Be cost effective – US advice to doctors

Bismillah, alhamdulillah:

A campaign has been launched in the USA called Choosing Wisely®, perhaps it is an interesting choice of words as in Arabic some patients refer to their doctor as حكيم hakeem (wise one). The campaign is an attempt by the American Board of Internal Medicine (ABIM) Foundation and other American Boards to get physicians to think carefully and wisely before choosing tests. Here are 5 things they highlighted in conjunction with the American Gastroenterological Association:

  1. Use the lowest effective dose of a Proton Pump Inhibitor or H2 receptor antagonist, neither are risk free.
  2. Do not retest with interval testing (i.e. Faecal Occult Bloods) if the patient has a normal high quality (i.e. adequate prep & resection of polyps) colonoscopy – follow up 10 years. Interval retesting generates unnecessary repeat colonscopies.
  3.  If no high risk polyps found repeat in 5 years. High risk i.e villous adenoma, >3 polyps, >1cm. If high risk repeat in 3 years .
  4. Barrett’s oesophagus : 1,1,3 i.e. Normal endoscopy, normal at repeat in one year can have three yearly screening.
  5. Stop ordering CT abdomens so frequently! For this I will quote from Dr David Johnson, Professor of Medicine and Chief of Gastroenterology at Eastern Virginia Medical School. He reminds us that the lifetime increased risk of intra abdominal malignancy caused by lifetime radiation exposure goes from average to high after an exposure of 5mSv. Do you know how many mSv are delivered by a single abdominal CT? 

Read the following short quote and find out:

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How useful is metformin when added to insulin? A little – BMJ Meta-analysis

Bismillah, alhamdulillah

A meta-analysis published in the BMJ and reported on in Medscape highlights the following findings which I have very briefly summarised below:

  • Hba1c lower by 0.5%
  • Weight lower by 1 Kg
  • Insulin reduction by 5 units
  • No difference in all cause mortality

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Smokers in Saudi Arabia

Bismillah, alhamdulillah:

Some scary statistics from the Arab News concerning the number of smokers in Saudi Arabia. I was quite surprised by the number of female smokers. I would not be surprised if the death rate is an underestimate or will be rapidly rising given the number of smokers in the future. I hope the GCC initiative to increase taxation from 100 to 200% is accepted by the WTO. Perhaps brand and logo free packaging is an idea to implement next:

“According to statistics, 22,000 people die in Saudi Arabia each year of various diseases resulting from smoking. According to figures released by the World Health Organization (WHO), there are 6 million smokers in the Kingdom, 1.5 million of whom are women.

Saudi Arabia is considered the fourth largest importer of tobacco with the average annual consumption per individual put at 2,130 cigarettes.”

Why is diabetes increasing?

Bismillah, alhamdulillah:

I came across this interesting lecture given by Barbara Corkey ( from the Boston University School of Medicine. She was asked to give the Banting Lecture 2011, yearly lectures given by experts in the field of Diabetes. Banting was a Noble laureate who received the award for his role in the discovery of insulin. The lecture begins with a preamble about how the world has drastically changed in terms of the environment from air to food in which we humans live. The degree of change is quite stark and I have excerpted some of the introductory text below, it is certainly an eye opener.

“Many environmental changes have accompanied the rising onset of obesity and diabetes. Much has changed in our world to explain this epidemic incidence of obesity and diabetes, and many of those changes have not been carefully studied. Our foods have changed; living conditions, activity levels, the air we breathe have all changed: so where can we start looking for culprits?”

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Aliskiren combination preprations FDA warning

Bismillah, alhamdulillah:

Personally I never like combined preparations, while convenient for patients and seeming to offer the benefit of better patient compliance – I am always worried about unpredicted consequences for my patients and the difficulty with which I came lay the blame for a side effect on a specific medication. Here is another example of a new agent being combined with an old agent causing trouble albeit in a specific population set but I think the general principle holds true.

“The label changes are based on preliminary data from a Novartis-sponsored clinical trial called Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE), which evaluated aliskiren in combination with ACE inhibitors and ARBs. A higher risk for renal impairment, hypotension, and hyperkalemia, along with an apparent lack of efficacy, caused Novartis to halt the trial in December 2011.”

Can we send patients with a PPM for an MRI? One study says yes.

From Evernote:

Can we send patients with a PPM for an MRI? One study says yes.

Clipped from:

I was just asked the question whether or not we could request an MRI for a patient with a PPM. I thought the answer was no but I rang our MRI department and they informed me that they did not accept patient’s with PPMs. But having Googled it I came across the following study. Perhaps I should get our MRI department to comment on it.

A team led by Saman Nazarian, MD, of Johns Hopkins University, conducted 555 MRI scans on 438 patients with pacemakers (237) or defibrillators (201). Of the 555 MRI examinations, 222 (40 percent) were of the brain, 122 (22 percent) were of the spine, 89 (16 percent) were of the heart, 72 (13 percent) were of the abdomen or pelvis, and 50 (9 percent) were of an extremity. The team monitored patients before, during, and after the scans.

The fight against junk food – some useful info.

From Evernote:

The fight against junk food – some useful info.

Clipped from:

  • 72% parents pestered to buy junk food – 1000 parent survey
  • ‘Wt loss 90% calorie cuts 10% exercise.’ American College of Cardiology
  • Mcdonalds natural sponsor of Olympics?

A survey by the Children’s Food Trust of more than 1,000 parents with at least one child aged between three and 15 revealed that the majority believed advertising had an effect on what their children asked for. Some 72% said they had bought fast food or other unhealthy products as a result of pestering by their child. …

This was backed by a spokesman for the American College of Cardiology, Dr Matthew Sorrentino, who said that 90% of weight loss is achieved by cutting calories, and 10% is achieved by significantly increasing physical activity. Soon, the Olympic Games will take place. Embarrassingly, McDonald’s is the main sponsor.

A nice quote for hard working Fillipino nurses in the Saudi health system

Just saw this in the Arab News, a wonderful quote for the hard working Fillipino nurses in the kingdom. Perhaps there needs to be a foreign nurses nurses association to recognise the hard work off all other expat nurses too.

From Evernote:

A nice quote for hard working Fillipino nurses in the Saudi health system

Clipped from:

“The commitment to save lives and serve mankind are the traits heroes and nurses share in common. We may not have the power to create fire, power to fly or be invisible like our superheroes but nurses are equipped with skills, knowledge and good attitude. These are more than enough to for them to fulfill their role,” Al-Amri said.

Knee study (No 111 Obese pats, MRI) – 5Kg weight loss IMPROVES knee cartilage within a year.

From Evernote:

Knee study (No 111 Obese pats, MRI) – 5Kg weight loss IMPROVES knee cartilage within a year.

Clipped from:

This is a nice article that can be a positive incentive for patients to loose weight. A 5 kilogram weight loss to save yourself having a knee replacement sounds like a good deal and perhaps is something that overweight patients can visualise as an early gain and hence be a more powerful motivator for behaviour change.

"A recent study is encouraging concerning the effects of weight loss on knee joint preservation and perhaps even on rejuvenation. A study published in the Annals of the Rheumatic Diseases looked at 111 obese patients, one third of whom already suffered knee arthritis.[4]

Knee cartilage thickness was assessed using MRI at the beginning of the study and again 1 year later. The researchers found that weight loss helped preserve knees and led to improvement in both the quality and quantity of knee cartilage. Patients lost, on average, 9-10 pounds, and the more weight lost, the greater the increase in cartilage thickness."