Tag Archives: BMJ

TOP MEDICAL PODCASTS: ‘DIVERTICULAR DISEASE’ (BMJ)

Colonic diverticulosis refers to herniation of the mucosa and submucosa through the muscular layer of the colonic wall and may be the result of colonic smooth muscle over-activity. Diverticular disease may be defined as any clinical state caused by symptoms pertaining to colonic diverticula and includes a wide-ranging spectrum from asymptomatic to severe and complicated disease. 

Mohamed Thaha, Senior Lecturer & Lead Consultant in Colorectal Surgery, National Bowel Research Centre, Barts and The London School of Medicine and Dentistry, tells us more. 

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INFOGRAPHIC: PROLONGED COVID-19 SYMPTOMS – “A MULTI-SYSTEM DISEASE” (BMJ)

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COMMENTARY

COVID 19 is a nasty disease, in case you hadn’t noticed. It is SNEAKY: you can catch it from a person who has no symptoms.

It is UNPREDICTABLE: you may develop no symptoms or Die from it. It can affect any part of your body, including HEART and BRAIN.

And now we hear that it can DRAG ON. The outstanding infographic, “a multi-systems disease, which is intended for PRIMARY CARE PROVIDERS, has a lot to offer patients, who can do a lot to Care for themselves:

  • –They can get a THERMOMETER and a PULSE OXIMETER to watch their own temperatures and oxygen saturations
  • –They can monitor their own COMORBIDITIES, like Diabetes and HYPERTENSION, which are common with severe Covid. In patients who get very ill .
  • –They can watch their GENERAL HEALTH, including SLEEP and DIET (the exercise part is relegated to DOCTORS recommendations).

You should also RESTRICT Alcohol, Caffeine and it goes without saying CIGARETTE SMOKING. Of course PREVENTION, with DISTANCING, MASKING and being Outside, coupled with SLEEP, DIET and EXERCISE is always best.

–Dr. C.

COGNITION & BRAIN STUDIES: APATHY, NOT DEPRESSION, ASSOCIATED WITH DEMENTIA

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We tested the hypothesis that apathy, but not depression, is associated with dementia in patients with SVD. We found that higher baseline apathy, as well as increasing apathy over time, were associated with an increased dementia risk. In contrast, neither baseline depression or change in depression was associated with dementia. The relationship between apathy and dementia remained after controlling for other well-established risk factors including age, education and cognition. Finally, adding apathy to models predicting dementia improved model fit. These results suggest that apathy may be a prodromal symptom of dementia in patients with SVD.

Cerebral small vessel disease (SVD) is the leading vascular cause of dementia and plays a major role in cognitive decline and mortality.1 2 SVD affects the small vessels of the brain, leading to damage in the subcortical grey and white matter.1 The resulting clinical presentation includes cognitive and neuropsychiatric symptoms.1

Apathy is a reduction in goal-directed behaviour, which is a common neuropsychiatric symptom in SVD.3 Importantly, apathy is dissociable from depression,3 4 another symptom in SVD for which low mood is a predominant manifestation.5 Although there is some symptomatic overlap between the two,6 research using diffusion imaging reported that apathy, but not depression, was associated with white matter network damage in SVD.3 Many of the white matter pathways underlying apathy overlap with those related to cognitive impairment, and accordingly apathy, rather than depression, has been associated with cognitive deficits in SVD.7 These results suggest that apathy and cognitive impairment are symptomatic of prodromal dementia in SVD.

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MEDICAL PODCAST: “ASSESSING CHEST PAIN” (BMJ)

Chest pain is a common chief complaint. It may be caused by either benign or life-threatening aetiologies and is usually divided into cardiac and non-cardiac causes. James E. Brown, Professor and Chair, Wright State University Boonshoft School of Medicine, Kettering, Ohio, gives us an overview of assessing chest pain in the emergency setting. 

COMMENTARY

Dr. James E Brown of the Wright State school Of medicine in Kettering Ohio gave a very interesting discussion of chest pain.

One interesting takeaway is the value of a very experienced clinician dealing with large volumes of emergency room patients. This would make telemedicine with an emergency room hub in a teaching center a very attractive platform.

The consultant doctor in the center has the advantage of his vast experience in rapidly narrowing down the heterogeneous list of different diagnoses that must be considered- the “differential diagnosis”.

Dr. Brown mentioned the “gestalt”, the incorporation of subjective features such as facial and voice cues which add to the objective parameters in patient evaluation. This of course would be amenable to telemedicine although other old-time clinical information like the changes in breath sounds would be more favorable to conventional in-person evaluation.

Ultrasound would More easily be done locally as well.

An interesting take away from this discussion is the value of The patient’s history and past laboratory data, so undervalued by rushed modern doctors. For instance, Electronic medical records (EMR) could provide past history or a previous electrocardiogram for comparison.

Dr. Brown favors the division of chest pain causes into cardiac and non-cardiac. It is easy  to develop tunnel vision and look at the patient only as a possible coronary thrombosis. In fact it is better to Rapidly consider the non-cardiac causes that would demand immediate attention while waiting for the results of the Troponin-T test.

For instance pulmonary embolism, aortic dissection, tension pneumothorax, cardiac Tamponade should be considered.

These considerations should be running through the head of the clinician as the IV,  EKG, and pulse oximetry are being set up.

In addition to the Troponin-T, bedside ultrasound, and Higher “slice count” CAT machines, and higher “Tesla” MRIs  are becoming available major centers which could support small emergency rooms.

If there is One place where “the Flow” would be Appropriate it would be in the mind of the emergency room doctor evaluating acute chest pain.
I have a hard time imagining artificial intelligence endangering her job.

—Dr. C.

PODCAST: “MEDDIET” ALTERS GUT MICRIOBIOME IN OLDER PEOPLE, IMPROVES FRAILTY, COGNITION, INFLAMMATION

We observed that increased adherence to the MedDiet modulates specific components of the gut microbiota that were associated with a reduction in risk of frailty, improved cognitive function and reduced inflammatory status. 

Dr Philip Smith, Digital and Education Editor of Gut and Consultant Gastroenterologist at the Royal Liverpool Hospital interviews Professor Paul O’Toole; who is Professor of Microbial Genomics, Head of School of Microbiology and Principal Investigator in APC Microbiome Ireland, an SFI funded centre at University College Cork, Ireland, on “Mediterranean diet intervention alters the gut microbiome in older people reducing frailty and improving health status: the NU-AGE 1-year dietary intervention across 5 European countries” published in paper copy in Gut in July 2020.

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COMMENTARY

Diet is one of the 3 pillars ( or 4, if you don’t consider intellectual stimulation a form of exercise) of health. And there are 3 prime dimensions to diet: Quality, Quantity, and Timing. This excellent study addresses the Quality of the diet. Vegetables, fruits and whole grains are the foundation.

Dietary Fiber is the main difference between the healthful Mediterranean diet and the highly processed diet so common in America.

How can you be sure you are eating enough fiber? Read on.
On almost all cans and boxes, you will find a nutritional statement, by law. Assuming that the contents are “real food”, and preferably “organic”, look for the “fiber” in grams, and the “calories” in 100’s, and mentally divide the grams of fiber by 100s  of calories, and you get a number. Let’s say that your fiber for the day totals “25” gms. and your calories for the day Totals 2500; that is “25” hundred calories. Divide the 25 grams by the 25 hundred calories, and you get “1”. Anything less than 1 is low in fiber.

25 grams of fiber is about the daily recommendation for fiber. 25 hundred calories is a ballpark figure for an average diet.
PORTION SIZE DOESN’T MATTER, since your dividend is a ratio.
The bacteria in your MICROBIOME feed on the fiber, and the higher and more diverse the fiber ( within reason. Hay is high in fiber) the healthier the food.

Blueberries are good for a fruit at 4-5 gms. of fiber per hundred calories. Broccoli is a good vegetable at 10 gms fiber per hundred calories, carrots about 3, and so on.

Sugar is the perfect “bad” food, at no fiber for as many calories as you can pack in. It makes you Want more, and “desensitizes” your taste buds to the natural sweetness of fruit, or even vegetables.

HIGH FIBER foods are MORE FILLING, leading you to eat less.
Civilization and Capitalism pushes too much food and too many calories at us. Overeating , obesity, and many of the modern illnesses is the result.
Generally, fresh fruits and vegetables are preferred, though cooking doesn’t do much harm, other than some vitamin loss that can be replaced.

Whole grain cereals have fiber in addition to other nutrients. Also, the complex carbohydrates in whole grains  are released more slowly than wIth refined cereals. This floods your blood less rapidly with glucose, and elicits a Less precipitous insulin response. This results in a lower, healthier  “glycemic Index”.

Vegetables, fruits Legumes, seeds, nuts and their oils are the mainstay of the Vegan diet, which is healthful If enough protein and essential fats are ingested.

Fish, eggs, milk and cheeses are other components of the Mediterranean diet.

I take many of my daily Vegetable and fruits and  liquefy them in a food blender. Drinking my daily vegetables and fruits is a tasty and convenient way to improve my diet. I Savor individually those items I find most tasty, like nuts, apples, avocado, And fruit in season. This exercises my jaws, which is probably healthy.

YOUR MICROBIOME helps you in many ways that science is just beginning to understand. A healthy Microbiome is a DIVERSE Microbiome. FIBER is the food of the Microbiome, and a diversity in dietary fiber leads to a diverse Microbiome. A diverse, happy Microbiome produces many biological substances, like neurotransmitters, and probably communicates with the brain directly through the gut-brain Axis.

The Podcast on the 1 year Meddiet showed how directly a diet can BENEFIT HEALTH STATUS.

-Dr. C.

OPINION: THE BENEFITS OF HIGHLY NUTRITIOUS DIETS

Vitamins and minerals, as we all know, are of critical importance to our health. Gone are the days when scurvy(vitamin C) was the scourge of the high seas, and rickets (vitamin D) was common in the children of smoke-filled industrial cities with insufficient sunlight.

We are in a state of such overabundance that many medical authorities feel that vitamin supplementation merely makes our toilets healthier.

Covid 19, with a deficit of prevention and treatment options, has forced a new appreciation of the role of our immune systems in fending off Covid, and future viral plagues that are certain to follow. Optimum Health has never been more important.

A May 4, 2020, British Medical Journal (BMJ) article highlights the role of vitamins C and D, and minerals, especially Zinc, in functioning of our immune systems. Here are several highlights from the article:

  • Foods that are naturally abundant in vitamin C such as broccoli (60 mg/100 g), blackcurrants (130 mg/100 g), fortified breakfast cereals (up to 134 mg/100 g) and oranges (37–52 mg/100 g)45  should be made accessible to older individuals who are most in need of their nutritional benefits.
  • In the UK 5.5% of men and 4% of women 65 years and over (around 1 in 20) presently have zinc intakes lower than the lower reference nutrient intake (the level below which deficiency could occur).46 The consumption of foods naturally abundant in zinc such as canned crab (5.7 mg/100 g), canned shrimps (3.7 mg/100 g), canned adzuki beans (≈2.3 mg/100 g) and boiled eggs (1.3 mg/100 g) should be encouraged as a supplementation strategy to reinforce immunity.
  • Tolerable upper intake levels (ULs) are intake levels which should not be surpassed as toxicity problems could appear.47 For vitamin D a UL of 50 µg/day is advised and for zinc a UL of 25 mg/day is recommended. 47 There is insufficient evidence to establish UL for vitamin C, but available human data suggest that supplemental daily doses of up to about 1 g, in addition to normal dietary intake, are not associated with adverse gastrointestinal effects.47 Not having an adverse effect, however, is not necessarily indicative of a benefit either, and ongoing trials are warranted.
  • Among those with established respiratory conditions or pneumonia, specific nutrients such as vitamin C, D or zinc could be considered as potential adjuvants to conventional treatment pathways.

Susceptible people, particularly the old, should use every safe measure to stay well.

– Dr. C

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CARDIOLOGY PODCAST: “ATRIAL FIBRILLATION – A COMPREHENSIVE OVERVIEW”

Atrial fibrillation is chaotic and irregular atrial arrhythmia, the prevalence of which increases progressively with age. It causes significant morbidity and death. Many patients are asymptomatic or have symptoms that are less specific for cardiac arrhythmias, such as mild dementia or silent strokes. 

Gregory Lip, Price-Evans Chair of Cardiovascular Medicine, University of Liverpool, gives us an overview of the condition.

Read more on Atrial Fibrillation at BMJ

TELECONSULTING: “DEEP BREATH IN” – THE BMJ LAUNCHES A NEW PODCAST

The BMJ’s new podcast aims to help doctors feel more connected, heard, and supported

“Deep breath in … and out. Again, deep breath in … and out.”

We tune in to patients’ breath sounds, seeking confirmation of a diagnosis—one more supporting piece of evidence to reassure anxious patients or to narrow the differential.

But since the SARS-CoV-2 pandemic arrived, saying “deep breath in” has been replaced by the need to take one ourselves: before looking at the morning news, before venturing out (or logging on) to work each morning, and before ringing the next patient on your list with the ominous note alongside their name: “fever and cough for a week, now feeling breathless.” Although chosen in what seems like a different era, the name for The BMJ’s new podcast for general practitioners—Deep Breath In—seems fitting for our troubled times.

Rebooting general practice

Before anyone in Wuhan fell ill, GPs had already been feeling the strain. In the UK, despite government promises of 5000 new practising GPs by 2020, there were 6.2% fewer full time equivalent GPs in 2019 than in 2015.1 Similarly, physicians in the US have been compensating for an estimated shortfall of some 14 500 primary care doctors since 2017.2 Recent attempts to take the strain off GPs in England by funding allied health professionals have faltered because of onerous new demands on fledgling primary care networks.3 Turning it off and switching it back on again is often the only thing that works when your computer grinds to a halt. Perhaps coronavirus will do the same for primary care.

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COMMENTARY

Primary Care Physicians are a vanishing species [1]. This is unfortunate, since PCPs are the only doctors who attend the whole field of Medicine (have you ever asked an orthopedist about your cough?).

However, some of the slack is being taken up by Nurse Practitioners [2] and Physicians Assistants [3].

If you know a retired Internist or Family Practice Physician, be sure to cultivate a friendly relationship (and give them a hug when the Covid 19 epidemic cools off). They might be inclined to be that greatest of all Medical Resources- the Patient Advocate [4].

—Dr. C.