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Archive for September, 2007

Delay in the diagnosis of coeliac disease prolongs morbidity and mortality.

The study by Dr Cannings-John et al in the Br J Gen Pract. 2007 Aug; 57 (541):636-42 17688758, examined with what sorts of complaints patients presented to their GP during the 5 years PRIOR to the diagnosis of coeliac disease. They looked at patients with BIOPSY-proven coeliac disease and in general it TOOK FIVE years, 4.9 to be exact, before these patients went from, there is nothing wrong with you, it is all in the mind, to having their problem diagnosed.

Interestingly enough, 90% of these patients were referred for hospital investigations either organised by their GP, or to see a consultant. Ninety four percent had blood tests done. And one in three even had an endoscopy, and still nothing was found. What was found though was, that these patients in the five years before diagnosis, consulted their GPs a lot more than healthy controls. We all know that patients most often have a pretty good idea what is wrong with them, i.e. is it a physical or a mental health problem. So we should keep this in mind when dealing with difficult problems. Or I should say, we should RECONSIDER our diagnosis if patients keep coming back. Three clinical features were independently associated with subsequent diagnosis of coeliac disease: depression and/or anxiety, diarrhoea and anaemia. But these patients also presented a lot more with common symptoms like: abdo pain, gastritis, insomnia, IBS and interestingly enough, headaches, before someone finally got the diagnosis right. The authors concluded by saying that GPs should consider testing for celiac disease when patients present often, especially with diarrhoea and/or who are discovered to be anaemic.

Again this proves the point, that frequent attenders might very well have an illness, and not a pseudo or imaginary illness, as some seem to belief. Even though in another article in the same BJGP, another author, called frequent attenders heartsink patients, and that was apparently all down to (sexual) abuse in their childhood. I will discuss that article another time.

But this celiac paper proves again that we as doctors don’t listen well enough, i.e. are not good at diagnosing. And if you don’t listen and don’t do the RIGHT test, you won’t get the DIAGNOSIS RIGHT.

So what do you need to do?? When you notice anaemia or think about coeliac, you have to request the specific coeliac blood test. To check for antibodies, and if these are present, you have to confirm the diagnosis via endoscopy performed in hospital. 

PS: I’m afraid this study is NOT available free of charge from the BJGP. If I will come across a link to the full text of this article I will put it here. But if you would like to read the extract  just click here.

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“Of course Adriane Fugh-Berman is correct that we need to bite something tender and to get out of that lap.

But we are fighting the wrong beast. The beast is not the pharmaceutical industry – it is ourselves.

We, as doctors, have created the atmosphere which has allowed companies to malfunction. We have allowed industry to subvert the rules of science . We have watched quietly as governments and academics have colluded with industry to hide information critical to our patients. We have remained silent as our medical schools have churned out graduates who have no knowledge of the dilemmas and scandals of medicine. We have allowed many of our medical journals to become corrupted and timid. We have remained silent as the General Medical Council and other bodies charged with maintaining integrity have taken action against doctors for raising questions of integrity, while ignoring serious concerns brought to their attention. We have failed to support our colleagues who have raised concerns.

The soft parts that need biting may well be our own.”

BY: Dr Aubrey Blumsohn. Consultant, Sheffield Teaching Hospitals, UK

http://www.bmj.com/cgi/eletters/333/7576/1027#149035

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New guidance from the National Institute for Health and Clinical Excellence recommends Herceptin in early breast cancer, but it provides no additional funding or any suggestion of which services to cut. This leaves medical staff with difficult decisions to make.

The media have made little mention of the restricted categories of patients for whom Herceptin may be appropriate, or of the lack of long term toxicity data, especially concerning effects on the heart. Although the three published trials showed a statistically significant improvement in rates of recurrence, as yet, only one has shown a benefit in survival (4.8% at four years). 

On the face of it, the answer to our question is simple—Herceptin will cost our trust £2.3m—but the real cost lies in the services that will be cut to provide this money. This is an important element currently missing from the debate.

Guidance from the National Institute for Health and Clinical Excellence on new treatments does not have additional funding attached, and does not recommend which services should be cut to pay for new treatments.

BY: Ann Barrett, lead clinician for oncology, Department of Oncology, Norfolk and Norwich University Hospital;

BMJ  2006;333:1118-1120 (25 November);

http://www.bmj.com/cgi/content/full/333/7578/1118

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Drug representatives are paid to be nice to us, as long as we cooperate, sustaining our market share of targeted drugs and limiting our continuing medical education lectures to messages that increase drug sales. This is an unspoken agreement, but no less clear for being covert.

The drug industry is happy to play the generous and genial uncle until physicians want to discuss subjects that are off limits, such as the benefits of diet or exercise, or the relationship between medicine and pharmaceutical companies. Any subject with the potential to reduce drug sales is anathema. Fair enough. He who pays the piper calls the tune.

BY: Adriane Fugh-Berman

http://www.bmj.com/cgi/content/full/333/7576/1027?ijkey=g0spTSn4hbnro4G&keytype=ref

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Recently a German Psychiatrist who works for the German Army stated that the main predictor of soldiers getting PTSD, Post Traumatic Stress Disorder, and other mental illnesses, was not so much the lenght away from home, even though they spend a lot more time at home than British soldiers. But that it was more if the soldiers, when presented with a dangerous or horrible situation, had the feeling they had an INFLUENCE on the outcome or not.

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AVOIDING GMC HEARING

dice.jpg Will rolling the DICE decide the outcome for doctors with the new rules as the adagium, beyound a reasonable doubt will be replaced by the new reasoning that you are guilty of professional misconduct if it is more than 50% probable that it was your fault. A VERY  strange new route and many doctors will face losing their homes, careers etc due to this new rule. It is very good to protect the patient but it seems that doctors are losing any right of a reasonable defence.

New rules expected to come into force within months will allow more doctors who undergo an investigation by the UK General Medical Council to avoid a public hearing by acknowledging their shortcomings and agreeing to undergo retraining or restrict their practice.

http://www.bmj.com/cgi/content/extract/335/7620/582-b 

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bmj-after-deployment.jpg The army is taking on too many jobs, resulting in too many soldiers going off sick.

http://www.bmj.com/cgi/content/extract/335/7620/571  

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