Bismillah, alhamdulillah: Sometimes a picture is worth a thousand words. This Venn diagram nicely illustrates how changing the diagnostic criteria for diabetes will affect the epidemiology of diabetes. A new set of patients will fall under the label of diabetes and some old timers will loose the label. The sceptics might note that overall the number of diagnosed diabetics will go up significantly and pharmaceutical sales of medication will no doubt reflect that. As a clinician who sees significant variability and mismatch between fasting glucose and HbA1c, especially in the Middle East, I sit firmly in the old timers camp and rely on the older more pathophysiologically consistent diagnostic criteria. I am sure the debate between experts over the issue has not ended. I have three thoughts that come to mind if the HbA1c is adopted:
If we accept HbAc as a diagnostic criteria what should we say to patients who had a HbA1c >6.5% but a normal FG who then manage to normalise their HbA1c through lifestyle changes. Did the lifestyle prevent diabetes or cure it? If we are consistent we should surely say – cure. Great news we have discovered a cure for diabetes! Indeed the pen is mightier than the sword.
Will clinicians behave in a paternalistic way and start to hunt for diabetes by any criteria? Instead of relying on a single criteria could this, coupled with the falling cost of tests and Health Information Systems offering ‘one click ordering’, result in more than one test done at a time. Will we have a rule-in or a rule-out attitude? I suspect a rule-in one is where doctors tend to head for. We will then have the ability to increase the incidence of diabetes from 9.1% of the population to 19.9% of the population. A small step for doctors, a giant leap for mankind.
No one seems to talk about the clinical value of the extra diagnoses over a period of time. A patient who is diabetic by HbA1c but not by fasting glucose today, and is truly destined to have diabetes will eventually have both criteria being positive after a period of time. What is that period of time? Is the earlier diagnosis clinically significant rather than statistically significant? Do we have long term studies that have tracked these two populations from pre-diagnosis and onwards?
My gut feeling is that the race between HbA1c and fasting glucose sounds like the old turtle and hare race story: at the end of the day the slower predictable turtle of fasting glucose will win over the faster but unpredictable hare.
The Venn diagram was taken from the following article:
Bismillah, alhamdulillah: a frequent question that our patients with hip and knee pain may ask their health care providers is should I have a hip or knee replacement? This BMJ podcast gives a patient’s view of having a total hip replacement for a fellow medic who was very wary of surgery. He had tried all the conservative therapies first. But the advise his orthopaedic doctor gave him stuck in his mind: ‘Do the operation when you are ready. When you can’t put your socks on – you are ready.’
2.46 million people in England have osteoarthritis of the hip, and many of those go on to eventually have a hip replacement – which is now widely considered one of the most commonly performed and successful operation.
Bismillah, alhamdulillah: well to a non medic this question is probably a no brainer, the answer must surely be yes. But hang on, what do most doctors in most consultations across the world – especially at the end? They order tests to help them work out what is going on. Why not just speed the process up and do the tests before you meet the doctor?
Well there are many good reasons why that is not a good choice. But one reason why this thought exists is that there is a zeitgeist that has taken hold of doctors, fuelled by technology that the clinical exam is not really that useful. The efficacy of the standard clinical exam is minimal and it doesn’t help much as we rely on technology as the final arbiter in diagnosis. This is what this discussion in the BMJ podcast talks about with Prof. Andrew Elder who was commissioned by the BMJ to seek out the evidence base of clinical exams. His findings run against the technology zeitgeist and reassuringly support the classical position as taught in medical schools throughout the world.
Bismillah, alhamdulillah: Who should we blame for the obesity ‘smoke and mirrors’? The canny sugar industry or the human foibles of academics? Or society for not paying academics well and leaving them vulnerable to such practices? After the Tobacco Legacy Documents this article does not come as a surprise and I wonder what will be written in the next 50 years about other well marketed ‘health’ interventions or should we call them deflections?
How the Sugar Industry Shifted Blame to Fat – NYTimes.com
Bismillah, alhamdulillah: the bionic pancreas uses two hormones: insulin and glucagon and is likely to be released in the next 2 years. This sounds like a real game changer. This podcast talks about the development process with one of the pioneers in the field Ed Damiano whose son (now 17) was diagnosed with Type 1 diabetes.
Bismillah, alhamdulillah: I was browsing around our local big supermarket trying to keep my self fruitfully engaged while my wife got on with the important things in life called shopping when I spotted one of these!
The toy obviously did not catch on, it had been relegated to a culdesac in the last corner of the large superstore. Dust was slowly gathering on the surface and the 38 QAR felt a bit over priced. But as a device to get children running around indoors and burning calories this looks like a really good idea! I will be trying it out and aim to report back. If it gets them running around the it’s the sort of indoor toy that Family Doctors and health centres could give away free as a means to combat obesity in our young population. Let me know if you have similar ideas or tips.
Well the “handinton” as opposed to badminton got the kids and me moving. But the space needed to play the game is more than available indoors. It also needs a net to allow for some game rules. The ‘feather hit’ is a bit heavier than I would like and my hand palm is smarting and I had to take evasive action when the returns were smashed back. Safety wise for indoors there are a few areas of concern.
I think the take home message is that we need to involve game / toy designers, architects, the sports fraternity and primary health care givers to come up with and promote games that get our kids (and their parents) moving in the home space. Anyone out there interested?
Bismillah, alhamdulillah: this sounds like a very odd question but reality can sometimes be stranger than fiction. Dr Martin Couney was a pioneer in neonatology and wanted to promote the use of incubators to help premature babies stay alive. At the time he started to promote the adoption in hospitals the response he received was in the negative. Hospitals refused to have such a device in their premises and the natural outcome of premature babies was death.
In order to promote public awareness he came up with the idea of setting up his own incubators for premature babies on display with real premature babies on show! He charged people to see the small babies and offered the service free to mothers and their premature babies.
This documentary speaks to some of the survivors who were exhibits at the amusement park. One of the odd side stories to this whole story was the story behind children going blind.
Once incubators became available in hospitals they provided premature children a hospital class service. Part of that was to provide their neonates with highly concentrated oxygen to help them breathe. On the other hand, Dr Couney who had to run his ‘ward’ for free and as a business only gave a mixture of oxygen and normal air. The neonates exposed to the high concentration of oxygen eventually became blind but the neonates in Dr Couney’s exhibition ward were saved from developing blindness due to retrolental fibroplasia, an unfortunate consequence of exposure to high concentration of oxygen at the neonatal stage.
Bismillah, alhamdulillah: a very interesting though small study which compared the average glucose measured in two ways between ‘black’ and ‘white’ Americans. Continuous glucose montors measured glucose levels for 90 days in 104 patients and compared this to the HbA1c. They also looked at the glycosylation rate of other proteins such as albumin and reversed the question by looking at the variability of glucose within each group at a given HbA1c see the degree of variation.
The conclusion was that ‘black’ Americans glycosylate their Hb by around a half percent more than ‘whites’ for a similar average glucose. But other proteins such as albumin had the same glycosylation rate. Also the intergroup variability of average glucose measured with continuous monitoring was quite high for a given HbA1c.
This will not come as a surprise to the astute clinician who will have noticed this especially when serving patients of a variable genetic background. I personally think the red cell membrane permeability to glucose is a big factor and perhaps genetic minor variations in Hb are key factors.
My take home message is that we may have to reappraise the way we use HbA1c across different populations and begin to see the HbA1c targets in a more relative light rather than an absolute one – especially in the light of plasma glucose levels.
Bismillah, alhamdulillah: Prince Charles from Britain once remarked about the ugly tall towers that were appearing in London. I remember him talking about this as a young teenager. At the time I wondered why he thought this was so important but with the passage of time I have begun to understand the social and human impact of architecture.
I met an architect as a patient and we started talking about what makes a really good health centre, architecturally speaking. ‘Don’t expansive spaces and high ceilings give a sense of well being’ I asked. He did not agree.
His response was: A health centre is somewhere I come when I am sick. I want to feel comfortable. I don’t want to feel that I am in a shopping mall. The mall experience is different, it is not cosy and caring but large and impersonal.
I couldn’t help but think he had put his finger on something important.