Podcasts about care excellence

Episode 194: Acute low back pain.  Future Dr. Ibrahim presents a clinical case to explain the essential points in the evaluation of back pain.  Future Dr. Redden adds information about differentiating between a back strain and more serious diseases such as cancer, and Dr. Arreaza shares information about returning to work after back strain.Written by Michael Ibrahim, MSIV. Editing and comments by Jordan Redden, MSIV, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Dr. Arreaza:Welcome back, everyone. Today's topic is one that every primary care provider, emergency doctor, and even specialist sees routinely: low back pain. It's so common that studies estimate up to 80% of adults will experience it at some point in their lives. But despite how frequent it is, the challenge is to identify which cases are benign and which demand urgent attention.Jordan:Exactly. Low back pain is usually self-limiting and mechanical in nature, but we always need to keep an eye out for the rare but serious causes: things like infection, malignancy, or neurological compromise. That's why a good history and physical exam are our best tools right out of the gate.Michael:And to ground this in a real example, let me introduce a patient we saw recently. John is a 45-year-old warehouse worker who came in with two weeks of lower back pain that started after lifting a 50-lb box. He describes it as a dull, aching pain that radiates from his lower back down the posterior left thigh into the calf. He says it gets worse with bending or coughing, but he feels better when lying flat. He also mentioned some numbness in his left foot, but he denies any bowel or bladder issues. His vitals are completely normal. On exam, he had lumbar paraspinal tenderness, a positive straight leg-raise at 40 degrees on the left and decreased sensation in the L5 dermatome, though reflexes were still intact.Dr. Arreaza:That's a great case. Let's take a minute and talk about the straight leg raise test. This is a bedside tool we use to assess for lumbar nerve root irritation often caused by a herniated disc. ***Here's how it works: the patient lies supine, and you slowly raise their straight leg. If pain radiates below the knee between 30° and 70°, that suggests radiculopathy, especially involving the L5 or S1 nerve roots. Pain at higher angles is more likely due to hamstring tightness or mechanical strain.Michael:Right. So, stepping back: what do we mean by "low back pain"? Broadly, it's any pain localized to the lumbar spine, but it's often classified by type or cause:Mechanical (like muscle strain or degenerative disc disease), Radicular (nerve root involvement), Referred pain (like from pelvic or abdominal organs), Inflammatory (AS), and Systemic or serious causes like infection or malignancy. Jordan:In John's case, we're thinking radicular pain, most likely from a herniated disc compressing the L5 nerve root. That's supported by the dermatomal numbness, the leg pain, and that positive straight leg test.Dr. Arreaza:Good reasoning. Now, anytime we see back pain, our brains should run a checklist for red flags. These help us pick up more serious causes that require urgent attention. Let's run through the red flags.Michael:Sure. For fracture, we think about major trauma or even minor trauma in the elderly, especially those with osteoporosis or on chronic steroids. Also, anyone over 70 years old.Jordan:Then we have infections, which could include things like discitis, vertebral osteomyelitis, or epidural abscess. Red flags include fever, IV drug use, recent surgery, or immunosuppression.Michael:Malignancy is another critical one, especially if there's a history of breast, prostate, lung, kidney, or thyroid cancer. Clues include unexplained weight loss, night pain, or constant pain not relieved by rest.Jordan:And don't forget about inflammatory back pain, like ankylosing spondylitis, which is often seen in younger patients with morning stiffness that lasts more than 30 minutes and improves with activity.Dr. Arreaza:And of course, we always rule out cauda equina syndrome: a surgical emergency. That's urinary retention or incontinence, saddle anesthesia, bilateral leg weakness, or fecal incontinence. Missing this diagnosis can be catastrophic.Michael:Thankfully, in John's case, we don't see any red flags. His presentation is classic for uncomplicated lumbar radiculopathy. But we must stay vigilant, because sometimes patients don't offer up key symptoms unless we ask directly.Jordan:And that's where associated symptoms help guide us. For example:Radicular symptoms like numbness or weakness follow dermatomal patterns. Constitutional symptoms like fever or weight loss raise red flags. Bladder/bowel changes or saddle anesthesia raise alarms for cauda equina. Pain that wakes patients up at night might point to malignancy. Dr. Arreaza:So when do we order labs or imaging?Michael:Not right away. For most patients with acute low back pain, imaging is not needed unless they have red flags. If infection is suspected, we'd get CBC, ESR, and CRP. For cancer, maybe PSA or serum protein electrophoresis. And if inflammatory back disease is suspected, HLA-B27 can be helpful.Jordan:Yes, imaging should be delayed for at least six weeks unless red flags or significant neurologic deficits are present. When we do image, MRI is our go-to especially for suspected radiculopathy or cauda equina. X-rays can help if we're thinking about fractures, but they won't show soft tissue or nerve root issues.Michael:In the example from our case, since the patient doesn't have red flags, we'd go with conservative management: start NSAIDs and recommend activity modification. As this is the acute setting, physical therapy would not be recommended.Jordan:For the acute phase, research shows no serious difference between those with PT and those without in the long term. However, physical therapy is really the cornerstone of management for chronic back pain. It's not just movement: it's education, body mechanics, and teaching patients how to move safely. And PT can actually reduce opioid use, imaging, and injections down the line for patient struggling with long term back pain.Dr. Arreaza:Yes, and PT is not one-size-fits-all. PT might include McKenzie exercises, manual therapy, postural retraining, or even neuromuscular re-education. The goal is always to build core stability, promote healthy movement patterns, and reduce fear of motion.Jordan:Let's take a minute to talk about the McKenzie Method, a physical therapy approach used to treat lumbar disc herniation by identifying a specific movement, (often spinal extension) that reduces or centralizes pain. A common exercise is the prone press-up, (cobra pose for yoga fans) where the patient lies face down and pushes the upper body upward while keeping the hips on the floor to relieve pressure on the disc. These exercises should be done carefully, ideally under professional guidance, and discontinued if symptoms worsen.Michael:For our case patient, our working diagnosis is mechanical low back pain with L5 radiculopathy. No imaging needed now, no red flags. We'll treat conservatively and educate him about proper lifting, staying active, and recovery expectations.Jordan:We also emphasized to him that bed rest isn't helpful. In fact, bed rest can make things worse. Keeping active while avoiding heavy lifting for now is key.Dr. Arreaza:Return-to-work recommendations should be individualized. For example, an office worker, positioning while working, or work hours may be able to return to work promptly. However, those with physically demanding jobs may need light duty or be off work.Ice: no evidence of benefit. Heat: may reduce pain and disability in pain of less than 3 months, although the benefit was small and short.And we should always teach safe lifting techniques: bend at the knees, keep the load close, avoid twisting. It's basic knowledge, but it is very effective in preventing recurrence.Jordan:Now, if a patient fails to improve after 6 weeks of conservative therapy, or if they develop new neurologic deficits, that's when we think about referral to spine specialists or surgical consultation.Michael:And as previously mentioned: in cases where back pain becomes chronic (lasting more than 12 weeks) a multidisciplinary approach works best. That can include:Physical therapy, Cognitive behavioral therapy (CBT) And sometimes pain management interventions. Jordan:We can't forget the psychological toll either. Chronic back pain is associated with depression, anxiety, and opioid dependence. Increased risk factors include obesity, smoking, sedentary lifestyle, and previous back injuries.Dr. Arreaza:Well said. So, let's summarize. Michael?Michael:Sure! Low back pain is common, and most cases are benign. But we have to know the red flags that point to serious pathology. A focused history and physical exam are more powerful than many people realize. And the first step in treatment is almost always conservative, with a strong emphasis on maintaining physical activity.Jordan:And don't underestimate the value of patient education. Helping patients understand their pain, set realistic expectations, and stay active is often just as important as the medications or therapies we offer.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478–491. https://doi.org/10.7326/0003-4819-147-7-200710020-00006Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62–68. https://doi.org/10.3122/jabfm.2009.01.080102National Institute for Health and Care Excellence. (2020). Low back pain and sciatica in over 16s: Assessment and management (NICE Guideline No. NG59). https://www.nice.org.uk/guidance/ng59Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514–530. https://doi.org/10.7326/M16-2367UpToDate. (n.d.). Evaluation and treatment of low back pain in adults. Wolters Kluwer. https://www.uptodate.com (Access requires subscription)Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. 

London Tech Week has wrapped for 2025.For a look at this year's highlights, we're joined by The Standard's technology editor, Alex Pell, who not only attended the event but also joined multiple panels across the week.Alex told us about why he thinks ​we ​need ​to ​use AI ​to ​become ​more ​than ​human (​"​bionic ​if ​you ​will”), plus, he explains the rise of the artificial intelligence super agents.UK officials are being deployed to India to support the investigation into the Air India Crash, the Air Accidents Investigation Branch has said.The Boeing 787 Dreamliner struck a medical college moments after takeoff on Thursday in the Indian city of Ahmedabad, killing 241 people on board.Blood cancer patients in England and Wales will be among the first in the world to have access to a new “Trojan horse” treatment.Blenrep has been approved by the National Institute for Health and Care Excellence for NHS use.Also in this episode:-Tesla sues former Optimus humanoid robotics engineer over alleged trade secret theft-A 'Google Maps for the sea' that's aiming to help cut the shipping industry's CO2 emissions-Flo Health respond to claims that women face “real and frightening privacy and safety risks” when using period tracker apps-US caregivers are dressing up as bears to care for a bear cub Hosted on Acast. See acast.com/privacy for more information.

Dr Eisert, from Humboldt University in Germany, told us how pulse rates in super-realistic deepfakes are hard to detect and could escape traditional detector technology.A new AI tool to spot suspected skin cancer has been approved for NHS use.The National Institute for Health and Care Excellence said that the technology has the potential to reduce waiting times.Plus, a soviet rocket entry capsule, which was headed for Venus, is expected to come crashing back to Earth in the coming days.Also in this episode:One in three report the ability ‘to sing better than speak' after a strokeThe UK could experience the warmest start to May ever recordedArchaeologists discover ancient penis shaped pendant near Hadrian's Wall - and it's believed to have been a good luck charm Hosted on Acast. See acast.com/privacy for more information.

Chelsea McGivney, DVM earned her Doctor of Veterinary Medicine degree from Colorado State University.Her diverse veterinary career includes completing a small animal internship, working as an emergency and general practitioner, serving as an in-home end-of-life care veterinarian, and working in the pet food industry as a veterinary consultant for a leading company. This unique blend of experiences prepared McGivney for her role as General Manager at Caring Pathways, where she leads a dedicated team of at-home, end-of-life specialists. Her deep passion for the human-animal bond allows her to combine her professional expertise with her love of veterinary care to support families during some of life's most tender moments. Tyler Carmack, DVM, CVA, CVFT, CHPV, CTPEP,  is the Director of Hospice and Palliative Care for Caring Pathways. She founded Hampton Roads Veterinary Hospice, an AAHA Accredited End of Life practice, and has practiced exclusively hospice and palliative care since 2011. She has served on the Board of Directors of the International Association for Animal Hospice and Palliative Care (IAAHPC) since 2016 in various roles, including President in 2020 and 2025. Carmack holds certifications in animal hospice and palliative care, veterinary pain management, peaceful euthanasia, veterinary acupuncture, TCVM food therapy, and TCVM End-of-Life care.

Local Pet Care Excellence: Boulder City Critter Sitter.In today's episode of The Best Dam Podcast, Jill has the pleasure of chatting with Michelle Carroll, the owner of Boulder City Critter Sitter. Michelle shares her journey of turning a lifelong love for animals into a thriving business. From pet sitting to professional training, Michelle offers invaluable insights into the world of animal care and how her dedicated critter crew is enhancing the lives of both pets and their owners in Boulder City.DISCUSSION TOPICSMichelle Carroll's BackgroundPassion for animalsOwnership of Boulder City Critter SitterPet Sitting Business in Boulder CityNeed for pet sitting services in Boulder CityImportance of providing assurance for pet owners when awayProfessionalism and CertificationsVarious certifications and training Michelle has acquiredImportance of being insured and bondedHiring and training of independent contractorsFormation of the "critter crew"Training and EducationContinuing education and additional certificationsApprenticeship with Sabrina SmilerFuture training workshops in Boulder CityPet Behavior and Owner EducationFocus on positive reinforcement training methodsExplanation of animal behavior understandingImportance of educating the pet ownersPersonal Stories and ExperiencesPersonal anecdotes, such as a cat stealing personal itemsConnection and trust-building with animalsCommunity Involvement and Future PlansDesire to work with local animal sheltersPlans for a ribbon-cutting and community event to promote animal adoptionPartnerships with local businessesPassion for Animals and the CommunityMichelle's personal journey and satisfaction working with animalsIntegration of technology skills into the businessEnthusiasm for community collaboration and eventsMEDIAhttps://www.bouldercity.com/new-business-critter-sitter-and-dog-walking/LEARN MOREClick here to learn more about Michelle and Boulder City Critter Sitter, visit their website at https://bouldercitycrittersitter.com or on Facebook at  https://www.facebook.com/bouldercitycrittersitterKEYWORDSMichelle Carroll, Boulder City Critter Sitter, Jill Lagan, Boulder City Chamber of Commerce, The Best Dam Podcast, Podcast Interview#MichelleCarroll #BoulderCityCritterSitter #BoulderCity #JillLagan #BCNVChamber2025 #TheBestDamPodcast #PodcastInterviewCREDITSThe Best Dam Podcast is a Boulder City Chamber of Commerce podcast production.This episode is sponsored by the i & i Podcast & Music Studio. Be Heard.

In this podcast recorded in early February, David Phizackerley and Julian Treadwell (DTB Associate Editor) provide an overview of the March 2025 issue of DTB. Julian talks about his work as an academic GP based at Bristol University. He explains why and how he developed the GP Evidence website (https://gpevidence.org/) as a resource for health professionals to use as part of a shared decision making process, and talks about the importance of providing patients with information on the absolute benefits and harms of different treatment options for long-term conditions.   The editorial discusses a paper published in The Lancet on the population-health impact of new drugs recommended by NICE and highlights the tension between NICE's role in ensuring that treatments are a cost-effective use of taxpayers' money and its role in championing the for-profit life-sciences - https://dtb.bmj.com/content/63/3/34. A DTB Select item summarises safety alerts issued by the US Food and Drug Administration and the European Medicines Agency on liver problems associated with fezolinetant (▼Veoza), a drug licensed for the treatment of moderate-to-severe vasomotor symptoms associated with the menopause - https://dtb.bmj.com/content/63/3/36. The main article provides an overview of systemic anticancer treatments and conventional cytotoxic drugs - https://dtb.bmj.com/content/63/3/37.   Links GP Evidence (https://gpevidence.org/)   Naci H, Murphy P, Woods B, et al. Population-health impact of new drugs recommended by the National Institute for Health and Care Excellence in England during 2000–20: a retrospective analysis. The Lancet 2025;405:50–60. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02352-3/fulltext)    Please subscribe to the DTB podcast to get episodes automatically downloaded to your mobile device and computer. Also, please consider leaving us a review or a comment on the DTB Podcast iTunes podcast page. If you want to contact us please email dtb@bmj.com. Thank you for listening.

Imagine living with an illness that can sap your energy levels so completely that even day-to-day tasks, such as doing laundry, walking the dog, or even getting out of bed can be insurmountable challenges. To make matters worse, this illness is not well understood either by the public or by medical staff, and is often dismissed and stigmatised, making it difficult to find understanding or treatment. This is the unfortunate lived experience of many people with myalgic encephalomyelitis/chronic fatigue syndrome (or ME/CFS for short). In a recent Communication article, researcher Caroline Kingdon of the London School of Hygiene and Tropical Medicine, and colleagues, discuss this misunderstood condition through the prism of the 2021 guideline for the treatment of those with ME/CFS, which have been published by the UK's National Institute for Health and Care Excellence (or NICE for short). Their article aims to inform primary caregivers about the NICE guideline, and, happily, reveals that the new guideline prioritises an overdue shift toward compassionate and patient-focused care for ME/CFS.

The latest episode of Digital Health Unplugged features Holly Coole, senior manager for digital mental health at the Medicines and Healthcare products Regulatory Agency (MHRA), talking about the regulation of digital mental health technologies (DMHTs). Tammy Lovell, news editor at Digital Health News, chats to Coole about the three-year Digital Mental Health Project, which aims to improve outcomes for people with mental health conditions by ensuring that both medical professionals and the public have safe and effective access to DMHTs. In the podcast they discuss how the project, led by the MHRA in partnership with the National Institute for Health and Care Excellence, aims to provide clarity around the key considerations for the regulation and valuation of DMHTs.   They also talk about the challenges of regulating this area and why it is so important to protect patient safety, and ensure access to effective products for mental health.  Coole, who is a registered mental health nurse, co-authored a paper on the project, published in The Lancet Digital Health in January 2025. Listen to this episode to discover what this project means for the future of mental health technology in the UK. Guest: Holly Coole, senior manager for digital mental health at the MHRA  

The National Institute for Health and Care Excellence in the UK looks set to reduce the number of people to be offered what's known as the ‘King Kong' of weight loss, Mounjaro. They are now going to offer the drug only to those with the highest clinical needs. Dr. Michael Crotty, the Irish College of GP's Clinical Lead on Obesity tells us more.

Today, we're speaking to Dr Charlotte Archer, Research fellow in primary care mental health based at the University of Bristol.Title of paper: GPs' views of prescribing beta- blockers for people with anxiety disorders: a qualitative studyAvailable at: https://doi.org/10.3399/BJGP.2024.0091Beta-blockers are licensed for managing the symptoms of anxiety, and new prescriptions for patients with anxiety have increased substantially in recent years. However, National Institute for Health and Care Excellence guidance for anxiety does not recommend beta-blockers as a treatment for anxiety, and recent reports have highlighted risks associated with the beta-blocker propranolol. Our research found that GPs prescribe beta-blockers for anxiety because they consider them to be low risk, a quicker solution than other treatments, and useful for managing associated physical symptoms.

The average full term baby weighs just over 7lbs. One pound of that is the baby's brain. Nature, via the mother's body, devotes enormous amounts of energy into building the baby's brain during and just after pregnancy. And as you've heard me say many, many times, the brain is the hungriest organ in the body and requires specific nutrients from the diet for proper structure and function.So why, dear listeners, is brain development completely absent from the National Institute for Health and Care Excellence guideline update on pregnancy and child nutrition?In this week's episode I am a starting a teeny tiny beef with NICE.Think Through NutritionThe Food ProgrammeNICE Maternal & Child Nutrition Stakeholder List___Newsletter sign up How to Build a Healthy Brain* Unprocessed: What Your Diet is Doing to Your Brain* Patreon Original music by Juan Iglesias *Affiliate links Support this show http://supporter.acast.com/strongerminds. Hosted on Acast. See acast.com/privacy for more information.

The National Institute for Health and Care Excellence has, for the first time, published a guideline on the identification and management of adrenal insufficiency, a rare condition which occurs when the adrenal glands do not produce enough essential hormones – particularly cortisol and aldosterone. We're joined by Dr Helen Simpson, a consultant endocrinologist at UCLH NHS Foundation Trust and Sally Tollerfield an endocrine clinical nurse specialist at Great Ormond Street Hospital, to discuss the guideline and the benefits it will provide to patients and healthcare professionals.

On this episode of the podcast, host Amanda Head talks with Dr. Richard Bosshardt, a seasoned, board-certified plastic surgeon with 35 years of experience, to discuss the growing influence of ideology and politics in medicine.Dr. Bosshardt dives into how critical race theory and Marxist ideology have infiltrated universities, steering the focus towards DEI (Diversity, Equity, and Inclusion) and anti-racism at the expense of patient care. He shares his professional concerns about the American College of Surgeons' embrace of these ideologies and recounts his own experience of being banned for speaking out against them.Dr. Bosshardt also addresses the controversial topic of gender-affirming surgeries for minors, highlighting the lack of evidence supporting such procedures and citing studies that show the majority of children with gender confusion eventually reconcile with their biological sex. Lastly, he commends the American Society of Plastic Surgeons for departing from medical establishment and taking a more cautious approach to gender-affirming care.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

What is mindfulness? What's the difference between mindfulness and doing things 'mindfully'? What does evidence about the positive impact of mindfulness tell us about the origins of our mental health struggles?We'll be discussing these topics with Dr Afrosa Ahmed, who has just written a book: "Mindful Healing, 5 Simple Steps to Transform your Life" published by Michael O'Mara Books.A practising GP in the NHS for over 20 years, as well as a Harley Street-based mindfulness coach, Afrosa launched life-coaching programme MindfulDoc in 2020.In her book, Afrosa shares her knowledge of how we can incorporate the ancient practice of mindfulness into our everyday lives. Mindfulness is now endorsed by the National Institute for Health and Care Excellence and the NHS. "Mindful Healing, 5 Simple Steps to Transform your Life" is published by Michael O'Mara Books.Follow @livelymindspod on X, Facebook, Instagram, LinkedIn and more at https://www.bio.link/livelymindsPlease note that this show does not constitute medical advice and is not a replacement for seeking professional help. You can find our more about the show and get signposting to support on our website anyamedia.net/livelyminds

Our Dragons' Den mentor Sara Davies MBE had gestational diabetes in both of her pregnancies and talks to us today about the guilt she felt when first diagnosed and what she has since learned about this condition that affects around 5% of pregnant women in the UK.We are also joined by Cathy Tabner of My Expert Midwife whose knowledge of gestational diabetes, and more widely about pregnancy and your body when you are pregnant, is unsurpassed!This conversation covers mum guilt, pregnancy hormones, how the placenta works, what happens in your body when pregnant, how your diet can help control gestational diabetes and much more.Any pregnant woman can develop gestational diabetes so if you are expecting a baby or may do in the future, you need to hear this conversation.*Please note, this episode references Dr Michael Mosley's work, in particular his blood sugar diet. This episode was recorded prior to his tragic death.If you love this episode, please share and leave us a podcast review, and don't forget to subscribe on your favourite podcast platform so that you never miss these important family health conversations.Follow Sara Davies here on Instagram or connect here on LinkedIn.Learn more about Dragons' Den here and watch Mini First Aid on Dragons' Den here.Connect with Cathy Tabner here and find out all about the brilliant work of My Expert Midwife here.Check out all the guidance and resources from Diabetes UK here on their website, in particular this page on gestational diabetes and learn more from Diabetes UK about the HBA1C test here and read the NHS information page for gestational diabetes here and learn about the drug Metformin hereVisit Dr Michael Mosley's website here and check out his recipe books hereNational Institute for Health & Care Excellence guidance for diabetes in pregnancyMini First Aid is an award-winning, Dragons' Den winning business bringing vital first aid training to parents, carers and workers across the UK. You can find out more about our wide range of first aid classes and courses here Mini First Aid first aid kits are designed to meet all your family's first aid needs. With a range of sizes available, you can keep our kits at home and take them out and about with you on day trips with your little ones. Browse our full range of kits hereSeries 3 of the Family Health Podcast by Mini First Aid is sponsored by Savlon Scar Prevention Gel. Savlon has been trusted by the nation for generations and can help the whole family with the range of products available.   

This detailed episode with Dr. Mark Harper, author of breaks down the benefits of cold water swimming for trauma, chronic pain, depression, bipolar disorder, and other illnesses plaguing so many of us these days. Dr. Mark Harper shares the findings of his cold swimming studies and the direction his research is going. We discuss the various reasons you might consider cold water swimming as a priority in your wellness habits and how to start, if, like me, you are terrified of being cold and unable to breathe. Mark explains how cold the water should be to be effective, how long one should stay immersed, and how often to engage in cold water swimming to receive its benefits. He shares the many stories of those whose health has been drastically improved by cold water swimming and many other recommendations for blue therapy, and why this therapy works to reduce stress in all areas of our lives. Dr. Mark Harper is a consultant anesthetist. His first field of research was investigating the best way to keep patients warm during surgery and thereby reduce the incidence of postoperative complications. The results of these studies have been incorporated into national and international guidelines and Mark was invited to be an expert clinical adviser to NICE, the National Institute of Health and Care Excellence. Shortly after taking up his consultant post in Brighton in 2003, he started swimming in the sea throughout the year. Around the same time, whilst working on his PhD, he brought together his clinical research and the physiology of cold-water adaptation to show how outdoor swimming could be employed to reduce surgical complications. Further insights – both from his personal experience and the experimental literature - led him to propose that cold water swimming might be an effective intervention for mental health problems. In collaboration Dr Chris van Tulleken and the Extreme Environments Lab in Portsmouth, he had the opportunity to test this in practice on the BAFTA award-nominated BBC television program “The Doctor Who Gave Up Drugs.”  Following this success, he set up and ran the first-ever clinical trial using sea swimming as a clinical treatment - for anxiety and depression – the outcomes of which were incredibly positive. In the process, he helped set up Chill UK which now provides outdoor swimming courses for hundreds of people around the UK. His book, ‘Chill – the cold water swim cure' was published in 2022 and is being translated into three other languages. Website | Instagram | Book ------------------------------------------------------------------------------------------------------------ Your support is deeply appreciated! Find me, Lara, on my Website / Instagram You can support this podcast with any level of donation here. Order The Essential Guide to Trauma Sensitive Yoga: How to Create Safer Spaces for All

This week we will continue our coverage of Bile acid malabsorption (BAM),  a gastrointestinal disease. It's a common cause of chronic diarrhea. When bile acids aren't properly absorbed in your intestines, they build up, upsetting the chemical balance inside. Excess bile acids trigger your colon to secrete extra water, leading to watery stools. This week we will continue our coverage of Bile acid malabsorption (BAM),  a gastrointestinal disease. It's a common cause of chronic diarrhea. When bile acids aren't properly absorbed in your intestines, they build up, upsetting the chemical balance inside. Excess bile acids trigger your colon to secrete extra water, leading to watery stools. Bile acid malabsorption (BAM) is often misdiagnosed as Irritable Bowel Syndrome or is overlooked in individuals with Crohn's disease. Bile Acid Malabsorption happens when the small intestine is unable to direct bile acid back to the liver. This means that the body doesn't absorb water properly and affects digestion. The condition results in what is known as Bile Acid Diarrhoea. How will a new test for Bile Acid Malabsorption be developed? Currently, the only test for bile acid malabsorption is the SeHCAT test which is expensive, time consuming and uses radiation. The team have developed a test which they believe will diagnose the condition more rapidly and cost effectively than the current test. For its initial testing phase, it will be used on stool (poo) samples, and in its second phase the research team will assess whether it can also guide treatment decisions on what dose should be given to individual patients. The aim of the study is to establish a better test for BAM, do the groundwork for a future study of the role of faecal bile acid measurements within the NHS, and use the data collected from this trial to prepare other studies to assist with the diagnosis and treatment of individuals with BAM. Why diagnose bile acid malabsorption? Chronic diarrhea is one of the most common reasons why people get referred to specialist gastroenterology clinics, and can account for as many as 1 in 20 referrals. Bile acid malabsorption is a major cause of chronic diarrhoea and is thought to affect up to 1 million people in the UK. As well as individuals with Crohn's disease, as many as one in three people diagnosed with IBS with diarrhoea (IBS-D) may actually be experiencing BAM but the current gold standard SeCHAT test is only available in certain UK centres. It is also time consuming and costly. In 2012 the National Institute for Health and Care Excellence's Diagnostic Advisory Group concluded that a new test for the diagnosis of BAM was needed. (credits: Diagnosing bile acid malabsorption - Bowel Research UK :Bowel Research UK )    

Listen in to learn how to challenge and encourage the next generation of leaders using real-life experiences as an accomplished professional. You will also learn the importance of always remembering your why because it will get you through any challenges you face in your career or business. Dr. Sabrina Dean is the CEO of Dr. Sabrina's Healthcare Consulting, LLC for healthcare organizations, the Founder of Sabrina's Consulting, where she helps individuals fulfill their holistic and health desires, and the Co-Founder of the African American Women Giving Circle, Dayton, OH. She is the former Director of Quality, Infection Control, Regulatory and Accreditation, Employee Health, Risk Management at several healthcare organizations, and she is an Adjunct Professor at Franklin University, Columbus, OH for their doctoral program. Dr. Sabrina is an experienced Registered Nurse with a demonstrated history of working in the healthcare industry. In this episode, Sabrina talks about her journey in the healthcare industry and the lessons she'd like to pass down to upcoming leaders in the industry.

As a member of the Parkinson's Disease guideline committee of the National Institute for Health and Care Excellence, Clare Johnson explains the vast number of ways Occupational Therapists help patients and their families cope with the everyday motor and non-motor challenges of living with Parkinsons. We hear about the benefits of multi-disciplinary clinics and why standard measurement scales can fall short compared to individualised evaluation.

Around 1 billion people around the world suffer from a mysterious neurological condition called migraine. Far more than just a headache, migraine is abnormal processing of the world around us that can have symptoms like loss of sight and speech, dizziness, nausea and extreme fatigue.There are drugs which can help those struggling with the condition like anti-depressants and anti-convulsants. However, they weren't developed specifically for migraine and can come with quite a lot of side effects or simply not work.For a long time migraine medication has been a process of trial and error. But a new class of drugs called anti-CGRPs are being hailed as a breakthrough migraine medication. Anti-CGRPs have a small side effect profile and were designed specifically to target migraine. They work by blocking CGRP (Calcitonin Gene-Related Peptide) from building up in the body and triggering a receptor in the brain which turns on a head pain pathway causing the migraine attack.Earlier this year the National Institute of Health and Care Excellence - or NICE – in England cleared the use of an anti-CGRP called Rimegepant to use as both a preventive and acute treatment. Clinicians are hoping this will massively improve the lives of those living with the condition.So this week on The Inquiry were asking ‘Have we reached a turning point with migraine medication?'Contributors: Dr. Amaal Starling, neurologist and headache specialist at Mayo Clinic in Scottsdale, in the US state of Arizona. Dr Faraidoon, researcher at the Georgian Institute for Global Health at the University of New South Wales, Sydney, Australia. Peter Goadsby , Director of the NIHR King's Clinical Research Facility and a professor of neurology at King's College London, England. Dr Lise Rystad Oie, researcher at the government funded Norwegian Centre for Headache Research - also known as NorHead.Presenter: Charmaine Cozier Producer: Anoushka Mutanda-Dougherty Editor: Tara McDermott Researcher: Matt Toulson Technical Producer: Craig Boardman Broadcast Co-ordinator: Jordan KingImage: eternalcreative - Getty Images: 1372323487

Dengue CDC. Clinical assessment. Centers for Disease Control and Prevention. Cdc.gov. https://www.cdc.gov/dengue/training/cme/ccm/page73112.html CDC. Dengue. Centers for Disease Control and Prevention. Published August 15, 2023. https://www.cdc.gov/dengue/index.html Rigby J. First Pill for Dengue Shows Promise in Human Challenge Trial. Medscape: Emergency Medicine. Published October 23, 2023. https://www.medscape.com/s/viewarticle/997558?ecd=wnlscitech231101MSCPEDIT_etid6007373&uac=255848DR&impID=6007373 Schnirring L. California confirms 2nd local dengue case. Center for infectious disease research and policy. University of Minnesota. Umn.edu. Published November 2, 2023. https://www.cidrap.umn.edu/dengue/california-confirms-2nd-local-dengue-case Penis Pain Lizza E. Peyronie Disease. Medscape.com. Published August 17, 2023. https://emedicine.medscape.com/article/456574-overview Malloy M, Sinert R. Dysuria and Discharge After a New Sexual Partner. Medscape. Published November 20, 2023. https://reference.medscape.com/viewarticle/847159 Promethazine 2018-2019 Targeted Medication Safety Best Practices for Hospitals. Ismp.org. https://www.ismp.org/sites/default/files/attachments/2019-01/TMSBP-for-Hospitalsv2.pdf Drug Shortage Detail: Promethazine Injection. Ashp.org. Updated November 21, 2023. https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=872 Fass O. Antiemetics and QT prolongation. Clinicalcorrelations.org. Published January 15, 2021. https://www.clinicalcorrelations.org/2021/01/15/antiemetics-and-qt-prolongation/ Ozempic Korte C. Ozempic side effects could lead to hospitalization — and doctors warn that long-term impacts remain unknown. CBS News. Published June 10, 2023. https://www.cbsnews.com/news/ozempic-side-effects-weight-loss-drugs-wegovy-mounjaro-doctors-warn/ Krishnan L, Dhatariya K, Gerontitis D. No clinical harm from a massive exenatide overdose – a short report. Clin Toxicol (Phila). Clinical Toxicology. Published December 11, 2012. https://www.tandfonline.com/doi/pdf/10.3109/15563650.2012.752495 MedWatch: The FDA Safety Information and Adverse Event Reporting Program. FDA: U.S. Food and Drug Administration. Published September 15, 2022. https://www.fda.gov/medwatch Nakanishi R, Hirose T, Tamura Y, et.al. Attempted suicide with liraglutide overdose did not induce hypoglycemia. Diabetes Research and Clinical Practice. Diabetesresearchclinicalpractice.com. Published November 12, 2012. https://www.diabetesresearchclinicalpractice.com/article/S0168-8227(12)00384-1/fulltext Ozempic® (semaglutide) injection for Type 2 Diabetes. Ozempic.com. https://www.ozempic.com/ Hearing Loss Ahmed OH, Gallant SC, Ruiz R, Wang B, Shapiro WH, Voigt EP. Validity of the Hum Test, a Simple and Reliable Alternative to the Weber Test. Ann Otol Rhinol Laryngol. NIH: National Library of Medicine: National Center for Biotechnology Information. Published June 2018. https://pubmed.ncbi.nlm.nih.gov/29776326/#:~:text=Results%3A%20When%20examining%20the%20ability,respectively%2C%20with%20low%20pitched%20humming. Clinical Practice Guideline: Sudden Hearing Loss (Update). American Academy of Otolaryngology – Head and Neck Surgery. Entnet.org. https://www.entnet.org/quality-practice/quality-products/clinical-practice-guidelines/sudden-hearing-loss-update/ Hearing loss in adults: assessment and management. National Guideline Centre (UK). Immediate, Urgent and Routine Referral. National Institute for Health and Care Excellence; 2018. NIH: National Library of Medicine: National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK536553/#:~:text=If%20the%20hearing%20loss%20developed,service%20or%20an%20emergency%20department. Mroz M. Do you know the three main types of hearing loss? Healthy Hearing. Published April 17, 2014. https://www.healthyhearing.com/help/hearing-loss/types Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. thesgem.com. http://www.thesgem.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

In this podcast episode titled "Building Trust and Reputation: The Consistency Factor in Child Care Excellence," we delve into the crucial role of consistency in child care centers. As a director, you're guided through the challenges and solutions for maintaining consistent policies and procedures. The episode emphasizes the positive impact of consistency on building trust with parents, enhancing word-of-mouth marketing, and ensuring employee retention and satisfaction. It offers actionable strategies like establishing clear policies, providing ongoing training, fostering a collaborative culture, leading by example, and regularly monitoring and evaluating practices. Additionally, it stresses the importance of explaining the "why" behind policies to empower and engage employees. The episode is a comprehensive guide for child care center directors to foster a stable, nurturing environment that benefits children, parents, and staff alike.Let's connect:www.thedirectorsclub.netCommunity:Join my FREE Facebook group and connect with other directors and me as we navigate leading a child care center together!  FB Group Child Care Center Owners and DirectorsSocials:Facebook page, The Director's ClubInstagram, The Director's ClubWORKING WITH NOELLE AND THE DIRECTOR'S CLUB:The ClubDiscover more about The Director's Club, a mastermind group designed for child care center directors who seek support and expert guidance to maintain high-quality early education centers.   LEARN MORE ABOUT THE CLUB HEREThe Teacher's LoungeDo you want to enhance your teachers' confidence in the classroom through a mentoring program tailored to their needs? Look no further than The Teacher's Lounge, a dedicated mentoring department that you've always wanted for your child care center. Don't hesitate, visit us now to learn more HERE   

In this podcast, James Cave (Editor-in-Chief) and David Phizackerley (Deputy Editor) talk about the November 2023 issue of DTB. They discuss the history of the BNF and the announcement that the 86th edition of the BNF and the 2023–2024 edition of the BNF for Children will be the last print issues to be purchased by the National Institute for Health and Care Excellence for the NHS in England (https://dtb.bmj.com/content/61/11/162 and https://dtb.bmj.com/content/61/11/166). They talk about a retrospective review of a case series of UK coroners' Reports to Prevent Future Deaths that found that around one in five reports involved a medicine (https://dtb.bmj.com/content/61/11/165). The main article provides an introduction to pharmacogenetics (https://dtb.bmj.com/content/61/11/168). They begin by responding to a listener's email.   Please subscribe to the DTB podcast to get episodes automatically downloaded to your mobile device and computer. Also, please consider leaving us a review or a comment on the DTB Podcast iTunes podcast page (https://podcasts.apple.com/gb/podcast/dtb-podcast/id307773309). If you want to contact us please email dtb@bmj.com. Thank you for listening.

Dustin Atwood and Sarah Myers talk about a variety of topics in the automotive industry, including: Dustin brings on special guest, Annie! Annie is the store manager for the Sunset store. Annie talks about what it's like running a busy shop and highlights some of her amazing team. Annie and Sarah compare their experiences when it comes to votech education. --- Send in a voice message: https://podcasters.spotify.com/pod/show/a1custom/message

Dustin Atwood and Sarah Myers talk about a variety of topics in the automotive industry, including: Dustin brings on special guest, Annie! Annie is the store manager for the Sunset store. Annie talks about what it's like running a busy shop and highlights some of her amazing team. Annie and Sarah compare their experiences when it comes to votech education. --- Send in a voice message: https://podcasters.spotify.com/pod/show/a1custom/message

Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. This episode covers depression in children and adolescents with Dr. Darren Courtney, a scientist with the Cundill Centre for Child and Youth Depression and the Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health and a staff psychiatrist in the Youth Addictions and Concurrent Disorders Service at the Centre for Addiction and Mental Health (CAMH) in Toronto. He is also an associate professor in the Department of Psychiatry at the University of Toronto.   Dr. Courtney earned his MD in 2004 at Queen's University and completed psychiatry residency in 2009 at the University of Ottawa. He was the clinical director of the Youth Inpatient Unit at the Royal Ottawa Mental Health Centre from 2009 to 2014 and moved to Toronto in 2014, where he worked on the Concurrent Youth Inpatient Unit at the Centre for Addiction and Mental Health until 2017 and where his clinical work with concurrent disorders continues now with outpatient youth.   Dr. Courtney's research focus is on the treatment of adolescent depression through the use of an integrated care pathway — a collaboratively developed treatment algorithm based on high-quality clinical practice guidelines. Through his research, he works on identifying quality practice guidelines and corresponding multi-disciplinary care pathways to facilitate evidence-based and measurement-based care for adolescents with depression. He has also participated in a systematic review and quality appraisal of clinical practice guidelines for psychiatric disorders in children and adolescents. Additionally, he has an interest in the management of concurrent disorders, where young people are affected by both primary psychiatric disorders and substance use disorders.   The learning objectives for this episode are as follows:   By the end of this episode, you should be able to… Outline the prevalence and risk factors for depression in children and adolescents Explain how children and adolescents with depression present in clinical practice Discuss the use of screening tools for depression in this population Describe an approach to the management of depression in children and adolescents Outline the management of an adolescent with suicidal thoughts or behaviours   Guest: Dr. Darren Courtney Hosts: Kate Braithwaite (MD) and Nikhita Singhal (PGY5) Audio editing by: Nikhita Singhal Show notes by: Kate Braithwaite and Nikhita Singhal   Interview Content: Introduction - 0:00 Learning objectives - 02:11 Prevalence of depression in youth - 03:11 Risk factors for depression in youth - 06:25 Diagnosing depression in youth - 08:30 Screening tools - 14:24 Approach to taking a history from youth - 19:45 Management of depression in youth - 30:12 Psychotherapies - 33:20 Medications - 37:37 Assessing and managing suicidality in youth - 44:00 Measurement based care - 51:00 Final thoughts - 55:10   Resources: Previous PsychEd episodes: PsychEd Episode 1: Diagnosis of Depression with Dr. Ilana Shawn PsychEd Episode 2: Treatment of Depression with Dr. Sidney Kennedy PsychEd Episode 18: Assessing Suicide Risk with Dr. Juveria Zaheer ICHOM Set of Patient-Centered Outcome Measures for Children & Young People with Depression & Anxiety Screening tools/rating scales: Revised Children's Anxiety and Depression Scale (RCADS) Mood and Feelings Questionnaire (MFQ) NICE guideline: Depression in children and young people: identification and management NICE guideline: Self-harm: assessment, management and preventing recurrence The CARIBOU Pathway by CAMH: A youth-centered program for the treatment of depression Includes links to download free clinician-specific and youth-specific resources co-developed with youth and mental health clinicians Clinical Innovations and Tools | Cundill Centre for Child and Youth Depression | CAMH Includes links to various tools for health care providers, researchers, youth, and other stakeholders (such as teachers and family members) informed by research evidence   References: Bennett K, Courtney D, Duda S, Henderson J, Szatmari P. An appraisal of the trustworthiness of practice guidelines for depression and anxiety in children and youth. Depress Anxiety. 2018 Jun;35(6):530-540. https://doi.org/10.1002/da.22752 Courtney D, Bennett K, Henderson J, Darnay K, Battaglia M, Strauss J, Watson P, Szatmari P. A Way through the woods: Development of an integrated care pathway for adolescents with depression. Early Interv Psychiatry. 2020 Aug;14(4):486-494. https://doi.org/10.1111/eip.12918 Georgiades K, Duncan L, Wang L, Comeau J, Boyle MH; 2014 Ontario Child Health Study Team. Six-Month Prevalence of Mental Disorders and Service Contacts among Children and Youth in Ontario: Evidence from the 2014 Ontario Child Health Study. Can J Psychiatry. 2019 Apr;64(4):246-255. https://doi.org/10.1177%2F0706743719830024 Goodyer IM, Reynolds S, Barrett B, Byford S, Dubicka B, Hill J, Holland F, Kelvin R, Midgley N, Roberts C, Senior R, Target M, Widmer B, Wilkinson P, Fonagy P. Cognitive-behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial. Health Technol Assess. 2017 Mar;21(12):1-94. https://doi.org/10.3310/hta21120 Hetrick SE, McKenzie JE, Bailey AP, Sharma V, Moller CI, Badcock PB, Cox GR, Merry SN, Meader N. New generation antidepressants for depression in children and adolescents: a network meta-analysis. Cochrane Database Syst Rev. 2021 May 24;5(5):CD013674. https://doi.org/10.1002/14651858.CD013674.pub2 MacQueen GM, Frey BN, Ismail Z, Jaworska N, Steiner M, Lieshout RJ, Kennedy SH, Lam RW, Milev RV, Parikh SV, Ravindran AV; CANMAT Depression Work Group. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Can J Psychiatry. 2016 Sep;61(9):588-603. https://doi.org/10.1177%2F0706743716659276 National Institute for Health and Care Excellence. Depression in children and young people: Identification and management NG134 [Internet]. London: NICE; 2019 Jun 25 [cited 2023 Sep 22]. Available from: https://www.nice.org.uk/guidance/ng134. Parikh A, Fristad MA, Axelson D, Krishna R. Evidence Base for Measurement-Based Care in Child and Adolescent Psychiatry. Child Adolesc Psychiatr Clin N Am. 2020 Oct;29(4):587-599. https://doi.org/10.1016/j.chc.2020.06.001 Walter HJ, Abright AR, Bukstein OG, Diamond J, Keable H, Ripperger-Suhler J, Rockhill C. Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Major and Persistent Depressive Disorders. J Am Acad Child Adolesc Psychiatry. 2023 May;62(5):479-502. https://doi.org/10.1016/j.jaac.2022.10.001 Wiens K, Bhattarai A, Pedram P, Dores A, Williams J, Bulloch A, Patten S. A growing need for youth mental health services in Canada: examining trends in youth mental health from 2011 to 2018. Epidemiol Psychiatr Sci. 2020 Apr 17;29:e115. https://doi.org/10.1017%2FS2045796020000281 World Health Organization. Mental health of adolescents [Internet]. 2021 [cited 2023 Sep 22]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health   CPA Note: The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association. For more PsychEd, follow us on Twitter (@psychedpodcast), Facebook (PsychEd Podcast), and Instagram (@psyched.podcast). You can provide feedback by email at psychedpodcast@gmail.com. For more information, visit our website at psychedpodcast.org.

Contributor: Aaron Lessen MD Educational Pearls: What is Carbamazepine (Tegretol)? Carbamazepine is an anti-epileptic drug with mood-stabilizing properties that is used to treat bipolar disorder, epilepsy, and neuropathic pain. It functions primarily by blocking sodium channels which can prevent repetitive action potential firing. What are the symptoms of an overdose? Common initial signs include diminished conscious state, nystagmus, ataxia, hyperreflexia, CNS depression, dystonia, and tachycardia Severe toxicity can cause seizures, respiratory depression, decreased myocardial contractility, pulmonary edema, hypotension, and dysrhythmias. How is an overdose treated? An overdose is treated with large doses of activated charcoal and correction of electrolyte disturbances. Be ready to intubate given the potential for respiratory depression. Carbamazepine is moderately dialyzable and dialysis is recommended in severe overdoses. Additional educational pearl: Individuals in correctional facilities can occasionally self-administer medications which means that medication overdose should still be on the differential for any of these individuals. References Epilepsies in children, Young People and adults: NICE guideline [NG217]. National Institute for Health and Care Excellence. (2022, April 27). https://www.nice.org.uk/guidance/ng217  Ghannoum M, Yates C, Galvao TF, Sowinski KM, Vo TH, Coogan A, Gosselin S, Lavergne V, Nolin TD, Hoffman RS; EXTRIP workgroup. Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2014 Dec;52(10):993-1004. doi: 10.3109/15563650.2014.973572. Epub 2014 Oct 30. PMID: 25355482; PMCID: PMC4782683. Seymour JF. Carbamazepine overdose. Features of 33 cases. Drug Saf. 1993 Jan;8(1):81-8. doi: 10.2165/00002018-199308010-00010. PMID: 8471190. Spiller HA. Management of carbamazepine overdose. Pediatr Emerg Care. 2001 Dec;17(6):452-6. doi: 10.1097/00006565-200112000-00015. PMID: 11753195. Tran NT, Pralong D, Secrétan AD, Renaud A, Mary G, Nicholas A, Mouton E, Rubio C, Dubost C, Meach F, Bréchet-Bachmann AC, Wolff H. Access to treatment in prison: an inventory of medication preparation and distribution approaches. F1000Res. 2020 May 13;9:357. doi: 10.12688/f1000research.23640.3. PMID: 33123347; PMCID: PMC7570324. Summarized by Jeffrey Olson, MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII  

On today's Summer Special, I am joined by Dr Louise Newson, a GP and renowned Menopause Specialist, author, podcast host and the founder of the Balance app. Louise is passionate about improving education about the perimenopause and menopause and improving awareness of safe prescribing of HRT to healthcare professionals. Women are increasingly discussing the forgetfulness, anxiety and suicidal thoughts they have experience as their hormones change in midlife. It's true that the link between menopause and depression is now sufficiently recognised and the National Institute for Health and Care Excellence now recommends HRT as the first line of treatment for low mood or anxiety in menopausal women. Today, I speak to Louise all about mental health and emotional wellbeing in the perimenopause and menopause, particularly the psychological symptoms and ask her about how we can support our mental health during these changes.Find Louise:Website: https://www.newsonhealth.co.uk/Podcast: https://podcasts.apple.com/gb/podcast/the-dr-louise-newson-podcast/id1459614845Instagram: https://www.instagram.com/menopause_doctor/?hl=enFollow Hurt to Healing on Instagram:@hurttohealingpodA big thank you our wonderful charity partner Shout. Shout is the UK's first 24/7 mental health text support service so if you're struggling or in need of someone to talk to, please remember to text Shout to 85258. And a massive thank you to The&Partnership for supporting my mission and showing what we can achieve when we come together. To find out more about the work The&Partnership creates, visit theandpartnership.com. Hosted on Acast. See acast.com/privacy for more information.

Faricimab, or as it is commercially known Vabysmo, is a drug that has recently been approved for use by the NHS to treat two eye diseases: diabetic macular oedema (DMO) and age-related macular degeneration (AMD), with fewer injections. Both conditions result in vision loss caused by swelling behind the eye, which can now be slowed or halted by injections. Robin Hamilton is an Ophthalmic Surgeon at Moorfield's Eye Hospital and he provides details of how this drug works and Bernie Warren tells us about its prospects from a DMO patient perspective. Bernie was also on a National Institute for Health and Care Excellence panel, that helped approve the drug for NHS use. Discovering Hands is a project in Germany that trains visually impaired women to perform breast examinations. The project involves using touch to locate early indications of breast cancer. Elvira Häußler is one of the women who is employed to perform them and she, along with gynaecologist Dr. Frank Hoffmann who came up with the idea, tell us more about it and whether it may one day come to the UK. Presenter: Peter White Producer: Beth Hemmings Production Coordinator: Liz Poole Website image description: Peter White sits smiling in the centre of the image, wearing a dark green jumper. Above Peter's head is the BBC logo (three individual white squares house each of the three letters). Bottom centre and overlaying the image are the words "In Touch" and the Radio 4 logo (the word Radio in a bold white font, with the number 4 inside a white circle). The background is a bright mid-blue with two rectangles angled diagonally to the right. Both are behind Peter, one of a darker blue and the other is a lighter blue.

Today's storyteller is Kitty Dry, telling the story of entirely losing her hair, learning she has the autoimmune condition alopecia, and navigating her twenties as a bald woman. In our conversation we talk about being stared at on the tube, techniques for coping with anxiety, hiding and being seen, social media and self-worth, and finding support online and off.More information about Alopecia UK can be found here: https://www.alopecia.org.uk.Updated information on The National Institute for Health and Care Excellence's decision not to recommend JAK inhibitor drugs to treat alopecia areata on the NHS, and what Alopecia UK are doing to oppose this, can be found here: https://www.alopecia.org.uk/news/baricitinib-nice-consultation-updateFollow True Story London online: https://linktr.ee/TrueStoryLDNFind out about our live shows, workshops and past podcast episodes on our website: https://www.truestorylondon.com Hosted on Acast. See acast.com/privacy for more information.

Fa poques setmanes s'han actualitzat les guies NICE sobre el Traumatisme Cranial (TCE) i en Xavi ens en parla en aquest episodi. NICE és el National Institute for Health and Care Excellence, una institució britànica que es dedica a la publicació de guies de pràctica clínica sobre diferents condicions de salut. Aquesta actualització de la … Continua llegint «Episodi 26: Guies NICE sobre el TCE»

Discover the key to unlocking success in your lawn care business with special guest Dr. Frank Holleman. In this episode, we dive into the power of professionalism and explore practical tips to elevate your business by becoming more professional. Don't miss this insightful conversation that can transform your lawn care journey. Get Your Copy of The Lawn Care Advantage Here! Secure Your Spot: Register for Lawn Care Life Conference 2024 Equip Expo: Register Now! The Resource Center at GreenIndustryPodcast.com Get Jobber Apply for Jobber Grants Start Your Website Journey w/ Footbridge Media The Landscaping Bookkeeper - Megan and Joey Coberly GPS Trackit Kubotausa.com The Hardscape Academy Paul Jamison's Books Try Audible Ferris Mowers

How do you recognise the signs of sepsis? And how should you respond when you suspect the patient in front of you is at risk?The latest episode of the podcast examines what nursing staff need to know about this life-threatening condition.Our guest, Sian Annakin, is deteriorating patient lead at the Dudley Group NHS Foundation Trust, and a sepsis practitioner.She tells Emergency Nurse editor Sophie Blakemore what to watch out for in adults and what the guidelines say about how and when to treat a patient with suspected sepsis.The National Institute for Health and Care Excellence sepsis guidance is currently under review with an update expected in late June.Ms Annakin, who is also communications officer for the UK Sepsis Practitioner Forum, discusses why the review is taking place and what it means for nurses and hospital trusts in the interim, as well as when the update is published, whatever the outcome. Listeners will also hear what tools are available to help them screen for sepsis and how to supplement these using their own clinical experience. For more episodes of the Nursing Standard podcast, visit rcni.com/podcast Hosted on Acast. See acast.com/privacy for more information.

How do you recognise the signs of sepsis? And how should you respond when you suspect the patient in front of you is at risk?The latest episode of the podcast examines what nursing staff need to know about this life-threatening condition.Our guest, Sian Annakin, is deteriorating patient lead at the Dudley Group NHS Foundation Trust, and a sepsis practitioner.She tells Emergency Nurse editor Sophie Blakemore what to watch out for in adults and what the guidelines say about how and when to treat a patient with suspected sepsis.The National Institute for Health and Care Excellence sepsis guidance is currently under review with an update expected in late June.Ms Annakin, who is also communications officer for the UK Sepsis Practitioner Forum, discusses why the review is taking place and what it means for nurses and hospital trusts in the interim, as well as when the update is published, whatever the outcome. Listeners will also hear what tools are available to help them screen for sepsis and how to supplement these using their own clinical experience. For more episodes of the Nursing Standard podcast, visit rcni.com/podcast Hosted on Acast. See acast.com/privacy for more information.

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!In part 1 we talked about a request that has been submitted for the World Health Organization (WHO) to add diet drugs to their list of “essential medicines.” We discussed who was making this request and the justification that they were using. Today we're going to take a deeper dive into the research that they used to try to support this request, and in part three will look at the research around harm and “efficacy,” as well as “cost effectiveness.” (I was originally going to write this in two parts, but I realized that it was just ridiculously long, and there is time before the WHO meets about this, so I've decided to break it into three parts.)Just a reminder that I don't hyperlink to studies or articles that come from a place of weight stigma, though I do provide enough information that someone could google them.In their ”Summary statement of the proposal for inclusion” they say“The use of GLP-1 RAs in the treatment of ob*sity has been well studied and meta-analyses of various GLP-1 RAs have demonstrated that this class of medications can lead to clinically significant weight loss. Compared to control groups, GLP-1 RAs were found to lead to more significant weight loss with a mean difference of approximately 7.1 kg as well as an improvement in glycemic control, with low concern for hypoglycemia[3].”The single paper they cite to back this up (Iqbal et al. Effect of glucagon-like peptide-1 receptor agonists on body weight in adults with ob*sity without diabetes mellitus-a systematic review and meta-analysis of randomized control trials, 2022) looked at weight loss on these drugs among “ob*se” adults without type 2 diabetes (so hypoglycemia would have been unlikely anyway.) It included 12 trials with a total of 11,459 participants. 80% of the participants were white, 10% were Black or African Americans and 5% were Asians. It is concerning that they are making a global recommendation based on a study population that is overwhelmingly white. There is also the issue of follow-up. Some of the trials were as short as 14 weeks and the longest trial included was only 3 years. The average weight loss was 15.6 lbs more in the group taking the drugs than in control, but some subjects on the drugs lost as little as 5.5 lbs. Those on the drugs also experienced vomiting, nausea, dyspepsia (indigestion,) diarrhea, constipation and abdominal pain as common side effects. There is no way to know how much of this (short-term) weight loss is due to experiencing these common side effects. These drugs also have significant (possibly life-threatening) side effects and the short-term follow-up included here is not likely long enough to capture those. Also, remember that the recommendation is for people to take these drugs for the rest of their lives (since, if they don't, their weight shoots right back up and they lose cardiometabolic benefits,) and they are making that recommendation (globally) on just 14 weeks to 3 years of data.The authors of this study cite no conflicts of interest. Per LinkedIn, someone with the same name as the lead author is a product specialist at Novo Nordisk but I imagine that must be a coincidence or surely it would have been listed as a COI. The article was published in “Ob*sity Reviews” which is an official journal of the “World Ob*sity Federation” (WOF). The WOF took over $5.3 Million dollars from Novo Nordisk (whose weight loss drugs are covered by this recommendation) over three years. Their “members” include the Ob*sity Action Coalition (whose chief funder is Novo Nordisk.) Their current President has taken money to speak on behalf of Novo Nordisk and their past president is John Wilding who was implicated in the recent Novo Nordisk scandal for not disclosing his financial ties to Novo Nordisk while praising their weight loss drugs in the media.There are more issues with this meta-analysis but I'll just stop there and say that I don't think there is any way that 14 weeks to 3 years of data on 11,459 people who are mostly white justifies a global recommendation of these drugs as “essential.”Under “Treatment details (requirements for diagnosis, treatment and monitoring)”Here again they say “Ob*sity, a preventable disease” but offer no citation or support for this narrative that has been largely architected and marketed by the weight loss industry. They continue:“When used in supplement to life style modifications, including a decrease in caloric intake and an increase in exercise, liraglutide is indicated for adults with ob*sity (BMI >30.00) or overweight (BMI >27.00) with a weight-related comorbidity”I just want to note here that this indication (which wasn't created by those who wrote the recommendation to the WHO) predicates risk on body size and simple correlation. These drugs have very unpleasant common side effects and other, possibly life-threatening, side effects. So the fact that those who are “overw*ight” have to have at least one condition that is correlated with being higher weight (with no proof of causation, by the way) but those who are “ob*se” are recommended to risk these side effects based on size alone, with no required symptomology, is pure weight stigma.Next is a table “Excerpts from national and international guidelines on the pharmacological treatment of ob*sity”It is a list of organizations with quotes pulled from various publications that are intended to show support for the drugs. Almost every one of the organizations has financial ties to Novo Nordisk and/or Eli Lilly which doesn't prove that there is anything shady going on, but would be worth disclosing given their use to back up the request that these companies' drugs be considered “essential.” Let's take a deeper look:The American College of Cardiology (ACC)The recommendation that is cited is for the use of these drugs for Type 2 diabetes (T2D), and they mention weight loss as an ancillary effect. This will be a pattern in these recommendations and it matters because the risk/benefit analysis is different for people who have an actual health condition (Type 2 diabetes) rather than those who are simply living in a higher-weight body. Also, one might be misled by the title of the section to believe that these recommendations are specifically for the use of the drugs in the treatment of “ob*sity” which is not the case.The ACC has a partnership with Novo NordiskThey have also partnered with Eli LillySouth Asian Task ForceAgain, this is a recommendation for these medications for the treatment of T2D, not for weight loss.The paper's lead author, Sanjay Kalra has received honoraria for lectures and advisory boards from Eli Lilly and Novo Nordisk.International Diabetes FederationThis, again, is a recommendation of these drugs for the treatment of T2D.Novo Nordisk is a “platinum partner” and Eli Lilly is a “gold partner” (the website isn't clear about how much money they donate, and an email I sent has gone unanswered so far.)National Institute for Health and Care Excellence (NICE)This one actually is a recommendation for these drugs for weight loss, however, NICE was implicated in the recent scandal which found that “Novo Nordisk had paid millions to prominent ob*sity “charities,” NHS trusts, universities and other bodies as well healthcare professionals who publicly praised the drug (typically without disclosure of their funding) and who advised NICE (The National Institute for Health and Care Excellence) on their reviewing of Novo's weight loss drug to decide whether or not it should be made available.”Position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM)This is a statement of recommendations for prevention of cardiovascular disease in patients with diabetes.Here is a selection of the authors “competing interests” (I've only included Novo Nordisk and Eli Lilly, the two main companies trying to sell this class of drugs for weight loss.) ROM has received speaker honorarium from: Novo Nordisk and Eli Lilly.CMV has received honoraria as speaker from Novo Nordisk.SV over the last 5 years, has received honoraria for clinical research from Novo Nordisk; Advisory Board to Novo Nordisk; has received honoraria as speaker from Novo NordiskFT has received honoraria for medical lectures from: Lilly, Novo NordiskRDS over the last 3 years has received honoraria for consulting, research and speaker activities from Eli LillyThe Brazilian Diabetes Society (SBD) has collaborated with Novo NordiskThe Brazilian Cardiology Society (SBC) holds an annual congress that is sponsored by Novo Nordisk and Eli Lilly. The Brazilian Endocrinology and Metabolism Society (SBEM) has partnered with Novo Nordisk on multiple occasions.Korean Society for the Study of Ob*sity Guidelines for the Management of Ob*sity in KoreaThis is not a study but guidelines put out by an organization that appears to represent those with a profit interest in “ob*sity treatment” (similar to the Ob*sity Action Coalition.) Their “recommendation” includes every drug that is approved for long-term use, fails to cite any evidence of efficacy (short or long-term) and they mention that “Not all ob*se people respond to ob*sity drugs, and there are a significant number of non-responders.”Novo Nordisk is a platinum sponsor for their conference. They are also a member of the World Ob*sity Federation which took over $5M from Novo Nordisk.European Medical Association[sic]Here they are citing a press release stating that the European Medicines Association (EMA) (the recommendation authors appear to have been mistaken on the name) has “recommended granting a marketing authorisation for Saxenda (liraglutide) for weight management in overweight or ob*se adults.” Per the EMA's website they are “a scientific body with the expertise required to assess the benefits and risks of medicines. However, under EU law it has no authority to actually permit marketing in the different EU countries. The role of EMA is to make a recommendation to the European Commission which then takes a final legally binding decision on whether the medicine can be marketed in the EU.”I could not find information about the panel that made the decision, or any conflicts of interest they may have had.Australia: NPS Medicine WiseThe citation they offer here is not to Australia: NPS Medicine Wise, but to a paper by a single author - Joseph Proietto who “has been on the medical advisory boards for liraglutide, semaglutide 2.4 mg and bupropion/naltrexone. He has been involved in educational sessions for ob*sity management for both Novo Nordisk (liraglutide, semaglutide) and iNova (phentermine and bupropion/ naltrexone) for which he has received honoraria.” In other disclosures it mentions that he was, in fact, chair of the medical advisory board for Saxenda (Novo Nordisk's brand name for liraglutide, the drug being recommended here.)In the paper he recommends all of the above weight loss drugs in general, but does not recommend the GLP-1 class of drugs over any of the others. The study he uses to recommend these drugs only follows participants for 68 weeks.Singapore HPB-MOH Clinical Practice GuidelinesIn the section on liraglutide they offer information for 56 weeks of follow up and conclude “The long-term safety of high dose liraglutide therapy is, however, unclear.”Canadian Medical Association Journal- Ob*sity in adults: a clinical practice guidelineFunding for these guidelines was provided by Ob*sity Canada, an organization that lobbies for the priorities of those who profit from “ob*sity treatment.” Specifically, the funds came from “Ob*sity Canada's Fund for Ob*sity Collaboration and Unified Strategies (FOCUS) initiative” Novo Nordisk is a supporter of this fund, as well as a sponsor for their annual summit.Here are excerpts from the 1,293 word competing interests statement for the authors (I've only included Novo Nordisk and Eli Lilly, the two main companies trying to sell this class of drugs for weight loss.) Sean Wharton reports receiving honoraria and travel expenses and has participated in academic advisory boards for Novo Nordisk, Eli Lilly. Sean Wharton is also the medical director of a medical clinic specializing in weight management and diabetes. David Lau reports receiving grants and research support from Novo Nordisk, speaker bureau fees from Eli Lilly and Novo Nordisk; and consulting fees from Eli Lilly and Novo Nordisk. Michael Vallis is a member of advisory boards for Novo Nordisk. Michael Vallis has also received consulting fees from Novo Nordisk and speaking fees from Novo Nordisk. Arya Sharma reports receiving speaker's bureau and consulting fees from Novo Nordisk. Laurent Biertho is a member of advisory boards for Novo Nordisk. Denise Campbell-Scherer reports receiving research funding from Novo Nordisk. She also reports receiving an unrestricted education grant from Ob*sity Canada, funded by Novo Nordisk Global. Jennifer Brown reports receiving nonfinancial support from Novo Nordisk, and personal fees Yoni Freedhoff is the co-owner of the Bariatric Medical Institute and Constant Health, which provide weight management services; Constant Health has received a grant from Novo Nordisk. Yoni Freedhoff also regularly speaks on topics related to ob*sity and receives honoraria and travel costs and expenses for same. Michel Gagner reports receiving consulting fees from Novo Nordisk. Marie-France Langlois reports receiving personal fees from Novo Nordisk, Eli Lilly. David Macklin reports receiving personal fees from Novo Nordisk. Priya Manjoo reports receiving personal fees from Novo Nordisk. Marie-Philippe Morin reports receiving speaker honoraria from Novo Nordisk, Eli Lilly and research subvention from Novo Nordisk, and consultation honoraria from Novo Nordisk, Eli Lilly. Sue Pedersen reports receiving personal fees from Novo Nordisk, Eli Lilly and grants from Eli Lilly, and nonfinancial support from Novo Nordisk and Eli Lilly.Megha Poddar reports receiving honoraria for continuing medical education (CME) from Novo Nordisk, Eli Lilly, education grants from Novo Nordisk, fees for mentorship from Novo Nordisk; fees for membership of advisory boards from Novo Nordisk. Paul Poirier reports receiving fees for consulting and continuing medical education from Eli Lilly, Novo Nordisk. Judy Shiau reports receiving personal fees from Novo Nordisk. Diana Sherifali reports receiving a grant from Ob*sity Canada to support the literature review process, during the conduct of the study. Shahebina Walji reports receiving consulting or advisory board fees from Novo Nordisk and speaker's bureau fees from Novo Nordisk.All of their recommendations around liraglutide are level 2a (Evidence from at least 1 controlled study without randomization) and Grade B ( Directly based on level 2 evidence or extrapolated recommendation from category 1 evidence) they suggest that these recommendations should use the terms “may” or “can” (as opposed to “should.”) The studies that they cite offer, at most, only 56 weeks of follow-up.Information supporting the public health relevanceIn this section they claim that “not only is the prevalence of ob*sity increasing, but the number of global deaths attributed to BMI has substantially increased from 1990 to 2017 (Figure 1) [23]. The global burden of disease of ob*sity study also found that though the age-standardized rate of high BMI related disability adjusted life years (DALY) increased by 12.7% for females and 26.8% for males, the actual global number of high BMI DALYs has doubled, despite sex”The study that they cite to support this (The global burden of disease attributable to high body mass index in 195 countries and territories, 1990-2017: An analysis of the Global Burden of Disease Study, Dai et al., 2020) calculates these numbers based on the assumption that the health problems higher-weight people have are due to their weight (even though people of all sizes experience them). They also fail to control for the health impacts of weight stigma, weight cycling, or healthcare inequalities, despite the research that shows that they are confounding variables. The assumption that higher-weight people's health issues are caused by their weight coupled with the failure to account for (or even discuss) confounding variables suggests to me either near-complete incompetence of the study authors around basic research methods, or a desire for specific conclusions.The study is at least honest that they don't know if weight loss would change this, stating “Successful population-wide initiatives targeting high BMI may mitigate the burden of a wide range of diseases” [emphasis mine].Thus, this doesn't actually support the recommendation to the WHO. Without proof that these medications would reduce disease or increase life years long-term, there is no reason to consider them “essential,” and no such evidence exists.Next they claim that “Ob*sity also plays a role in health care related costs; for patients and families, total healthcare costs for patients with ob*sity were higher than that of patients who are overweight.”First of all, this begins to wade into the idea that higher-weight people should be eradicated because they are “too expensive,” which is heading down a bad road when it comes to ethics. Further, the study they use to support this is based on 97 Dutch people who filled out a survey. The study included costs such as “expenditures related to the respondent's weight, such as adapted clothing, gym subscription, diet books, parking permit, food, etc.” First of all, thin people also have gym subscriptions and parking permits, but, moreover, telling fat people that they should buy diet books and pay for various weight loss foods and methods (despite the near-total failure rate,) then blaming them for the cost of following those dubious recommendations (as well as the additional costs of living in a world where structural weight stigma creates a lack of accommodation in clothing etc.) as a justification for more expensive, more dangerous “interventions” is a long way from being ethical science and is a particularly craven marketing tactic. I'm just going to stop there, but to say that I've seen elementary school science fair projects with more rigorous methodology and I would be beyond embarrassed to cite this for any reason ever, other than as an example of the piss-poor state of weight science.They finish up the section with “Given the global burden of ob*sity and the goal of reducing preventable disease related deaths, it is evident that affordable and available pharmacotherapy for ob*sity is needed on a global level.”Let's rephrase this to reflect the evidence they provided: “Based on a survey taken by 97 people, a study that failed to control for any confounding variables and made wild assumptions about causality based on simple correlation, and their own research's acknowledgment that changing body size may not change health outcomes, it is evident that affordable and available pharmacotherapy for ob*sity is needed on a global level.”Which is to say, what they provided here does not come close to justifying their request.In part three we'll wrap this up with a look at the evidence they use to discuss harm, effectiveness, and cost-effectiveness.Did you find this post helpful? You can subscribe for free to get future posts delivered direct to your inbox, or choose a paid subscription to support the newsletter and get special benefits! Click the Subscribe button below for details:Liked this piece? Share this piece:More research and resources:https://haeshealthsheets.com/resources/*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings' Fearing the Black Body – the Racial Origins of Fat Phobia and Da'Shaun Harrison's Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing!In Part 1 we talked about how Novo Nordisk got suspended from The Association of the British Pharmaceutical Industry for their shady marketing practices. Today, we're going to talk about an investigation by The Observer that found what so many of us have been saying for a looooong time - that Novo Nordisk had paid millions to prominent ob*sity “charities,” NHS trusts, universities and other bodies as well healthcare professionals who publicly praised the drug (typically without disclosure of their funding) and who advised NICE (The National Institute for Health and Care Excellence) on their reviewing of Novo's weight loss drug to decide whether or not it should be made available.The Observer article by Shanti Das and Jon Ungoes-Thomas “‘Orchestrated PR campaign': how skinny jab drug firm sought to shape ob*sity debate” (Note: per my policy I'm not linking to it because it still comes from a place of weight stigma) found that in three years, Novo Nordisk had shelled out £21,700,000 (about $26,415,301.50 USD) over 3,500 transactions which were separate from their research and development spending.The Observer found:“The payments include donations, event sponsorship, grants and other fees to prominent ob*sity charities, NHS trusts, royal colleges, GP surgeries, healthcare education providers and universities - on top of £28m spent by the company on research and development. A further £4m in payments such as consulting and lecture fees went to health professionals, including experts on ob*sity. The business has also provided financial support for the running of the all-party parliamentary group on ob*sity - a cross party group of MPs and members of the Lords that lobbies the government on health policy.”I've written before about how major papers like the New York Times are writing articles that are, essentially, lobbying for Novo Nordisk's priorities where every expert quoted is on Novo's payroll with no disclosure. One question I get asked a lot is “how is that legal?” First I'll point out that legal and ethical are two different things. Beyond that, there is a tendency to believe that doctors and academics are somehow immune to industry influence (or to the ways that their promotion of the weight loss paradigm will support their careers) such that reporters and others (including those on the pharma industry's payroll) claim that disclosing these conflicts of interest isn't important.An excellent example of the ways in which those who are seen as “impartial” experts in academia are, in fact, on the payroll of these companies and actively shilling for them is Professor John Wilding. Professor Wilding is at Liverpool University, where he leads clinical research on “ob*sity.” He also serves as president of the “World Ob*sity Federation” (an astroturf organization similar to the Ob*sity Action Coalition) which took more than £4.3M over three years, per The Observer. Somehow, this did not make its way onto his conflicts of interest statement. Meanwhile, he was quoted extensively in the media recommending Novo's drug Wegovy. Jason Halford, who is the Head of the School of Psychology at the University of Leeds, told an audience of millions on BBC that Wegovy is “one of the most powerful pharmaceutical tools” for treating “ob*sity.” He did not disclose that he is also the president of the European Association for the Study of Ob*sity (EASO), another astroturf organization (which is to say, an organization that claims to advocate for marginalized people but, in reality, is predominantly funded by and acting as a lobbying arm of, the pharmaceutical/weight loss surgery industry.) The Observer found that the EASO received more than three-quarters of its income (more than £3.65m) from Novo Nordisk. He was also a previous member of Novo Nordisk's UK advisory board.I'm glad Novo Nordisk's lack of ethics are getting wider coverage (though, as I pointed out in part 1, people in fat liberation and weight-neutral health advocates like Mikey Mercedes, Louise Adams, Asher Larmie, myself and others have been talking about this for some time,) but I don't expect it to stop them until we can put enough pressure on them to force them to stop. This is a company that orchestrated aggressive price gouging on insulin, proving beyond a doubt that they will kill people for money. And as pressure in the US is forcing Novo to lower the price of insulin, they seem to have a lot of eggs in the Wegovy basket. Prior to launch, they promised their shareholders the “fastest ever” post FDA-approval launch and that they would double their “ob*sity” sales by 2025. In fact, The Observer found that Novo Nordisk's sales on their new “ob*sity treatments” rose 84% in 2022 to $2.4B – a figure Novo projects will “grow significantly” in 2023.And what will they do to grow this figure significantly this year? I think their behavior makes it clear – absolutely anything they can get away with.Did you find this post helpful? You can subscribe for free to get future posts delivered direct to your inbox, or choose a paid subscription to support the newsletter and get special benefits! Click the Subscribe button below for details:Liked this piece? Share this piece:More research and resources:https://haeshealthsheets.com/resources/*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da'Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe

In this episode, we explore the importance of customer service in optometry with Dr.Jennifer Stewart. She is the Editor of Independent Strong, Founder of OD Perspective, Co-Founder and Chief Vision Officer of Performance 2020, and an optometrist with almost 20 years of experience. Dr. Jennifer shares her insights on how to create a welcoming and comfortable environment for patients, the role of technology in enhancing customer service, and the benefits of investing in staff training and development. If you're a healthcare professional looking to improve your customer service skills, this episode is for you. 

In this podcast, James Cave (Editor-in-Chief) and David Phizackerley (Deputy Editor) talk about the March 2023 issue of DTB. They discuss incorrect penicillin allergy labels and ways that these can be corrected (https://dtb.bmj.com/content/61/3/34). They review clinical trial results for lecanameb in early Alzheimer's disease (https://dtb.bmj.com/content/61/3/37) and also talk about a new combined oral contraceptive that contains estetrol and drospirenone (https://dtb.bmj.com/content/61/3/39). They begin by discussing a proposal from the National Institute for Health and Care Excellence to lower the threshold for offering statins for primary prevention. The contact address for the DTB team is dtb@bmj.com. Please subscribe to the DTB podcast to get episodes automatically downloaded to your mobile device and computer. Also, please consider leaving us a review or a comment on the DTB Podcast iTunes podcast page (https://podcasts.apple.com/gb/podcast/dtb-podcast/id307773309). Thank you for listening.

W mediach społecznościowych pojawia się wyjątkowo dużo komunikatów, które zachęcają, by w święta odejść od restrykcji, od liczenia kalorii, żeby skupić się na radości płynącej z jedzenia i na czasie z bliskimi. Sporo mówi się o luzie żywieniowym, zachęca, żeby odpuścić i nie martwić się kaloriami. Warto zastanowić się, czy nie popadamy tu w skrajności. I właśnie o tych skrajnościach i o ich negatywnych konsekwencjach mówię w tym odcinku podcastu. Źródła naukowe, o których mowa w podcaście: O konieczności prowadzenia podczas terapii ED edukacji żywieniowej, planu żywieniowego oraz monitoringu tego, co się je, mówią standardy pracy w zaburzeniach odżywiania: National Institute for Health and Care Excellence (2020). Clinical guideline. Eating disorders: recognition and treatment. Zaczerpnięte dnia 20.12.22 z: https://www.nice.org.uk/guidance/ng69 Przegląd badań na temat przyczyn zaburzeń odżywiania: Jacobi, C, Hayward, C., de Zwaan, M., Kraemer, H. C., Agras, W. S. (2004). Coming to Terms With Risk Factors for Eating Disorders: Application of Risk Terminology and Suggestions for a General Taxonomy. Psychological Bulletyn, 130(1), 19-65. Badania, które pokazują, że kontrolowanie kalorii jest ważne z punktu widzenia utrzymania masy ciała na stałym poziomie: Helander, E. E., Wansink, B., Chieh, A., (2016). Weight Gain over the Holidays in Three Countries. N Engl J Med., 375(12), 1200–1202. Wing, R. Phelan, S. (2005). Long-term weight loss maintenance, The American Journal of Clinical Nutrition, 82. Zapraszam Cię do udziału w moich szkoleniach na temat pracy z pacjentem: Praca z pacjentami z zaburzeniami odżywiania w ujęciu psychodietetycznym - 3,5- godzinne szkolenie https://lp.instytutpsychodietetyki.pl/zaburzenia-odzywiania/ Akademia pracy z pacjentem https://lp.instytutpsychodietetyki.pl/akademiapracy/ Może Cię zainteresować: #12 Liczyć kalorie czy nie? #7 Dlaczego diety tuczą?

In 2020 a black 15 year old schoolgirl, known as Child Q, was strip-searched by police while on her period after being wrongly suspected of carrying cannabis. A safeguarding report on the incident concluded it was unjustified and racism was "likely" to have been a factor. New data published by the Children's Commissioner has found what she calls a “concerning” number of children have been strip-searched by the Metropolitan Police without an appropriate adult present. BBC reporter Celestina Olulode joins Jessica to talk us through this data and we also hear from Jacqueline Courtenay, a mother from North London who organised a rally about this issue. Following the launch of the Women's Health Strategy we speak to the new chief executive of NICE - the National Institute for Health and Care Excellence. The agency makes recommendations to the NHS in England and Wales on medicines treatments and procedures. Dr Sam Roberts took up the post in February 2022. Before joining Nice, she was Managing Director of Health and Care at Legal and General but began her career in clinical practise and spent some time working as a junior doctor in a London hospital.

If you want to improve your health and reduce your risk of earlier death, you might measure your waistline. According to new guidance from the National Institute for Health and Care Excellence in the U.K., people should aim to cut their waistlines to less than half of their height. For example, for people 5 feet […] The post 166. Keep your waistline less than half your height for good health appeared first on Dr. David Geier - Feel and Perform Better Than Ever.

In episode #103 of Productivity Mastery, we talked about a topic that more and more companies are aware of - neurodiversity! Did you know that 1 in 7 people has a neurodivergent condition, and this is crucial to be considered in order to help them do their best at work? Our guest was the incredible Theo Smith, who, being neurodivergent himself, is a leading advocate for neurodiversity and its opportunities that come along. In this episode, hear about:

In this episode we talk to Dr Simon Fraser who is an associate professor of public health at the School of Primary Care at the University of Southampton. Paper: Persistently normal blood tests in patients taking methotrexate for RA or azathioprine for IBD: a retrospective cohort study https://doi.org/10.3399/BJGP.2021.0595 (https://doi.org/10.3399/BJGP.2021.0595) Clinical guidance from the National Institute for Health and Care Excellence recommends 3-monthly blood-tests for the ongoing safety monitoring of conventional synthetic disease-modifying anti-rheumatic drugs, but questions have been raised about the need for this testing frequency. Using 2 years' data from a large primary care database, this study found that persistent normality of blood-test results was common and abnormalities were dominated by reduced renal function among older people, with relatively few hepatic or haematological abnormalities. Greater stratification of monitoring may reduce workload and costs for patients and health services, but more evidence is required on the long-term safety, acceptability, and cost-effectiveness of changing current practice. BJGP research on optimising primary care research dissemination: an online surveyERGO number: 70228.A1 We would like to find out how often practising GPs and GP trainees access primary care research (in any form), and how we could improve its dissemination. We are very much interested in the views of those who don't access research regularly, as well as those who do. We would therefore be very grateful if you could consider completing a short online survey which will take less than 5 minutes to complete. If you are willing to participate, please access the survey via this link: https://southampton.qualtrics.com/jfe/form/SV_bIRKhaA0CrmZJ3w (https://southampton.qualtrics.com/jfe/form/SV_bIRKhaA0CrmZJ3w)

Sarah Le Brocq is a person living with obesity and is the founder of All About Obesity http://allaboutobesity.org, is a Director & Lay Member at NICE - National Institute for Health and Care Excellence, and member of the All Party Parliamentary Group of Obesity in the UK. Charlotte Kemp sat down with her to speak on her experience with the disease as well as how she is moving towards health justice. To read more about our work on chronic disease and urban living please go to www.urbanhealthcouncil.com Please consider supporting the non-profit Urban Health Council via our Patreon account: https://www.patreon.com/centriclab

In this first episode of season 2 we discuss Health Technology Assessment, a multidisciplinary, transparent process for evaluating therapeutic agents and technologies in terms of efficacy and value in treating the indicated population, within the wider context of a country's healthcare system. Joining us to discuss this is Dalia Dawoud, Senior Scientific Advisor at NICE, the National Institute for for Health and Care Excellence in London, and Eline van Overbeeke, Health Economics and Outcomes Research Manager, Pfizer, both co-leading work package 2 in EHDEN focusing on evidence generation in HTA and outcomes benchmarking. In a broad ranging conversation Dalia and Eline, viewing this from a HTA agency and a biopharmaceutical company, cover what is 'HTA', and how RWD is rapidly growing as a data source for evidence generation to support contextual insights into therapeutic areas, longer term evaluation in-market, especially also where RCT data is minimal or absent, and in validation of modelling and assumptions. Challenges in utilising RWD are discussed, and how EHDEN is responding to this, for instance as addressed in the PharmacoEconomics paper of late 2019. Finally, we focus on the learning curve for all concerned and a forthcoming, initial module of courses related to HTA and use of RWD/RWE to be launched in the EHDEN Academy. The views expressed by the participants are personal and not necessarily reflective of their organisations.

We're back with a new episode of Plano Pulse, featuring Dr. Hilda Loria and Dr. Laura Lamminen with the Rees-Jones Center for Foster Care Excellence, part of the Children's Health system. Kelle Marsalis (President & CEO) and Steve McSwain (2021 Chair of the Board) connected with the doctors to learn about why it's so important for children in foster care to receive specialized health care, Rees-Jones' Foster Care Policy, Advocacy and Research program, and how Children's Health collaborates with community partners including CASA to meet the needs of children in foster care.

SMA News Today's multimedia associate, Price Wooldridge, discusses how The National Institute for Health and Care Excellence has recommended that Evrysdi be provided at low or no cost to eligible SMA patients in England. Also, the process of modifying a wheelchair for specific needs is no easy task. DeAnn Runge shares how difficult it's been for her simply to receive comfortable arm rest pads. Even after replacing them, they're not what she hoped for. She's now contemplating what her next action should be. Are you interested in learning more about spinal muscular atrophy? If so, please visit https://smanewstoday.com/

In this episode with Theo Smith - Neurodiversity Evangelist, Author, and Podcast Host: ✔️ What is neurodiversity and why it matters to recognize it, ✔️ How to best support neurodiverse people and create a win-win, ✔️ The challenges for parents, managers, and workers who face neurodiverse needs, ✔️ The far-reaching impact that addressing neurodiversity will bring, and much more! Theo Smith is a leading advocate for neurodiversity. Passionate to raise awareness of neurodiversity, Theo has founded Neurodiversity At Work LTD to advocate the importance of neurodiversity in the workplace. Recently, Theo joined forces with Dynamis Group to help take neurodiversity to the top of organisations agendas via the CEOs and their leadership teams. Formerly, Theo has been the Recruitment Manager for the National Institute for Health and Care Excellence, enjoying a successful career in HR and recruitment, ensuring organisations had a diverse workforce and thrived. He has also been an advisor for TapIn and host of the Talent Hacks for Scaleups podcast. Sharing his expertise on neurodiversity, Theo helps businesses to have a better understanding of neurodiversity, why it is important and what the benefits of having a neurodiverse workforce can have in business. Spreading the message that an organisation's employees are their biggest competitive advantage, Theo shares the importance of different skills, strengths, approaches and problem-solving techniques that are evident in a diverse workforce. Known for his love of speaking, Theo is now a popular choice as a speaker for diversity and inclusion-themed events. Sharing his experience of being neurodiverse as a passionate neurodiversity evangelist, Theo has formerly spoken for the likes of Wayfair and is commended for his concepts on neurodiversity in the workplace. Covering topics such as DE&I, neurodiversity at work, neurodiversity recruitment and being ADHD, Dyslexic and Dyscalculia, Theo Smith is the perfect speaker when looking for an expert on neurodiversity. Tune in!

Chances are you or someone you love has had a biopsy to check for cancer. Doctors got a tissue sample and they sent it into a pathology lab, and at some point you got a result back. If you were lucky, it was negative and there was no cancer. But have you ever wondered exactly what happens in between those steps? Until recently, it's been a meticulous but imperfect manual process where a pathologist would put a thin slice of tissue under a high-powered microscope and examine the cells by eye, looking for patterns that indicate malignancy. But now the process is going digital—and growing more accurate.Harry's guest this week is Leo Grady, CEO of, Paige AI, which makes an AI-driven test called Paige Prostate. Grady says that in a clinical study, pathologists who had help from the Paige system accurately diagnosed prostate cancer almost 97 percent of the time, up from 90 percent without the tool. That translates into a 70 percent reduction in false negatives—nice odds if your own health is on the line. This week on the show, Grady explains explain how the Paige test works, how the company trained its software to be more accurate than a human pathologist, how it won FDA approval for the test, and what it could all mean for the future of cancer diagnosis and treatment.Please rate and review The Harry Glorikian Show on Apple Podcasts! Here's how to do that from an iPhone, iPad, or iPod touch:1. Open the Podcasts app on your iPhone, iPad, or Mac. 2. Navigate to The Harry Glorikian Show podcast. You can find it by searching for it or selecting it from your library. Just note that you'll have to go to the series page which shows all the episodes, not just the page for a single episode.3. Scroll down to find the subhead titled "Ratings & Reviews."4. Under one of the highlighted reviews, select "Write a Review."5. Next, select a star rating at the top — you have the option of choosing between one and five stars. 6. Using the text box at the top, write a title for your review. Then, in the lower text box, write your review. Your review can be up to 300 words long.7. Once you've finished, select "Send" or "Save" in the top-right corner. 8. If you've never left a podcast review before, enter a nickname. Your nickname will be displayed next to any reviews you leave from here on out. 9. After selecting a nickname, tap OK. Your review may not be immediately visible.That's it! Thanks so much.Full TranscriptHarry Glorikian: Hello. I'm Harry Glorikian. Welcome to The Harry Glorikian Show, the interview podcast that explores how technology is changing everything we know about healthcare.Artificial intelligence. Big data. Predictive analytics. In fields like these, breakthroughs are happening way faster than most people realize. If you want to be proactive about your own health and the health of your loved ones, you'll need to learn everything you can about how medicine is changing and how you can take advantage of all the new options.Explaining this approaching world is the mission of my new book, The Future You. And it's also our theme here on the show, where we bring you conversations with the innovators, caregivers, and patient advocates who are transforming the healthcare system and working to push it in positive directions.Chances are you or someone you love has had a biopsy to check for cancer. Doctors got a tissue sample and they sent it into a pathology lab, and at some point you got a result back. If you were lucky it was negative and there was no cancer.But have you ever wondered exactly what happens in between those steps?Well, until recently, it's been an extremely meticulous manual process. A pathologist would create a very thin slice of your tissue, put it under a high-powered microscope, and examine the cells by eye, looking for patterns that indicate malignancy. But recently the process has started to go digital. For one thing, the technology to make a digital scan of a pathology slide has been getting cheaper. That's a no-brainer, since it makes it way easier for a pathologist to share an image if they want a second opinion.But once the data is available digitally, it opens up a bunch of additional possibilities. Including letting computers try their hand at pathology. That's what's happening at a company called Paige AI, which makes a newly FDA-approved test for prostate cancer called Paige Prostate.The test uses computer vision and machine learning to find spots on prostate biopsy slides that look suspicious, so a human pathologist can take a closer look.So why should you care?Well, in a clinical study that Paige submitted to the FDA, pathologists who had help from the Paige system accurately diagnosed cancer almost 97 percent of the time, up from 90 percent without the tool.That translates into a 70 percent reduction in false negatives. At the same time there was a 24 percent reduction in false positives. I gotta tell you, if I were getting a prostate biopsy, I'd really like those improved odds. And it's a great example of the kinds of AI-driven medical technologies that I write about in The Future You, which is now available from Amazon in Kindle ebook format.So I asked Paige's CEO, Leo Grady, to come on the show to explain how the test works, how Paige trained its software to be more accurate than a human pathologist, how the company got the FDA to give its first ever approval for an AI-based pathology product, and what it could all mean for the future of cancer diagnosis and treatment.Here's our conversation.Harry Glorikian: Leo, welcome to the show.Leo Grady: Hi, Harry. Glad to be here.Harry Glorikian: Yeah. You know, I've been watching the company for some time now, and the big story here seems to be that we're really entering the area of digital pathology, also known as sort of computational pathology, and it's funny because I've been talking about digital pathology since I think I started my career back when I was 25, which seems like a long time ago at this point. But for a lot of laboratory tests that we use, like it's usually done by eye, and now we can get a lot from sort of AI being assistive in this way. So keeping in mind that some of the listeners are professionals, but we have a bunch of sort of non-experts, could you start off explaining the term maybe computational pathology and summarize where the state of the art is, which I assume you guys are right at the cutting edge of it?Leo Grady: Yeah, so I think it actually might help just to jump back a level and talk about what is pathology and how is it done today? So today, so pathology is the branch of medicine where a doctor is taking tissue out of a patient through a biopsy, through surgery and making glass slides out of that tissue, looking at it under a microscope in order to make a diagnosis. And today, all of that process of taking the tissue out, cutting it, staining it, mounting it on slides. Then gets looked at under a microscope by a pathologist to make a diagnosis, and that diagnosis the pathologist makes is the definitive diagnosis that then drives all of the rest of the downstream management and care of that patient. When pathologists are looking through a microscope, sometimes they see something that they're not quite sure what it is. And so they may want to do another test. They may want to do another stain. They may want to cut more out of the tissue, make a second slide. Sometimes they want to ask a colleague for their opinion, or if they really feel like they need an expert opinion, they may want to send that case out for a consultation, in which case the glass slides or are put in a, you know, FedEx and basically shipped out to another lab somewhere. All of those different scenarios can be improved with digital pathology and particularly computational pathology and the sort of technology that we build at Paige. So in a digital world, what happens instead is that the slides don't go to the pathologist as glass. They go into a digital slide scanner, and those slide scanners produce a very high resolution picture of these slides.Leo Grady: So these are quarter-micron resolution images that get produced of each slide. And then the pathologist has a work list on their monitor. They look through those those cases, they open them up and then that digital workflow, they can see the sides digitally. When they have those slides digitally, if they want to send them out to a second opinion or or show them to a colleague, it's much easier to then send those cases electronically than it is to actually ship the glass from one location to another. Once those slides are digital it, it opens up a whole other set of possibilities for how information can come to the pathologist. So if they want additional information about something they see in those slides, rather than doing another stain, doing another cut, sending for a second opinion, what we can do and what we do at Paige is we we identify all the tissue patterns in that piece of tissue, match those against a large database where we have known diagnoses and say, OK, this case, this pattern here has a high match toward to something that's in this database. And by providing that information to the pathologists on request that pathologists can then leverage that information, integrate it and use it in their diagnostic process. And this is the product that the FDA just approved. It's the first ever AI based product in pathology that is specifically aimed at prostate cancer and providing this additional information in the context of a prostate needle biopsy.Harry Glorikian: Well, congratulations on that. That's, you know, that's amazing. And I'm. You know, the fact that the FDA is being more aggressive than I remember them being in the past is also a great thing to see. But, you know, we've been talking and quote digitizing things in pathology for for quite some time, let's say, separate from the AI based analytics part of it moving in that direction. What was the kind of technology advance or prerequisite that you guys came up with when you started Paige that that took this to that next level.Leo Grady: Well, as you're pointing out, Harry, most slides are not digitized today, single digits of slides in a clinical setting get digitized. And the reason for that has been you need to buy scanners, you need to change your workflow, you need to digitize these slides. They're enormously large from a file size and data complexity. So then you have to store them somehow and you make all of that investment and then you get to look at the same slide on a monitor that you look at under a microscope. And so pathologists for years have said, why? Why would we make this investment? Why would we go through all of that expense? And that trouble and that change and learn a new instrument when we don't really get a lot of value out of doing so? And furthermore, there was even a question for a long time, do you get the same information on a digital side that you get on glass through a microscope? Yep. There have been a number of things that have been changing that over time. So one is the maturity of the high capacity digital side scanners. There are now a number of hardware vendors that produce these. Storage costs have come down. And one thing that we offer at Paige is is cloud storage, which is really low cost because we're able to effectively pool costs with the cloud providers from multiple different labs and hospitals, so we can really drive those prices down as far as possible.Leo Grady: So that lowers that barrier. And then back in 2017, the first digital side scanner got approved, which demonstrated there was equivalency in the diagnosis between looking at the slide on a monitor and looking at it under a microscope. And that is something that that we also replicated with our digital side viewer, demonstrated that equivalency between digital and glass. But all of those barriers were barriers just to going digital in the first place. And now, really, for the first time, because of the maturity of the scanners, because of the FDA clearance of just the viewer, because of lower cost storage, many of those barriers have come down. Now what has not happened is still a major clinical benefit for going digital in the first place. Yes, you can share slides easier. Yes, you can retrieve slides easier. Yes, you can do education easier. It's still a lot of cost and a lot of changed your workflow, so I really think that that the introduction of the kinds of technologies that that the FDA approved, which we built with Paige Prostate, that actually adds additional information into the diagnostic workflow that can help pathologists use that information help them. You get to a better diagnosis, reduce false positives, reduce false negatives, which is what we showed in the study that for the first time is is going above and beyond just going digital and some of these conveniences of a digital workflow to providing true clinical benefit.Harry Glorikian: Yeah, I mean, whenever I look at this from an investment perspective, like if you take apart something and break it into its first principles, you know, levels, you have to have certain milestones hit. Otherwise, it's not going to come together, right? And I've, you know, looking at digital pathology, it's the same thing. You have to have certain pieces in place for the next evolution to be possible, because it's got to be built on top of these foundational pieces. But, you know, once you get there, the exponential nature of of how things change, once it's digitized and once you're utilizing it and prove that it works is sort of where you see the, you know, large leaps of benefit for the pathologist as well as, you know, ultimately we're doing this for better patient care. But you know, your product was I think the FDA called it the first ever FDA approval for an AI product in pathology, which is a big deal, at least as far as I'm concerned, because I've been doing it for a long time. But because it was first, it must have been a one hell of a learning process for you and the FDA to figure out how to evaluate a test like this. Can you sort of explain maybe a little bit about the process? You know, how did you win approval? What novel questions did you have to answer?Leo Grady: It was a long process. You know, as you point out, this is this is the first ever technology approved in this space. And I think you saw from the FDA's own press release their enthusiasm for what this technology can bring to patient benefits. Fortunately, we applied for breakthrough designation back in early 2019, received that breakthrough designation in February of 2019. And as a result, one of the benefits of breakthrough designation is the FDA commits to working closely with the company to try to iterate on the study protocol, iterate on the the validation that's going to be required in order to bring the the technology to market. And so because of that breakthrough designation, we had the opportunity to work with the the FDA in a much tighter iterative loop. And I think that they are they were concerned, I mean, primarily about the impact of a misdiagnosis and pathology, right? Which is really understandable, right? Their view is that, yes, maybe in radiology, you see something and maybe aren't totally sure. But then there's always pathology as a safety net, you know, in case you ever really need to resolve a ground truth. You can always take the tissue out and look at it under a microscope. But when you're dealing with a product for pathology, that's the end of the road. I mean, that is where the diagnostic buck stops. And so anything there that that was perhaps going to misinform a pathologist, mislead them, you know, ultimately lead to a negative conclusion for the patients could have more severe consequences.Speaker2: The flip side, of course, though, is that if you get it right, the benefits are much greater because you can really positively impact the care of those patients. So I think they they, you know, appropriately, we're concerned with the exacting rigor of the study to really ensure that that this technology was providing benefit and also because it was the first I think they wanted to be able to set a standard for future technologies that would have to live up to the same bar. So there were a lot of meetings, you know, a lot of trips down to Silver Spring. But I have to say that that the FDA, you know, I think in technology, there are a lot of companies that are are quick to, you know, malign regulators and rules. I frankly both at Paige and my previous experience at HeartFlow, at Siemens, I think the FDA brings a very consistent and important standard of clinical trial design of of, you know, technology proving that is safe and effective. And I found them to be great partners to work with in order to really identify what that protocol looks like to be able to produce the validation and then to, you know, ask some tough questions. But that's their job. And I think, you know, at the end of the day, the products that get produced that go through that process really have met the standard of of not only clinical validation, but even things like security and quality management and other really important factors of a clinical product.Harry Glorikian: Oh no, I'm in total agreement. I mean, whenever I'm talking to a company and they're like, Well, I don't know when I'm going to go to the agency, I'm like, go to the agency, like, don't wait till the end. Like there, actually, you need to look at them as a partner, not as an adversary.Leo Grady: Yeah. And a pre-submission meeting is is easy to do. It's an opportunity to make a proposal to the FDA and to understand how they think about it and whether that's that's going to be a strategy that's going to be effective and workable for them. So I always think that that pre subs are the place to start before you do too much work because you generally know whether you're on the right path or not.Harry Glorikian: Yeah, I agree. And it's funny because you said, like, you know, they're concerned about the product, but it's interesting. Like from all the College of American Pathology studies where you send slides to different people, you don't always get the exact same answer, depending on who's looking at it. So I can see how a product can bring some level of standardization to the process that that helps make the call so uniform, even across institutions when you send the slides. So I think that's moving the whole field in a really positive direction.Leo Grady: Well, only if that uniform call is correct, right? Or better? Great. I mean, if you bring everybody down to the lowest common denominator that that standardization, but it's not moving the field forward. So. Correct. One of the curses of of bringing that level of standardization is that you have to really meet the highest bar of the highest pathologists and not not just the average. That said, you know, we're fortunate to come from Memorial Sloan-Kettering and to have the opportunity to work with some of the the leading pathologists in the world to really build in that level of rigor and excellence into the technology.Harry Glorikian: Yeah. So that brings me to like, you know. The algorithms are built on a fairly large training set would be my assumption and of pre labeled sort of images, where do you guys source that from? Is it you have like a thousand people in the background sort of making sure that everything is labeled correctly before it's fed to the to the algorithm itself?Leo Grady: Well, what you're describing is very common where you have pathologists or in radiology radiologists or other experts really marking up images and saying this is the important part to pay attention to. This part is cancer. That part's benign. Our technology actually works differently. Our founder, Thomas Fuchs, and his team at Memorial Sloan-Kettering actually really made a breakthrough not only in the the quality of some of the the AI systems that were building, but also in the technology itself. And what what they did, this was all published in Nature Medicine a couple of years ago, is basically find a way to just show the computer a slide and the final diagnosis without having a pathologist, you know, mark up the slide, but just show them the final diagnosis. And when you show the computer enough examples of the slide and the final diagnosis, the computer starts to learn to say, OK, this pattern is common to all grade threes. This pattern is common to all grade fours. Or whatever it is. And the computer learns to identify those patterns without anybody going through and marking those up. Well, this technology is important for a few reasons.Leo Grady: One, it means we can train systems at enormous scale. We can not just do thousands of cases, but tens of thousands, hundreds of thousands of cases. Second, it means that we can really build out a portfolio of technologies quickly that are very robust and not have to spend years annotating slides. And third, it allows us to start looking for patterns that no pathologists would necessarily know how to mark up. You know, can we identify which tumors are going to respond to certain drugs or certain therapies? You know, no pathologists are going to be able to say, OK, it's this part of the the tumor that you need to look at because they don't really know. But with this technology where we we know these tumors responded, these tumors didn't it actually helps us try to ferret out those patterns. So that that's one of the real key benefits that differentiates Paige from from other companies in this space is just the difference in the technology itself.Harry Glorikian: Yeah. I mean, it's funny because I must admit, like when we talk about stuff like this, I get super excited because I can see where things can go. It's. It's always difficult to explain it where somebody else can envision what you've been thinking about because you've been thinking about it so long, but it's super exciting. So let's jump to like the most important benefits, like if you had to rank the benefits of the technology, I mean, I've I read on your website that in the clinical study you guys submitted to the FDA, pathologist used using the Paige Prostate were seven percent more likely to correctly diagnose the cancer. Is that the major innovation? Would that by itself be enough to justify an investment in the technology? I mean, I'm trying to. You know, if you were to say God, this is the most important thing and then go down the list, what would they be?Leo Grady: Yeah, that's right. So so the study that we did was like this. We had 16 pathologists. They diagnosed about six hundred prostate needle core biopsy patients and they they did their diagnosis. They recorded it and then they did it a second time using Paige so they could see the benefit of all this pattern matching that that Paige had done for them. And what we did is we compared the diagnosis. They got the first time and the second time with the ground truth, consensus diagnosis that we had from Memorial. And what we found is that when the pathologists were using Paige, they had a 70 percent reduction in false negatives. They had a 24 percent reduction in false positives, and their interest in obtaining additional information went down because they had more confidence in the diagnosis that they were able to provide. And what was interesting about that group of 16 pathologists is it it included pathologists that were experienced, that were less experienced, some that were specialists in prostate cancer, some that were not so specialized in prostate cancer. And among that entire group of pathologists, they all got better. They all benefited from using this technology. And what's more, is that the gap between the less experienced, less specialized pathologists and more experienced, more specialized pathologists actually decreased as they all used the technology. So it allowed them to, like we were talking about before, actually come up to the level of of the better pathologists and even the better pathologists could leverage the information to get even better.Harry Glorikian: So as a male who you know who's going to age at some point and potentially have to deal with, hopefully not, a prostate issue, we want them to make an accurate diagnosis because you don't want the inaccurate diagnosis, especially in in that sort of an issue. But what about the speed? I mean, you've you talk about that, you know, it helps streamline the process and reduce reduce turnaround time for for patients. What does that do to workload and and how quickly you're able to turn that around compared to, say, a traditional method.Leo Grady: Our study was really focused on clinical benefit and patient benefit. We were not aiming to measure speed and the way in which the study was designed and the device is intended to be used is that the pathologist would look at the case, decide what they they think the result is, and then pull up the Paige results and see if it changes their thinking or calls their attention to something that they may have missed. So the focus of the the product was really on the the benefit to the the clinical diagnosis and the clinical benefit to patients by providing more information to the doctors. And the result of that information was, you know, clearly demonstrated benefit. Now if they can get to that result by looking at the Paige results and they don't need another cut, they don't need another stain, they don't need another consultation, then that's going to get the results back to the urologists faster, back to the patient faster and will ultimately enable them to start acting on that diagnosis more quickly. But the intention of the study, the intended use of the device is not around making pathologists faster. It's really around providing them this additional information so that they can use that in the course of their diagnosis and get the better results from patients.[musical interlude]Harry Glorikian: Let's pause the conversation for a minute to talk about one small but important thing you can do, to help keep the podcast going. And that's to make it easier for other listeners discover the show by leaving a rating and a review on Apple Podcasts.All you have to do is open the Apple Podcasts app on your smartphone, search for The Harry Glorikian Show, and scroll down to the Ratings & Reviews section. Tap the stars to rate the show, and then tap the link that says Write a Review to leave your comments. It'll only take a minute, but you'll be doing us a huge favor.And one more thing. If you like the interviews we do here on the show I know you'll like my new book, The Future You: How Artificial Intelligence Can Help You Get Healthier, Stress Less, and Live Longer.It's a friendly and accessible tour of all the ways today's information technologies are helping us diagnose diseases faster, treat them more precisely, and create personalized diet and exercise programs to prevent them in the first place.The book is now available in Kindle format. Just go to Amazon and search for The Future You by Harry Glorikian.And now, back to the show.[musical interlude]Harry Glorikian: So I asked this out of naivete because I didn't I didn't go looking for it. But have you guys done a health economic analysis of the system?Leo Grady: We have one. It certainly it's, as you know, it's really key to be able to look at that we have a model that we've built. We're still refining it with additional data. There was a study that was announced in the U.K. a couple of weeks ago where the NHS is actually funding a prospective multicenter trial that includes Oxford, Warwick, Coventry, Bristol to be able to evaluate the the health, economics and clinical benefits of using this technology in clinical practice prospectively. So that's something that we engaged with NICE [the National Institute for Health and Care Excellence] on in order to try to get the design correct that will help feed in real world data into the model. But we have a model that we've been using internally and are continuing to build and refine.Harry Glorikian: So. Again, incredible that you guys got FDA approval, I think the company was founded in 2017, if I'm correct. Can you talk about, you know, the founders and yow you guys, you know, built this so quickly, I mean time scale wise, it's a pretty compressed time scale, relatively speaking.Leo Grady: Well, yeah, it isn't, it isn't, ...so the company started in 2017, our first employee was actually middle of 2018 and we had our first venture round and in early 2018. However, the work that went into the company that spun out of Memorial Sloan-Kettering started earlier. So there is a group of really visionary individuals at MSK that back, I want to say, 2014, 2015, actually had started this push toward digital pathology, computational pathology, really seeing where the puck was going and building this technology. They formed something called the Warren Alpert Center, and the Warren Alpert Center provided some initial funding to really get this going and to hire some of the founders and to really move this technology in the right direction. And it was really because that technology started to show such promise that MSK made the decision that that was at a point where it could be better, you know, more impactful to actually go outside of MSK into a company where where we could industrialize the technology and really bring it to hospitals and labs around the world. So the technology started earlier, 2014, 2015. Paige was really launched in, I would say, 2018, although technically it was incorporated earlier and and then from that point I personally joined in 2019. And so I'm not I'm not a founder, but when I joined in 2019, you know, we we really spun up a significant team and and brought to bear some of my own experience and industrializing AI technology and bringing it out to clinical benefit.Harry Glorikian: Well, you know, most founders don't take the company all the way. It's a rare breed that's able to get it that far. So you know this a great story, but let's step back here and talk about like now you have to like, get people to accept this technology right, which is the human factor which I always find much more confounding than the the the the computational factor. So you've got to get, you know, somebody inside a hospital or pathology lab. Do you run into resistance or pushback from the technology, I mean, are they skeptical about the algorithm? How do you get a human to sort of buy off on this? I remember when we were presenting this, oh God, again, 25 years ago, they hated it. I mean, just hated it. And as time has gone by, you've seen that that digitization is slowly taking effect and where you know, it's assistive as opposed to something, I remember when we first launched this, it was, "This is going to be better than" or "take your job," which is a great way to make an enemy on the other side. And I see that the two actually being better than one or the other per se on on its own. So how are you guys approaching this? And do you have any anecdotal stories that you might be able to share?Leo Grady: Yeah, and so I think there are two elements are one is, you know. Are people resistant by the nature of the technology because they feel threatened by it, and then the other is how does market adoption start with this sort of technology to just the first point? You know, I tend to be very careful about the term AI. I feel like it know it often introduces this concept of, you know, people think of a robot doctor that's going to run in and start doing things. And it's just it's not. I mean, AI is a technology that's been in development for four decades. I did my PhD in AI, in computer vision, 20 years ago, and it's just a technology, right? It's like a transistor. It can be used to build many different things. At its core, it's just complex pattern matching, which is what we how we leverage that technology. In the case of Paige Prostate was to help provide that information. I think, you know, the better frame to think about this technology is as a diagnostic. This is just like a diagnostic test. You validate it with a standalone sensitivity and specificity. The information gets provided the doctor. You have to do a clinical trial that samples the space effectively of the patient population and the intended use.Leo Grady: And you have to make sure the doctors understand the information and know how to use it effectively. It's before my time, but I heard that when immunohistochemistry was first really introduced in pathology, that there is a discussion that this was going to take all the pathologists' jobs. And who needs a pathologist if you can just stain with IHG and get get a diagnostic result out of it? Well, you know, 20 years, IHT is an essential component of of pathology, and it's a key element of of the diagnostic workflow for pathologists. So, far from replacing any pathologists, it's empowered them. It's made there the benefit that they can provide to the clinicians, even more valuable and even more important. And I think we're going to see a similar trajectory with this computational technology. Now your first question about market adoption, how people adopting this, I would say that, you know, last week I went to the College of American Pathology meeting, which was in person in Chicago. It's my first in-person meeting since COVID, so a year and a half ago. And I noticed--and this was this was right after the announcement by the FDA of of the approval for Paige Prostate--I noticed there was a market shift in the conversations I was having with pathologists.Leo Grady: It was a shift away from "Does this technology work? Is it ready for prime time? What does it really do?" Toward, "Ok, how do we operationalize this? How do we bring it in house, how do we integrate this into a workflow and how do we how do we pay for it?" You know, those are the conversations that we were having in Chicago at CAP. Not does this work? Is it ready for prime time? So I do think that there is a market understanding that the technology is real, that it works, that it can provide benefit. Now it's just a question of how do we operationalize and how do we get it paid for? Because today there's no additional reimbursement for it. But you know, again, with market adoption, you're got your Moore adoption curve for anything. You get them and you get your innovators and early adopters, your early majority, late majority and your laggards. And you know where I think we're at a stage where we've got innovators and early adopters that are excited to jump in and start leveraging this technology. And I think, you know, we're going to get to your early majority and the late majority over time. It's always going to be a process.Harry Glorikian: Yeah, no. I mean, you know, reflecting on your IHC [immunohistochemistry], that's where I started my career. Like, I think I taught like two hundred and fifty IHC courses over the first, say, three or four years that I was in the in the business. Three or four years. And you know, I agree with you. There's no way that any one of these technologies takes the place of [a pathologist]. They're additive, right? It's just a tool that helps. Make the circle much more complete than it would be in any one component, all by itself.Leo Grady: Could you ever hear when you were teaching these classes? Did anyone ever say that like, are we even going to need pathologists anymore?Harry Glorikian: No, it was when the is is when imaging systems came out that said the imaging system would then replace the pathologists. The IHC was was really the cusp of precision medicine, where I remember when I first started because we were working with ER and PR and, you know, when I first learned, you know about like, you know, the find and grind method, I would always be like, OK, it's x number of femtomoles. Like, What does that really telling you, right? Compared to this stain over here where I can see, you know, the anatomy, I can see where the cells are. I can see. I mean, there's so much more information that's coming from this that lets me make a better call. I will tell you selling it was not that hard to a lot of people, they they could see the benefit and you could you could really sort of get them to adopt it because they saw it as a tool.Leo Grady: Was that post-reimbursement?Harry Glorikian: Uh, even pre-reimbursement.Leo Grady: Really interesting. Yeah, there's there's a lot we can learn from you then.Harry Glorikian: Yeah, it was. It was. It was an interesting ride back then. I mean, I remember my first day at work. My boss comes to me and says. By the way, you're going to give a talk in Arizona in two weeks, and I was like, What do you mean I'm going to go? Who am I going to give a talk to you? He goes, Oh, you got to give a talk on the technology and how to use it. And I said, who's in the audience? And he said histo techs, and there'll be some pathologists. And I was like, Are you kidding me? And he goes, You got two weeks to get ready. Oh my God, I was cramming like crazy. I was in the lab. I was doing all the different types of assays that we had available. And you know, it was you went out there and I learned very quickly like, the show must go on, like you got to get out there and you got to do your thing. But it was it was a great time in my career to be on that on that bleeding edge of what was happening. So quickly, like, why did you guys start with prostate cancer, though like? It's not the most common cancer, although it's high on the list, so. Or maybe it's the second most type of cancer, but why did you guys start with that and where do you guys see it going from there, I guess, is next.Leo Grady: Well, the the decision of how to rank the different opportunities for, you know, ultimately we believe this technology can benefit really the entire diagnostic process, no matter what the question is in pathology. However, we did have to prioritize right and elements of of where to start, right. The elements of prioritization had a few factors. So one factor was how how prevalent is the disease? I mean, as you know, prostate cancer is one of the big four. Second, is there are a lot of benefit that we can provide today with prostate cancer. You know, man of a certain age goes in, gets a PSA test. It's high, they go and they get 12 cores, 14 cores, 20 cores out of their prostate and that produces. You know, it can be 30 slides, it can be 50 slides, I mean, it really depends, and this can take the pathologist a long time to look through. Most of those cores are negative. In fact, most of those patients are negative, but the consequence of missing something is really significant. And so we felt that this was a situation where there was a big need. There's a lot of there's a lot of screening that goes on with prostate cancer. Prostate cancer is prevalent and the consequence of missing something is really significant. So that's where we felt like we could provide maximum benefit, both in terms of the patient, in terms of the doctor, and also that it was a significant need across the space.Leo Grady: We also had the data and the technology that we could go after that one well. But that said, you know, we announced that we have a breast cancer product that is got a CE mark in an enabling clinical use in Europe. We're doing a number of investigational studies with that product in the US right now and and working toward bringing that one to market. You know, after our our recent funding round, we spun up a number of teams and a number of of verticals that were we're going after in other cancer types and ultimately even beyond cancer. So there's more to come. We wanted we really take seriously the quality, the regulatory confirmation as well as the deployment channel. I mean, we built the whole workflow to be able to leverage this technology throughout the workflow in a way that is meaningful to the pathologist. So the development is is maybe a little bit more heavy and validation than some other companies where you have a PhD student that says, Oh, you know, I won some challenge and I went to go bring this to market building real clinical products, validating them, deploying them, supporting them is a real endeavor. But prostate was just the first, breast is second, and we have a whole pipeline coming out. So stay tuned.Harry Glorikian: So before we end here, I want to just tilt the lens a little bit towards the consumer and say, like, you know. Why would consumers show interest or at least be aware that these things are coming? Because I always feel like they're almost the last to know, or they just don't know at all. But, you know, in the future, you know, with technologies like this, do you see it identifying tumors sooner, faster, more accurately? Or, you know, will it will it help increase survival or help us find better drugs? I mean that that's I think, what people are really... If you went down one level from us of the people that are affected by this. Those are the sorts of things they'd want to know.Leo Grady: Well, I think, you know, a useful analogy is what happened with the da Vinci robot. You know, when it was necessary for a patient to get prostate cancer surgery, they often chose centers that had the da Vinci robot. Why? Because they believed that they were able to get better care at those centers. And it's not because the surgeons at the other centers were no good. It's because the the da Vinci added elements of precision and standardization and accuracy that could be demonstrated that would enable the the patient to feel more confident they're getting the best treatment at those centers. So as I think about Paige Prostate and and ultimately the other technologies that we're bringing to market behind that, I would imagine that from the standpoint of the patient, they would want the diagnosis done at a lab where they had access to all of the available information, all the latest technology that could inform the pathologists to get the right answer, right? So would you want to go to a lab where the pathologists had no access to IHC? Would you want to send it to a lab where the pathologist had no ability to do a consultation? Do you want to send your your sample to a lab where the pathologist doesn't have access to Paige? I think in the future the answer is going to be no.Leo Grady: And I think that we're going to see ultimately, insurance companies and Medicare recognize that those labs are able to provide better care to patients and are going to encourage them and incentivize them to adopt these technologies. So, you know, ultimately from a patient standpoint, they they want to choose centers where they're going to get the best care, they're going to get the best diagnosis. I think one of the exciting elements of digital technology is that not everybody is able to go to Memorial Sloan-Kettering, not everyone's able to go to MD Anderson or Mayo Clinic. I think the opportunity with digital technology is to really increase the accessibility and increase the availability of these diagnostic tools that can really empower and enable pathologists in many parts of America, as well as beyond to really get to better results for their patients. And ultimately, you know, every patient cares about getting those those results accurately for themselves and for their loved ones.Harry Glorikian: Yeah, I mean, I'm always explaining, you know, to different people like once you digitize it, there's so many opportunities that may open up to make things better, faster, easier, more accurate and even start to shift the business model itself of what can be done and where it can be done. So it's it's a super exciting space, and thanks for taking the time. It was great to talk to you. I mean, I don't get to talk to people in pathology all the time anymore. I'm sort of all over the place, but it's it's near and dear to my heart, that's for sure.Leo Grady: Well, thank you so much, Harry. We're so excited by these recent developments with the first ever FDA approved technology in this space and, you know, really excited to help roll this out to labs and hospitals around the country and around the world to really benefit those doctors and patients.Harry Glorikian: Excellent. Well, I look forward to hearing about the next FDA approval.Leo Grady: Working on it. Look forward to telling you.Harry Glorikian: Thanks.Leo Grady: All right. Thanks so much, Harry.Harry Glorikian: That's it for this week's episode. You can find past episodes of The Harry Glorikian Show and MoneyBall Medicine at my website, glorikian.com, under the tab Podcasts.Don't forget to go to Apple Podcasts to leave a rating and review for the show.You can find me on Twitter at hglorikian. And we always love it when listeners post about the show there, or on other social media. Thanks for listening, stay healthy, and be sure to tune in two weeks from now for our next interview.

Dr. Ardeshir Z. Hashmi MD, FACP, Section Chief of Geriatrics at Cleveland Clinic and is the Endowed Chair of Geriatric Innovation and Section Chief/ He is Assistant Professor of Medicine at the Case Western Reserve University and the Cleveland Clinic Lerner College of Medicine. He has conducted lectures and workshops in geriatrics nationally and internationally. Under Dr. Hashmi's leadership Cleveland Clinic Geriatrics has garnered the following milestones; Age Friendly Health Systems Committed to Care Excellence designation via the Institute for Healthcare Improvement; highest Geriatrics US News and World report national rankings in Cleveland Clinic history; national accreditation as a top tier Level 1 Geriatrics Emergency Department by the American College of Emergency Physicians. Dr. Hashmi's niche area of interest is the intersection of affordable technology solutions and geriatric population health in the service of our most vulnerable populations. Sponsor: www.BeyondDrivingwithDignity.com

Dr. Ardeshir Z. Hashmi MD, FACP, Section Chief of Geriatrics at Cleveland Clinic and is the Endowed Chair of Geriatric Innovation and Section Chief/ He is Assistant Professor of Medicine at the Case Western Reserve University and the Cleveland Clinic Lerner College of Medicine. He has conducted lectures and workshops in geriatrics nationally and internationally. Under Dr. Hashmi's leadership Cleveland Clinic Geriatrics has garnered the following milestones; Age Friendly Health Systems Committed to Care Excellence designation via the Institute for Healthcare Improvement; highest Geriatrics US News and World report national rankings in Cleveland Clinic history; national accreditation as a top tier Level 1 Geriatrics Emergency Department by the American College of Emergency Physicians. Dr. Hashmi's niche area of interest is the intersection of affordable technology solutions and geriatric population health in the service of our most vulnerable populations. Sponsor: www.BeyondDrivingwithDignity.com

The National Institute for Health and Care Excellence in the U.K. put out a list of recommendations in April 2021, for the treatment of chronic pain, based on a meta-analysis of research in the area. In this episode we talk about the recommendations and what it could mean for the well-being of Chronic Pain Warriors.In this episode we discuss:5 evidence-based treatment for chronic painwhat was not included as a recommendation and whywhat we should do with this informationRemember that this podcast is for psychoeducation/health education only, and you should always consult with your healthcare team before making any lifestyle changes.Here's the link to the full report by NICE.Support the show on Patreon and get access to extra weekly content only for Patrons.Follow the show on Instagram @chronically.living_ and on Twitter @janevspainSign up for Instacart by following this link.

In this month's episode, the P4A team take a deep dive into the impact of Brexit on the UK's market access landscape. Four months after leaving the European Union, the UK's attractiveness as a key destination for commercialisation of new drugs is being tested. In order to improve its credentials, the UK is exploring a slew of measures that could potentially spark a reform. But will that happen? P4A's Joanna Fernandes and Jayne Watson consider two distinct initiatives - MHRA's (Medicines Healthcare Regulatory Agency's) new I-LAP (Innovative Licensing and Access Pathway) scheme and England's HTA body NICE's (National Institute for Health and Care Excellence's) method review. Presenter and Contributor: Joanna Fernandes Other contributors: Jayne Watson Producer: Aparna Krishnan

Welcome to Ask Stago, the Podcast dedicated to provide expert answers to your expert questions in coagulation.  In today’s episode, our expert our expert François Depasse, Clinical development Director, will help us to clarify when thrombophilia testing is appropriate and how to perform it according to international standards.   As usual, don’t forget to send any question you may have to ask@stago.com we will be glad to answer to it.  Literature sources:  https://www.cochranelibrary.com/advanced-search/mesh;jsessionid=DED8CB403679070FD38E81E38E5A7ECA accessed March 17, 2021  Montagnana M, Lippi G, Danese E. An Overview of Thrombophilia and Associated Laboratory Testing. Methods Mol Biol. 2017;1646:113-135. doi: 10.1007/978-1-4939-7196-1_9.  Merriman L, Greaves M. Testing for thrombophilia: an evidence-based approach. Postgrad Med J. 2006 Nov;82(973):699-704. doi: 10.1136/pgmj.2006.048090.   Gruel Y et al, Thrombophilia testing: Proposals of the 2020 GFHT. Rev Francoph Hémost Thromb 2020 ; 2 (3) : 93-126  Delluc A, Antic D, Lecumberri R, Ay C, Meyer G, Carrier M. Occult cancer screening in patients with venous thromboembolism: guidance from the SSC of the ISTH. J Thromb Haemost. 2017 Oct;15(10):2076-2079. doi: 10.1111/jth.13791. Epub 2017 Aug 29. Erratum in: J Thromb Haemost. 2017 Dec;15(12 ):2471.  D'Astous J, Carrier M. Screening for Occult Cancer in Patients with Venous Thromboembolism. J Clin Med. 2020 Jul 27;9(8):2389. doi: 10.3390/jcm9082389  Connors JM. Thrombophilia Testing and Venous Thrombosis. N Engl J Med. 2017 Sep 21;377(12):1177-1187. doi: 10.1056/NEJMra1700365.  National Institute for Health and Care Excellence. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. NG 158, London 2020  De Stefano V, Rossi E. Testing for inherited thrombophilia and consequences for antithrombotic prophylaxis in patients with venous thromboembolism and their relatives. A review of the Guidelines from Scientific Societies and Working Groups. Thromb Haemost. 2013 Oct;110(4):697-705. doi: 10.1160/TH13-01-0011.  Moll, S. Who should be tested for thrombophilia?. Genet Med 13, 19–20 (2011).  Cooper PC, Pavlova A, Moore GW, Hickey KP, Marlar RA. Recommendations for clinical laboratory testing for protein C deficiency, for the subcommittee on plasma coagulation inhibitors of the ISTH. J Thromb Haemost. 2020 Feb;18(2):271-277. doi: 10.1111/jth.14667.   Marlar RA, Gausman JN, Tsuda H, Rollins-Raval MA, Brinkman HJM. Recommendations for clinical laboratory testing for protein S deficiency: Communication from the SSC committee plasma coagulation inhibitors of the ISTH. J Thromb Haemost. 2021 Jan;19(1):68-74. doi: 10.1111/jth.15109.  Van Cott EM, Orlando C, Moore GW, Cooper PC, Meijer P, Marlar R; Subcommittee on Plasma Coagulation Inhibitors. Recommendations for clinical laboratory testing for antithrombin deficiency; Communication from the SSC of the ISTH. J Thromb Haemost. 2020 Jan;18(1):17-22.   Devreese KMJ, de Groot PG, de Laat B, Erkan D, Favaloro EJ, Mackie I, Martinuzzo M, Ortel TL, Pengo V, Rand JH, Tripodi A, Wahl D, Cohen H. Guidance from the Scientific and Standardization Committee for lupus anticoagulant/antiphospholipid antibodies of the International Society on Thrombosis and Haemostasis: Update of the guidelines for lupus anticoagulant detection and interpretation. J Thromb Haemost. 2020 Nov;18(11):2828-2839. doi: 10.1111/jth.15047.  Sevenet PO, Cucini V, Hervé T, Depasse F, Carlo A, Contant G, Mathieu O. Evaluation of DOAC Filter, a new device to remove direct oral anticoagulants from plasma samples. Int J Lab Hematol. 2020 Oct;42(5):636-642. doi: 10.1111/ijlh.13267.  Exner T, Michalopoulos N, Pearce J, Xavier R, Ahuja M. Simple method for removing DOACs from plasma samples. Thromb Res. 2018;163:117-122  Related podcasts:   S1E13 - The Lupus Anticoagulant Diagnosis Work up - https://www.podcastics.com/episode/54015/link/ ____________________________________________________________________________________________________________ Content is scientific and technical in nature. It is intended as an educational tool for laboratory professionals and topics discussed are not intended as recommendations or as commentary on appropriate clinical practice. 

NICE (National Institute of Health and Care Excellence) defines a clinical audit as follows:Audit in healthcare is a process used by health professionals to assess, evaluate and improve care of patients in a systematic way. Audit measures current practice against a defined (desired) standard. It forms part of clinical governance, which aims to safeguard a high quality of clinical care for patientsRecently I’ve had several requests regarding how to audit occupational health practice. The first question to me was 'How on earth do you audit an occupational health service which has never had an audit before? Where do you start?'Here I take you through a simple and pragmatic way of auditing an occupational health service to improve consistency and quality over your whole organisation or maybe just one process which needs modifying.Audit is a daunting task if you’ve never done it before but if you use a stepped approach, it becomes simpler. The hardest part being the planning. If you’ve audited nothing before in your organisation, start with something simple and small.The fours steps are:1. Planning the audit, 2. Doing the audit, 3. Checking against the standards and 4. Action, that is, correcting all the things you've discovered aren't compliant with what you wanted.To illustrate my four step approach, I will go through a clinical notes audit because every OH service keeps clinical notes and, being a paper exercise, will not interfere with day to day work.How to decide what needs auditingFind out what you need to do at each stage and why Issues to avoid and problems which can occurNo long words to confuse you Links to research and the checklist from my website blog which accompanies this podcast: Download the Free Notes Audit Checklist hereRead the full article which accompanies this podcast with much more detail here.Further Reading/Resources to help with Audit:Faculty of Occupational Medicine advice on Data Protection in Occupational HealthSee also SEQOHS website for accrediting your OH services at www.seqohs.orgAudit and audit cycle for Medical Professionals on the Patient websiteBest Practice in Clinical Audit from Healthcare Quality Improvement PartnershipIntroduction to Clinical Audit in OH from my websiteA brief summary of Plan, Do, Check, Act from the HSE

In this episode, let's talk about what ADHD is, how common autism and ADHD are in individuals, and the cause and impact these co-occurring conditions have on individuals. References: Autism and ADHD. (2017). Autism Spectrum Australia. Retrieved March 24, 2021. Casanova, M.F., Frye, R.E., Gillberg, C., & Casanova, E.L. (2020). Editorial: Comorbidity and autism spectrum disorder. Frontiers in Psychiatry. doi: 10.3389/fpsyt.2020.617395. Chen, M. H., Wei, H. T., Chen, L. C., Su, T. P., Bai, Y. M., Hsu, J. W., ... & Chen, Y. S. (2015). Autistic spectrum disorder, attention deficit hyperactivity disorder, and psychiatric comorbidities: A nationwide study. Research in Autism Spectrum Disorders, 10, 1-6. Davis, N. O., & Kollins, S. H. (2012). Treatment for co-occurring attention deficit/hyperactivity disorder and autism spectrum disorder. Neurotherapeutics, 9(3), 518-530. Gargaro, B. A., May, T., Tonge, B. J., Sheppard, D. M., Bradshaw, J. L., & Rinehart, N. J. (2014). Using the DBC-P Hyperactivity Index to screen for ADHD in young people with autism and ADHD: A pilot study. Research in Autism Spectrum Disorders, 8(9), 1008-1015. Matson, J.L. (2016). Comorbid conditions among children with autism spectrum disorders. Berlin, Germany: Springer. National Institute for Health and Care Excellence (2018). Attention deficit hyperactivity disorder: Diagnosis and management. London: NICE. Retrieved 8 August 2019 from nice.org.uk/guidance/ng87. Thapar, A., Cooper, M., Eyre, O., & Langley, K. (2013). Practitioner review: What have we learnt about the causes of ADHD? Journal of Child Psychology and Psychiatry, 54(1), 3-16. doi: 10.1111/j.1469-7610.2012.02611.x. Van Steijn, D. J., Oerlemans, A. M., Van Aken, M. A., Buitelaar, J. K., & Rommelse, N. N. (2014). The reciprocal relationship of ASD, ADHD, depressive symptoms and stress in parents of children with ASD and/or ADHD. Journal of Autism and Dvelopmental Disorders, 44(5), 1064-1076. Zablotsky, B., Bramlett, M. D., & Blumberg, S. J. (2017). The Co-Occurrence of Autism Spectrum Disorder in Children With ADHD. Journal of Attention Disorders, 1087054717713638. ADHD links: https://kidshealth.org/en/teens/adhd.html https://raisingchildren.net.au/for-professionals/mental-health-resources/adhd-ocd-odd Autism and ADHD support: https://www.adhdsupportaustralia.com.au/adhd-listings/autism-community-network/ Support networks for ADHD: http://www.parentsforadhdadvocacy.com.au NSW: http://www.adhdsupportaustralia.com.au/ www.macquarieadhd.org.au www.adultadhd.org.au ACT: www.addact.org.au WA: www.adhdwa.org VIC: www.adhdsupport.org.au QLD: https://www.meetup.com/Brisbane-ADHD-Meetup/ For more information, head over to Aspect Australia - www.autismspectrum.org.au. Disclaimer: I'm not a professional, just a student with a passion for autism.

Age-Friendly Health Systems: History and Overview "Age-friendly Health Systems create a system of care where there's good communication, good leadership, and information systems that track across (care settings)."— Alice Bonner, PhD, RN With nine years to go before the last Baby Boomers reach age 65, our nation is on a short timeline to develop the infrastructure needed to provide quality care for older adults in our hospitals and health care systems.  With that vision in mind, a system of "age-friendly environments" is emerging from the collaborative efforts between the John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA). The first podcast interview for This is Getting Old: Moving Towards an Age-Friendly World was with Dr. Terry Fulmer who has led development of the Age-Friendly Health Systems initiative (Episode 3). Building on that interview, in this episode, Dr. Alice Bonner shares the history and an overview of the Age-Friendly Health Systems. The goal of the age-friendly health system is to guide development of an infastructure required for hospitals and health systems to deliver evidence-based care for all - not just for older adults. Discover how the system empowers all health care settings to implement the 4M’s Framework to facilitate care for older adults. Part One of 'Age-Friendly Health Systems: Evidence-Based Care for All Older Adults'  Age-Friendly Health Systems: A History And Overview The Age-Friendly Health Systems: Evidence-Based Care for All Older Adults offers healthcare systems opportunities to help older adults residing within them. The model further emphasizes that societies must strive to counter age-based stigma, referred to as ageism, towards elderlies. This is to encourage independence for older people and to implement strategies that promote healthy aging. The idea came about from several organizations and individuals who look at the current health system, the current system of communities and public health, and how healthcare facilities are run.  They brought together expert clinicians, researchers, and people who spent their lives working with older adults. They started doing a big review of the literature and combed through several references. They've found that there are 90 elements of care guided explicitly toward older people's best care. They did lots of brainstorming, had meetings, and repeatedly went over the literature until they got down from 90 elements to 13 elements. Then everybody said, "13 things are just too many things to ask nurses and doctors and social workers to do". So they got together in a room and didn't come out until they had called it down to four elements, and those four elements all start with the letter M. What Matters? Medications, Mobility, and Mentation. "Age-friendly health systems allow people to customize; it promotes leadership; it requires leadership. And not just a medical director, but nursing leadership, social work, leadership, pharmacy leadership. It's about the interprofessional team."- Alice Bonner, PhD, RN  Age-Friendly Care – 4Ms Framework The 4M's are the core practices that clinicians believed to make a difference in administering care. Alice emphasized that health systems should implement these 4Ms accurately. According to her, "By addressing these 4Ms, we're talking about assessing people and then acting on those assessments. It isn't enough to do an assessment and put a piece of paper in the chart. What you want to do is say, "Okay, how can we act on this?" The Age-Friendly Care Systems 4Ms frameworks evolve on the following concepts:   What Matters   Know and align care with each older adult's specific health outcome goals and care preferences, including end-of-life care and across settings of care.    Medication   If medication is necessary, use age-friendly medication that does not interfere with What Matters to the older adult, mobility, or mentation across the setting of care.   Mentation   Prevent, identify, treat, and manage dementia, depression, and delirium across care settings.   Mobility   Ensure that older adults move safely every day to maintain function and do What Matters. Part Two of ''Age-Friendly Health Systems: Evidence-Based Care for All Older Adults’  The Principles Behind Age-Friendly Health System   Alice further stressed that most people are not thinking about ageism and includes stereotyped beliefs that discriminate against older adults. It’s not widely recognized, until it happens to you or someone you love.  Age-friendly systems look at how workers at health systems speak, the language they use, the references they make, and how they handle ageism and get rid of it. The Frameworks Institute has several resources and reports to help you learn more about how to effectively counter ageism. That is the primary reason why the forerunners of the 4Ms framework of the age-friendly systems anchored the system on the following principles. The 4Ms are set to be integrated into care for every adult ages 65 and older during every inpatient stay for over a year in a primary care setting.   Age-Friendly Health Systems and the 4Ms are a framework to organize the efficient, reliable delivery of effective care with older adults.  The framework is intended to be an infrastructure that builds on the care you provide today.  Age-Friendly Health Systems are designed to close the gap between the evidence-based care that we know works and the reliable practice of that care with every older adult in every interaction. "We started with five health systems. We're now at over a thousand health systems across the country, which is pretty miraculous for a three or four-year project. And the goal is to make it not just a project but to make it sustainable in the way we deliver care everywhere, all the time, every day." — Alice Bonner, PhD, RN Why Should Health Systems Implement The 4Ms Framework? As of December 2020, over 1,000 hospitals, outpatient practices, retail-clinics, and post-acute long-term care communities have been recognized as working to become Age-Friendly Health Systems. Having described a detailed 4Ms approach in their setting, 178 of these have been identified as Committed to Care Excellence as exemplar sites working toward the 4Ms reliable practice. What Are Participants Saying? There's always measurement involved in being recognized as an age-friendly health system. You or your organization can participate by signing up and joining an active community.  Here are what some of the participants are saying about 4M's Framework of the Age-friendly System.  "My hospital joined the movement and was recognized as an Age-Friendly Health System Participant after sharing with IHI how we are putting the 4Ms into practice. I'm going to encourage my doctor's office to join, too. " "IHI recognized us as leaders in the movement, and as an Age-Friendly Health System Committed to Care Excellence when we shared three months of data on the number of older adults, we cared for with the 4Ms." About Melissa Batchelor, PhD, RN, FNP, FAAN: I earned my Bachelor of Science in Nursing ('96'96) and Master of Science in Nursing ('00'00) as a Family Nurse Practitioner (FNP) from the University of North Carolina Wilmington (UNCW) School of Nursing (SON). I genuinely enjoy working with the complex medical needs of older adults. I worked full-time for five years as FNP in geriatric primary care across many long-term care settings (skilled nursing homes, assisted living, home, and office visits), then transitioned into academic nursing in 2005, joining the faculty at UNCW SON as a lecturer. I obtained my PhD in Nursing and a post master's Certificate in Nursing Education from the Medical University of South Carolina College of Nursing ('11'11) and then joined the Duke University School of Nursing faculty as an Assistant Professor. My family moved to northern Virginia in 2015 and led to me joining the faculty at George Washington University (GW) School of Nursing in 2018 as a (tenured) Associate Professor. I am also the Director of the GW Center for Aging, Health, and Humanities. Find out more about her work at https://melissabphd.com/.

In this episode Dr Jonathan Bardgett and Dr Francesca Moroni discuss the importance of recognising and treating malnutrition in the acutely ill patient. This podcast offers practical advice on assessing malnourished patients and provides an overview on available interventions from simple dietary adjustments to artificial feeding. Particular interest is posed on recognising patient at risk of refeeding syndrome and how to prevent it. A multidisciplinary approach to the malnourished patient is key in the successful management of malnutrition with specific focus on the fundamental role of the dieticians. Dr Moroni touches upon different tubes and feed modalities and practical advice on managing high NG aspirates. A brief mention on parenteral nutrition can stimulate the listener to read more about it. The extreme malnutrition scenario is offered by patients with anorexia nervosa who require admission in acute medicine. These patients should be treated with extreme caution and involvement of gastroenterologist, dietician and psychiatrist should be priority. MUST Tool: https://www.bapen.org.uk/screening-and-must/must/introducing-must Reefeeding risks: National Institute for Health and Care Excellence. Nutrition support in adults. Clinical guideline 32: https://www.nice.org.uk/guidance/CG32 Moroni F, Metcalfe E, McKinlay A. Assessing the nutritional status of an acutely ill patient. BMJ 2017; 357 doi: https://doi.org/10.1136/sbmj.j1448 (Published 31 May 2017) MARSIPAN Guidelines: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr189.pdf

In this podcast, James Cave (Editor-in-Chief) and David Phizackerley (Deputy Editor) preview the November issue of DTB. This includes an editorial that focuses on the National Institute of Health and Care Excellence's draft guideline on the management of chronic pain, and in particular, the approach to treating chronic primary pain (https://dtb.bmj.com/content/58/11/162). The editors talk about a new patient-held steroid emergency card that has been introduced to help healthcare staff identify adult patients with adrenal insufficiency (https://dtb.bmj.com/content/58/11/163). They also discuss the diagnosis and treatment of orthostatic hypotension. This month's case report involves a patient who developed medication-related osteonecrosis (MRONJ) of the mandible and maxilla (https://dtb.bmj.com/content/58/11/172). Please subscribe to the DTB podcast to get episodes automatically downloaded to your mobile device and computer. Also, please consider leaving us a review or a comment on the DTB Podcast iTunes podcast page (https://podcasts.apple.com/gb/podcast/dtb-podcast/id307773309). Thank you for listening. Go well and stay well.

In this episode Professor Tammy Hoffmann talks about research into the natural history of uncomplicated urinary tract infections that could have a big impact on conversations with women and treatment with antibiotics. She is a professor of Clinical Epidemiology and leads the Centre for Evidence-Informed Health Decisions in the Institute of Evidence-Based Healthcare, Bond University. Natural history of uncomplicated urinary tract infection without antibiotics: a systematic review Read the paper: https://doi.org/10.3399/bjgp20X712781 (https://doi.org/10.3399/bjgp20X712781) Uncomplicated urinary tract infections (UTIs) are a very common reason for general practice consultations and one of the most common reasons for the prescription of antibiotics. Informed decision making should consider the benefit/harm trade-off of antibiotic use and the natural course of the illness. The studies reviewed in this paper, which focused solely on women, demonstrated that UTI symptoms resolve spontaneously in approximately a third of women in the first 7–10 days. Current guideline recommendations from the National Institute for Health and Care Excellence are to delay prescribing by two days but the findings of this systematic review indicate that this may be too short a timeframe.

Graham Parsons is the Chief Pharmacist at Turning Point. He is a pharmacist with a wide range of experience in many aspects of pharmacy. As a specialist in Substance Misuse he has worked at both local, regional and national level (through the Advisory Council on the Misuse of Drugs, National Institute of Health and Care Excellence and Turning Point) to deliver a wide range of initiatives and policies which have impacted on both substance misuse services and the lives of individuals affected by substance use disorders. This has included over six years as a prescriber within the Plymouth Specialist Addiction Service. During this time he has also developed an interest in Mental Health and Pain and the management of these conditions in this cohort of patients. He has also delivered a number of training sessions covering a diverse range of topics from substance misuse to Controlled Drug legislation for a number of institutes including the University of Bath and the Royal College of General Practitioners and developed Post Graduate addiction courses for Medway University. I am an experienced public speaker who has presented at many events including the College of Mental Health Pharmacy International Conference and on local BBC radio. In the written media I have produced a number of articles on substance misuse and its treatment for the Pharmaceutical Journal. We had a wide-ranging discussion about the issues of the day in the area of substance misuse. There has been a move towards the use of Buvidal slow-release injection. Have you got any thoughts on this move especially in light of the current pandemic? What is the future of substance misuse services delivered through community pharmacy? What is the role of naloxone in community pharmacy? How can community pharmacy support alcohol brief interventions? Why are drug deaths still so high? How is polypharmacy relevant to the area of polypharmacy? Has nudge theory got a role in tackling the alcohol crisis in this country?

Bom dia, boa tarde, boa noite! Esse é mais um podcast do Medicina do Conhecimento. Ciência e informação a qualquer momento, em todo lugar. Eu sou Pablo Gusman, o Anestesiador. E como compartilhar é multiplicar segue uma dica sobre a reposição volêmica e fluidoterapia em pacientes adultos hospitalizados. Revisado em 2017, o guideline do NICE – National Institute for Health and Care Excellence que fala da fluidoterapia intravenosa para pacientes adultos hospitalizados abrange 5 princípios, ou 5 R’s. Resuscitation – Ressuscitação: pode ser necessária uma ressuscitação urgente de fluidos após hemorragia, infecção, trauma ou queimaduras. Se os pacientes precisarem de ressuscitação com fluidos intravenosos, use cristalóides que contenham sódio na faixa de 130 a 154 mmol / l, onde temos soluções de ringer próximo de 130, soluções salinas 0,9% com valores próximos de 154 e solução cristaloide fisiologicamente balanceada com valores próximos do plasma, 140 mmol/l em bolus de 500 ml por menos de 15 minutos. Não está indicado o uso de soluções colóides de tetrastarch para essa ressuscitaçao hídrica. Routine maintenance – a manutenção de rotina do balanço hídrico pode ser necessária, por exemplo, em pacientes que são incapazes de atender às suas necessidades hídricas por via oral ou enteral, mas que, de outra forma, estão bem em termos de equilíbrio e manuseio de líquidos e eletrólitos. Isso inclui pacientes que sofreram um acidentes vasculares cerebrais com disfasia, pacientes jejum antes de cirurgias e pacientes com quadros obstrutivos. O objetivo principal é recuperar a capacidade de atender suas necessidades via oral ou enteral, interrompendo a manutenção venosa o mais rápido possível. Redistribution – Redistribuição: a fluidoterapia IV de caráter urgente pode ser necessária para fins de redistribuição em pacientes com distúrbios sistêmicos que afetam a distribuição de líquidos, como sepse e anafilaxia. Na sepse, a resposta inflamatória causa vasodilatação e vazamento de líquido dos capilares e, portanto, causa um aumento no espaço vascular que pode levar à hipovolemia e choque. Replacement: Substituição - substituição venosa de fluidos pode ser necessária para tratar déficits existentes ou perdas externas em andamento, geralmente dos tratos gastrointestinal ou urinário; por exemplo, em pacientes com gastroenterite ou cetoacidose diabética. Reassessment – Reavaliação – frequente reavaliação da resposta dos pacientes e necessidade contínua a fluidoterapia intravenosa é essencial. Mas para esse tema, vamos em breve falar um pouco sobre monitorização não invasiva de fluido responsividade. É importante lembrar que os cristalóides são bem diferentes com composições próprias quanto aos seus eletrólitos, pH e osmolaridade e com isso repercussões específicas. Isso pode fazer muita diferença nos doentes mais graves e responsivos a fluidos. E com a idéia de assertividade, devemos oferecer para o paciente aquilo que ele realmente precisa. Acesse o estudo na íntegra pelo link https://www.nice.org.uk/guidance/cg174/chapter/1-Recommendations#resuscitation-2 Escute a rádio web Medicina do Conhecimento www.medicinaconhecimento.com.br Escolha sua plataforma e ouça mais podcasts. Siga pelo Spotify, Deezer, Itunes, Google Podcasts, Soundcloud, Youtube e mais uma dezena de agregadores de podcast. Na medicina do conhecimento, você escolhe o player da sua preferência. É muito importante seu feedback. Compartilhe nas suas redes e deixe seu like. Isso aumenta a divulgação do projeto. Além disso, você pode entrar em contato conosco e sugerir o próximo tema! Fique ligado nas redes sociais Twitter, Facebook e Instagram Medicina do Conhecimento, afinal compartilhar é multiplicar!

Back in November 2018, parents of children with epilepsy in the UK who'd been fighting to get legal access to medical cannabis were celebrating the prospect of finally getting the medicine they needed.Over eighteen months later, thanks to some extremely restrictive guidelines from NICE (National Institute for Health and Care Excellence), very few children have received a prescription through the NHS. Charlie Hughes, who will be three in July is one of these children. Resistant to all anti-epilepsy medication, Charlie's seizures were totally out of control, numbering up to 120 a day. In desperation, Charlie's parents turned to medical cannabis, following the success stories of children like Alfie Dingley who'd found seizure control from medical cannabis products containing CBD and small amounts of THC. A year on from starting with a CBD rich cannabis oil with THC (with a private prescription), Charlie's seizures have reduced by 85% and his cognitive development has also improved. However, this treatment, the only one that has successfully controlled Charlie's seizures, cannot be funded through the NHS who state a lack of evidence and safety concerns related to presence of THC in his medicine. So, dad Matt, is taking his local NHS trust and NICE to the high court for a judicial review, hoping that by shining a light on the inconsistencies and unnecessary rigidity, a shift will result allowing for Charlie and the other children like him in the UK to have their medical cannabis treatment funded by the NHS. ResourcesCharlie's crowd funding pageEnd Our Pain Support the show (https://www.paypal.com/paypalme/marybiles71)

This week on MIA Radio we chat with Professor John Read of the University of East London. John worked for nearly 20 years as a Clinical Psychologist and manager of mental health services in the UK and the USA, before joining the University of Auckland, New Zealand, in 1994, where he worked until 2013. He has published over 140 papers in research journals, primarily on the relationship between adverse life events (e.g. child abuse/neglect, poverty, etc.) and psychosis. He also researches the negative effects of biogenetic causal explanations on prejudice, the opinions, and experiences of recipients of antipsychotic and antidepressant medication, and the role of the pharmaceutical industry in mental health research and practice. John joins us to discuss the UK licensing of esketamine nasal spray (Spravato) for so-called ‘Treatment Resistant Depression’. John led a group of 12 academics and professionals who wrote to the UK regulator expressing concerns about esketamine. We Discuss: Concerns about the basic concept of using derivatives of hallucinogenic, addictive street drugs to address complex human problems. The particular details of the clinical trials that raise concerns about treatment with esketamine. How the US Food and Drug Administration approved Spravato in January 2019 and the European Medicines Agency recommended that member states approve it on October 17, 2019, giving 67 days for member states to comment. That the Medicines and Healthcare products Regulatory Agency approved esketamine for UK use. That there have been no trials of the efficacy of esketamine in the medium or long term, with most trials being only four weeks duration. That only one of the trials found a benefit for esketamine over placebo, yet this was deemed sufficient for licensing by the USA’s FDA. That there were deaths and suicides recorded during the esketamine clinical trials. The relationship between the drug regulators and funding from the pharmaceutical manufacturers. How there was no response from the MHRA to the concerns raised by John’s group. In addition, no reply was made to concerns raised by Sir Oliver Letwin writing on behalf of the All Party Parliamentary Group on Prescribed Drug Dependence as well as letters from independent researchers from Kings College London and a group of service users. A recent response to the approval by the UK National Institute for Health and Care Excellence. A response to the NICE announcement from the Science Media Centre.

Áine Ní Tighearnaigh In Conversation with Professor Sotiris Vardoularkis, Professor of Global Environmental Health at the ANU National Centre for Epidemiology and Population Health. – Climate Change, the Canberra Air Quality Crisis and the Impact of Vulnerable Communities. We discuss climate change, the impact on vulnerable communities, the elderly, people with mental illness, the current Canberra Air Quality Crisis and the short and long-term impacts of bushfire smoke on health and mental well-being. Professor Vardoulakis also provides guidance on what measures we need to take individually, as a community and as a nation to address climate change into the future. "Sotiris is founding co-chair of the International Consortium for Urban Environmental Health and Sustainability (Healthy-Polis) and Honorary Professor at the European Centre for Environment and Human Health at University of Exeter Medical School. Previously he was Head of the Environmental Change Department at Public Health England and held academic positions at the London School of Hygiene and Tropical Medicine and the University of Birmingham. He was one of the lead authors of the first UK Climate Change Risk Assessment and contributor to the National Adaptation Programme. He served as a member of the NICE (National Institute for Health and Care Excellence, UK) Public Health Advisory Committee on Air Pollution. Over the last 20 years, he has advised national and local governments and international organizations, such as the World Health Organization and the European Parliament, on the health effects of climate change and air pollution, and on environmental sustainability and urban health. Sotiris has been involved in numerous research projects, including field studies, environmental modelling, risk assessment and policy analysis in Europe, Africa, Asia, Australia and the Pacific".

Sarah Garner is the Acting Programme Manager of Health Products and Pharmaceuticals of the WHO Euro, and is the former Associate Director for Scientific Policy and Research at the UK’s National Institute for Health and Care Excellence. She is a visionary seeking new approaches to improve innovation, access, and outcomes in healthcare, and has a nuanced view of the financial realities of R&D and the challenges of our national healthcare systems. In this podcast, Sarah discusses the need to support the evaluation of medicines for countries on the periphery of EMEA, as well as the role science and innovation are playing in personalised medicines, and orphan indications. We also discuss the WHO’s interest in using its convening power to discuss strategies to overcome barriers to access to high value medicines.

We have all probably heard or read about how antidepressants can cause sexual dysfunction such as decreased libido, erectile dysfunction, decreased response to sexual stimuli, and delayed or absent orgasm. Given how widespread the use of antidepressants are, you may have personal experience with an antidepressant affecting your sexual function. What you may not know is that research consistently finds that sexual dysfunction continues in the majority of people even after they stop taking the medication. This is known as Post SSRI Sexual Dysfunction, or PSSD.  Less frequently, another form of sexual dysfunction may continue to manifest even after discontinuation of the medication: Persistent Genital Arousal Disorder (PGAD). This is essentially the opposite of PSSD, with PGAD causing a relentless sense of arousal and discomfort in the genitals, but without any accompanying feeling of desire.  So this is what can happen to adults. What happens when children are given antidepressants, right through their puberty? How does it affect their sexual function? In this episode I interview Daryl Brown about his experience with the mental health care system when he started to be medicated with antidepressants when he was 9 years old - even though he wasn’t depressed - and medicated with antipsychotics, even though he wasn’t having psychosis.  Daryl shares how it has affected his sexual function, and by extension his sense of self and his intimate relationships. Daryl asks the tough questions of the medical system: How could he, a mere child, have been given multiple medications - for over a decade - that provided no benefit, only harm? And how is that doctors continue to deny antidepressants can cause sexual dysfunction after they have been discontinued, in spite of research and patient reports confirming the harm? SHOW NOTES OCD and Tourette's syndrome 0:07:15 Daryl grew up in a suburb of London (United Kingdom) with 2 good parents, they are not together, but lucky to have them - a mix of nature and the city - 2 older siblings, 1 younger sibling 0:08:15 But missed a lot of family time due to mental health issues and hospitals - and his behaviour changed on the psychiatric drugs - and he went to special needs school far away - Daryl had some movement disorder and phobias since he was a baby 0:09:15 His brother noticed Daryl had strange movements as a baby and told others that Daryl had Tourette's Syndrome before he was diagnosed - Daryl got much sicker when he was about 9 years old, his OCD (obsessive compulsive disorder) and Tourette's got disabling worse 0:10:15 Daryl OCD caused him to spin around, and do repetitive rituals in a particular way - if it didn't feel like it went right, he would have to start the ritual over again - when it got really bad it was life consuming - he lost a lot of sleep worrying - a common feature 0:11:15 OCD symptoms was frustrating for Daryl, when it got out of control - Tourette's manifested has a lot of arm movements, leg movements, constantly parts of his body moving, even if people couldn't see what was happening with his toes and fingers, known has motor tics - Daryl also had a vocal tic of clearing his throat and making a weird noise 0:13:15 When Daryl's OCD and Tourette's got really bad, it was hard to live with the symptoms, but when mild they felt like a normal part of Daryl's life - for Daryl, only when its a the extremes does is it bothersome, and that may sound strange to some people - it doesn't interfere too much 0:14:15 Daryl remembers that his school was pushed around his phobias - other kids were yelled at, Daryl was yelled at when he coloured outside the lines - he was constantly being punished and he got scared at the way the other children were shouted at as well - they pushed him really hard about his phobias, and he tried really hard to break through and he did, but it was very hard - it all became very stressful and made everything a lot worse - at one point he ran away from school 0:15:15 The OCD and Tourette's was interfering with Daryl's ability to get dressed for school and it was all a stress on his Mom as she had to go to work - as Daryl got sicker, she called the local GP and child psychiatrist and they started prescribing medications - Daryl was only 9 years old 0:16:15 The child psychiatrist was convinced Daryl had OCD and brought an orange sugary liquid for Daryl to drink - it glowed in the dark - turns out the orange drink contained an SSRI (selective serotonin reuptake inhibitor - an anti depressant) - though Daryl didn't have depression - NICE (the UK's National Institute for Health and Care Excellence) guidelines said antidepressants are the standard treatment for OCD Antidepressants and antipsychotics 0:18:15 Daryl doesn't remember the effects of it, other than it tasted good because of the sugar and it had a cool colour - but it had no effect on his symptoms - because he was so sick he missed some school, so they visited a children's mental hospital 0:19:15 They said he needed to come in straight away - it was a diagnostic hospital, so children would be there for a year, there would be cameras watching them, and meeting with psychiatrists and psychologists and everyone in between - there was also a school so Daryl got some form of education - they put Daryl on anti-psychotic medications for the Tourette's Syndrome, also according to NICE guidelines - even though Daryl didn't have psychosis - so they are giving him both antidepressants and antipsychotics 0:20:15 The antipsychotics had no positive effect on his Tourette's, they just made his movements even more tiring on his body and upsetting - after a few months, his symptoms died down a little bit because some normality to his environment had returned and he was around other children - not because of the medications 0:21:15 Daryl's body also got used to the mixture medications, so he started to feel less tired - but he put on a lot of weight, when historically he was impossible for him to gain excess weight - Daryl also started to experience cravings, but he didn't feel in control of his actions and his emotions were all over the place, which is not like Daryl - crying one minute, angry the next, arguing with everyone, but didn't know why he was arguing but couldn't stop himself 0:22:15 It was frightening and confusing - after 9 months they confirmed diagnosis of OCD and Tourette's Syndrome - Daryl was recommended to go to a special needs school, but it was the middle of the school year and it was a nightmare to find a school - they did find one very far away, but that meant Daryl was not part of his home community 0:23:15 Daryl also continued treatment in a center that specialized in OCD and Tourette's in children and adolescents in south London - but that was also very far from where Daryl lived, so he had to go to that center and then school, and it was too much traveling and stress - and Daryl wouldn't say there was any real treatment - they expected Daryl to continue to take the antidepressants and antipsychotics, there was no plan to come off of them - it was expected that Daryl take them, no questions asked 0:24:15 Living away and going to another school was hard - if Daryl was strange to the other children in the community before, he was a lot more strange when he was removed - he would get teased in the street, and that got worse 0:25:15 Daryl really missed out on any thing in the community and didn't have a social life or a normal childhood - he was a normal intelligent child and wanted to do what every body else was doing - he did get to go home on weekends - the treatment center maybe helped with some of the phobias Daryl had Seizures. Brain Tumour? 0:26:15 Daryl stopped going to the after school day center after about 2 years - but there was no plan to stop the medication - sometimes there were promises that maybe one day in the future if their treatment miraculously works, he might be able to stop the meds - but there was no realistic plan to stop them, even when he stopped going 0:27:15 Daryl continued on the medication until he was living on his own and was 21 years old - Daryl had some seizures and passed out a couple of times - he didn't know yet it was from the medications - Daryl just attributed the new symptoms to OCD and Tourette's 0:28:15 Even though it was a special needs school, Daryl joined the football (soccer to North Americans) team and started to lose the excess weight - but it was hard to run, he was wheezing, because of the medications - but it was good to play football for the short periods he could - because the meds changed Daryl's behaviour so much, he was always arguing and he wasn't the same person - their only explanation was that Daryl had mental illness - as a result, Daryl lost contact and relationships with his siblings 0:29:15 The medications also blunted Daryl's impulsivity - he ran into traffic once - Daryl knows that he did not think that way before the meds, or since he stopped the meds - another time he took all his meds at once, not to kill himself, but because he couldn't stop the impulse 0:30:15 When Daryl was 21 years old he got very, very sick - and his erections stopped working properly - his penis wouldn't respond as it previously had with women - nor was he having the spontaneous erections like other young men 0:31:15 That was very scary - Daryl looked at the leaflets for the medications and saw sexual dysfunction far down the list - he went to the psychiatrist and he said it was probably the medications, we know about this, go off the medications and every thing will go back to normal - he just had to get a blood test to check on things - the results showed that Daryl's prolactin was through the roof - and wouldn't go down for a long time and they said that was impossible, 'nobody's prolactin stays that high' 0:32:15 They thought maybe it was a brain tumour causing high prolactin, but didn't really elaborate and left Daryl thinking he may have a brain tumour and wondering how long he has to live - but it wasn't a brain tumour, his prolactin levels normalized but his thyroid was messed up - eventually his blood tests normalized but the symptoms didn't go away and his 'willy' never went back to normal - the doctors kept fobbing him off, 'sometimes it takes a couple of weeks' - 'sometimes a couple of months' - then they said it was impossible because the drug had completely left his system and it had nothing to do with them Withdrawal weirdness 0:33:15 Then they started to say it was caused by a mental illness - the withdrawal actually caused a weird psychosis, deluded and confused thinking and weird adrenaline, all sorts of symptoms like brain zaps, even to his genitals when they were over-sensitized during withdrawal, like when he ejaculated when he was shopping, it is known as PGAD - Persistent General Arousal Disorder - and this is known to happen temporarily during withdrawal - but at 21 Daryl knew this was not normal 0:34:15 But the doctors and psychiatrists didn't believe in that, but Daryl knew full well what was going on and wondered how little did they know? - he looked up on the internet the medications he was on - they had added another med, Lyrica, to his antidepressant and antipsychotic, and the doctors touted how is was a 'wonder drug' and 'amazing' 0:35:15 Who knows how many other people they've given it to - its classified as a class 3 drug now, a street drug - Daryl never had an apology for that either - so he had to withdraw from all of those meds - they don't know how these meds work, even the drug companies don't know how or why - Daryl felt fear realizing for the 1st time how little these psychiatrists and psychologists really knew 0:36:15 The anxiety caused by withdrawal was a lot to deal with - also brain zaps, a full body 'electric shock sensations' during withdrawal as described in the NICE guidelines - Daryl started by tapering off the medications by cutting up the pills, but at 21 and his dick not working, and realizing the so-called experts didn't know much, was very scary and he wasn't going to keep taking them - he completely stopped taking them after about 4 weeks because they were making his dick numb and not work 0:38:15 Daryl wanted to know who did this to him and why - he felt targeted in that they were giving a child with disabilities medications that they did not know how it would affect him, its really abusive and he didn't feel like he was safe - and it is very lucrative for these pharmaceutical industries and in reality it is very dangerous and nobody stepped in any where 0:39:15 When Daryl was off the medications, there was no change in his OCD or Tourette's symptoms - there was no need to take these substances - Daryl says you would think they would have questioned that 0:40:15 Daryl advocates for safety measures to be taken and joined the Everyday Psych Victims Project and he's interviewed a few people who've been through the mental health system to give them and himself a voice - there is a 'side effect' charity with some psychiatrists and psychopharmacologists that know about this and have read the research, they're called Rxisk http://www.rxisk.org/ - and they are very aware of the permanent sexual side effects of antidepressants Brain Zaps and a Marathon 0:41:15 Both SSRIs and SNRIs - they've started a campaign to raise money and awareness - so Daryl signed up for a marathon to raise money and awareness for them - but it is hard to ask people to give money because your dick doesn't work - and it is not a mainstream charity, and some people won't donate for that reason - but Daryl followed through and did the marathon even though he missed all the training due to injury, but managed to finish somehow 0:42:15 Daryl has always liked sport, football, exercise - during withdrawal needed to distract from the horrible physical symptoms, and one of the ways to deal with that was to go for a run - doing sprints especially helped to manage his adrenaline - however, it felt like his life plans had been thrown out the window and he was very upset about what had been done to his genitals 0:43:15 But it doesn't just affect his genitals, it affected everything, how he felt and related to the world, especially at that age - so he focused on sport as a distraction, and that gave him some experience for the marathon, but he only played football twice about 2 weeks before the marathon - he ran until about half way then started walking and the last 10 kms was painful and a 6 hour finish time 0:44:15 Daryl tried to train through the injury as much as he could, but it came to a point where he was doing more damage - but he was determined to show up at the start line 0:45:15 He thought he would walk it, but when you line up at the start line you run with everyone else and he just tried to keep going - the music, crowds and kids cheering so he kept going as far as he could 0:46:15 With the brain zaps, his dick not working properly, or ejaculating sporadically, and pain in stomach - and that has not gone away, there is not a day that he is not constipated - Daryl had been medicated for over a decade, all through puberty 0:47:15 It impacted his emotions, angry one minute, sad the next, hyper the next - impeded his ability to think - he had to untangle his delusions and illusions - the adrenaline and emotions were all over the place and exercise even those out a bit - Daryl will turn 30 soon 0:48:15 In his early 20s it was extremely difficult to socialize, he felt like an alien, and he didn't want to do those things like flirting - it was horrible to be the only one in the world in that situation0:49:15He didn't think he'd ever socialize again, he wondered what planet he was living on - there is less pressure now to be flirtatious, so its a little easier - but he still often feels terrible when he compares himself to other people - so it still affects him a lot, but less so Post SSRI Sexual Dysfunction 0:50:15 Daryl still has quite a lot of pain, the stomach pain can be quite nasty - he does part-time work and volunteering, but the social part of his life is always missing - he has a leg injury from 2 years ago and still no diagnosis and he's limping very badly, he barely made it down stairs this morning, and this is after having hip surgery - there is talk of a hip replacement and pain killers but not sure what will happen with that 0:51:15 His hip and leg problems could be due to pressure from his bowels, he doesn't really know - and there has not been much research on side effects of psychiatric drugs - and he's been put off seeing doctors 0:52:15 Daryl likes watching football, but would rather be playing - he likes writing songs on his guitar and going for a jog - so exercise is a big part of self care and he's not sure what he'll do if his leg doesn't get better - though it hurts a lot to play guitar 0:53:15 Daryl has a couple of good friends that he could tell what has happened to him and they still liked him as a human being and that helped a lot because he felt he wasn't interested in flirting any more - some people thought he was going through a strange weird period, or was dealing with trauma, and that pushed people away as well 0:54:15 Daryl was wary to be public about his experience, set up a website and did a couple of videos, and started telling people in his life as well, to share his experience 0:55:15 There was no outpatient groups for adults, and they weren't allowed to socialize with other patients outside the hospital or clinics - one of their concerns is they don't want patients to meet, and they don't want patients to talk about their experiences with medications - Daryl thought he was the only one having this side effect and was on his own, and wasn't allowed to talk to the others to see if they also had this side effect - it is called Post SSRI Sexual Dysfunction (PSSD) 0:56:15 It means that the sexual side effects of SSRIs continue even after you stop taking them - he discovered others on the internet and that's when he decided to do something about it, since keeping it a secret wasn't working so well - it felt good to know there was other people, and that he was doing something about it - he also found other people that had bad experiences in the mental health system as well like Speak Out Against Psychiatry, Friends of East London Loonies, and The Every Day Psych Project 0:57:15 Daryl doesn't want this to happen to any one else, and the lack of regulation - it is criminal except they've got themselves covered legally - there is no reason except bank balances and careers that are set up on misinformation and secrecy and it needs to stop - and Daryl deserves validation that itactually happened instead of living his whole life with some imaginary thing that isn't happening Doctor Denial of PSSD 0:58:15 When he was a child, being around other children also going through similar experiences was good, but the drugs were not necessary 0:59:15 The school could have been more accommodating to a child instead of being so aggressive when that child wasn't exactly how they wanted them to be - but the staff were nice - he was scared before going in that the staff would be in white coats and do weird experiments on him, which they did, but not that they were collecting the data on their experiments - the staff were nice and well meaning, but obviously somebody should have intervened and stopped them from drugging every one into oblivion 1:00:15 His relationships now with his parents is good, but its taken a chunk out his life - when Daryl told his Dad about PSSD, his father said he was worried this would happen - his Mom was upset to, she was lied to and told the meds were safe - but the doctors insist that there can't be any permanent harm once the meds are out of the system - there is no risk, 'there's nothing to lose' as they say 1:01:15 They try to convince any one in his life that Daryl is mad and its not real - and they tried to turn his family against him and not to believe him - so its obviously very upsetting to go through - when Daryl was going through withdrawal he was paranoid so it was difficult to speak to his Mom and Dad - and he missed out a lot of life with his siblings 1:02:15 Daryl feels like his OCD and Tourette's symptoms are part of him, and they are not always at their worse - so its not the worse thing in the world - Daryl has hunch, in listening to other parents, that vaccines as babies may be causing tics and stuff - but there is a lack of research on vaccinations as well Connect with Daryl Brown: Twitter: @RunAgainstCastr Daryl's blog: PSSDblog Daryl's marathon campaign Info about Post-SSRI Sexual Dysfunction: Rxisk The Everyday Psych Victims Project - Their YouTube and Twitter __________________________________________________________________________ Be a podcast patron Support Medical Error Interviews on Patreon by becoming a Patron for $2 / month for audio versions.  Premium Patrons get access to video versions of podcasts for $5 / month. Be my Guest I am always looking for guests to share their medical error experiences so we help bring awareness and make patients safer. If you are a survivor, a victim’s surviving family member, a health care worker, advocate, researcher or policy maker and you would like to share your experiences, please send me an email with a brief description:  RemediesPodcast@gmail.com  Need a Counsellor? Like me, many of my clients at Remedies Counseling have experienced the often devastating effects of medical error. If you need a counsellor for your experience with medical error, or living with a chronic illness(es), I offer online video counseling appointments. **For my health and life balance, I limit my number of counseling clients.**  Email me to learn more or book an appointment:  RemediesOnlineCounseling@gmail.com Scott Simpson: Counsellor + Patient Advocate + (former) Triathlete I am a counsellor, patient advocate, and - before I became sick and disabled - a passionate triathlete. Work hard. Train hard. Rest hard. I have been living with HIV since 1998. I was the first person living with HIV to compete at the triathlon world championships.Thanks to research and access to medications, HIV is not a problem in my life. I have been living with ME (myalgic encephalomyelitis) since 2012, and thanks in part to medical error, it is a big problem in my life. Counseling / Research I first became aware of the ubiquitousness of medical error during a decade of community based research working with the HIV Prevention Lab at Ryerson University, where I co-authored two research papers on a counseling intervention for people living with HIV, here and here.  Patient participants would often report varying degrees of medical neglect, error and harms as part of their counseling sessions. Patient Advocacy I am co-founder of the ME patient advocacy non-profit Millions Missing Canada, and on the Executive Committee of the Interdisciplinary Canadian Collaborative Myalgic Encephalomyelitis Research Network. I am also a patient advisor for Health Quality Ontario’s Patient and Family Advisory Council, and member of Patients for Patient Safety Canada. Medical Error Interviews podcast and vidcast emerged to give voice to victims, witnesses and participants in this hidden epidemic so we can create change toward a safer health care system. My golden retriever Gladys is a constant source of love and joy. I hope to be well enough again one day to race triathlons again. Or even shovel the snow off the sidewalk. Remedies Counseling - Making Life Better Have you had traumatic experiences with the health care system? Are you living / struggling with a chronic illness? Do you need a counsellor with proven expertise and experience to make life better? Book an appointment with me at RemediesOnlineCounseling@gmail.com    

This week, we warmly welcome Hari Guliani, COO at Grow Biotech to the show! Grow Biotech help to bring medical cannabis products to the UK and research and develop market entry strategies and technologies for medical cannabis producers to create better, cost effective medicines.Together, we discuss the current laws and regulations governing medical cannabis, availability, access to medicine, and hopes for the future. Episode SummaryMedical cannabis was legalised last November in the UK by Sajid Javid, the Home Secretary with the aim to give more UK patients access to cannabis-based medicines. Although technically legal, only a small number of patients have access as it is only prescribed privately and only by specialist consultants who can only prescribe when they see no other options available.Many patients in the UK are incredibly frustrated due to the lack of access, especially since it is not currently supported by the NHS who are concerned with the lack of supporting evidence and the cost of purchase. In August 2019, NICE (The National Institute for Health and Care Excellence) published its draft recommendations on the use of cannabis-based medicinal products following a comprehensive evaluation of their clinical and cost-effectiveness. The review highlighted the lack of evidence about the long term safety and effectiveness of medicinal cannabis.The draft guidance did not recommend Sativex for treating spasticity in people with multiple sclerosis because it was found to be not cost-effective at its current list price in relation to the benefits it provides, although it has been licensed in the UK to treat this problem.If we want to see the widespread adoption of medical cannabis based products within the UK, we need to see the collection of clinical data. This will happen as doctors become more comfortable and informed about cannabis. Because of the rapid expansion of cannabis markets, (recreational and medical), products are often becoming unavailable and cannot be bought consistently. This poses a problem for the UK medical cannabis market as medical drugs need to be readily available if patients are relying on them. Hari is a former corporate finance lawyer & strategy & operations consultant with experience across a wide range of sectors. He left law behind to work across startups within crisis management and consultancy before being inspired by Tom Gray (founder of Blume Jobs) to join the cannabis industry. RESOURCESJoin Hari on Linkedin:https://www.linkedin.com/in/harigulianiGrow Biotech Official Website: https://growbiotech.com/Grow Biotech Twitter: https://twitter.com/growbiotech?lang=enNICE Guidance (Medical Cannabis): https://www.nice.org.uk/guidance/indevelopment/gid-ng10124/documentsBlog post - Does the UK really have medical cannabis?: https://blogs.spectator.co.uk/2019/05/does-the-uk-really-have-medical-marijuana/

This episode sees the midwives discuss early pregnancy for people who choose to continue with their pregnancy - there will be a full episode focusing on termination of pregnancy later in the series. Morning sickness, hyperemesis, what is happening in the womb, hormonal shifts all discussed. Our Feminist of the Fortnight is Candice Braithwaite, founder of Make Motherhood Diverse, an online space focused on representing a picture of real motherhood, from all sorts of women around the world. Please contact us on yonicboompodcast@gmail.com and follow us on Instagram@boomyonic www.youtube.com/watch?v=W_twYPeBSRg (fetal development vid)www.youtube.com/watch?v=cfn04QUO4B8 (first trimester what to expect - todays parent; bit presumptious that its a positive, HATE the use of term ‘rag time’ for your period but thats just me!)www.youtube.com/watch?v=0gAsdEUNUJY (NAKED SCIENCE - very very intense on the miracle talk etc.) www.hse.ie/eng/services/yourhe…thservice/hcharter/ www.tommys.org/pregnancy-informa…mester-weeks-1-12 www.tommys.org/pregnancy-informa…s-safer-pregnancy NHS Choices. Your pregnancy week by week www.nhs.uk/conditions/pregnanc…-by-week.aspx#close(Page last reviewed: 28/02/2017 Next review due: 28/02/2020)Macdonald S, Magill-Cuerden J (2012) Mayes’ Midwifery, 14th edition, London, Ballière TindallNICE (2008) Antenatal care for uncomplicated pregnancies, NICE Clinical Guidelines 62. National Institute for Health and Care Excellence publications.nice.org.uk/antenatal-care-cg62aeon.co/essays/the-idea-that-…st-another-macho-mythwww.yourhormones.info/topical-issues…cy-and-labour/ (hormones and physiological changes)www webmd.com/mental-health/mental-health-pica#1www.nhs.uk/conditions/pregnanc…idwife-appointment/www2.hse.ie/wellbeing/child-hea…s/appointments.htmlwww2.hse.ie/pregnancy/oralb.com/en-us/oral-health/co…at-is-ptyalism#close

Craig Williams is a returning guest on the podcast.  A Traditional Chinese Medicine & Ayurvedic practitioner, Craig resides in Austin, Texas.  In this episode, we delve into Craig's recent writings, why Dry Needling and the National Institute for Health and Care Excellence are creeping up on our profession, and a rhetorical question as to whether Chinese medicine colleges should offer business courses.  Join us as we unearth a few rocks to see what's under them. For more information or to contact Craig, please visit ayurvedaaustin.com The Strength of TCM Workbook, along with digital downloads, study charts and practice support are all available at kentonsefcik.com Track is Samurai Code by Levox: levox.bandcamp.com

We discuss whether or not the National Institute for Health and Care Excellence, (NICE), will recommend funding of Spinraza in England’s National Health System for all SMA patients. Also, SMA News Today’s Director of Multichannel Content, Michael Morale, discusses how he treats each day as a blessing while living with SMA. Are you interested in understanding gene therapy? ExploreGeneTherapy.com has helpful information about gene therapy, including its history and how it is being investigated for the treatment of genetic diseases. Visit www.exploregenetherapy.com

Professor Mike Kelly, Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, gives a talk for the Evidence Based Healthcare seminar series. Professor Mike Kelly is Senior Visiting Fellow in the Department of Public Health and Primary Care at the Institute of Public Health and a member of St John's College at the University of Cambridge. Between 2005 and 2014, when he retired, he was the Director of the Centre for Public Health at the National Institute of Health and Care Excellence (NICE). From 2005 to 2007, he directed the methodology work stream for the World Health Organisation's (WHO) Commission on the Social Determinants of Health. His research interests include the prevention of non-communicable disease, living with chronic illness, health inequalities, health related behaviour change, end of life care, dental public health, the relationship between evidence and policy and the methods and philosophy of evidence based medicine. This talk will describe the approach to development of public health guidelines adopted by NICE (the National institute for Health and Care Excellence) between 2005 and 2014 when Mike Kelly was leading the public health team there. It will consider the influences that realist theories and methods had on the process which NICE engineered as it applied the conventional model of evidence based medicine to public health matters. Some of the academic opposition to this endeavour will be noted and the broader political environment described. Using the development of the guideline on the prevention of alcohol misuse as a case study, the paper will examine the political consequences of taking a realist approach to the evidence. The controversy, which ensued after NICE, published the guideline, which among other things recommended minimum unit pricing, will be analysed. Some of the lessons of working at the policy/practice/politics/academy interface will be discussed.

Professor Mike Kelly, Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, gives a talk for the Evidence Based Healthcare seminar series. Professor Mike Kelly is Senior Visiting Fellow in the Department of Public Health and Primary Care at the Institute of Public Health and a member of St John's College at the University of Cambridge. Between 2005 and 2014, when he retired, he was the Director of the Centre for Public Health at the National Institute of Health and Care Excellence (NICE). From 2005 to 2007, he directed the methodology work stream for the World Health Organisation's (WHO) Commission on the Social Determinants of Health. His research interests include the prevention of non-communicable disease, living with chronic illness, health inequalities, health related behaviour change, end of life care, dental public health, the relationship between evidence and policy and the methods and philosophy of evidence based medicine. This talk will describe the approach to development of public health guidelines adopted by NICE (the National institute for Health and Care Excellence) between 2005 and 2014 when Mike Kelly was leading the public health team there. It will consider the influences that realist theories and methods had on the process which NICE engineered as it applied the conventional model of evidence based medicine to public health matters. Some of the academic opposition to this endeavour will be noted and the broader political environment described. Using the development of the guideline on the prevention of alcohol misuse as a case study, the paper will examine the political consequences of taking a realist approach to the evidence. The controversy, which ensued after NICE, published the guideline, which among other things recommended minimum unit pricing, will be analysed. Some of the lessons of working at the policy/practice/politics/academy interface will be discussed.

After working in the fire and rescue service, John Durkin placed the real world challenges of incident stress, colleagues’ suicides, and Post Traumatic Stress Disorder under academic scrutiny, to design an evidence based programme of crisis intervention for the emergency services. John assisted the post 9/11 peer response with New York police officers, and led the Metropolitan Police Service’s crisis response to the 2017 London terror attacks and Grenfell Tower fire. He has become a leader of a movement that places experience above qualifications, and skill above expertise—a bottom up approach to mental health and well-being. “When you’ve survived something that could’ve taken your life, you’ve kind of earned your stripes…I returned to work bigger better and stronger, but found myself worried to death about a job I used to be confident in.” [4:55] When John was 19 he had what he calls “naïve ambitions” to become a doctor. Back then jobs were dropping off trees and John had to decide between being a banker or joining the fire brigade, and he turned down the suit job and joined the brigade. His uncle had been killed in a factory collapse as a sub officer, so even going in fresh, John had an idea of what could await him, his colleagues, and citizens. John was seriously injured after 12 years on the job after falling out of an attic in a shop that was on fire. After a recovery period, he returned to work with a strong fear of dying in an environment that was macho and hostile to such emotions. He felt he was betraying his peers for being what they perceived as weak. [10:45] “That was the point at which I was beginning to realize how suddenly you can go from something made of leather to something made of wet tissue paper.” [13:30] His own experiences started to shed light on what his colleagues were feeling, sadly, after the fact for some of them who ended up committing suicide. The reasons and scenarios behind each instance of suicide were distant, with one firefighter not even having been to the fire that was thought to have caused him distress. This hinted though at a common theme, that a sense of betrayal was prevalent in all these instances. After a horrific accident on the M5 and how his team and superiors handled the after effects, John began down a path of study and research into a term that didn’t exist when he first entered the service —PTSD. John went on to learn from officers and departments in the United States after 9/11, earned his Masters and PhD, and has given over everything to implement debriefing practices after calls in order to help responders work through trauma—and his results have been astounding, even though he has still received backlash and push back from higher ups and even the National Institute for Health and Care Excellence. “Somebody pointed out to me that the worst pain anyone can endure is the one you’re feeling right now.” It is a tremendous story that shows John’s struggles as well as all those who serve to protect citizens around the world. While some parts of the story seem unbearably heavy and hopeless, John wants me to tell you it’s not all bad, and if he has his way, things will continue on a path that protects and helps responders better understand and work through some of our cities greatest tragedies. https://www.linkedin.com/in/john-durkin-25151024/ Support this podcast

Was ist Psychotherapie? Michael Buchholz findet das gar nicht so leicht zu definieren. Ziemlich sicher ist, dass es darum geht, miteinander zu sprechen und dadurch psychische Probleme zu behandeln. Die Psychoanalyse wird daher auch als "Redekur" bezeichnet. Doch was unterscheidet verschiedene Formen von Psychotherapie – und wann gelingt eine psychotherapeutische Behandlung? Im Gespräch erwähnte Literatur: Buchholz, Michael (2017). Zur Lage der professionellen Psychotherapie. Forum der Psychoanalyse, 33, S. 289–310. Buchholz, Michael (1999). Psychotherapie als Profession. Psychosozial-Verlag. Woofolk, Robert L. (2015). Vom gesellschaftlichen und kulturellen Wert der Psychotherapie. CIP-Medien. Personen: Winnicott, Donald W. (1896–1971): Englischer Kinderarzt und Psychoanalytiker, vor allem bekannt für seine psychoanalytische Arbeit mit Kindern Luborsky, Lester (1920–2009): Psychoanalytiker und Psychotherapieforscher, bekannt für empirische Psychotherapieforschung Wampold, Bruce (*1948): Emeritierter Professor für Beratungspsychologie, University of Wisconsin Insel, Thomas R. (*1951): Neurowissenschaftler, Psychiater und ehemaliger Leiter des NIMH Beck, Aaron T. (*1921): Psychiater, Psychotherapeut, unter anderem Entwickler des Beck-Depressions-Inventar (BDI) und Wegbereiter der Kognitiven Verhaltenstherapie Abkürzungen: DSM – Diagnostic and Statistical Manual NIMH – National Institute of Mental Health NICE – National Institute for Health and Care Excellence

This episode features Dr Karen Neoh (St Gemma’s Academic Unit of Palliative Care, University of Leeds, Leeds, UK). This national audit  aimed to determine national transfusion practice in hospices and compare this against National Institute for Health and Care Excellence and British Society of Haematology guidelines to develop recommendations to improve practice. The results demonstrated that patients are not usually investigated for the cause of their anaemia, of those that were a significant proportion would have benefitted from B12, folate or iron supplementation, although these were rarely used. Transfusion practice remains too liberal despite greater risks of transfusion-associated circulatory overload in patients with advanced disease. Only 18% of transfused patients had an improvement maintained up to 30 days; 42% had no or very transient benefit, and 32% were dead at 30 days. The authors conclude that more rigorous investigation of anaemia, increased use of alternative therapies and a more restrictive approach to red blood cell transfusions are needed. Furthermore, clinicians should discuss with patients the limited benefit versus higher risks of red blood cell transfusion in this patient group to inform treatment decisions and ensure informed consent. Full paper available from: http://journals.sagepub.com.liverpool.idm.oclc.org/doi/full/10.1177/0269216318801755 If you would like to record a podcast about your published (or accepted) Palliative Medicine paper, please contact Dr Amara Nwosu: anwosu@liverpool.ac.uk

On August 1, 2017, Prem Soman and James E. Udelson discussed James’s article entitled ‘The United Kingdom’s National Institute for Health and Care Excellence guideline on chest pain of recent onset: A United States perspective’. The authors of this article have provided a PowerPoint file which summarises the contents of the paper and is free for re-use at meetings and presentations: http://bit.ly/2w8gVq3 The article is available at: https://rdcu.be/MlV2 Be sure to subscribe on your mobile device - search 'JNC/ASNC Podcast'.

Next episode in the #HLA17 Conference series with Professor David Haslam. Hear about his motives for medicine, the serendipity in his journey into leadership and the insights gained from his roles as current chair of the National Institute for Health and Care Excellence and as past-president of the RCGP and the BMA. We also speak about the extraordinary potential in medical careers and how we can make the most of the opportunities around us in becoming stem-cell medics. Feeling NICE? Click play…

Dr. Kim walks us through the history of cord clamping and examines the evidence behind delayed vs. immediate clamping.    feedback@obgyn.fm   ACOG, Committee Opinion. Delayed Umbilical Cord Clamping After Birth. (American College of Obstetricians and Gynecologists, 2017). Downey, C., and Bewley, S. Third Stage Practices and the Neonate. Fetal and MAternal Medicine Review 20, 229-246 (2009). Downey, C., Bewley, S. HIstorical Perspectives on umbilical cord clamping and neonatal transition. Journal of the Royal Society of Medicine 105, 325-329 (2012). Drife, J. The start of life: a history of obstetrics. Postgrad Medicine 78, 311-315 (2002). Loudon, I. General practitioners and obstetrics: a brief history. JR Soc Med 101 (2008). McDonald, S., Middletone, P, Dowswell, T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes (Review). Cochrane Database of Systematic Reviews, 1-93 (2013). Mercer, J., Vohr, BR, McGrath, MM, PAdbury, JF, WAllach, M, Oh, W. Delayed Cord Clamping in Very Preterm Infants Reduces the Incidence of Intraventricular Hemorrhage and Late-Onset Sepsis: A Randomized Controlled Trial. Pediatrics 117, 1235-1242 (2006). Mercer, J., Vohr, BR, Erickson-Owens, DA, Padbury, JF and Oh, W. Seven-month developmental outcomes of very low birth weight infants enrolled in a randomized controlled trial of delayed versus immediate cord clamping. Journal of Perinatology 30, 11-16 (2010). Mercer, J., Erickson-Owens, DA, Collins, J, Barcelos, MO, Parker, AB, Padbury, JF. Effects of Delayed cord clamping on residual placental blood volume, hemoglobin and bilirubin levels in term infants: a randomized controlled trial. Journal of Perinatology 37, 260-264 (2017). National Institute for Health and Care Excellence,. Intrapartum care for healthy women and babies, 2014). Paco, C., Florido, J, Garrido, MC, PRados, S, NAvarrete, L. Umbilical cord blood acid-base and gas analysis after early versus delayed cord clamping in neonates at term. Arch Gynecol Obstetric 283, 1011-1014 (2011). Rabe, H., Wacker, A, Hulskamp, G, Hornig-Franz, I, Schulze-Everding, A, Harms, E, Cirkel, U, Louwen, F, Witteler, R, Schneider, H. A randomised controoled trial of delayed cord clamping in very low birth weight preterm infants. Eur J Pediatrics 159, 775-777 (2000). Rabe, H., Reynolds, G. Diaz-Rossello, J. A Systematic Review and Meta-Analysis of a Brief Delay in Clamping the Umbilical Cord of Preterm Infants. Neonatology 93, 138-144 (2008). Rabe, H., Jewison, A, Alvarez, RF, Crook, D, Stilton, D, Bradley, R, Holden, D. Milking Compared with Delayed Cord Clamping to increase Placental Transfusion in preterm neonates. Obstetrics and Gynecology 117, 205-211 (2011). Rabe, H., Diaz-Rossello, JL, Duley, L, Dowswell, T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews, 1-84 (2012). Rabe, H., Sawyer, A, Amess, P, Ayers, S. Neurodevelopmental outcomes at 2 and 3.5 years for very preterm babies enrolled in a randomzied trial of milking the umbilical cord versus delayed cord clamping. Neonatology 109, 113-119 (2016). Speer, H. Obstetrics and Gynecology: A history and iconography. New England Journal of Medicine 352, 844-845 (2005). World Health Organization. WHO recommendations on Postnatal care of the mother and newborn. (2013)

"By the pricking of my thumbs, Something wheezing this way comes." -- Witches in Macbeth, with apologies to William Shakespeare   "Bronchiolitis is like a pneumonia you can’t treat. We support, while the patient heals." -- Coach, still apologetic to the Bard     The Who The U.S. definition is for children less than two years of age, while the European committee includes infants less than one year of age. This is important: toddlerhood brings with it other conditions that mimic bronchiolitis – the first-time wheeze in a toddler may be his reactive airway response to a viral illness and not necessarily bronchiolitis. The What The classic clinical presentation of bronchiolitis starts just like any other upper respiratory tract infection: with nasal discharge and cough, for the first 1-2 days. Only about 1/3 of infants will have a low-grade fever, usually less than 39°C. We may see the child in the ED at this point and not appreciate any respiratory distress – this is why precautionary advice is so important in general. Then, lower respiratory symptoms come: increased work of breathing, persistent cough, tachypnea, retractions, belly breathing, grunting, and nasal flaring. Once lower respiratory symptoms are present, like increased work of breathing, they typically peak at day 3. This may help to make decisions or counsel parents depending on when the child presents and how symptomatic he is. You’ll hear fine crackles and wheeze. A typical finding in bronchiolitis is a minute-to-minute variation in clinical findings – one moment the child could look like he’s drowning in his secretions, and the next minute almost recovered. This has to do with the dynamic nature of the secretion, plugging, obstruction, coughing, dislodgement, and re-plugging. The Why Respiratory syncytial virus is the culprit in up to 90% of cases of bronchiolitis. The reason RSV is so nasty is the immune response to the virus: it binds to epithelial cells, replicates, and the submucosa becomes edematous and hypersecretes mucus. RSV causes the host epithelia and lymphocytes to go into a frenzy – viral fusion proteins turn the membranes into a sticky goop – cells fuse into other cells, and you have a pile-on of multinucleated dysfunction. This mucosal chaos causes epithelial necrosis, destruction of cilia, mucus plugs, bronchiolar obstruction, air trapping, and lobar collapse. High-Risk Groups Watch out especially for young infants, so those less than 3 months of age. Apnea may be the presenting symptom of RSV. Premature infants, especially those less than 32 weeks’ gestation are at high risk for deterioration.  The critical time is 48 weeks post-conceptional age. Other populations at high-risk for deterioration: congenital heart disease, pulmonary disease, neuromuscular disorders, metabolic disorders. Guiding Principles In the full term child, greater than one month, and otherwise healthy (no cardiac, pulmonary, neuromuscular, or metabolic disease), we can look to three simple criteria for home discharge. If the otherwise healthy child one month and older is: Euvolemic Not hypoxic Well appearing He can likely go home. The How Below is a list of modalities, treatments, and the evidence and/or recommendations for or against: Chest Radiograph Usually not necessary, unless the diagnosis is uncertain, or if the child is critically ill. Factors that are predictive of a definite infiltrate are: significant hypoxia (< 92%), grunting, focal crackles, or high fever (> 39°C). Ultrasound Not ready for prime time.  Two small studies, one by Caiulo et al in the European J or Pediatrics and one by Basile et al. in the BMC Pediatrics that show some preliminary data, but not enough to change practice yet. Viral Testing Qualitative PCR gives you a yes or no question – one that you’ve already answered. It is not recommended for routine use. PCR may be positive post-infection for several weeks later (details in audio). Quantitative PCR measures viral load; an increased quantitative viral load is associated with increased length of stay, use of respiratory support, need for intensive care, and recurrent wheezing. However, also not recommended for routine use. There is one instance in which viral testing in bronchiolitis can be helpful – in babies less than a month of life, the presence of RSV virus is associated with apnea. Blood or Urine Testing Routine testing of blood or urine is not recommended for children with bronchiolitis.  Levine et al in Pediatrics found an extremely low risk of serious bacterial illness in young febrile infants with RSV. The main thing is not to give in to anchoring bias here. If an infant of 3 months of age or older has a clear source for his low-grade fever – and that is his bronchiolitis – then you have a source, and very rarely do you need to go looking any further. He’s showing you the viral waterfall from his nose, and his increased work of breathing. It’s not going to be in his urine. Bronchodilators! Should we use bronchodilators in bronchiolitis?  It seems lately that this is a loaded question – with strong feelings on either side amongst colleagues. The short answer is that the American Academy of Pediatrics, the UK’s National Institute for Health and Care Excellence, as well as the Canadian Pediatric Society currently recommend against them. However, in continental Europe and Australia, the language is softened to “not routinely recommended”. Pros and Cons in Audio; the 2006 AAP Guidelines and the 2014 AAP Guidelines use same data to come to divergent recommendations. Steroids There is no role for steroids in the treatment of bronchiolitis, even in those with a family or personal history of atopy. Nebulized Hypertonic Saline May show some benefit in admitted patients, after repeated treatments; no data to support its use in ED patients (no immediate effect). Nebulized Epinephrine One randomized controlled double blinded study in eight centers in Norway published in the NEJM showed no benefit to nebulized epinephrine over nebulized saline. Again, probably asking too much of one single intervention. The Cochrane review found 19 studies that included a total of 2256 children with acute bronchiolitis treated with nebulized epinephrine. There were no differences in length of hospital stay between the placebo and treatment groups, and so they concluded that for inpatients, nebulized epinephrine is not worth the hassle. However – and this may just be an artifact of meta-analysis – there may be some benefit to outpatients. One study of combined high-dose steroid and epinephrine therapy was not statistically significant when other factors were controlled, but Cochrane concluded that nebulized epinephrine itself may be helpful for outpatients. It won’t affect the overall disease time course, but it may make them feel better enough to go home from the ED and continue observation there. High-Flow Nasal Cannula Oxygen High-flow oxygen via nasal cannula requires specialized equipment and delivers humidified oxygen at 1-2 L/g/min.  In addition to oxygenation, high flow nasal cannula also likely offers some low-grade positive end-expiratory pressure, which may help with alveolar recruitment. The evidence for its use is based on observational studies, which have found improved respiratory parameters and reduced rates of intubation.  Nasal CPAP also has some promising properties in the right clinical setting. Antibiotics Not recommended. When bronchiolitis is from a clear viral source, the risk of accompanying bacteremia is less than 1%. A meta-analysis of randomized clinical trials found that antibiotics in bronchiolitis did not improve duration of symptoms, length of hospital stay, need for oxygen therapy, or hospital admission. Summary: The Good, the Bad, and the Ugly The Good Nasal suction and hydration are your best allies. You may elect to give a bronchodilator as a trial once and reexamine, if you’re a bronchodilating believer. The Bad Steroids, antibiotics, and a blind obeying of the guidelines. Weigh the risks and benefits of every intervention, including hospitalization – it’s not always a benign thing. The Ugly Take a moment to assess the child and make a clinical diagnosis of bronchiolitis, after you’ve excluded cardiac disease, anatomic anomalies, and foreign body aspiration. Wheezing without upper respiratory symptoms is not viral, and it is not bronchiolitis. When all else fails, remember: in the otherwise healthy, term infant greater than a month of age, if he is well appearing, euvolemic, and not hypoxic, he will often do well with good precautionary advice and supportive care at home. Every thing else: be skeptical, be thorough, and above all, be careful. References Alansari K, Toaimah FH, Khalafalla H, El Tatawy LA, Davidson BL, Ahmed W. Caffeine for the Treatment of Apnea in Bronchiolitis: A Randomized Trial. J Pediatr. 2016 May 14. pii: S0022-3476(16)30170-6. [Epub ahead of print] American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006 Oct;118(4):1774-93. Beggs S, Wong ZH, Kaul S, Ogden KJ, Walters JA. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database Syst Rev. 2014 Jan 20;(1):CD009609. Bergroth E, Aakula M, Korppi M, Remes S, Kivistö JE, Piedra PA, Camargo CA Jr, Jartti T. Post-bronchiolitis Use of Asthma Medication: A Prospective 1-year Follow-up Study. Pediatr Infect Dis J. 2016 Apr;35(4):363-8. Cunningham S, Rodriguez A, Adams T, Boyd KA, Butcher I, Enderby B, MacLean M, McCormick J, Paton JY, Wee F, Thomas H, Riding K, Turner SW, Williams C, McIntosh E, Lewis SC; Bronchiolitis of Infancy Discharge Study (BIDS) group. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet. 2015 Sep 12;386(9998):1041-8. Flett KB, Breslin K, Braun PA, Hambidge SJ. Outpatient course and complications associated with home oxygen therapy for mild bronchiolitis. Pediatrics. 2014 May;133(5):769-75. Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet. 2016 Aug 20. [Epub ahead of print] Halstead S, Roosevelt G, Deakyne S, Bajaj L. Discharged on supplemental oxygen from an emergency department in patients with bronchiolitis. Pediatrics. 2012 Mar;129(3):e605-10. Johnson LW, Robles J, Hudgins A, Osburn S, Martin D, Thompson A. Management of bronchiolitis in the emergency department: impact of evidence-based guidelines? Pediatrics. 2013 Mar;131 Suppl 1:S103-9. Lashkeri T, Howell JM, Place R. Capnometry as a predictor of admission in bronchiolitis. Pediatr Emerg Care. 2012 Sep;28(9):895-7. Lehners N, Tabatabai J, Prifert C, Wedde M, Puthenparambil J, Weissbrich B, Biere B, Schweiger B, Egerer G, Schnitzler P. Long-Term Shedding of Influenza Virus, Parainfluenza Virus, Respiratory Syncytial Virus and Nosocomial Epidemiology in Patients with Hematological Disorders. PLoS One. 2016 Feb 11;11(2):e0148258. Liet JM, Ducruet T, Gupta V, Cambonie G. Heliox inhalation therapy for bronchiolitis in infants. Cochrane Database Syst Rev. 2015 Sep 18;(9):CD006915. Mammas IN, Spandidos DA. Paediatric Virology in the Hippocratic Corpus. Exp Ther Med. 2016 Aug;12(2):541-549. Mansbach JM, Clark S, Teach SJ, Gern JE, Piedra PA, Sullivan AF, Espinola JA, Camargo CA Jr. Children Hospitalized with Rhinovirus Bronchiolitis Have Asthma-Like Characteristics. J Pediatr. 2016 May;172:202-204.e1. Meissner HC. Viral Bronchiolitis in Children. N Engl J Med. 2016 Jan 7;374(1):62-72. Munywoki PK, Koech DC, Agoti CN, Kibirige N, Kipkoech J, Cane PA, Medley GF, Nokes DJ. Influence of age, severity of infection, and co-infection on the duration of respiratory syncytial virus (RSV) shedding. Epidemiol Infect. 2015 Mar;143(4):804-12. Oakley E, Borland M, Neutze J, Acworth J, Krieser D, Dalziel S, Davidson A, Donath S, Jachno K, South M, Theophilos T, Babl FE; Paediatric Research in Emergency Departments International Collaborative (PREDICT). Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial. Lancet Respir Med. 2013 Apr;1(2):113-20. Epub 2012 Dec 21. Oakley E et al. Nasogastric Hydration in Infants with Bronchiolitis Less Than 2 Months of Age. J Pediatr. 2016. [Article in Press] Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S. Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis. JAMA Pediatr. 2016 Jun 1;170(6):602-8. Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502. Roqué i Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2016 Feb 1;2:CD004873. Skjerven HO et al. Racemic adrenaline and inhalation strategies in acute bronchiolitis. N Engl J Med. 2013 Jun 13;368(24):2286-93. This post and podcast are dedicated to Linda Girgis MD, FAAFP, for her authenticity, innovation, and clear and honest voice on the the frontlines.  Thank you, Dr Linda. Bronchiolitis Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

Carolyn: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and it's editors. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. In today's podcast interview we will be discussing the ruling in and ruling out of myocardial infarction with the European Society of Cardiology 1-hour algorithm. Stay tuned for a discussion of new data and controversies on this hot topic. Now, here's a summary of this weeks issue.     The first paper brings us one step closer to the ultimate goal of cardiac tissue engineering. That is to replicate functional human myocardium in vitro. In this study, by first author Dr. Ruan, corresponding authors Dr. Murry and Regnier from the Institute for Stem Cell and Regenerative Medicine and University of Washington, authors recognize that human-induced pluripotant stem cells, or iPSC-derived cardiomyocytes, really provide a cell source for cardiac tissue engineering. However, their immaturity limits their potential applications. Hence, they sought to study the effect of mechanical conditioning and electrical pacing on the maturation of iPSC-derived cardiac tissues.     They found that after two weeks of static stress conditioning, the engineered myocardium demonstrated increases in contractility, tensile strength, construct alignment, cell size, and SERCA2 expression. When electrical pacing was combined with static stress conditioning the tissue showed an additional increase in force production and further increases in expression of RyR2 and SERCA2. These studies really demonstrate that electrical pacing and mechanical stimulation promote the maturation of the structural, mechanical, and force generation properties of iPSC-derived cardiac tissues and constitute a really important contribution to cardiac tissue engineering.     The next study is the first large-scale, nationwide, population-based investigation of the association between congenital heart defects and any placental measure. This study by Dr. [Matheson 00:02:27] and colleagues from Aarhus University Hospital in Denmark, included all 924,422 live-born Danish singletons from 1997 to 2011. Congenital heart defects was present in 7,569 newborns. The authors compared the mean differences in placental weight between newborns with and without congenital heart defects and found that only three specific subgroups of congenital heart defects were associated with measures of impaired placental growth. These included Tetralogy of Fallot, double outlet right ventricle, and major ventricular septal defects. In these subgroups, the mean deviations from the population mean head circumference and birth weights were reduced by up to 66%, with adjustment for placental weight. In other words, up to two thirds of the deviations in fetal growth, including fetal cerebral growth, may be related to the impaired placental growth. The present work provides an important contribution to the existing knowledge on the association between congenital heart defects and placental anomalies as well as the possible importance for fetal growth in this population.     The next study provides an up-to-date evaluation of the cost effectiveness of antibiotic prophylaxis in the prevention of infective endocarditis. In this study by first author Dr. Franklin, corresponding author Dr. Thornhill, and colleagues from the University of Sheffield, the cost effectiveness of antibiotic prophylaxis, namely single dose amoxicillin or clindamycin, in patients at risk of infective endocarditis. They did this using, firstly, recent estimates of the effect of antibiotic prophylaxis on infective endocarditis in the English population; secondly, rates of antibiotic adverse drug reactions; and thirdly, estimates of the probability of developing infective endocarditis following dental procedures derived from French data. All this as foundation for analysis of cost and health benefits.     A decision analytic cost effectiveness model was used based on the decision model by the National Institute for Health and Care Excellence, or NICE, that was used to inform the 2008 guidelines. The authors found that antibiotic prophylaxis was less costly and more effective than no antibiotic prophylaxis for all patients at risk for infective endocarditis. In fact, if antibiotic prophylaxis was reinstated in England for those at moderate or high risk of infective endocarditis, it could save 5.5 to 8.2 million pounds and result in health gains of more than 2,600 quality-adjusted life years. Antibiotic prophylaxis was even more cost effective for those at high risk of infective endocarditis, being cost effective even if only on 1.44 cases of infective endocarditis was prevented per year. In summary, these updated findings really support the cost effectiveness of guidelines recommending antibiotic prophylaxis use, particularly in high risk individuals.     The last study provides data on long term cardiac mortality among survivors of cancer diagnosed in teenagers and young adults in the largest population-based cohort to date. Furthermore, the study provided, for the first time, risk estimates of cardiac death after each cancer diagnosed between the ages of 15 to 39 years. For example, survivors of Hodgkin lymphoma, lung cancer, acute myeloid leukemia, non-Hodgkin lymphoma, and CNS tumors experience 1.3 to 3.8 times the population-based mortality rates. This study provides important insight into the cardiotoxicity of the treatments given in the past to teenagers and young adults with each individual type of cancer and importantly, provides an initial basis for developing evidence-based follow up guidelines.     Those were you summaries. Now for our feature interview.     Our feature paper today discusses the hot and controversial topic of ruling in and ruling out myocardial infarction with the European Society of Cardiology 1-hour algorithm. I'm so excited to have with us the corresponding author of the paper that really represents the first multi-center external validation of these ESC guidelines for MI and the first multi-centered direct comparison of the performance of the algorithm with high-sensitivity troponin I and high-sensitivity troponin T assays. This would be Dr. Martin Than from Christ Church Hospital in New Zealand. Welcome Martin.   Martin: Thank you very much. It's a great pleasure for me to be able to join everybody and talk here.   Carolyn: It's great to have you. We also have with us the editorialist on this paper, Dr. Allan Jaffe from Mayo Clinic, Rochester, Minnesota. Allen, it's so good to hear your voice again.   Allan: Good to talk to you again too, Carolyn.   Carolyn: Finally, we have Dr. Deborah Diercks, Associate Editor from UT Southwestern. Welcome Deb.   Deborah: Oh, it's good to be here and I'm looking forward to the conversation and what we're going to learn from these two gentlemen.   Carolyn: Absolutely. You know what? I'm going to start with Martin. I love the way to set up your paper. You very correctly pointed out that there's a tension in that ED physicians require really high sensitivity to confidently rule out MI and send patients home, whereas cardiologists do not want high proportion of false positives because we don't want false high risk to lead to invasive testing. I just love, if you could start by telling us how the ESC 1-hour algorithm fits into all this and what you were trying to do in your study.   Martin: I heard Deb Diercks on the phone as well, who's a very respected emergency physician in this area, and I think we would both say that we have a certain bias in our perspective on this, which is of course we are the people at the end of the day that have to send people home when they present with chest pain and possible myocardial infarction. We are also, of course, the people that take the fall if there are any mistakes made. Historically, people have not been very kind to emergency physicians who miss such a diagnosis. It's an extremely high source of medical legal action in the United States and, in fact, worldwide. So we're somewhat paranoid as a speciality about missing cases of myocardial infarction because at the end of the day, the worst thing that can possibly happen is for you to send someone home who comes to harm from the very clinical complaint for which they came to you for help. We want to avoid that at all costs and that was the basis behind us trying to put together this paper.     Soon after the ESC guidelines come back and I returned from London, where they were announced at the conference, to New Zealand, I received quite a lot of phone calls and correspondence saying, "Okay, we see these new ESC guidelines are out. When are we going to start introducing them?". I immediately wanted to say, "Well, the key thing is to understand how they would work, how they would be implemented, and whether they'd work in my own setting" because if we want to implement them in New Zealand or Australasia, we would want to double-check on that first. That's the basis and the philosophy behind the manuscript.   Carolyn: Tell us what you found.   Martin: As Allan will be the first to point out, I think there are a number of flaws in the data we had available to us that allowed us to do this analysis, but based on the concept that when we've surveyed emergency medicine physicians, the sensitivity that was wanted was at least 99% if not higher. We found that neither of the algorithms produced that level of sensitivity, although the algorithm based on hsTnI was very close. I think it's 98.8%, so that was very good. Reasonably wide confidence intervals on that. The hsTnT algorithm performed slightly less well with a sensitivity around 97%. I guess, if I was to start with an a priori question, which is did we reach a standard of 99%, then our answer to this was, in one case, not quite, and the other case, no, we probably didn't. We said that if you wanted to use a metric of negative predictive value, which I know a lot of people do, then there was actually very good negative predictive value in the high 99 percentage range for both pathways.   Carolyn: Do you mind if I stretch you a little bit and ask you to describe exactly what you did in the cohorts? You were saying that there were some imperfections. Maybe you'd like to tell us a little bit about that.   Martin: Absolutely. As always, when you're writing a paper, you look back and you always feel there are far too many imperfections, but I guess the principle one I would say that's been noted is that we had samples done on arrival and the algorithm itself specifies a [inaudible 00:11:43] one-hour second sample. We didn't have those specimens, so we had to base our data analysis on samples done either at 90 minutes afterwards or two hours afterward. It's clearly not being tested exactly as it was written, although one could argue that that slightly delayed sampling is potentially reflective of real life, where it's very hard to hit a one hour mark in a busy emergency department, and two, where the slight delay in getting the samples would actually allow more time for a troponin to rise and therefore give a chance of providing a better sensitivity.     I think the other I guess key flaw is that of course, the people present to emergency departments at different time frames following the onset of their symptoms. There's been some valid concern raised that algorithms may not necessarily perform as well in very early presenters. In fact, that is something that's being emphasized now in the ESC guidelines.   Carolyn: Right. Allan, I loved your editorial. You did mention a couple of these points. Would you like to maybe clarify your view of this?   Allan: I think that there are two or three terribly important issues. We all would like to have very facile algorithms. Particularly given removing the high sensitivity, the idea would be gee, wouldn't it be nice to have something really simple that works perfectly? If you look at the validation and the way the algorithm has been put together, immediately there are some concerns that people ought to have and that at least we tried to point out, that were important. One of them Martin has already discussed a little bit, which is one looks at most of the validation studies. There are very few patients who are evaluated very early after the onset of their symptoms. That's a potential problem because the overlap, since they use very low values or very small change, that there could be, with people who have real disease, is in those very early presenters. The initial algorithm from the ESC used both a very low level troponin and a set of change criteria. Actually when they published those criteria, they changed that and eliminated, at least for the first three hours, the very low values. If one looks at Martin's study, it was again, the very early patients who potentially may have been missed. I think we need more data before we go ahead and acknowledge that this will be working for those early presenters.     There are two other problems with the population that we need to be careful about. It's been well known that when you have a negative troponin at six hours all the way back to [Chrisann's 00:14:26] original article in the '90s, that you're pretty safe. The population that you'd like to look at really are the patients who, after two hours in Martin's study, since he took a little bit longer given the logistics that were there in New Zealand and Australia, is the patient who came in at four hours because by six, they're actually meeting that six-hour criteria. When you have a large number of other such patients, you simply add noise and it makes you sensitivity look better, but it's not necessarily the case that that give you that same degree of reassurance that ED physicians would like.     The third population-related issue is that you'd like to do this in all-comers. The protocol was developed for chest pain patients, but there are a variety of patients in whom we evaluate myocardial infarction in, who may not qualify for that. The patients who are critically ill, for example, who may have Type 2 infarctions. The individuals who may come in who are very elderly, who often don't have chest pain so we don't identify them necessarily as a rule out. Interestingly, if you start thinking about those groups, they tend to have much higher troponin, so they may well skew the cut-offs that are used and change the algorithm.     In truth, we don't want more than one way of defining myocardial infarction. We only want one algorithm for ruling in and ruling out. Having an all-comers study, in my way of thinking, would be important. In that same regard, let me point out that you can rule out myocardial infarction because you don't have an acutely changing pattern of troponin elevations, but what we really rule in myocardial infarction? You rule in acute cardiac injury. Could be myocarditis, could a apical ballooning. There are a whole variety of other types of disease entities that could be involved and the arbitrary value of 52 that was put in the algorithm really, I think, is much too low for two reasons. One reason, because it didn't include all-comers. A second reason is because of the way in which the comparison between troponin T and I were done. I'll talk about that in just a moment. I would point out that using a different assay, the troponin I assay, in another set of studies, another group from Hamburg has suggested that very different metrics would be much better.     The final thing to say about extrapolation between the assays, and then I have some suggestions about what would make this better if you want to go there now or we can wait, is the comparison and the way in which the metrics for troponin I were developed really weren't by using troponin I as a gold standard. It was by taking and using troponin T as the gold standard for the diagnosis, then thawing samples many years later, running troponin I, and then extrapolating from the gold standard of troponin T to troponin I. Well, there's several problems with that. Number one is that appropriate comparisons should be fresh samples. Fresh samples. In addition, we believe, from the way in which we think about high sensitivity, which may not be correct, that the troponin I assay should be more sensitive and in [inaudible 00:18:05] fact, in the papers that were done validating this approach or attempting to describe the approach, troponin T was wildly more sensitive than was troponin T. We're extrapolating some data that doesn't sort of fit the way in which the information we have, it would mean all of the troponin I validation studies are incorrect.     That's where those numbers came from and even more problematic are the change numbers, which are very low. For the troponin T assay, they're three in five between ruling in and ruling out, which if you look at the assay imprecision, is something the assay can't do. Now you're extrapolating them in a very, very loose manor to troponin I and making them even lower. Those are not doable sorts of things. There's a real problem with the way in which the metrics for troponin I, even though it performed well in this circumstance, ended up being developed. I think all of those things need to be taken into account when we look at the results of the study. The results that Martin and his group got are very similar to the other validation studies that have been done because they've all done it pretty much that same way. There's not a surprise that their validation is similar, but I think unfortunately, we didn't have an opportunity to unmask, in a data-driven way, the problems that I just described.   Carolyn: Thank you Allan. Deborah, if you could share your thoughts on this.   Deborah: Martin raises some valid issues. That if something goes out as an algorithm, people want to use it. That use needs to be predicated on does it work in their patient population and is it feasible in the time frame and can it be adopted safely and what the indications are. In the emergency department, the value really is the negative predictive value because we want to be able to safely send people home. That's where rapidity of an evaluation is very important.     The other issue raised was exactly what Dr. Jaffe talked about. Does the algorithm itself reflect what we really need? Can you validate something that was created by the scientific way, but really a combination of a lot of information? Are the thresholds really valid themselves? That's the challenge with it. I think what you heard here are kind of two issues we struggle with it. We have a very respectable organization putting out an algorithm that is scientifically based and we want to adopt early, but there are questions on both sides of the issue on whether it can be adapted into real-world clinical practice on a global nature where prevalence of disease is different and the patients it'll be applied to vary, whether it's been on time of presentation or overall demographics.     Also on the scientific side, on the assays itself, are we using the right cutoff? Especially when we're looking at deltas and looking at such a rapid change. It's very nice to hear both of those points so eloquently described today during the discussion.   Carolyn: Thanks Deb. I fully agree. Hence, again, the importance of this paper. Martin, I'd love to hear your responses to Allan's comments and then also share with us, what's the take-home message for you as a clinician? How are you applying what you just found?   Martin: The guidelines are good on the right line, it's just as I said, they may not necessarily translate to all other environments. I guess that's my take-home message to myself, which was if I were to look at my own data from my own center, in Christ Church, and the way it's applied here, if I had applied the ESC guidelines and it had met the metrics which I was satisfied with, which I guess would be a very high sensitivity for me in terms of rule out, then I would actually seriously consider implementing it in my own center. It didn't reach that threshold so now I want to try and refine or explore further how I could allow the guidelines to do that. For example, one way that, and this is in the guidelines, but not necessarily in the flow chart, is the importance of applying clinical judgment and clinical findings with the results of the algorithm. I think that's a very important step in it. For example, if I was going to apply this in my own center, I'd want to be setting out clearly for the doctors concerned, how one would incorporate clinical judgment rather than it being a very subjective thing, which might vary significantly between a junior doctor or a far more experienced one.     I guess the take home message for me is this. The ESC guidelines are a very important piece of work. They've been robustly developed. For people who want to implement them, I'm no saying don't use them at all. I'm just saying that, you know, just think about carefully how you would use them and check whether you think they're appropriate for your setting.   Carolyn: That's great. Allan, what about you? What are your thoughts on how this may be applied in clinical practice and what more needs to be done?   Allan: I think we need to have a real trial where patients are managed based on the results of these approaches rather than more observational studies. I would argue that those management trials that involve an all-comers sort of population, so we are comprehensive, and should also interrogate whether or not the protocol itself is adequate or whether or not it requires follow-up to meet the metrics that have been proposed. I would point out that in the past, in the studies from the group from New Zealand and Martin Than particularly, have had very, very good follow-up. One at least needs to ask the question whether or not the algorithms that are proposed work perfectly without any follow-up or whether or not follow-up is an important component. We don't know that yet.   Carolyn: Thanks Allan. I'd love to give the final words to Deb. Take home messages?   Deborah: You know, I think that we need to look at this as a positive in that we're looking at time frames that provide a rapid evaluation and the discussion is around safety. As long as we keep focused on appropriate evaluations for the patients and applying the right algorithm to the right patient, we're going to benefit the care of those we're really concerned about. I appreciate the work that both Martin and Allan both have done on really pointing out how we can do that in a great manor.   Carolyn: Thank you, all of you, for joining us today. I mean, it's been such an enlightening conversation. I'm sure the listeners have enjoyed it and thank you listeners for tuning in. Don't forget to tune in again next week.  

5 live Investigates reveals that some online pharmacies are selling antibiotics against guidelines laid down by the National Institute for Health and Care Excellence. It comes at a time when doctors are being encouraged to cut the number of antibiotics they prescribe because of real concerns we're breeding antibiotic resistance. The GMC has launched an investigation based on the programme's findings and Lord Jim O'Neill who carried out an investigation into Antimicrobrial Resistance, has described the revelations as 'disturbing.'.

5 live Investigates reports on claims that thousands of women and girls with mental health problems are being routinely failed by the NHS - sometimes with tragic consequences. Marjorie Wallace - chief executive of the mental health charity Sane - has called the situation 'the UK's hidden national emergency.' The charity Agenda - an alliance of more than 60 organisations representing women and girls at risk - submitted a Freedom of Information request to 57 NHS mental health trusts in England. But of the 35 trusts which responded, only one had a specific women's mental health strategy. Not only that, but more than half had no policy of routinely asking patients if they'd been abused - and that goes against best practice guidance from the National Institute for Health and Care Excellence. The Department of Health said: "It is vital that all mental health care, particularly when abuse is involved, takes account of gender. Clinical guidelines are clear on this and the NHS has recently published its strategy for mental health - equality is central to this and we expect this to lead to rapid improvement across all care.".

Uno de los temas más controversiales sobre el manejo de un paro cardiaco es cómo decidir terminar los esfuerzos de resucitación. Como profesionales de la salud tenemos un deseo innato de intentar resucitar a todo paciente en paro cardiaco, pero la vida es eventualmente finita. Una vez aprendí, y nunca he olvidado, que en la medicina tenemos el honor de presenciar dos de los eventos más significativos de un ser humano...su nacimiento y su muerte. Cuando las circunstancias se dan para que estos dos momentos ocurran, van a ocurrir indistintamente de lo que nosotros hagamos para evitarlo. Es nuestro deber honrar este proceso natural. La muerte no siempre representa el fracaso de nuestros esfuerzos, sino el fin de un proceso natural. Las Guías 2010 y 2015 de la American Heart Association proveen mucha información sobre los aspectos éticos a considerar a la hora de discutir el tema de detener la resucitación. La intención de este episodio no es discutir los aspectos éticos, aunque hay algunos aspectos que es inevitable considerarlos. No obstante, no es la intención de este artículo discutirlos todos, por lo que los invito a visitar la página de la AHA para las Guías 2015, disponibles gratuitamente en http://eccguidelines.heart.org. El tiempo no es relevante El tiempo del intento de resucitación no es el factor principal en la toma de decisiones. Debemos dejar de usar el tiempo para decidir si hemos intentado mucho o poco la resucitación. El uso del tiempo como factor exclusivo denota desconocimiento de los objetivos de la reanimación. ¿Debo mencionarlo nuevamente? El tiempo es un elemento muy subjetivo. La subjetividad del tiempo El tiempo es objetivo. Lo medimos con un reloj...segundos, etc... de eso no cabe duda. Podemos medirlo con precisión atómica. Lo que varía es nuestra percepción del tiempo. Aunque parezca irónico, la percepción del tiempo es una de las cosas más subjetivas que hay. Haga usted la prueba... cuando usted quiere que el tiempo corra rápido, toma una eternidad. Viceversa, cuando quiere que el tiempo se detenga, pasa todo muy rápido. Es común oir frases como "esto acaba de ocurrir ahora mismo"...pero ya van unos 10 minutos. Por otro lado es posible oir "la ambulancia está tardando una eternidad". pero solo han pasado 2 minutos y 35 segundos desde que terminó la llamada al 9-1-1. ¿Cuándo no iniciar la resucitación? En muchos casos no es apropiado ni siquiera iniciar la resucitación. Tiempo de resucitación = 0 minutos. No se intentó la resucitación. Algunos ejemplos son: Situaciones donde intentar realizar la resucitación pondría al rescatador en peligro Directriz avanzada, testamento u orden de no resucitar (DNR) Signos obvios de muerte irreversible (decapitación, rigor mortis, descomposición, etc.) En estos casos, desde el inicio, se sabe que el intento de resucitación va a ser inconsecuente y futil. Cabe señalar que el no iniciar la resucitación y el dar por terminado los esfuerzos de resucitación son ambos éticamente equivalentes. Ante la duda, saluda Ante ausencia de alguna buena razón para no comenzar (ver anterior), siempre que creamos que podemos resucitar al paciente, debemos fallar a favor del paciente e intentar la resucitación. Pero si fuera así, todavía estaríamos intentando resucitar a los padres de la patria. Tiene que haber una forma para decidir detenerse. DNR A veces la mejor forma de detener la resucitación es una forma (formulario) indicando las intenciones del paciente. Nunca es demasiado temprano para comenzar una discusión, en el momento oportuno, con un paciente sobre sus deseos al final de la vida. Es nuestro deber encontrar ese momento oportuno. Esta página ayuda a las familias a comenzar esta discusión de la manera correcta: http://deathoverdinner.org/ Pero cuando esto no ocurre, el médico debe hacerlo. El programa POLST provee unos fundamentos para lograrlo: Conversación entre el paciente, profesionales de la salud, y familiares cercanos Toma de decisión compartida entre el paciente y su profesional de la salud acerca de el cuidado que el paciente desea recibir al final de su vida Asegurar que los deseos del paciente se cumplan, documentándolo en un formulario Tenemos que mejorar nuestro conocimiento de cuidado de fin de la vida. Cuidado paliativo no es retirar el cuidado...es proveer comodidad al final de la vida. De igual manera, tenemos que aprender a manejar ese cuidado paliativo una vez se comenzaron a realizar medidas avanzadas, tales como la intubación endotraqueal y ventilación mecánica. El no saber extubar a un paciente en etapa terminal resulta en preguntas erróneas tales como "¿desea que lo intuben"? en vez de "¿desea que lo resuciten?". El National Institute for Health and Care Excellence del Reino Unido publica sus guías de fin de la vida para adultos, disponibles aquí. En adición, aquí hay un ejemplo de un protocolo de cuidado para la extubación terminal de un paciente: http://www.aacn.org/WD/Palliative/Docs/terminal_weaning_st_thomas.pdf Como siempre, siga sus protocolos locales. Los hospitales que miden tazas de sobrevivencia se benefician de tener órdenes de DNR debidamente firmadas ya que estos pacientes terminales entonces no entrarán a los registros de intentos de reanimación. A veces la evidencia de una orden DNR llega luego que la reanimación ha comenzado. En el caso de los proveedores fuera del hospital, se debe seguir el protocolo local. Si no existe un protocolo de cómo proceder en estos casos, se debe consultar al control médico para detener la resucitación. El objetivo final debe ser respetar los últimos deseos válidos y legítimos del paciente. Protocolo de Terminación de BLS en paro cardiaco fuera del hospital American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 3: Ethical Issues. ECCguidelines.heart.org. En términos generales, la RCP se realiza hasta que: Retorno de circulación espontánea Transferencia de cuidado a un equipo que provea soporte vital avanzado (en cuyo caso la resucitación puede continuar, pero bajo el control de los nuevos proveedores) El rescatador no puede continuar debido a cansancio o riesgo a su seguridad. Se cumplen criterios confiables de muerte cerebral irreversible, se identifican criterios de muerte obvia, o criterios para terminar la resucitación. A nivel de profesionales de BLS, los criterios incluyen: El paro cardiaco no fue presenciado por el primer respondedor o proveedor del SEM No hay retorno de circulación espontánea luego de 3 rondas de RCP y análisis del DEA El DEA no emitió ninguna descarga Es importante que la decisión se consultada con el médico para detener la reanimación a nivel de BLS. Los proveedores deben ser instruídos acerca de cómo comunicarse con la familia durante este momento de crisis.   https://eccguidelines.heart.org/wp-content/uploads/2015/10/ACLS-Termination-of-Resuscitation.png American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 3: Ethical Issues. ECCguidelines.heart.org. https://eccguidelines.heart.org/wp-content/uploads/2015/10/ACLS-Termination-of-Resuscitation.png El paro cardiaco no fue presenciado por el primer respondedor o proveedor del SEM. Ningún testigo realizó RCP No hubo RCE (retorno de circulación espontánea) luego de un intento completo de resucitación en la escena. El AED no recomendó ninguna descarga. El paciente vive o muere en la escena La única oportunidad de sobrevivencia del paciente en paro cardiaco es que se obtenga retorno de circulación espontánea en la escena. Las Guías 2015 de la AHA recomiendan que el paciente sea atendido en el lugar donde se encontró. Es más conveniente, en términos generales, atender al paciente en la misma escena que dentro de la ambulancia ya que en la escena comúnmente hay más espacio y comodidad que en espacio cerrado de la ambulancia. El paciente que no obtiene retorno de circulación espontánea en la escena tiene 0.7% de sobrevivencia, a diferencia del que sí obtiene RCE, cuya posibilidad de sobrevivencia asciende a un 17.2%. (Prehosp Emerg Care. 2012 Oct-Dec;16(4):451-5) La RCP durante el transporte es pésima. No produce ningún flujo sanguíneo significativo, pone a los proveedores en riesgo de accidentes, y no está asociado a aumento en sobrevivencia. No se debe realizar RCP en movimiento. ¿Cómo resucitar a un paciente? Paso 1: Proteger al cerebro mediante compresiones cardiacas Paso 2: Tratar la causa del paro ¿Por qué su paciente está en paro cardiaco? Los pacientes en paro cardiaco se pueden dividir, según el algoritmo, en dos tipos: los que tienen un problema de ritmo [arritmias como fibrilación ventricular (FV) y taquicardia ventricular (TV) sin pulso] vs los que no tienen un problema de ritmo. Identificar esto es fácil si se tiene un monitor cardiaco. Una simple revisión rápida del ritmo nos provee esta respuesta. Todo paciente en paro cardiaco recibe el siguiente tratamiento: Compresiones de alta calidad, con la menor cantidad de interrupciones. Análisis del ritmo cardiaco inicialmente y cada dos minutos. Si el ritmo es desfibrilable, se desfibrila, si el ritmo no es desfibrilable, no se desfibrila. Epinefrina 1 mg cada 4 minutos (3-5 minutos) Tratar las causas reversibles probables. (si es una arritmia, se administra un antiarrítmico) Causas Reversibles Las causas reversibles son: "Heart" (arritmias del corazón) - desfibrilación + antiarrítmicos Hivolemia - líquidos y sangre Hipoxia - oxígeno Hidrógeno (acidosis) - bicarbonato si estaba acidótico antes del paro Hipotermia - calentar al paciente Hipoglucemia (especialmente en pediátricos) - dextrosa Hipo/hiperpotasemia - calcio, bicarbonato, dextrosa + insulina Toxinas - antídoto (naloxona si es un opioide, o lo que recomiende el Centro de Envenenamientos 1-800-222-1222) Tension, pneumotórax - descompresión Tamponada cardiaca - descompresión Trombosis coronaria - reperfusión Trombosis pulmonar - reperfusión Volvamos al Paso 1: Proteja al cerebro Primum non nocere (primero no cause más daño). En este caso, esto significa que no causemos más anoxia al cerebro. Si usted interrumpe las compresiones, pierde perfusión cerebral. Tenemos que volvernos una máquina perfecta de perfusión cerebral... ya sea manual o mecánica. De la forma en que yo lo veo, tenemos un problema (cualquiera de las H's y T's mencionadas anteriormente), y tenemos una solución. Entre medio del problema y la solución, tenemos un obstáculo: la pobre perfusión al cerebro está acabando con el cerebro rápidamente. En otras palabras, tenemos que actuar rápido. El problema es que algunas de las soluciones requieren TIEMPO. Es fácil y rápido descomprimir un pneumotórax a tensión, pero hacer una embolectomía por una embolia pulmonar, o una intervención coronaria percutánea toma más tiempo del que usualmente tenemos. Tenemos una solución a esto... RCP mecánico. Existe mucha controversia sobre el rol del RCP mecánico... pero si se decide que el paciente requiere un cuidado definitivo que va a durar más tiempo, no hay duda que las máquinas que proveen compresiones continuas tienen esa ventaja: proveer compresiones por largo tiempo. Lea este artículo de EMSWorld: qué hacer cuando su paciente en RCP mecánico recupera conciencia durante las compresiones. Sin leer el artículo, deducimos que la perfusión al cerebro fue tan buena que el paciente recuperó conocimiento durante las compresiones. Pero lo más importante de esto, en mi opinión, es que si podemos mantener el cerebro con buena perfusión infinitamente, tenemos un tiempo infinito para tratar de corregir la causa que tiene el paciente. Antes no nos enfocábamos mucho en la calidad de las compresiones. Las compresiones eran malas (y siguen siendo malas en muchos sitios) y esto provocaba que no hubiera buena perfusión cerebral. A su vez, esto provocaba daño cerebral en poco tiempo. Por lo tanto, antes, el tiempo era importante porque estaba asociado a muerte cerebral. Debido a las pobres compresiones, en pocos minutos empezaba a ocurrir acidosis respiratoria y era necesario tratar la acidosis. Ahora, la acidosis respiratoria se corrige gracias a las buenas compresiones. Ahora, si podemos perfundir perfectamente al paciente, hemos quitado la barrera. El tiempo no es el problema. El verdadero problema ahora es entender si hay algo que podamos hacer por el paciente. Si existe la posibilidad de hacer algo, se intenta. Si no existe la posibilidad, entonces es momento de suspender el esfuerzo. No es un asunto de tiempo, es un asunto de entender qué tiene el paciente y cuáles son las opciones reales. Es decir, el tiempo era el factor limitante. Si podemos perfundir perfectamente al paciente, hemos quitado la barrera. Escuchen este podcast sobre la embolia pulmonar que sufrió el Dr. Joseph Ornato, MD FACEP FACC FAHA. El Dr. Ornato es uno de los principales investigadores sobre el uso de oxigenación por membrana extracorporea (ECMO) durante paro cardiaco para realizar embolectomías. ¡Resulta que él fue uno de sus propios pacientes en su propio estudio! Óigalo contar su historia, la cual incluyó ECMO, compresiones cardiacas, hipotermia terapéutica por 1 semana, y una recuperación neurológica completa. Las guías 2015 de la AHA recomiendan que la RCP extracorpórea (ECPR) puede proveer tiempo adicional para tratar causas reversibles del paro cardiaco (tales como síndrome coronario agudo, embolia pulmonar, fibrilación ventricular refractaria, hipotermia extrema, intoxicación por drogas, y otras causas más). Lea más sobre ECPR en este website: http://edecmo.org/ El tiempo no es el factor determinante de cuándo detenemos la resucitación. Se detiene el esfuerzo cuando se han intentado las cosas que razonablemente se pueden intentar y no ha habido una respuesta. Se detiene la RCP cuando no hay más nada que hacer. Paro cardiaco por trauma Analicemos un caso hipotético: Los paramédicos llegan 8 minutos luego de que se reporta un serio accidente. Cuando llegan, el paciente está inconsciente, sin signos de vida. ¿Qué posiblemente le pudo haber pasado a este paciente? Probablemente una o varias de las siguientes: Lesión traumática cerebral Hipovolemia por un sangrado masivo Hipoxia Pneumotórax a tensión Tamponada cardiaca ¿Cuánta RCP y epinefrina va a resolver estos problemas anteriores? NINGUNA! Si su paciente se desangró, le administraron líquidos IV, sangre, no ha respondido y está en asístole, ¿cuál es el objetivo de realizar RCP por 20, 30, 60 minutos? De seguro usted realizó estas intervenciones mucho antes de 20 minutos. Si usted ya ha determinado que no hay respuesta y está en asístole... ¿cuánta RCP es necesaria? Probablemente ninguna. Si alguien necesita darle RCP por 30 minutos... pues que lo haga hasta que se sienta que "hizo todo lo posible". En un futuro, los libros de historia de la medicina mirarán esta época y contarán que: En el siglo 21 tuvimos una especie de "ritual de paso" para declarar a una persona muerta y dejarla descansar en paz. En este "ritual" le brindámanos epinefrina y ceremonialmente contábamos mientras comprimíamos el pecho rítmicamente y danzábamos alrededor del paciente realizando diferentes procedimientos como desfibrilación, intubación, canalización, etc., hasta que por fin decidíamos, por diferentes y siempre cambiantes razones, que debíamos parar. En cambio, si usted decide hacer algo, ¡realice intervenciones significativas! ¿Qué son intervenciones significativas? Las "intervenciones significativas", según John Hinds, son aquellas que directamente arreglan algo. Son intervenciones o acciones específicas. En momentos de crisis, donde el tiempo y los recursos pueden ser limitados, es críticamente importante que todas las personas envueltas no pierdan tiempo en cosas que no sean intervenciones significativas. Según el Dr. Hinds, las intevenciones significativas en el paciente de trauma son: Intubación usando un "bougie" y capnografía de onda Toracostomía digital (con el dedo) bilateral Colocar una faja pélvica (SAM Splint) Enderezar fracturas de huesos largos Administrar bolos de fluído (administrar sangre si está en el hospital) Luego de realizar esto, entonces analizan cuál es el estatus del paciente y cuáles son los problemas que se han descubierto para decidir cuáles son las alternativas (ver abajo más info sobre toracotomía de emergencia y sobre REBOA). (Nota: El Dr. Hinds falleció en un accidente de motora este año. Vea un tributo aquí). Pero dejemos que sean las propias palabras del fenecido John Hinds que describan lo que él mismo llamó "intervenciones significativas".                   Paro cardiaco por trauma... toracotomía de emergencia Si usted entiende que su paciente tiene un sangrado masivo, la mejor forma de estabilización es detener el flujo pinzando la aorta. Si usted está decidiendo resucitar al paciente de trauma y se va en paro cardiaco frente a usted... este es el momento. De lo contrario, recuerde que las compresiones cardiacas y la(s) epinefrina(s) son completamente inútiles en este momento.       La toracotomía de emergencia está asociada a mortalidad excesivamente altas. El problema no es solamente encontrar la aorta, sino resolver lo que uno encuentre. Si usted no va a hacer esto, y su paciente requiere un control inmediato de un sangrado masivo abdominal, entonces considere si es útil continuar los esfuerzos. REBOA: una opción en el futuro cercano         Donación de órganos En lugares que tengan un sistema de captación inmediata de órganos y un programa preparado para implementarlo efectivamente, los pacientes que no logran RCE podrían ser candidatos para donar hígado y riñones. Corazones muy buenos para morir A todos nos corre la adrenalina por las venas cuando llegamos a un paro cardiaco. La mejor satisfacción es ver a un equipo verdaderamente coordinado realizando un esfuerzo genuino e inteligente por corregir la causa. Aunque el obtener el pulso (retorno de circulación espontánea, o RCE) NO es el objetivo final (el objetivo final es lograr el egreso del hospital neurológicamente intacto o viable), el RCE es un paso importante en el progreso del paciente. A los que nos apasiona ese juego entre la vida y la muerte, saben que una de las mejores emociones es saber que puedes revertir el paro cardiaco, intentarlo, y luego de esforzarte, obtener ese retorno de circulación, sentir el pulso y ver una presión sanguínea en el monitor. A los que me conocen y han trabajado conmigo, saben que usualmente mi frase favorita es "¡buen trabajo mi gente... estamos en cancha todavía!" Conclusión...memento mori Recuerde que todos vamos a morir algún día, y si hacemos las cosas correctamente, la muerte puede ser tan digna como la vida. Referencias American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 3: Ethical Issues. ECCguidelines.heart.org.

From this week all UK babies will be vaccinated against that most feared disease, meningitis B, the first country in the world to take this step. But the decision to include Men B in the national immunisation programme has come too late for parents, Freya and Ross. A year ago their baby daughter, Harmonie, nearly died after contracting the infection. Her arms and legs as well as the tip of her nose had to be amputated because of the resulting sepsis. Sue Davie, Chief Executive of Meningitis Now tells Mark that the vaccine is great news and will save many lives. But she hopes in the future that it will be offered to older babies and young children, as well as another at risk group, adolescents. Mental health problems have long been linked to fluctuating hormone levels, at times of menstruation, childbirth and menopause. Dr Michael Craig who runs the Female Hormone Clinic at the Maudsley Hospital in London discusses the role of hormone replacement treatments. Statins are the most commonly prescribed medicines in the UK. They work to lower the level of cholesterol in your blood. There's been considerable debate about when doctors should start prescribing statins and NICE, the National Institute for Health and Care Excellence, had been keen for GPs to be paid to put more patients on the cholesterol-reducing drugs. Dr Margaret McCartney outlines the controversy and NICE Deputy Chief Executive, Professor Gillian Leng, tells Mark that the health advisory body has listened to concerns and why their new statins targets are now to be tested in the field. Young, healthy, sporty people don't get heart attacks. Except when they do. Dr Stuart Miller, Clinical Director of Sport and Exercise Medicine at the University of Bath admits that he was shocked when he had a heart attack, even though he cycles, swims and eats a healthy diet. Sanjay Sharma is professor of cardiology at St George's Hospital in London and he tells Mark how common unexpected heart attacks are. Producer: Fiona Hill.

Diabetes in pregnancy, gestational diabetes, is on the increase, and the risks to mother and baby if this condition is untreated, are very serious. Around one in fourteen pregnant women will develop GD, but the risk is much greater according to age and weight of the mother, whether there's a history of diabetes in the family and in certain ethnic groups. Dr Mark Porter visits The Rosie Maternity Hospital in Cambridge, where Dr Helen Murphy introduces him to the specialist teams that enable 70% of the women diagnosed there to manage their diabetes through diet and exercise, rather than medication. The UK's National Institute for Health and Care Excellence, NICE, has introduced new guidelines for diagnosing gestational diabetes which differ from international thresholds backed by the World Health Organisation. Mark talks to researcher Dr Claire Meek from The Rosie, one of the authors of research published in the journal Diabetologia, which found that up to 4,000 women, at risk of serious birth complications, would be missed under the new UK criteria. The teams at The Rosie are shunning the new NICE guidelines and continuing to follow the WHO thresholds. Professor Rudy Bilous, who runs the Diabetes in Pregnancy Service at the James Cook University Hospital in Middlesbrough and chaired the development group at NICE that produced the new diagnostic guidelines, tells Mark that he's confident that the thresholds, which were drawn up using the latest available evidence, are set at the right level. Weight loss properties and low carbohydrate diets: listener Mark Robins from Southampton describes his success following a low carb diet (he lost nearly four stone in a year) and Inside Health's Dr Margaret McCartney and Susan Jebb, Professor of Diet and Population Health at the University of Oxford discuss the evidence behind weight loss and low carb diets. The number of children who say they are afraid of injections is increasing and Dr Amy Baxter, a paediatric emergency doctor from Atlanta, Georgia and an expert in needle pain, has shown a link between the number of jabs and fear of needles. UK children have up to 15 vaccinations, with the new Meningitis B on the horizon, so managing that fear is important. Dr Baxter tells Mark what parents and health care professionals can do to help, and saying "Sit still, don't move, this will only hurt a bit", isn't recommended! Producer: Fiona Hill.

The vast majority of men in their 50s, and more than half of women over 60, could soon be offered statins - cholesterol-lowering drugs - to reduce the risk of heart disease. That would mean that a 59 year old man who doesn't smoke, has no history of heart disease and has healthy weight, blood pressure and cholesterol levels could find himself taking a statin a day for life. The National Institute for Health and Care Excellence proposes that up to twelve million people - one in four adults - should take the medication. Critics argue against such mass medication and claim that there is a high incidence of side effects including muscle aches, sleep problems and diabetes. They also question the drugs' effectiveness in reducing the number of heart attacks. But the defenders of statins say that this is scaremongering and risks unnecessary deaths. Tom Esslemont investigates how the UK has become the so called 'statins capital' of Europe and explores the arguments for and against. Producer: Emma Rippon Researcher: Ben Weisz.