (Academic Model Providing Access to Healthcare), an organisation that has done an extraordinary job in treating the many patients in that region infected with HIV. Now AMPATH wants to “layer in” the treatment of patients with hypertension, diabetes, chronic obstructive pulmonary disease, and other chronic conditions. Dr Sylvester Kimaiyo points out that HIV infection is a chronic disease now that it can be treated with antiretroviral drugs and that it should be entirely possible to use the established system treat patients with other chronic diseases. more…

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