The 15/15 rule for hypoglycemia

Bismillah, alhamdulillah: lovely and simple advice regarding hypoglycemia. If under 70 mg/dl the simple advice states take 15 g of sugar and retest in 15 minutes. Half a sugar fizzy drinks 15 grams. Glucagon is for patients on insulin and for their near and dear to administer. 

Have a listen …

Treat Hypoglycemia Fast, but How?
Medscape Diabetes & Endocrinology Podcast
Duration: 07:19
Published: Thu, 3 Aug 2017 11:18:32 EDT

Juicy Juice® or juicy apple? Join this conversation on hypoglycemia to learn best practices for treatment and optimal patient education.

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Dear Microsoft can you help prevent dysergonomia?

Bismillah, alhamdulillah:

If you work or study with a computer – and the chances nowadays are pretty high – you may have had regular wrist pain, neck ache, shoulder pain, back pain or even foot pain. The resulting pain and discomfort would lead many people to the door of their family doctor or health care provider. The recorded diagnosis would be scattered among many distinct and different domains ranging from dorsalgia (back pain), to RSI (repetitive stress injury) to dry eye syndrome and so on. There is no clearly common thread that ties all these disparate symptoms together. Herein lies the problem. If we can’t tie it together we will not identify the common cause.


When looking at the average office worker and in today’s world that includes many including doctors, nurses and reception staff in health care facilities who spend a large proportion of their time relatively immobile in front of a computer. It is not rocket science to work out that our relatively immobile position is likely to be a key causative factor that ties all these problems together.

For example, at times our necks are held very still as we read what is on the screen causing neck and shoulder pain later in the day. Our eyes dry more because our blink rates drop as we stare at the screen and our natural tears are not spread as regularly over our eyes. In some this leads to repeated sty’s or eyelash infections as the anti-bacterial properties of our tears are not being properly harnessed.  Our backs hurt as we are riveted to the screen and don’t move our backs at all many minutes if not hours at a time. Our feet stay in an awkward position as we forget to move and then we wonder why we have foot pain when we hobble away from our chairs.

So what shall we call this problem? No particular term exists in the medical text books to describe this, so I have decided to coin one: dysergonomia – from the suffix dys as in dysfuntional and ergonomics: “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system” (Wikipedia).

So what can Microsoft do to help?

We need to encourage all of us to move more. Even if it is a short break or what is known as a microbreak. Just as our computer screens have the power capture our attention and eyeballs they also have the power to break that attention by asking us to take a microbreak. An opensource example of  such software is present at The software lives in your taskbar and reminds you to take microbreaks from time to time. A simple idea that is likely to go a significant way in reducing dysergonomia.

Open source software is something that large institutions are reluctant to incorporate into their local machines and networks due to security concerns. This is where we need leadership from the industry giants such as Microsoft. The human health case for making such software widely available is strong. It should be a standard requirement for all computer systems. Something that is as widely used as Microsoft Windows is one of the best candidates to kick start this.

Just as seat belts have become standard safety feature in our cars I strongly believe it is time for giants of industry to make tackling dysergonomia one of their highest priorities. Microsoft are you listening?

Summary of current research on connection of food to anxiety

Bismillah, alhamdulillah:

Interesting article on meals and anxiety, fMRI studies show effects can be fast and linked even to a single meal. Here is a quick summary:

INCREASED anxiety:
Western diet (inc ~30%),
Sugar rich foods

DECREASED anxiety:
Choline rich foods (B like Vitamin) found in eggs, tofu and meats;
Fermented foods i.e. yoghurt,
Omega 3 (fatty fish).


How to Choose a Basal Insulin

Bismillah, alhamdulillah: 

Some very simple, short and to the point tips on the choice of basal insulins in this podcast. My take home message:

NPH has a peak at 6 hours, hence good for people who have high sugars at dawn but are relatively okay for the rest of the day. If you use a longer acting insulin they are likely to get hypos at the end of the day.

NPH works best for steroid induced hyperglycemia because the peak onset – at least for prednisone – matches the peak onset of NPH. 

More than 50 units of insulins like Glargine & Determir can have problems in absorption due to the large volume needed for injection. Hence splitting the dose is an option.

We now have 40 hour basal insulins!

Have a listen…

How to Choose a Basal Insulin
Medscape Diabetes & Endocrinology Podcast
Duration: 09:11
Published: Mon, 12 Dec 2016 16:35:48 EST

So many choices! A diabetes expert provides tips on selecting a basal insulin for a patient with diabetes.

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Test yourself: How good is chemotherapy for 90% of adults with metastatic cancer?

Bismillah,  alhamdulillah:

What answer would you give to someone who asked you the following question:

Someone sent me a video of an interview of a doctor in the USA who was criticising the extent of use of chemotherapy despite its poor outcome, especially in adults with cancer. Having heard the clip and the doctor talking about the ability of Selenium supplementation to prevent cancer, I filed it under the ‘not too sure this sounds right’ folder in my brain. Later I found out that he was a ND (Naturopathic Doctor and not a Medical Doctor). I dismissed the issue from my mind because my MD gut answer to the above question was at the higher end and surely the ND had to be wrong! But then I heard a BMJ podcast on the very same issue and it was quite an eye opener.

The interview was with Dr Peter White a former consultant and senior lecturer at the Imperial School of Medicine. He recently authored an article for the BMJ called Cancer drugs, survival and ethics.

He points to a meta-analysis done in 2004  looking at the 5 year survival of patients with metastatic cancer in randomised trials published in Australia and the US. How much do you think chemotherapy increased survival by in 90% of cancers including lung, prostate, colorectal and breast cancer? The answer was 2.5% or in terms of months 3 months. But what about newer drugs? Surely biotech and pharma industry have improved leaps and bounds since 2004? He says (the emphasis is mine):

Similarly, 14 consecutive new drug regimens for adult solid cancers approved by the European Medicines Agency provided a median 1.2 months overall survival benefit against comparator regimens.4 Newer drugs did no better: 48 new regimens approved by the US Food and Drug Administration between 2002 and 2014 conferred a median 2.1 month overall survival benefit.5


There have been exceptions to this poor outcome of the fight against cancer and these include cancers such as:  testicular cancer (40%), Hodgkin’s disease (37%), cancer of the cervix (12%), lymphoma (10.5%), and ovarian cancer (8.8%). The improved 5 year survival is given in brackets. Sadly these cancers account for less than 10% of cancers.

He goes on to argue that the financial motivation for such drugs is very high and the regulatory process for their approval needs tightening.

Have a read or a listen:

Article:  Cancer drugs, survival and ethics



Advertising junk food to children

Bismillah,  alhamdulillah:

Have you heard of YouTube Kids? It was news for me. What was more surprising is that some of the channels, according to the panelists on this BMJ podcast,   are sponsored by fast food companies. 

The panelists discussed how subtle advertising and product placement are being used in these channels to advertise junk food to children. In some cases circumventing advertising restrictions that apply to traditional media such as TV. The WHO are currently thinking of coming up with ways to tackle the problem. First step: awareness. Please have a listen, the link and excerpt are below:

Advertising junk food to children
The BMJ Podcast
Duration: 18:30
Published: Fri, 04 Nov 2016 17:18:13

In the UK, junk food advertising is banned on children’s TV – but manufactures are still able to target children in other ways.  A recent report from the WHO  “Tackling food marketing to children in a…

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Are doctors ready to share their notes with patients?

Bismillah, alhamdulillah: Are you ready to share your notes with your patients? Your paternalistic side will probably shrink from the idea. You may start to imagine horrific consequences but the world seems to be in the let’s move forward gear. This article in Medscape presents the idea and gives helpful tips to all those who wish to engage in this approach. The idea to me sounds like one of those really good ideas but I do worry about the way this increasing oversight is going to affect the way doctors will start to behave and how it will affect the privacy of the consultation. 

Medicine was an altruistic profession where helping others was an important motivational factor in choice of career. The trend of patients becoming clients, health institutions becoming health industries mark the increasing influence of a profit metric on every aspect of care. 

While there is nothing wrong with business and profit motivation,  like all good things balance is the key. Sharing notes can be great but is it motivated more by better patient outcomes or by the Health Information Industry and the great potential – and cost – of designing systems that allow patients to read their notes and gain access to many “add ons”.

Possibilities include:

  • Automated note review by Oogle analytics or 
  • A medical record check by Real Doctors from St Elsewhere who will offer many helpful suggestions for the next consultation.
  • Will patients be required to co-sign their own notes, to confirm they actually said what they said?
  • League table of misspelled words.

While the speculative list can be endless and some may seem a bit far fethced the advantages and pitfalls clearly exist. What is needed is  a common sense rather than a ‘can do’ approach.We also need to learn from our colleagues who are used to patient held records such as obstetricians, radiologists and pathologists.

The above three fields have a limited scope or well structured layout to their notes and these help the physicians ‘stay on track’ and not get derailed into areas that are likely to prove to be problematic or embarrassing in the future. Writing for the select few is a different art than writing for the many. Medical schools would do well to start training their students on what to and what not to write. 

The article link on Medscape is given below:

Desert Doctors – invitation

​Bismillah,  alhamdulillah:

I am setting up a group for doctors interested  in, or currently  working in the Middle East. Old ME’rs are invited too. It’s called Desert Doctors on Telegram. It will inshaAllah be a good place to network and search / advertise for job opportunities.  Please click on the following link to join and forward this message to those who may be interested.

Driverless cars and the human resistance –  a lesson from the doctor patient relationship

Bismillah,  alhamdulillah: The driverless car is a clearly disruptive technology. With the rapid and breathtaking advances in technology it seems the limit to this technology being introduced is no longer technological but human. 
Once the technology companies consistently demonstrate that a driverless car is 100 or 1000 times safer than  one driven by a human they will have proven their technological prowess. But one significant obstacle will stand in their way: the human.  What I mean by the human is the emotional reluctance of us as humans to be driven by computers. The thought of putting our lives in the hands of algorithmic robot drivers makes us balk. But why? Two things come to my mind: autonomy and irrationality.
Autonomy appeals to a base human instinct: freedom. As humans we got used to driving our cars and having the autonomy to drive them, wherever,  whenever and sadly sometimes into whoever and whatever. The driverless car will virtually eliminate this negative effect of driving, the roads will be safer, little children  who run out in front of a car will have an amazingly improved survival rate. But this safety will come at the price of the loss of freedom. The freedom to off road, to park in tight spaces, to climb the pavement when no one is looking, to break the speed limit when the road is clear and empty. To let the wind rush through your hair and feel the exhilaration of adrenaline pumping through your body and awakening your senses. 

Technology companies can try and talk logically about the issue,  state the number of lives saved, the increased time we can spend answering emails and social media messages while being driven to work and all the other wonderful economic reasons. But I am afraid we have become rather accustomed to driving ourselves around. The tech companies will have to learn how to pander to our hurt sense of freedom.

An idea would be to have ‘cheat’ modes that assuage this emotional resistance. The degree of ‘cheating’ should be enough to appeal to our emotional side but constrained enough to not cause harm. You can imagine a program that calculates the distance to the next car and tells the driver that s/he is a zone where certain rules can be relaxed and the controls can be handed to the driver or ideas that appeal to younger drivers may include the option to drive on two wheels or do perfect handbrake turns. You get the idea.

Doctors sometimes do this with their patients. As a medical profession we emphasise the importance of taking medication on a daily basis, but we know that as many as 50 or 60% don’t follow the rules, even though it’s for their benefit. A good doctor who perceives this problem in a particular patient may negotiate a ‘cheat’ day or two and achieve a  much better compliance then the stern faced doctor who insists medication has to be taken everyday. Patients can take a pill break or be simply told it’s okay to miss a day or two of medication  every now and then – as long as it’s not a habit. Patients respond to this flexible approach.

The second problem is our tendency to use irrational comprehension when we think about safety. The safety of a driverless care is demonstrably safer and is likely to become safer still. Yet, as with all machines there are things that will go wrong,  as seen in the Tesla car test fatality recently. 

When a human drives a car, it is under their direct control. This gives the human a heightened but false sense of control and hence security. This sense of security is lacking with driverless cars. Here an accident is less likely to happen but the reason why it happened is now not connected to the human. This lack of connection and control heightens the perception of risk. 

As humans we tend to analyse risk in an emotional and irrational way. This is a potential barrier to the adoption of this technology. In medicine doctors tend to face this problem frequently with patients who under or over estimate risk based on many irrational thoughts. It is not infrequent to find a patient consulting a doctor because their friend died or had had a disease. The proximity of the person and their close emotional response to their friend induces empathy. As part of the empathy they too feel they are at risk of suffering from the same disease. Irrational but real. Dealing with this ‘gut’ approach is what doctors, especially family doctors, do on a daily basis. So how do they overcome an irrational and wrong conclusion?

Trust is a key factor.  ‘Doctor I trust in you’ is not an infrequent statement that is heard in the consulting room. From a logical perspective this approach is equally irrational. What should decrease a patient’s anxiety is facts and figures.  Trust in someone, on in its own should not decrease anxiety or worry, but it does. The irrational human problem finds is best treated with an irrational solution.

Turning back to the driverless car, what equivalent approach will help?  One idea is to draw an analogy between the driverless car and another potentially driverless form of transport: the horse or camel.

These animals, once trained, can continue to take their riders on their journey even if they don’t pay attention to where they are going. Animals have been part and parcel of human history for  thousands of years and they are a symbol of trust and reliability. 

Harnessing this connection is likely to provide an avenue to bridge this gap.The technology giants have to turn back to the humble horse and camel because the rider is the same. 

I wanted to explore the idea as I can sense we are close to achieving technological breakthroughs which will introduce the idea of the doctorless or doctorlight consultation in the future. But I will leave that thought hanging in the air, for the moment.

MERS – Dr Shalhoub, a King Abdulaziz alumni on the BMJ podcast

Bismillah, alhamdulillah: Great to hear a home grown graduate from King Abdulaziz University in Saudi Arabia discuss MERS on a BMJ podcast. Dr Sarah Shalhoub, a consultant at King Fahad Armed Forces Hospital,  gives an update on the current state of affairs regarding the disease.king_abdulaziz_university_emblem

Middle East respiratory syndrome
The BMJ Podcast
Duration: 20:09
Published: Fri, 21 Oct 2016 15:25:24 +0000