Saturday, November 30, 2019

? the fountain of eternal life perhaps

STEM cell research .
superman Christopher Reeves is dead .
did he leave instructions for some of his cells to be frozen ?
so that in future we can clone a superman.

another news of frozen ovarian tissue is transplanted back in to a woman and she is pregnant .
May be this is the beginning of ovarian factories
all women who have had children and want no more will donate their ovaries which are transplanted in to a primate and these are translocated in to a subcutaneous sac.
so that they can be easily harvested
sperm can already be frozen and kept
somatic cells can be frozen .
After getting an order an ovum with a sperm or somatic cell cloning is done and newer tissues and organs are created .
? the fountain of eternal life perhaps .

Substance Abuse In Health Care


Doctors and nurses account for one of the highest rates of addiction in the workforce. According to USA Today, “Across the country, more than 100,000 doctors, nurses, technicians and other health professionals struggle with abuse or addiction, mostly involving narcotics such as Oxycodone and Fentanyl.”

Why 
Work Stress
Easy availability
emotional pain from a day of hard decisions and upsetting outcomes.
What sets doctors and nurses apart from other professionals is their accessibility to highly sought-after drugs — because it’s easier for them to get the drugs, it’s easier to create or feed an addiction.

Personality

 What is the difference between God and a Surgeon ?

 God does not think he is a surgeon.
Boredom

 Looking for a way to stay alert on an all-day or overnight shift 

A way to escape the emotional pain from a day of hard decisions and upsetting outcomes.



Like many other working professionals facing an addiction, there are many reasons a medical professional might turn to drugs or alcohol. They could be looking for a way to stay alert on an all-day or overnight shift or a way to escape the emotional pain from a day of hard decisions and upsetting outcomes.
What sets doctors and nurses apart from other professionals is their accessibility to highly sought-after drugs — because it’s easier for them to get the drugs, it’s easier to create or feed an addiction.
The rate at which doctors and nurses suffer from addiction may be high, but this subgroup of people also has a high rate of recovery when they get treatment.

Signs Of Addiction Within Medical Professionals

Recognizing a drug or alcohol dependence in doctors or nurses can be difficult because many are considered to be highly functional addicts. This means that they are able to maintain their career, home life and substance abuse for a period of time without others noticing.
Common signs of addiction in doctors and nurses include:
  • Changing jobs frequently
  • Preferring night shifts where there is less supervision and more access to medication
  • Falling asleep on the job or in-between shifts
  • Volunteering often to administer narcotics to patients
  • Anxiousness about working overtime or extra shifts
  • Taking frequent bathroom breaks or unexplained absences
  • Smelling of alcohol or excessively using breath mints or mouthwash
  • Extreme financial, relationship or family stress
  • Glassy eyes or small pupils
  • Unusually friendly relationship with doctors that prescribe medications
  • Incomplete charting or repeated errors in paperwork

Why Medical Professionals Turn To Drugs of Alcohol

There are many unique aspects of a doctor or nurse’s profession that makes them more likely than other occupations to form a substance addiction.
A common reason that medical professionals may be tempted to abuse substances such as Oxycodone or Fentanyl is due to the easy access they have to powerful prescription medications that aren’t properly accounted for as they are administered. They also have an extensive understanding of the effects these substances have on an individual and this may motivate them to try to mimic these sensations in themselves in order to produce a high or euphoria.
Along with their unpredictable and exhausting work hours, medical professionals are required to make spur-of-the-moment decisions regarding their patients’ health and wellbeing. If they feel responsible for a certain outcome or come to regret a choice that was made, this can greatly affect their emotions and mental state, leading to substance abuse.

The Effects Of Addiction In The Workplace

An addicted medical professional is more likely than their non-addicted colleagues to cause an accident in the workplace or neglect patients’ health. They may be distracted on the job or abruptly leave important appointments or surgical procedures to use drugs.
Sometimes I’d be standing in the operating room and it’d look like I had the flu. So I’d excuse myself and I’d run into the bathroom, eat 10 [Tylenols with codeine], and in maybe five or 10 minutes I’d be normal again.

- Richard Ready, former chief resident of neurosurgery at a prominent Chicago hospital, LA Times
Doctors and nurses suffering from addiction are not only putting their own health at risk, but also the wellbeing of patients in their care. It may be hard for a medical professional to accept they have an addiction, but the sooner that the addiction is faced head on, the better. This can help prevent accidents on the job or not attending to important signs of health issues in patients.

A comparison of tuberculin skin tests and interferon-gamma release assays


A comparison of tuberculin skin tests and interferon-gamma release assays
TST IGRAs
Advantages TST does not require equipment and can be done without a laboratory. It is less expensive than for IGRAs (but greater personnel time is required).
Longitudinal studies have demonstrated the predictive value of TST, and randomized trials show that LTBI therapy is much more effective in those who are TST positive than TST negative.
IGRA does not require follow-up visit to complete the testing process (but follow-up visits may be needed for LTBI therapy).
IGRA does not give false-positive results because of prior BCG vaccination.
Disadvantages TST requires an intra-dermal injection and a subsequent follow-up visit with trained staff to interpret results in 48 to 72 hours.
TST may give false-positive results because of prior BCG vaccination or sensitization to nontuberculous mycobacteria.
TST may give false-negative results because of immunosuppression (eg, HIV or active TB), natural waning of immunity, and technical limitations (including reader variability).
Serial TST interpretation is complicated by potential boosting, although this can be minimized through initial two-step testing.
TST can cause adverse reactions (skin blistering and ulceration); these are rare.
IGRA requires a blood draw, laboratory equipment, and technical expertise for specimen collection, processing, and assay. Reagent costs are substantially higher than costs of TST.
IGRA test results are available within 24 hours at the earliest.
IGRA may give false-negative results because of immunosuppression (eg, HIV or active TB) and technical variability.
Interpretation of serial IGRA is complicated by frequent conversions and spontaneous reversions and by lack of consensus on optimum thresholds for conversions.
TST: tuberculin skin test; IGRA: interferon-gamma release assay; HIV: human immunodeficiency virus; LTBI: latent tuberculosis infection; BCG: Bacillus Calmette-Guerin.
Graphic 76107 Version 4.0

Low Dose Naltrexone : Miracle cure?

When I was in medical school, I discovered that indeed most of us were there because we wanted to help people, even though I'd been told in response to my essay that, no matter what, one should never write that down as the reason. It was too common of an answer, indicating too much emotion and not enough reason. My peers and I were all focused on patients, studying hard and memorizing all kinds of strange facts, so that if we ever encountered a patient who had a very unusual illness, we would know just what to do. Yet several years into practice, I found that my days were filled with insurance paperwork, phone calls, chart reviews, and a stack of unfinished progress notes that would take me long past sunset every day to complete. I was spending more time at the computer than with patients. Despite all of this, I can tell you that if I thought I was making a difference in anyone's life or truly helping them get better, it would all have been worth it. But that was not the case. My schedule was filled with patients who had chronic disease and who never got better. Every time they came in they needed more medications. Their numbers never got better, their illnessesnever improved, and they never felt better. I know that I have patients who have been with me since the beginning who will argue with me about this, but it's true. This all changed when I found LDN. At first I was very doubtful, and I wrote my first prescription at the insistence of my seventy-year old patient Marla, who had learned all about LDN from the Internet (doctors generally dread patients who bring in information printed off the Internet; they are second only to patients who happen to have a nurse in the family). When Marla's symptoms improved, I thought it was interesting, but I was too busy with my paperwork to actually delve deeper into LDN. I knew it was being used as an alternative medicine to treat multiple sclerosis (MS), and at the time none of my patients had that illness. Then, years later, I met Christian. At thirty-two, he was the youngest male patient I had with a serious illness. "Doctor Jill, I've done the research on LDN, and I want to try it out for my symptoms," he said. Christian had an episode of what was basically optic neuritis presenting as double vision. Both his

brain MRI report and the report from his spinal tap were consistent with MS. Because this episode of double vision was only a single event, his diagnosis was not yet called MS, and was instead called clinically isolated syndrome. It carried a high probability of turning into MS, and his neuro-ophthalmologist recommended aggressive immunosuppressant therapy. "I understand the risks, and I'm willing to accept them. My symptoms are already nearly gone, and I want to try LDN first, before taking an immunosuppressant," he said. I had mixed feelings about this idea. I knew his specialist and did not want to step on his feet. In addition, I am not a neurologist, and at that time had no experience whatsoever in treating MS, both facts that I pointed out to my patient. However, I am a big proponent of patient choice, and I was willing to support his choice to decline conven- tional treatment. I carefully documented in his chart that we had discussed all the risks, contraindications, and alternatives.

I followed Christian very closely, seeing him frequently and documenting as thoroughly as possible everything about his case. I prescribed the LDN exactly according to how other clinicians were prescribing it. Christian's symptoms resolved within about five months of starting treatment, and his MRI reports were slightly improved each time we ran them. In a startling development, the MRI of his brain was read as normal at the two-year mark of treatment. There were no longer signs of any disease at all.


Having been trained in traditional allopathic medicine, I was well aware that this was what would be called an anecdotal case. It was possible that his results could be coincidental and completely unrelated to the treatment. However, a year later, when he was still symptom-free, my curiosity about LDN finally got the better of me. I started doing research into LDN. What I discovered was extremely interesting, and completely changed the way that I thought about LDN. During my medical training I had always assumed that if a treatment was not conventional, with double-blind, placebo-controlled, randomized trials, then it was not a legitimate treatment. I discovered that I was wrong. When I had first heard about LDN, I had no idea who Dr. Bernard Bihari was or how impressive his credentials were. I had no idea how much infor- mation was available about LDN's biochemistry; I found that the cellular pathways were known down to the very receptors involved. Before doing my research, I did not realize that small studies and case reports had already been published. In the ear that I started considering LDN seriously I attended a confer-


In the year that I started considering LDN seriously, I attended a confer- ence in Las Vegas put together by the LDN Research Trust. It was fascinating to listen to the many speakers talk about their personal experiences with LDN, and to witness the presentations of many interesting case studies. A good number of the doctors had been prescribing LDN for as long as I had been in practice. But throughout the day a question kept bothering me. If LDN was a legitimately successful treatment, then it seemed to me that all these doctors should have been writing up their findings and getting them published. It was during a conversation with one of the oldest doctors in attendance that I finally realized the answer. All these doctors were just as busy as I was. The only difference was that they were busy taking care of patients. They did not have time to be writing case reports or conducting trials. It was at that point I realized how much my view of the practice of medicine had changed. IhisI wanted to help people. When I got back to my office, my level of comfort in prescribing LDN was considerably increased. I decided that I needed to tell more people about LDN. I typed up a patient information page in a question-and- answer format. When I saw patients who seemed like good candidates for treatment with LDN, I told them about the treatment and gave them the information. Many patients were interested.


Currently, I have over one hundred patients taking LDN. Ihe results I've seen far exceed anything that could be attributed to a placebo effect. Because I have a general internal medicine practice, I see a wide variety of illnesses, many of them chronic. This has given me the opportunity to try out LDN in many clinical situations and monitor the response. I have used LDN for autoimmune joint diseases, including rheumatoid arthritis, psoriatic arthritis, lupus, and ankylosing spondylitis. I have used it for inflammatory bowel disease, celiac disease, and irritable bowel syndrome. I have also used it for chronic-pain syndromes such as fibromyalgia, neuropathic pain, chronic regional pain syndrome, and osteoarthritis. Other disorders such as fatigue, asthma, allergies, and dermatitis have also responded. These illnesses may all look different on the surface, but the underlying problems are the same. Most chronic diseases have a component of inflammation and immune system dysfunction. LDN works at the root of the problem, addressing the core issues, resulting in improvement in the clinical syndrome.

I have one patient with stage one prostate cancer who prior to seeing me was being treated with expectant management alone (also known as watchful waiting). We started LDN and watched his PSA (prostate cancer tumor marker) drop by over 20% in two months. Six months later it had dropped again, and we are continuing to monitor it. I have kept careful records and maintain a spreadsheet on my computer of all my patients taking LDN, detailing their diagnoses and progress. As a very conservative figure, at least 70% of the patients who have tried LDN have had a clinical response. If you take out the patients who stopped early because of side effects, the number increases to over 80%. Of the patients who have had a clinical response, the percentage who rate their response as much improved (which would be a level 5 on a scale of 1 to 5) is around 30%. Not everyone has had a dramatic response, but there are many who have. Some of my patients became symptom-free within just a few months of treatment. Some of my chronic-pain patients were pain-free within the

I have one patient with stage one prostate cancer who prior to seeing me was being treated with expectant management alone (also known as watchful waiting). We started LDN and watched his PSA (prostate cancer tumor marker) drop by over 20% in two months. Six months later it had dropped again, and we are continuing to monitor it. I have kept careful records and maintain a spreadsheet on my computer of all my patients taking LDN, detailing their diagnoses and progress. As a very conservative figure, at least 70% of the patients who have tried LDN have had a clinical response. If you take out the patients who stopped early because of side effects, the number increases to over 80%. Of the patients who have had a clinical response, the percentage who rate their response as much improved (which would be a level 5 on a scale of 1 to 5) is around 30%. Not everyone has had a dramatic response, but there are many who have. Some of my patients became symptom-free within just a few months of treatment. Some of my chronic-pain patients were pain-free within the

A lot has changed in my life since I got that first stethoscope. A lot has changed since my days of wanting to walk away from medicine. My sense of hope has been renewed, and I love being a doctor again. My sincere desire is for other doctors to also have their lives and practices renewed. I want more patients to know about LDN and have the opportunity to try it if they might benefit. I want to help spread the word, and thanks to Linda Elsegood and the LDN Research Trust, this book is an important step in that direction. In the following pages, many different experts tell their stories about how low dose naltrexone has made a difference in their areas of expertise. Information is presented about LDN's development, pharmacology, clinical trials, efficacy in the treatment of various disorders, and current areas of ongoing study. Our hope is to educate clinicians and give them the informa- tion and tools they need to feel comfortable incorporating treatment with LDN into their practices. 
We are also expecting that a number of patients will be interested in this information as well, and that the book can open a door of communication between patients and their clinicians in a positive way, as we work together toward our common goal of healing. JILL COTTEL, MD MEDICAL DIRECTOR, POWAY INTEGRATIVE MEDICINE CENTER, POWAY, CA

Understanding the cost of Addiction and Rehab

Understanding the Cost of Addiction and  Rehab


The Cost of Addiction

In the long run, rehab is not nearly as expensive as drug and alcohol addiction. Alcohol and drug users are more likely to skip work and switch jobs more often than sober individuals, which has a negative impact on income. The price of drugs, legal problems, health issues and loss of productivity at work all add up over time.
An alcoholic who drinks a 12-pack a day consistently for a year spends over $3,000. This cost doesn’t include potential legal issues that can cost thousands more. It’s harder to estimate the price of illicit drug addiction, but it can be much higher.

Like  a physician who loses his license
Some former heroin users have reported spending tens of thousands of dollars on their addiction.
The financial costs of addiction are only part of the equation. They don’t include the personal costs on relationships and a meaningful life.
The cost of addiction treatment varies between each center. Some programs are free while some cost thousands of dollars a day. No matter your budget, there is a center for you. The opportunity to heal is accessible to anyone if they know what resources can help them. There are also people who can help you find a way to pay for treatment as soon as possible.
Most rehabs offer financial aid, accept insurance or have financing options.
Insurance is one of the most common ways of paying for rehab. The amount insurance covers depends on the insurer and what the health provider accepts.
Types of insurance that may cover addiction care include:
Not everyone has insurance, but there are still ways to get the help you or a loved one deserves. One way is to look for a free or low-income center. The other is to look into programs that offer financing options. Financing is often a better choice because free rehabs often have limited funding and waiting lists.
Many inpatient rehabs offer financing options for those without insurance.
Some people may be anxious to take on debt, but it’s important to view addiction rehab as an investment. Over time it pays off. Getting sober gives people the tools to get their life and career on track. Recovered addicts are also able to save more because they aren’t spending on drugs or alcohol.

Types of Addiction Treatment and Costs

The type of care offered by a rehab affects the total cost of getting sober. Treatment types are also different for some addictions. There are many other factors that affect the cost of rehab, from medical care to amenities. The following estimates are based on costs reported by studies and individual facilities.
DetoxOutpatient detox ranges from $1,000 to $1,500 in total. Most inpatient rehabs include detox in the cost of a program. The exact cost of detox depends on whether it’s part of an inpatient program and the type of drug addiction being treated. Substances with dangerous detox side effects require more careful monitoring, making the price higher.
Inpatient RehabSome inpatient rehabs may cost around $6,000 for a 30-day program. Well-known centers often cost up to $20,000 for a 30-day program. For those requiring 60- or 90-day programs, the total average of costs could range anywhere from $12,000 to $60,000.
Outpatient RehabOutpatient programs for mild to moderate addictions are cheaper than inpatient rehab. Many cost $5,000 for a three-month program. Some outpatient programs, such as the program at Hazelden Betty Ford, cost $10,000. The price tag depends on how often the individual visits the center each week and for how long.
MedicationsThe type of treatment and medications needed affects the price tag on rehab. Some people don’t need medication for their addiction. Medications most often treat alcohol and opiate addiction. It can cost several thousand dollars a year. Year-long methadone treatment for heroin users costs around $4,700.

What Factors Into the Cost of Addiction Treatment?

There are several factors that affect the cost of rehab. Some of the predominant factors include:
  • Type of Center
    There is a big divide in the price of inpatient and outpatient programs. The costs of inpatient programs are higher because the costs of housing and intensive care are higher.
    The cost of these programs also depends on the length of the program and location. A center in a state with a higher cost of living, like California, can be more expensive.
  • Treatments Offered
    Some people don’t need medical detox when they start rehab. Cocaine users usually don’t experience dangerous withdrawals when they stop using, so there is no technical detox other than being monitored. But alcohol and heroin users often experience intense withdrawals during detox and usually need medication.
    Those requiring more medical care tend to pay more for rehab. Certain therapies like professional counseling also affect how much you could pay.
  • Amenities
    The amenities offered by a rehab don’t come for free. Amenities may include massages, acupuncture, swimming pools, tennis courts, large individual rooms or award-winning chefs. Luxury rehabs typically frequented by the rich and famous are expensive because of amenities.
    Luxury centers can cost tens of thousands of dollars per month. While most rehabs aren’t this expensive, more amenities mean a higher price tag.

Friday, November 29, 2019

Conjunctivitis was treated with instilling breast milk in the eyes.: Down the memorylane



When we were children we had very few medical facilities.
My mother  who had 6 children had  some of traditional treatments for some common pediatric ailments.

One of them was treatment of Conjunctivitis by instilling a few drops of breast milk which is freshly squeezed

Scientifically a sound proposition i think
It is  sterile if collected correctly like cleanse the nipple discard the first few squeezes in to a cleaned silver spoon.
It is isotonic
It has high fat content to lubricate the eye
It has  a significant  amount of various antibodies cytokines etc
which are protective agains  bacteria/viruses and even fungi.

A New Class of Antimicrobials Has Just Been Found in Human Breast Milk 

 

 

The looming threat of antibiotic resistance means we desperately need new remedies to counter deadly superbugs, and researchers could have just found one in the most natural food source of all: breast milk.
Scientists have long known that, in addition to general sustenance, breast milk offers babies vital nutrients to build up their immune systems. Now, researchers have discovered a new mechanism behind this antibacterial boost – in breast milk sugars.
Contrary to the understanding that antibacterial defences are passed from mothers to their babies solely through proteins in breast milk, a team from Vanderbilt University says sugars – or carbohydrates – also demonstrate properties that can protect against bacterial infections.
"This is the first example of generalised, antimicrobial activity on the part of the carbohydrates in human milk," says chemist Steven Townsend.
"One of the remarkable properties of these compounds is that they are clearly non-toxic, unlike most antibiotics."
The most prominent infection that affects newborns is called Group B Streptococcus (GBS), which can lead to babies developing sepsis or pneumonia before their immune systems are strong enough to fight off the bug.
Luckily, while GBS can be deadly for babies, most newborns don't get infected by it, and the team wanted to investigate whether those infants might be getting protection courtesy of their mothers' milk.
"We wondered whether [GBS's] common host, pregnant women, produces compounds that can either weaken or kill strep, which is a leading cause of infections in newborns worldwide," Townsend explains.
To find out, the researchers took human breast milk carbohydrates from five human donors and isolated complex sugars from them (called oligosaccharides), before introducing the oligosaccharides to strep cultures in the lab.
Analysing the interaction under microscope, the team found the carbohydrate could both kill the bacteria as well as weaken its natural defences – by preventing it from forming a protective biofilm to fend off threats.
23948 breastmilk 1Steven Townsend/Vanderbilt
In the image above, that biofilm can be seen on the left – but it's prevented from forming in the presence of the carbohydrates (on the right).
"When bacteria want to harm us, they produce this gooey protective substance," Townsend explains, "which allows them to thwart our defence mechanisms."
In one sample, the sugars killed the strep entirely. In another, they were moderately effective at killing the strep, while in the remaining three samples the carbohydrates weren't very effective.
To help explain what's going on here, the team is currently conducting another set of tests.
In new research not yet published but presented this week at a meeting of the American Chemical Society in Washington, DC, Townsend's group again found a mix of results.
These included two cases where breast milk sugars broke down the biofilm and killed the bacteria; four where the biofilm was broken but the bacteria survived; and two where the bacteria died, but the biofilm persisted.
It's early days, and it's clear that more research will be needed to figure out the spectrum of these outcomes.
But if the team can solve the puzzle, it could lead to the beginnings of a new class of antibiotics, now that we know how these carbohydrates function in the presence of bacteria.
"[T]hese sugars have a one-two punch," says Townsend.
"First, they sensitise the target bacteria and then they kill them. Biologists sometimes call this 'synthetic lethality' and there is a major push to develop new antimicrobial drugs with this capability."
In addition, the team says its preliminary, still-in-progress data indicates that milk sugars can make bacteria more susceptible to common antibiotics – such as penicillin and erythromycin.
We shouldn't get too carried away until the team has more to show, but if those results pan out, it's possible that the carbohydrates might be able to one day lessen our reliance on these kinds of common antibiotics, and in doing so help to unravel a big part of the resistance problem.
We won't know more until the latest research is complete, but it's a hugely promising direction to investigate further – and one that, one day, could reap benefits for everybody.
"If you can figure out how the sugars are acting, then you can justify attempting to make large-scale amounts of them," Townsend says, "and then putting them in humans."
The findings are reported in Infectious Diseases.

 



Thursday, November 28, 2019

Caring for VIPs. Damned if You Do – Damned if You Don’t

Caring for VIPs

NTR

MGR

Jayalalitha

Vajpayee

Arun jaitley

Chenna reddy

Manohar Prrikar

Jayaprakash Narayan

 

Balakrishna  ( Malingering  politicians )

death of Eleanor Roosevelt from miliary tuberculosis  

JFK Addison's and  his assassination

The care of President Ronald Reagan after the 1981 assassination attempt is a benchmark of how to release information to the public

“Usually, the VIP is relieved if the physician states explicitly, ‘I am going to treat you as I would any other patient.’ I very much doubt this  happens in India

 

 

 Medical tourism is on the rise,1 and since medical tourists are often very important persons (VIPs), hospital-based physicians may be more likely to care for celebrities, royalty, and political leaders

a patient’s special social or political status—or our perceptions of it—induces changes in behaviors and clinical practice

  • Caring for VIPs creates pressures to change usual clinical wisdom and practices. But it is essential to resist changing time-honored, effective clinical practices and overriding one’s clinical judgment.
  • Designating a chairperson to head the care of a VIP patient is appropriate only if the chairperson is the best clinician for the case.
  • Although in some cases placing a VIP patient in a more private and remote setting may be appropriate, the patient is generally best served by receiving critical care services in the intensive care unit.
  •  
  • Vow to value your medical skills and judgment
  • Intend to command the medical aspects of the situation
  • Practice medicine the same way for all your patients.
PRINCIPLE 1: DON’T BEND THE RULES
“Since the standard operating procedures […] are designed for the efficient delivery of high-quality care, any deviation from these procedures increases the possibility that care may be compromised. 

ER LIGHTBULB INCIDENT
SLAPPING a VIP ATTENDANT


PRINCIPLE 2: WORK AS A TEAM, NOT IN ‘SILOS’ 
team work but also a sutradaar 
medical practice “is not a committee process; it must be clear at all times which physician is responsible for directing clinical care.
PRINCIPLE 3: COMMUNICATE, COMMUNICATE, COMMUNICATE

PRINCIPLE 4: CAREFULLY MANAGE COMMUNICATION WITH THE MEDIA  

Early implementation of an explicit and structured media communication plan 
 
Away from the site of the President’s care. 

senior hospital physician? problems 
currying favor 
penchant for fame 
scapegoating

PRINCIPLE 5: RESIST ‘CHAIRPERSON’S SYNDROME’

The pressure may come from the patient, family, or attendants, who may assume that the chairperson is the best doctor for the clinical circumstance. The pressure may also come from the chairperson, who feels the need to “take command” in a situation with high visibility 

encourage the participation of trainees in the care of VIP patients because excluding them could disrupt the usual flow of care, and because trainees offer a currency and facility with the nuances of hospital practice and routine that are advantageous to the patient’s care. 

PRINCIPLE 6: CARE SHOULD OCCUR WHERE IT IS MOST APPROPRIATE 
Caring for the VIP patient in a setting away from the mainstream clinical environment may offer the appeal of privacy or enhanced security but can under some circumstances impede optimal care, including prolonging the response time during emergencies and disrupting the optimal care routine and teamwork of allied health providers 
a request to transfer a VIP patient to a special setting designed for private care with special amenities (eg, appealing room decor, adjacent sleeping rooms for family members, enhanced security) available in some hospitals15–16 can be honored as soon as the patient’s condition permits. The benefits of such amenities are often greatly appreciated and can reduce stress and thereby promote recovery. The benefits of enhanced security in sequestered venues may especially drive the decision to move when clinically prudent 
PRINCIPLE 7: PROTECT THE PATIENT’S SECURITY

if a doctor has to go through a bodysearch to attend to a VIP medical emergency 
(Story)
important to protect them from attacks on confidentiality via unauthorized access to the electronic medical record, and this is perhaps the more difficult challenge, as examples of breaches abound

PRINCIPLE 8: BE CAREFUL ABOUT ACCEPTING OR DECLINING GIFTS  
Patients offer gifts out of gratitude, affection, desperation, or the desire to garner special treatment or indebtedness. 



The acceptance of a gift from a VIP patient or family member may be interpreted by the gift-giver as a sort of unspoken promise, and this misunderstanding may strain the physician-patient relationship, especially if the clinical course deteriorates

( Pochampalli silk saree)

accept the gift at the end of the episode of acute care

affirm the commitment to excellent care that is free of gift
the recommendations of the American Academy of Pediatrics—ie, attempt to appreciate appropriate gifts and graciously refuse those that are not.

PRINCIPLE 9: WORKING WITH THE PATIENT’S PERSONAL PHYSICIANS
VIP patients, perhaps especially royalty, may be accompanied by their own physicians and may also wish to bring in consultants from other institutions. Though this outside involvement poses challenges (eg, providing access to medical records, arranging briefings, attending bedside rounds), we believe it should be encouraged when the issue is raised. Furthermore, institutions and caregivers should anticipate these requests and identify potential outside consultants whose names can be volunteered if the issue arises.

this should not be viewed as an expression of doubt about the care being received. Rather, we prefer to view it as an opportunity to validate current management or to entertain alternative approaches
Collegial interactions with these physician-colleagues can facilitate communication and decision-making for the patient



 

Antisocial personality disorder : Sociopath / Prime example TRUMP ?

Antisocial personality disorder signs and symptoms may include:
  • Disregard for right and wrong
  • Persistent lying or deceit to exploit others
  • Being callous, cynical and disrespectful of others
  • Using charm or wit to manipulate others for personal gain or personal pleasure
  • Arrogance, a sense of superiority and being extremely opinionated
  • Recurring problems with the law, including criminal behavior
  • Repeatedly violating the rights of others through intimidation and dishonesty
  • Impulsiveness or failure to plan ahead
  • Hostility, significant irritability, agitation, aggression or violence
  • Lack of empathy for others and lack of remorse about harming others
  • Unnecessary risk-taking or dangerous behavior with no regard for the safety of self or others
  • Poor or abusive relationships
  • Failure to consider the negative consequences of behavior or learn from them
  • Being consistently irresponsible and repeatedly failing to fulfill work or financial obligations
Prime example TRUMP ?

Sunday, November 24, 2019

Dehumanizing Diagnosis

Dehumanizing Diagnosis 

It's also one of the aspects of medicine that can seem most dehumanizing.
It's how the elegant retired schoolteacher who mesmerized three generations
Of her students with stories Of the Roman Empire as she inspired them (0
master noun declensions in Latin is quickly reduced, in diagnosis-speak,
to the seventy-three-year-old woman with rapidly progressive dementia in
room 703.

Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis

By Lisa Sanders

How knowledge is acquired?

How knowledge is acquired?

The approach to knowledge management
in health services has generally been to try and deliver better-researched facts
to clinicians and to try and help them to make good use of such facts. But this
strategy assumes a rational and individualistic approach to knowledge acquisition
that flies in the face of all the evidence about what some have called ‘the social life’
of knowledge – the intricate, convoluted and confusing pathways by which people
in an organization negotiate, adapt and transform new knowledge that is often
far from factual. Maybe, we surmised, clinical knowledge also had a ‘social life’
that could be the key to overcoming the persistent frustrations of evidence-based
practice. The task we set ourselves, therefore, was to look afresh at how clinicians
actually acquire and use their knowledge in practice.

Tensions between clinical autonomy and (IR)rationalist bureaucracy

Tensions between clinical autonomy and (IR)rationalist bureaucracy

practitioners are nowadays more likely to be exposed to the best evidence either directly or – more usually – through widely promulgated guidance.

Few would now dispute the principle that clinical practice should be based on the best available evidence, or that the basic principle of EBP is potentially beneficial to practice and hence to patient outcomes.
What can be wrong with systematically and explicitly reviewing and using all the
available evidence about the likely effects of alternative courses of action before
making a clinical decision? Moreover, can increasingly cash-strapped health systems
afford the waste that occurs when clinicians act idiosyncratically?) But there
have been many barriers to overcome, not least the defiance of clinicians, and
especially those who argue that the evidence is often impracticable, irrelevant or
absent, and takes too long to find. Knowledge, attitudes and beliefs have all played their part in
that resistance , as have the complexities of organizational behaviour . The knowledge
base both of individual clinicians and of the relevant sciences in general has
often been inadequate to sustain EBP; the attitude of clinicians has often been
one of wariness of the motives and competence of those producing guidance or
advocating changes to practice; and strongly held beliefs have undermined the use
of evidence. In one study of the implementation of EBP, for example, the senior hospital doctors believed that the guidelines on asthma and
glue ear did not apply to their specialized and complicated patients, while the general
practitioners believed that the guidelines did not apply to their mostly atypical
patients, and the junior doctors said they really didn’t have time to practise
evidence-based medicine (EBM) and anyway had to do as their bosses told them.
In short – at least in the 1990s when EBM was relatively new – all parties believed
that the guidelines applied to someone else but not to them. Catch-22. Yet the
direction of central policy is tending inexorably towards more protocol-driven
systems of care, exacerbating the potential tensions between clinical autonomy
and rationalist bureaucracy .
Even where there has been a willingness to adopt evidence and try to change
practice, organizational barriers such as inadequate resources or inappropriate
systems have provided further obstacles. For example, one might accept the
importance of scanning all patients who have had strokes, but what if the magnetic
resonance imaging (MRI) scanners are not available ? Perhaps
above all, practitioners have found that the science base is often not there when
they need it; that there are still large shadows of uncertainty where the evidence
is too insubstantial to justify a change in practice. That, indeed, is why there has
been such an increase in needs-led, service-oriented research whose aim is to produce
answers to the practical questions facing clinicians. Yet,
despite that increase, the landscape still seems full of grey areas and unresolved
questions . In sum, for all these reasons
and more, while there has been a reform in the way evidence is applied to practice,
the change is not nearly as radical or fundamental as the proponents of EBP
might wish.


First there was the gap between research and practice, encapsulated in the
persistent problem that, despite the massive efforts by the establishment – health
professions, research funders, educators, patient organizations, governments,
health commissioners, insurers and other payers – to promote EBP, clinicians still
so often seem to ignore research evidence in their daily practice. Second there
was the glaring disparity between the policy makers’ methods for trying to promote
EBP and what social scientists, philosophers, psychologists – and just about
anyone who studied such things – have long told us about the nature of knowledge
and how it gets used in the real world.

The demise of the acquiescent patient.Good or Bad ?

Even by the 1990s the reputedly
omniscient senior physician, the dependably avuncular general practitioner,
the handmaiden nurse and the acquiescent patient were already disappearing.
Across the health professions, where the traditional hierarchies were tumbling, new
relationships between professionals were emerging (see, for example, Ashburner
and Birch 1999; Childs 2008) with general practitioners employing increasingly
larger numbers of nurse practitioners and indeed in some rare instances doctors
and nurse practitioners combining on an equal footing to form general practices.
Since then multidisciplinary teams have been increasingly expected to break down
the old pecking order; innovative roles such as nurse practitioners and physicians’
assistants have been blurring professional boundaries. Patients – gradually becoming
relabelled as ‘clients’ by some health professions to stress this very point – seem
often to know a great deal about, and are ever more encouraged to have a strong
say in, how their illnesses are managed. To that end they now have potential access
to rich resources of knowledge and advice not only through patients’ organizations
but through the internet. Clinicians too are faced with many more sources
of knowledge that they need to take account of when practising.
As a result the professions have been described as being ‘under siege’ (Fish
and Coles 1998: 3). As clinical freedom and authority give way to managerialism,
the once autonomous doctor must now comply with bureaucratic norms and
targets or face the consequences (e.g. Ferlie et al. 1996). The clinicians’ employers
might well constrain how they may or may not manage their patients. The shift of
doctors’ status from self-determining professional to regulated employee has even
2 Practice-based Evidence for Healthcare
been described as the ‘proletarianization’ of medicine (e.g. Elston 1991), a term
that certainly reflects the shift of power but underplays the equally important shift
in education, lifelong learning and the status of clinical knowledge.
The training of clinicians has evolved hand in hand with these changes in
their environment. The tradition of undergoing a fixed period of didactic clinical
teaching followed by bedside apprenticeship is being phased out across the healthcare
disciplines in favour of more flexible, self-directed and reflective learning.
New educational principles have been transforming clinical education through
problem-based learning, inter-professional learning, competencies-based training,
ever more rigorously objective examinations, continuous professional development,
clinical audit, appraisal and revalidation. Lifelong learning has replaced the
once-and-for-all qualification. There is increasing stress on delivering and checking
competencies rather than inculcating values and professional wisdom (Fish and
Coles 2005). The job for life is being supplanted by mobile career paths, portfolio
careers and complex private/public partnerships that undermine the traditional
job security of the health professional. Moreover, the specialized knowledge that
clinicians bring to their practice no longer carries the arcane mystique that it once
did. The incontestability of a senior clinician’s individual, autonomous knowledge
has been undermined by the clinical guideline, the systematic review, the organizational
target and the web-based expert system open to all, including patients.
Senior doctors can be challenged by (perhaps brave) members of the clinical team
who have read the latest guidance, or by patients who have had access to alternative
sources of information about their disease, or by healthcare managers whose
paymasters charge them with cajoling if not coercing clinicians to comply with
new, more cost-effective ways of practising. As a result, the old acceptance that
‘we do things this way because distinguished professors tell us we should and it’s
not for the likes of us to question it’ is much harder to sustain. In short, the clinical
knowledge base is being democratized.
And this is just as well, since the old elitism had produced unacceptable variations
in practice, dependent more on the power of opinionated senior doctors
than on any rational review of all the appropriate evidence. Indeed it was that
very problem that provided much of the fuel for both the democratization of
clinical knowledge and the proletarianization of the clinical professions in the first
place. The aim of many of the reforms was precisely to expose and minimize the
clinical misjudgements of a lofty elite; to replace eminence-based practice with
evidence-based practice.
Evidence-based practice (EBP) took root in the medical profession in the 1990s
(Sackett et al. 1997; Gray 1997) paralleled by other healthcare professions (Mulhall
and le May 2004) and like all social movements it has had many forms and interpretations
among friends and detractors alike (Harrison 1998; Timmermans and
Berg 2003; Dopson et al. 2003; Pope 2003; Rycroft-Malone 2006). At its core,
however, the EBP movement, in whatever guise it might appear, has urged clinicians
to use the available research evidence either by finding, appraising and
applying the best evidence themselves or through using evidence-based guidelines
and treatment protocols (Figure 1.1).
Introduction 3
When David Sackett and his colleagues, who spearheaded the movement,
defined evidence-based medicine as ‘the conscientious, explicit and judicious use
of current best evidence in making decisions about the care of individual patients’
(Sackett et al. 1996: 71; Straus and Sackett 1998; Haynes 2002), they were being
more sophisticated than many who joined them to create the EBP bandwagon
(Trinder and Reynolds 2000).2 Sackett and colleagues’ definition recognizes the
importance of clinical judgement when applying the best evidence in any given
set of circumstances. In contrast, however, much of the organizational change
linked to the EBP movement seems to have been about applying research evidence
overzealously and unthinkingly in clinically inappropriate ways. Clinicians find
themselves urged, for example, to apply the results of clinical trials that might have
been carried out in selected minorities of patients who are quite different from the
majority that they themselves treat. Or, worse, they find themselves under pressure
to use clinical guidelines that are not always as explicit as they should be about the
sources and the limitations of the evidence on which they are based (e.g. Grol et al.
1998; Lugtenberg et al. 2009).
EBP has led to a host of reforms across healthcare. They include the mass of
guidelines now available to clinicians, many of which are now prepared to the
very highest standards of evidence and practical relevance, even though – much to
the dismay of those who carefully prepare the guidelines – clinicians are notorious
for ignoring or rejecting them unless they are somehow coaxed or coerced into
using them. EBP has also grown in tandem with the Cochrane Collaboration in
which colleagues from around the world sign up to a lifelong mission to systematically
review all the available research evidence using meticulously controlled and
scrupulous techniques in order to inform best practice in their chosen area.3 This
has been revolutionary not only in the way it has critically collated huge quantities
of research information that was previously ignored, misinterpreted or used
inappropriately, but also in the way it has inspired an almost evangelical fervour
to pursue high-quality evidence and discard bad science (CRAP writing group
2002). Excellent as it is, however, the Cochrane Collaboration still relies heavily on
the randomized controlled trial as the chief arbiter of truth, playing down other
forms of legitimate knowledge and still largely ignoring the social and economic
Focus the question
Search systematically for research evidence
Appraise the relevant evidence for its validity
Seek and incorporate patients’ views
Apply the findings to solve the problem
Evaluate outcome against planned criteria
Figure 1.1 The idealized pathway of evidence-based practice.
4 Practice-based Evidence for Healthcare
aspects of healthcare. Moreover, on close examination the detail often seems to
favour scientific pedantry over the needs of clinical practice. EBP has also fostered
a welcome emphasis on applied health sciences (as characterized, for example, by
the rise of pragmatic and complex trials, of health services research and of health
technology assessment). A parallel development has been the growing industry of
research on the implementation of research, little of which, paradoxically, is widely
implemented.4 Finally, we see the growing influence of the National Institute for
Health and Clinical Excellence (NICE) not only in its native UK, but in countries
the world over that are also experiencing pressures to deliver more cost-effective
care. NICE issues both general guidelines and specific directives about new
treatments; both are rooted in detailed and rigorous assessments of the evidence
on cost-effectiveness. But, like many of NICE’s counterparts that are springing
up around the world, its work is also accompanied by unprecedented levels of
bureaucratization and organizational accountability in healthcare, designed to
encourage if not enforce conformity to ‘best practice’.

More abbreviations

ACE angiotensin-converting enzyme
BMI body mass index
BMJ British Medical Journal
BTS British Thoracic Society
CHD coronary heart disease
CKD chronic kidney disease
CPD continuing professional development
CRP C-reactive protein
CURB-65 confusion, urea, respiratory rate, blood pressure (composite score)
DVT deep vein thrombosis
EBM evidence-based medicine
EBP evidence-based practice
ECG electrocardiogram
eGFR estimated glomerular filtration rate
ENT ear, nose and throat
GMS general medical services
GP general practitioner (family physician)
GTT glucose tolerance test
IBS irritable bowel syndrome
ICU intensive care unit
IT information technology
LDL/HDL low-density lipid to high-density lipid ratio
MI myocardial infarction
MMR measles, mumps and rubella
MMSE Mini Mental State Examination
MRCGP Membership of the RCGP (examination)
MRCP Membership of the Royal College of Physicians (examination)
MRI magnetic resonance imaging
NHS National Health Service
NICE National Institute for Health and Clinical Excellence
NSAIDs non-steroidal anti-inflammatories
NSF national service framework
PCT primary care trust
Abbreviations xix
PSA prostate-specific antigen
QOF Quality and Outcomes Framework (of new GP contract)
QPA Quality Practice Award (by RCGP)
R&D research and development
RCGP Royal College of General Practitioners
rep pharmaceutical company representative/detail
SECI socialization, externalization, combination and internalization
SIGN Scottish Intercollegiate Guidelines Network
SOPHIE the term for a pop-up computerized guide in Lawndale’s IT system
SSRI selective serotonin re-uptake inhibitor (an anti-depressant)
STD sexually transmitted disease
TB tuberculosis

self-discipline :On creating Systems

On creating Systems
Martin Medows
365 days with self discipline

 I value self-discipline, but creating systems that make it next to impossible to misbehave is more reliable than self-control.

—Tim Ferriss


 A lot of people think that being self-disciplined means that you can sit in front of a delicious piece of cake
 and stare at it for hours without eating it. They think of resisting temptations as being like a knight
 defending his kingdom against the invader
If you go to seedy bars every week, your chances of getting punched in the face are higher than those
 of a person spending their evenings at home with a book. Likewise, the best way to protect yourself 
against temptations is to avoid them — and for that, plain old preparation is more valuable than 
self-control.
 Your chances of cheating on a diet are higher if you have forbidden foods at home. 
Removing them from your house — a simple act that requires little willpower, as long as 
you’re satiated while doing so — will protect you when you get hungry and the urge to gorge
 on them hits you like a ton of bricks.
 Your chances of sleeping in are lower if you set three different alarms and place them away from
 your bed.
 You’ll be less likely to waste time at work when you block the most distracting websites instead of 
relying on your willpower to stop you before loading those funny cat pictures.
Prepare yourself for difficult situations by putting up roadblocks ahead of time, when your resolve
 isn’t being tested. Your selfcontrol system
 will do some of the heavy lifting for you, leaving your reserves of self-discipline to be used
 for the unplanned situations, when they arise.



Ouzouk woke up with the first rays of sunlight hitting his face. He scanned the interior of his dusty hut, constructed with twigs, mud and dry grass. He scratched his back, which, as always, had been bitten by insects over and over again throughout the night. Grateful that the night had passed without any danger to his family, he crawled out, careful not to make any sounds.
 It was a crisp and clear morning. He would have loved to take his family for a walk around the waterfall and play with his little son, but there was work to do. It had been five days since the tribe ate something more substantial than a fistful of berries. Unfazed by the bloodthirsty mosquitoes buzzing by, Ouzouk walked over to the fire pit and warmed his calloused hands. The light scent of wood smoke filled his nostrils. He rubbed his hands together, still feeling the painful absence of his index finger lost during that fateful hunt many moons ago.
 One by one, his fellow tribesmen crawled out of their huts and joined him at the fire. There was Dhizgab, his friend who was bitten by a snake and was left partly paralyzed on his left side. Gnokk limped along next, with his broken foot badly healed, and a part of his skull partly caved in after a stone thrown by an enemy tribesman hit him smack dab in the middle of his forehead. Rekknodd sauntered into the group next. So far, he was the luckiest of the band, with only a deep scar on his cheek, left from an attack by a tiger that had massacred a half of the tribe. Other men—some missing limbs,
some having lost their entire families, some with even more horrible memories—joined the group.
 When the men were ready, they separated into two groups and ventured out to secure food for the tribe. They made it back to the camp in the early afternoon, forced to make a hasty retreat after spotting a leopard resting in the thick bushes. Yet again, they had failed to obtain food, but at least they were grateful that (unlike two moons ago) this time nobody had been hurt.
 With empty stomachs, the adults gathered around the fire pit while small children, supervised by teenagers armed with spears and bows, played by the creek a short distance from the camp.
 They reluctantly decided that the area could no longer support them. While clean water was plentiful and predators rare, food was becoming increasingly scarce and successful hunts were few and far between.
 The next day they would gather their belongings, put them on their backs, and walk for a long time until they would find another suitable place for a new temporary dwelling. Some would die along the way, some would get hurt, but such was life, Ouzouk thought to himself. A human being couldn’t ever
 stop struggling and fighting to survive each day.
 I can hear you thinking, “What a weird prologue to a book about self-discipline!” Bear with me, please…
 Our basic human nature hasn’t changed since the days of Ouzouk. While the vast majority of humans fortunately no longer have to live in constant discomfort and fear of death, we would still
do well to possess even a fraction of mental toughness and self-discipline our ancestors had. In the modern world, it’s easy to live without even a modicum of self-discipline.
 Back then, nobody could avoid discomfort. It was a fact of life that one couldn’t thrive unless they ventured into the world, facing unknown risks and possible death in a quest for a better life.


Today, most people are unable to wake up early without an alarm clock, and even then, it takes them thirty minutes just to crawl out of bed. Most would find it impossible to sleep on the bare floor, with insects crawling over them and biting their bodies the entire night. If they experienced just a slight ache, most would skip work and complain about how much pain they were in. Most wouldn’t be able to fast for an entire day, let alone go without food for five days in a row.
 Compared to our ancestors, we have it easy
.
 Yet, or perhaps because of it, so many people struggle with self-discipline today. A great majority of them do nothing to fix that, and the ones who try are often met with ridicule. If you belong to the group that is trying to better themselves or wanting to do so, the book you’re now reading is for you.
 I wrote 365 Days With Self-Discipline
 with the intention of creating a daily companion to help you embrace self-discipline in your everyday life.
 As the author of several bestselling books about self-discipline and being a personal growth junkie myself, self-control is a topic close to my heart. I believe that if a person wants to reach their full
potential, he or she can’t avoid discomfort. Doing things that might not be entirely pleasant is key to achieving long-term objectives.
 In the following pages, I’ll share with you one thought for each day of a year that is devoted to the topic of self-discipline, mental toughness, success, or self-improvement in general. The thoughts come from some of the world’s brightest minds: successful entrepreneurs, athletes, bestselling authors, researchers, performers, bloggers, and more.
 Since the entries are brief and get straight to the heart of the matter, you’ll be able to quickly find ongoing inspiration to continue working on your most important long-term goals and on becoming an ever better person.
 Due to the large number of days in a year, some themes will inevitably repeat, but I strove to address each subtopic from different perspectives. Please note that I have quoted various people from numerous sources, including books, articles, blogs, speeches, interviews, and more. By citing their words, I don’t necessarily endorse their works or their persona.
 (A note on quotes in the physical and ebook version of the book — whenever I could, I cited the source and included an endnote. Unfortunately, the exact source of a small number of quotes, particularly those by historic figures, was elusive to me. Whenever I couldn’t find the author — as is often the case with many inspirational quotes circulating around the Internet — instead of risking misattribution I wrote “Unknown.”
)
 Let’s turn the page and start with Day 1 and the most important thought that defines the difference between a self-disciplined person and a weak-willed one The next day they would gather their belongings, put them on their backs, and walk for a long time until they would find another suitable place for a new temporary dwelling. Some would die along the way, some would get hurt, but such was life, Ouzouk thought to himself. A human being couldn’t ever
 stop struggling and fighting to survive each day.
 I can hear you thinking, “What a weird prologue to a book about self-discipline!” Bear with me, please…
 Our basic human nature hasn’t changed since the days of Ouzouk. While the vast majority of humans fortunately no longer have to live in constant discomfort and fear of death, we would still
do well to possess even a fraction of mental toughness and self-discipline our ancestors had. In the modern world, it’s easy to live without even a modicum of self-discipline.
 Back then, nobody could avoid discomfort. It was a fact of life that one couldn’t thrive unless they ventured into the world, facing unknown risks and possible death in a quest for a better life.