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Editors choice

Safer prescribing by empowering patients?

1 Jul, 15 | by Kristy Ebanks

By Kristian Dye

For this post, I have chosen to write about a Case Report that comes from the United Kingdom. It’s about a patient with a complex set of management challenges, however none of them are rare – and the United Kingdom is almost certainly one of the best places in the world to be with such a complex constellation of conditions.

So far, this does not sound like compelling global health territory, however it addresses a problem that is universal within health care systems globally – polypharmacy. This is an issue which affects certain populations more than others (for example, in elderly populations (1), an average of 2-9 medications are taken daily, with one in six (2) over 65s taking 10 or more daily).

The issue, in this case, is further complicated by the prescriptions not all originating from a single physician. In an older person, they maybe taking antihypertensives, a statin and drugs to reduce cardiovascular risk – however, they will likely all originate with the primary care physician.

The patient… is supported regularly by general practice, the school nurse, ear nose and throat specialists, general and community paediatrics, dietetics, specialist dentistry and ophthalmology’

From this list of involved specialties, the potential formulary that prescriptions will come from is probably as wide as in any case imaginable. This opens up an enormous range of potential drug interactions.

This is a real day-to-day patient safety issue faced in all healthcare settings, whether the system is well integrated or highly fragmented.

‘An example where the lack of an up-to-date medication list led to a potential medication-related problem was the prescription of azithromycin for an ear infection by an ENT surgeon. There is a documented drug interaction between azithromycin and domperidone, a medicine used regularly to treat the patient’s gasto-oesophageal reflux’

The solution suggested in the case is to centralise the patient’s records, but not in the way we usually imagine.

Integrated health care records are usually conceived of as a centralised database that healthcare workers are able to tap into and pull down records for their patient. These systems are highly resource intensive and logistically difficult to deliver over large geographical areas. The alternative is wonderfully elegant.

We trust our patients. If we ensure that when we prescribe something, we add it to a patient-held record, then we know that our colleagues will know what we have done, and are able to factor this in to their own treatment decisions. The solution in the case is a smartphone app (3), which is highly convenient for the more than 1.75 billion smartphone users (4) worldwide – however there’s no reason why a similar approach couldn’t be undertaken on old-fashioned paper for those who don’t have access to the technology – in the UK we’ve been doing this for child health (5) for years.

Surely, then, this seems like an easy decision. We can improve the safety of our patients, by trusting our patients. If we can trust patients with the risk of possessing the medicines, why not trust them with the records too?


Jogini Culture and HIV

5 Jun, 15 | by Kristy Ebanks

By Manasi Jiwrajka

The case report HIV in India: the Jogini Culture presents a case of a 32 year old Jogini from rural Andhra Pradesh who is HIV positive.

‘Jogini’, ‘Devadasi’ or ‘Mathamma’ are terms used to describe a girl committed to theogamy, or in other words, who is ‘married’ to a deity when she reaches puberty, and spends her entire life being sexually exploited by the deity’s priests or devotees. (1-3). Although similar practices have existed in many ancient European and Middle Eastern cultures, this practice is currently prevalent in Andhra Pradesh, a state in southern India. It is estimated that there are 16,799 documented Joginis in Andhra Pradesh and 22,943 Devadasis in Karnataka. (1)

Historically, the practice originated in medieval India when a woman “would become a Jogini in order to upkeep the services of the temple…sweeping the temples, and carrying the utensils for workship.” (1) However, the current practice involving sexual exploitation has emerged as a result of the caste system in India, and specifically due to “a schism [that] appeared between the ‘clean’ and the ‘unclean’ castes,” whereby the “Jogini from the ‘unclean’ castes were often pushed into the sexual exploitation,” and women from the ‘clean’ castes were somewhat protected by The Madras Act V of 1929 or the 1934 Bombay Devadasi Protection Act that “tried to emancipate the Jogini from their servitude.”(1) Whilst technically the practice is prohibited in India since Indian Independence, clandestine practices still exist, and in fact, some argue that the “efforts to abolish these practices since the days of British rule has increased the stigma attached to its victims and reinforced their risk of entry into commercial sex work.”  Today, all Jogini or Devadasis are Dalit, or “untouchables” from the lowest caste. (4)

Inherently, the Jogini culture is religious in nature but other cultural beliefs also play a role in the continuation of these practices. For example, Borick mentions that the patient’s father was worried about who would cremate him after his death, and his cultural beliefs dictated that “only a son could light his funeral pyre.” However, “since he did not have a son, he was in danger of becoming a ghost,” and as such he decided that if his daughter were a Jogini, “because of her special relationship to Goddess Yellamma, she would be able to light his funeral pyre when he died.”

Some of the Global Health issues that arise in this case are as follows:

1.       Poverty

2.       Lack of education

3.       Gender Equality and Women Empowerment

4.       Child Mortality

5.       Maternal Health

6.       HIV/AIDS

It is important to note that this one case of the Jogini raises 6 out of the 8 issues that are addressed by the Millenium Development Goals.

The patient’s father, as previously mentioned, decided that his daughter should be a Jogini compelled by his poverty and lower socioeconomic status as a Dalit (or untouchable). In his case, poverty prevented him from paying a dowry, a cultural practice that still exists in India, and as such, “the options for his daughter were limited.”

Due to this poverty, or perhaps as a result of a lack of education and literacy among Dalits in general (5), “the patient never attended school.” Dalit women “suffer from 17% more illiteracy” compared to women from other castes and “92.8% of Jogini” are illiterate. (1)

Education is intrinsically linked to women’s empowerment, child mortality, maternal health and HIV/AIDS. “Education is one of the most important means of empowering women with the knowledge, skills and self-confidence necessary to participate fully in the development process.” (5) Borick speculates that “perhaps even a few years of primary school would have provided [the patient] with literacy skills and the confidence necessary to seek an alternative way to earn a living,”(1) and had the patient been given educational opportunities, she would have had a different source of income.

Additionally, literacy and child mortality are linked as well: “in India, literate mothers have lower rates of severely stunted (40% compared with 44%) and severely underweight (7% compared with 9%) children when compared with illiterate mothers. For every 10% increase in female literacy in India, there is a 9/1000 decrease in the child mortality rate.” (1)

Similarly, there is evidence to suggest that educated mothers have better maternal health compared to those who are not educated, as they have “a greater spacing between pregnancies [and] the more education that woman has, the more likely she is to understand contraceptive methods taught by health workers including condom usage.” (1)

Safe contraceptive methods can prevent sexually transmitted diseases including HIV, which is “five times as high” (2.6%) in Devadasi districts compared to the state average (0.52%). Joginis and Devadasis, are at a higher risk of HIV and other sexually transmitted infections “due to high risk sexual activity.” Additionally, Jogini have a ten times higher mortality rate due to AIDS compared to the national average of women in India. (1)

Whilst the Jogini culture is known only in India, similar ‘ritual servitude’ practices exist in other countries; the practice is known as ‘deuki’ in Nepal or ‘trokosi’ or ‘vudusi’ in Ghana, Togo and Benin wherein “a female child, usually a virgin, is selected by her family to serve in a shrine in reparation for crimes committed by other members of the family.” (6, 7) Therefore, similar global health issues exist around the world where just like the 32 year old patient, women are sexually exploited, come from rural areas, with a lack of educational opportunities and suffer severe discrimination.

1. Borick J. HIV in India: the Jogini culture. BMJ Case Reports. 2014;2014.

2. Black M. Women in Ritual Slavery: Devadasi, Jogini and Mathamma in Karnataka and Andhra Pradesh, Southern India*. Pakistan Journal of Women’s Studies = Alam-e-Niswan = Alam-i Nisvan. 2009;16(1/2):179-205.

3.Misra KK, Rao KK. Theogamy in Rural India: Socio-Cultural Dimensions of the “Jogini” System in Andhra Pradesh. Indian Anthropologist. 2002;32(1/2):1-24.

4.Torri M-C. Abuse of Lower Castes in South India: The Institution of Devadasi. Journal of International Women’s Studies. 2009;11(2):31-48.

5. UNFPA. Report Of The International Conference On Population And Development. Cairo: UNFPA, 1994 1994. Report No.: (94/10/18).

6. Ameh RK. Child bondage in Ghana: A contextual policy analysis of trokosi [Ph.D.]. Ann Arbor: Simon Fraser University (Canada); 2002.

7.  CEDAW. Shadow Report on the 4th & 5th Periodic Report by The Government of Nepal on CEDAW. 2011

This article is published under a CC-BY-NC licence for permissions email

Ramifications of poor medical education and screening in minority populations: an extensive acral melanoma

26 May, 15 | by Kristy Ebanks

By Manasi Jiwrajka

Ramifications of poor medical education and screening in minority populations: an extensive acral melanoma reports a case of a Samoan man with acral melanoma and explores the precipitating factors leading to the progression of a condition that may otherwise have been screened for and treated at a much earlier stage.

This case is from the Naval Health Clinic in Honolulu, Hawaii. The authors report the case of an 82 year old Samoan man who presents with pain in his left heel “due to a large [9x7cm], exophytic, hyperpigmented, polypoid mass.” No lymphadenopathy or symptoms were reported. A diagnosis of acral lentiginous malignant melanoma was made after an MRI and a biopsy of the fungating mass. The case reports that “Native Hawaiians and Pacific Islanders were one of the only two racial groups where the leading cause of death was cancer, with rates above the national average.”

The Pacific Islands including Fiji, Tonga and Samoa have a rich cultural history dating back to about 1000BCE, followed by German, American, New Zealand and British colonial rule until the 1900s (2).Samoa is made up of nine volcanic islands, located in the Pacific Ocean. The islands are divided into two territories: the American territory and the Independent State of Samoa. Of cultural and political relevance is the social structure of families and groups, whereby although nuclear families exist, traditionally, each family is part of an ‘aiga’ or an extended family headed by a mataai (leader) who has a voice in the village.

Whilst the American part of Samoa is developed due to the resources available from the United States, the Independent Samoa lags behind economically as well as in terms of healthcare. In the 1940s, many primary healthcare institutions were set in place as an after-effect of the historical colonial rule, and medical practitioners now exist in Samoa. “In 2005, Samoa had 0.27 physicians per 1,000 population, 0.02 pharmaceutical personnel per 1,000, 0.03 dentistry personnel per 1,000, and 0.94 nurses and midwives per 1,000 [compared to Australia that had] 2.99 physicians per 1,000 population, 1.04 pharmaceutical personnel per 1,000, 0.69 dentistry personnel per 1,000, and 9.59 nurses and midwives per 1,000.” (3) In many Samoan villages the traditional healers or fofo (most recent estimate is 900 traditional healers in Samoa) still continue to provide traditional care (3). In more recent times, these fofos have received public health training, which has given rise to a combination of both biomedical and traditional theories of illness, while at the same time creating a conflict between the two paradigms (2). For many Samoans overseas in Australia, New Zealand or the United States, there is a belief that illness occurs either through spirits or because they have not helped their family back in Samoa (4). Perhaps as a consequence of previous colonial rule, there is a lack of trust towards Western medical practices, and if medicine does not work, Samoans refer to the fofo (4).

Melanoma as a Global Health Issue

Melanoma is a Global Health issue; globally, it is the 19th most common cancer and 232,000 new cases were diagnosed in 2012, which constitutes 2% of all cancers (5). The WHO estimates that one in three diagnoses of cancer is in fact skin cancer. In countries such as Australia, melanoma is the fourth most common cancer diagnosed (6) and as such national preventative strategies have been implemented, and screening processes have been employed by healthcare services for early identification and excision of melanomas. These preventative strategies include reducing sun exposure, sun protection and a complete skin examination by the primary care doctor (7). In the case, the Samoan patient there was a two-fold delay: first, in the delay of diagnosis, which is common in people of colour because of the common misconception that melanoma does not affect dark-skinned people (8); and second, a delay in seeking care at an earlier stage of his condition “due to lack of understanding of knowledge to disease and the long distances that must be traveled to obtain proper, specialty care.” (1)

Accessing Healthcare – Equity and Barriers

There are biological and social determinants of health. In the above mentioned case, a biological determinant of the Samoan patient would be his dark skin tone, and as such his increased predisposition to acral melanomas. Some of the social determinants include socioeconomic status, education, cultural beliefs and health insurance. Specifically, the case report mentions that “low socioeconomic status patients generally know little about their own medical condition, tend to have a high school education or less, and have difficulties arranging transport, all factors contributing to care barriers.”(1) These factors have a follow-on effect that influences access and compliance of care. Problems with access or proper compliance invariably results in patients presenting with advanced disease, which is a burden both for the patient as well as the health system.

The three-delay model (9) used in maternal health is a useful tool to conceptualize the barriers experienced by minority groups: (i) a delay or barrier in making a decision to seek care (ii) barrier to reaching care, as well as (iii) barriers to receiving adequate health care.

(i) Delay in seeking care

Lack of knowledge

In the case report, the authors write about the relevance of education: “low socioeconomic patients generally know little about their own medical condition, tend to have a high school education or less”. As a result, they present to the doctor much later in the progression of their disease compared to patients of a higher socioeconomic status who “tend to recognise skin changes when they self-screen and obtain medical treatment earlier”(1).

Some Samoans believe in the role of traditional healers or fofo, creating a conflict between Western medicine and traditional beliefs. “Healthcare practices often clash with societal beliefs, and so patient education regarding their disease and its possible progression is important.” (1)

Cost – benefit

Similarly, other factors causing delay in seeking care are economic in nature. There is an opportunity cost associated with seeking care — leaving work to go to a healthcare practice implies that the patient (and maybe another relative) will need leave from work and lose income.  In the case of acral melanoma, where early identification of the melanocytic lesion is hugely influential on prognosis, a delay in seeking care due to a lack of knowledge or due to the cost of seeking care can have significant implications on the progression of the condition.

(ii) Barriers to reaching care

These barriers are often physical or geographical. Remoteness and a lack of transportation networks for access to even basic services is prohibitive of Global Health. “Poor access to care for [rural and isolated] populations is mainly due to remoteness, travel time, lack of speciality care, and the cost of obtaining healthcare services, with longer distances correlating with infrequent doctor visits, decreased use of preventive services and fewer routine follow-up visits” (1). There is good evidence that rural populations have poor access to healthcare services and consequently poorer health outcomes (10-12). “Having a usual source of care improves access to medical screening services and decreases health disparities; however, this is often not available to minorities.” (1)

(iii) Barriers to receiving adequate care

These barriers are crucial to identify and address as they are a pervasive barrier to Global Health. In Samoa, there is no universal medical benefit system; however some government healthcare agencies provide some free healthcare (3). American Samoans and other “uninsured minorities are eligible for insurance [but] they often do not sign up for it due to lack of awareness or limited proficiency in English” (1). Language barriers can cause poor communication and decreased trust between the doctor and the patient. Another barrier to receiving good care is the cultural competency of the physician. “Typically, the ethnicity of physicians does not reflect that of their patients, who consequently believe that their physician is unaware of popular culture alternative/holistic medicine. Perhaps a Samoan provider would have related better to our patient…and would have educated him about his advanced disease and need for modern medical treatment, thus leading to a better outcome (1).”

We as health professionals can play a crucial role in addressing some of these barriers to adequate healthcare, and subsequently reducing the burden on health systems globally.

1. Jackson CR, Fernelius C, Arora N. Ramifications of poor medical education and screening in minority populations: an extensive acral melanoma. BMJ Case Reports. 2015;2015.

2. Ember Ea. Encyclopedia of Medical Anthropology: Health and Illness in the World’s Cultures. New York: Kluwer Academic Publishers; 2004 2004.

3. Boslaugh SE. Health Care Systems Around the World: A Comparative Guide. Health Care Systems Around the World: A Comparative Guide. SAGE Publications, Inc. Thousand Oaks, CA: SAGE Publications, Inc.; 2013.

4. Queensland Health SoQ. Samoan Ethnicity and Background [Web]. 2014 [updated 12 June 2014]. Available from:

5. Holmes D. The cancer that rises with the Sun. Nature. 2014;515(7527):S110-S1.

6. Waterford K. Melanoma: from little things, deadly things can grow: Australian Medical Association; 2014. Available from:

7. Markovic S, Svetomir NM, Lori AE, Ravi DR, Roger HW. Malignant Melanoma in the 21st Century, Part 1: Epidemiology, Risk Factors, Screening, Prevention, and Diagnosis. Mayo Clinic proceedings. 2007;82(3):364.

8. Gupta S. Skin colour: No hiding in the dark. Nature. 2014;515(7527):S121-S3.

9. Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Social Science & Medicine. 1994;38(8):1091-110.

10. Armstrong KEJPJV, B K, K. E. Jong PJV, Armstrong BK. Rural inequalities in cancer care and outcome. Medical journal of Australia. 2005;182(1):13-4.

11. Casey MM, Thiede Call K, Klingner JM. Are rural residents less likely to obtain recommended preventive healthcare services? American Journal of Preventive Medicine. 2001;21(3):182-8.

12. Nemet GF, Bailey AJ. Distance and health care utilization among the rural elderly. Social Science & Medicine. 2000;50(9):1197-208.

Breast pain in a patient on dialysis

24 Apr, 15 | by Kristy Ebanks

Calcific uremic arteriolopathy

We have some very interesting images for you but, can you answer the questions below?

buscher_4 buscher_3 buscher_2

1. What are the indications for dialysis?
2. What are the complications of dialysis?
3. What is calcific uremic arteriopathy?

If you don’t know the answers or want to know more read ’Breast pain in a patient on dialysis: a rare manifestation of calcific uremic arteriolopathy

The Case of an ACL deficient knee

9 Apr, 15 | by Kristy Ebanks

Anterior Drawer test in an ACL deficient knee

We have some very interesting images for you but, can you answer the questions below?


1. What is the anterior draw test?
2. What do you see in these figures?
3. How else might the ACL be tested?

If you don’t know the answers, want to see a video or want to know more read ’Patient self-demonstration of the Anterior Drawer test in an ACL deficient knee

A rare but potentially fatal cause of diarrhoea and weight loss

2 Apr, 15 | by Kristy Ebanks

Enteropathy associated T-cell Lymphoma

We have some very interesting images for you but, can you answer the questions below?

Figure_2 (3) Figure_3 Figure_4 (1)

1. Diarrhoea can kill – under what circumstances may diarrhoea be fatal?
2. What types of enteropathy do you know?
3. How would you manage life-threatening diarrhoea due to a range of causes?
4. How would the different causes affect your management?

If you don’t know the answers or want to know more read ’A rare but potentially fatal cause of diarrhoea and weight loss: Enteropathy associated T-cell Lymphoma

Virchow-Robin spaces

19 Mar, 15 | by Kristy Ebanks

Hydrocephalus due to extreme dilatation of Virchow-Robin spaces

We have some very interesting images for you but, can you answer the questions below?

Image3 Image2 Image1

1. What are Virchow Robin spaces?
2. What do these images show?
3. How would you manage this hydrocephalus?

If you don’t know the answers or want to know more read ’Hydrocephalus due to extreme dilatation of Virchow-Robin spaces

A straight-forward stroke?

6 Feb, 15 | by Kristy Ebanks

A typical presentation of type A aortic dissection

We have some very interesting images for you but, can you answer the questions below?

fig_3 (6) fig_2 (6) fig_1 (8)

1. How common is non-carotid disease stroke?
2. How would you routinely investigate a patient who presents with stroke?
3. Which patients benefit from anti-coagulation to prevent a first stroke?

If you don’t know the answers or want to know more read ’A straight-forward stroke? May be not: atypical presentation of type A aortic dissection

Quiescent infective endocarditis in a patient with bronchopneumonia

30 Jan, 15 | by Kristy Ebanks

Splenic abscess

We have a very interesting image for you but, can you answer the questions below?


1. What would be your differential diagnosis in Figure 1?
2. What factors would determine whether you perform a splenectomy?
3. What is the latest evidence in terms of post-splenectomy sepsis?

If you don’t know the answers or want to know more read ’Splenic abscess as a potential initial manifestation of quiescent infective endocarditis in a patient with bronchopneumonia

A word from the Editor In Chief – 10,000+ cases!

21 Jan, 15 | by Kristy Ebanks

What would you do if you woke up one morning and found that you could not stand, your legs simply won’t move.

This was exactly what the patient in this, our 10 000th case at BMJ Case Reports, discovered.

He presented to the Accident and Emergency Department with sudden bilateral lower limb paralysis and urinary retention. How would you manage his care? What would you do? He needs urgent attention. Is this trauma? Is there cord compression? Could this be Guillain – Barre? Could the paralysis become generalized? Will he stop breathing?

Put yourself in this patient’s position. How would you feel? Put yourself in the admitting doctor’s position. There is a need to act fast. Multiple disciplines will need to consult. The patient may need intensive care.

What is your working diagnosis? What do you need to exclude? How will you investigate?

Read on and tell us what you would do. How would discover what is wrong? How would you discuss this with the patient? What about his family?

Read on and find out whether the symptoms improve…. Sudden flaccid paralysis

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