Karen, 25, had been on Yasmin for years without problems but now had three weeks of spotting. No missed pills, pregnancy test negative, seemed like just one of those things until she told me about her 'other doctor'.
It turned out her wa of the alternative ilk, and Karen had visited him for tiredness on the recommendation of her sister.
After a blood test, she was told her DHEA level were abnormnally low, "the level of an 80 year old", and advised to take DHEA to counteract the pill and boost her energy. At no time was it mentioned that DHEA was an androgen or that it could have side effects, although interestingly she complained of worsening acne.
She was also sold a multivitamin preparation, DHEA and three other vitamin/mineral combinations, and I'm sure they didnt come cheap.
Without knowing exactly whether DHEA was a likely cause of Karen's spotting, the sensible thing to do was to stop it and see what happened. A kindly endocrinologist agreed, observing that DHEA levels were useless and taking an androgen plus an anti-androgenic pill made little sense.

Is it just me?

Article in the BMJ today re whether long or short needles are best for infant vaccinations, including at 2 months. Found that longer needles same for immunogenicity, and caused less local reactions at the 1, 2 and 3 day follow-up, but not at six hours. The needle calibre, previously thought to matter, didn't.
Now, I love evidence as much as the next GP, and am well aware that the recommendation is for longer needles, but admit to being slightly worried about these findings when confronted with some full-term 2 month old babies, you know the one's without much padding.
The technique referred to in the BMJ article is stretching the skin flat between thumb and forefinger, inserting needle at 90 degrees and pushing down into muscle.
Did the authors push down until they thought they had hit muscle? Or did they go all the way in until hub met skin? If the former, not very scientific, if the latter, in some full term but petite babies I see, I'd hit bone or end up in the biceps femoris.
The accompanying editorial notes that 'if the subcutaneous and muscle tissue are bunched to minimise the chance of striking bone, as some have recommended, then a 25 mm needle is required to ensure intramuscular administration in infants'.
Yet this is not the technique used in the study.
Furthermore, at six hours after vaccination, when the greatest number of local reactions were seen, there was no statistical difference between longer and shorter needles. This seems to be glossed over in the paper.
I havent had the pleasure of visiting Birmingham, maybe they make 'em bigger than in Sydney.
Or maybe it's just me?

Name and shame but dont give me excuses

Fascinating cloak and dagger tale in the BMJ (link) recently told by researcher Iain Chalmers. Searching for studies in the late 80s to include in a systematic review about epidurals, Chalmers found a paper that was, for the large part, identical to an earlier paper by other authors, but not unacknowledged. Not just a few words here and there, but over half the text and some of the actual data was pinched.
Concerned by his findings, Chalmers contacting John Beazley, one of the paper's authors, who was even more concerned - he knew absolutely nothing about the paper he'd supposedly coauthored. Chalmers wrote to the remaining author and obvious culprit, Asim Kurjak, Professor of obstetrics at the University of Zagreb, as well as reporting the matter to the relevant bodies. Unfortunately, it was only the WHO that seemed to take action, with the university effectively sweeping the matter under the carpet, replying it would appreciate Chalmers's 'tactful handling of the case'. Chalmers now regrets acquiesing in this request.
To cut a long story short, Kurjak's paper was discovered to be an amalgam of two papers - he'd committed not just plagiarism, but scientific fraud. In addition, a book chapter he'd had published was lifted from someone else's PhD thesis.
As Chalmers puts it, universities, journals and professional associations 'need to expose very publicly those found guilty of this form of scientific misconduct'.
I'm not so sure though I agree with the thrust of an accompanying piece by psychology professor, Miquel Roig, who runs the line that teaching ethical writing would prevent much of the problem. Roig says writing can be an arduous task, and he's right, and yes universities should make sure their students know the rules.
But let the responsibility for this behaviour rest where it belongs.
When Professor Kurjak, and others of his ilk, decide to cobble together a publication with pinched data rather than do the hard yards, they know exactly what they're doing.

Is that a facial nerve palsy or are you just sad to see me?

It's always satisfying when your memory kicks in when it's needed. Fortunately, this happened yesterday when I saw an elderly gentleman for the first time, carefully escorted into the consulting room by his wife.
While husband and wife agreed Mr A wasn't quite himself, more specific details were difficult to elicit. Eventually I gleaned that Mr A had prostate cancer with bony metastases, was considered stable by his specialist, but had been 'sleepy' for a few days. No vomiting, no headache. Strikingly, neither husband or wife mentioned the bleeding obvious, Mr A's facial assymetry.
My questions on this point revealed that Mr A didnt know what on earth I was talking about but that Mrs A had also noticed her husband's mouth had taken on a certain diagonal quality.
This is where the memory banks came in, for the immediate question was whether he had an upper or lower motor neurone lesion. Sure, it's medicine 101, but to be honest it had been a while since an instant verdict was needed on this one.
Fortunately, the bilateral upper motor neurone innervation of the upper face was still somewhere in my brain's deeper recesses, and the presence of a left sided pronator drift confirmed the probability of an intracerebral lesion, although on this one my memory perplexed me by suggesting prostate metastases rarely went to brain.
Interestingly but sadly, a head CT revealed multiple metastases, perhaps prostate but most likely melanoma. Unbenown to our practice, Mr A had had a melanoma removed decades before.
If you'd like a brush up on upper versus lower motor neurone lesions, go to
http://clinicalcases.blogspot.com/2004/09/stroke-or-bells-palsy-facial-droop.html

You're killing people, Mr Abbott

A few decades ago, it became clear drink driving was costing lives, lots of lives, and predominantly taking its toll on our young. An education program telling drink-drivers they were silly, naughty and dangerous didn’t work, and hence the advent of random breath tests.
Predictably, RBT was at first unpopular in some circles, attracting criticism about nanny states and lost civil liberties. Now, however, it’s accepted as a necessary and successful public health measure. Who knows if you or I or one of our loved ones might be dead today if not for random breath testing?
The same goes for a myriad of other public health programs. Compulsory fitting and wearing of seat belts, compulsory bicycle and motor cycle helmets aim to save us from ourselves, as do divided roads, rest stops and registration checks on cars.
In the health sphere, think no-smoking areas and legislation forbidding the sale of tobacco products to under 18’s.
The big question on everyone’s lips right now, especially since last month’s Obesity conference (link) is why we don’t use a similar approach for obesity, an epidemic of gross proportions.
Sure, telling people they should exercise more and eat less is wise advice, but that doesn’t mean it works. In the words of two people who should know, the ‘decades-long reliance on health promotion and intense media coverage of obesity have had virtually no effect”. Writing in the MJA, Professor Paul Zimmet and UK Professor Philip James call for evidence-based approaches to the ‘unstoppable Australian obesity and diabetes juggernaut’ (link). And despite the mounting pressure for GPs to pack a brief intervention for just about every lifestyle illness into a 20 minute consultation, our effect on the weight of the nation has been negligible.
Thousands of people will die as a result of the Federal government’s preference for ideology over evidence on this issue, we just don’t know which ones. Tony Abbott may not find his stance so justifiable if the beneficiaries of government intervention were identifiable.
Given he’s shown no sign of yielding despite public pressure from countless Australian and international experts, perhaps the next step should be the creation of a cenotaph (link) in memory of those who’ve died from obesity and its complications, listing the names of the dead.
I wonder how long politicians would allow the toll to grow?

MJA 2006 Vol 185 Number 4

Doctors ain't doctors

As a GP, I've generally got better things to do than worry about the plight of surgeons, although polishing the Merc must be kind of tough at times. But in recent weeks, I've found myself in sympathy with College of Surgeons president, Dr Russell Stitz, currently in a stoush with the ACCC over surgical trainee numbers.
It's all too easy for the ACCC to assume the worst of doctors; I guess surgeons, not exactly renowned for their compassion, are easy targets. But it seems a bit stiff to accuse the College of Surgeons of being so greedy it'd limit trainee places just to maintain surgeon's high incomes.
To be honest, I've no idea whether the claim has any truth, but it seems a bit simplistic.
Even the public know there's insufficient operations going on in our hospitals to meet patient demand - headline newspaper stories of long waiting lists, closed beds and nursing shortages are commonplace - let alone provide a flood of new trainees with enough cases to become adept in their art.

Like most people, if I'm going to have an operation, I'd like a surgeon who's got lots of procedures under their belt, not one who's been to the 'see one, do one, teach one' school of surgery.
It's convenient for state governments to deflect blame for long waiting lists onto surgeons, but most surgical training takes place in public hospitals run by the states, and for their part, surgeons complain that hospital bureaucrats constantly cancel or cut short their lists.
Meanwhile some universities, such as Melbourne University, have their eyes on the fries, perhaps in conjunction with state governments, and I'm sure the Feds are watching closely, as it will be their Medicare dollars paying for any increases in surgical procedures.
Maybe it's time the ACCC took off it's 'doctors are greedy bastards' glasses.
If you're running a burger bar, I guess it's pretty much about making money, and a rival shop opening across the road might well influence your customer service and prices.
But doctors arent burgers, and more competition doesn't always mean better quality. Sure, surgeons want to make a good living, but their claims that there's a finite number of training places to train surgeons well makes sense.
It's also hardly greedy to willingly train those who in a year or two will be your direct competitors, yet this is precisely what surgeons, and other doctors, are asked to do.

Plugging the hole

The big issue in the dailies following Steve Irwin's death are now centred around whether the video of his very public death should be made public. Apparently Irwin, after being hit by the stingray in the chest, can be seen pulling the barb out of his chest before losing consciousness.
At the time of writing this, it is unclear whether the cause of death was the stingray's poison or cardiac tamponade, and this raises another issue.
If the latter, would he have been better of leaving the barb in place to plug the hole?
Anyone thoughts?

death of a doctor

I didnt even know him, but I'd heard quite a bit about this GP who was helping keep my friend's depressed sister alive and out of harm's way. Many GPs had tried but failed to make a difference during her long battle, but this time something had clicked and a trusting therapeutic relationship had ensued.
Things were looking up despite the inevitable ups and downs. She'd moved out of home at aged 50 and even had a 'gentleman friend' as her mother called him.
That was the last thing I'd heard. Until yesterday, that is, when I asked my friend about her sister's progress.
She's still fine, said my friend, but did I tell you about the GP she liked so much?
Obviously she hadn't, and the news stopped me in my tracks - he'd taken his own life just a few months ago.
It's a sad but well-known fact that general practitioners have higher rates of suicide, substance abuse and marital problems than other members of the community.
But the tragic irony of this particular GP's death really brings these figures home.