Wednesday, 25 May 2016

How do doctors treat a blood sugar of 13 mmol/l (234 mg/dl)? They give intravenous glucose!!!

Here is the local protocol for treatment of diabetics on insulin.

It dictates that a diabetic with a blood sugar of 13 (234) be given intravenous glucose, in the form of 4%dextrose/saline, usually at 120 ml/hr. That is 120 g of glucose per day for a standard hospital patient resting in bed.
Many type 1s lead very active lives on much less carbohydrate per day than this, yet when they are confined to bed, doctors obsession with high carbs give them much more. They then treat the resulting hyperglycaemia with massive doses of insulin. The recommended starting rate equates to almost 100 Units per day, a massively supra-physiological level.
Mammalian evolution has equipped injured animals to deal with immobilising injuries without exogenous glucose, yet doctors still feel the need to overdose patients on sugar, and insulin.

Even if this results in a near normal blood sugar, problems are not infrequent. Insulin is one of the medicines most commonly listed in adverse drug reports. Any interruption of the dextrose delivery means that the patient is receiving a large amount of insulin unopposed. A low-insulin/low-glucose protocol would see hypoglycaemia developing much more slowly, and much more likely to be detected before harm was done.
Dilutional errors in the preparation of infusions are also frequently reported. A high delivery rate magnifies the effect of these.
I could also go on and on about the water load, effects in head injured patients, infection risks, longer term effects and the larger variability of blood sugars with a high glucose load...

You will also note that the protocol contains 2 contradictory thresholds at which saline should be started.
Have I previously mentioned doctors poor numeracy skills?

Monday, 16 May 2016

Should I work standing up. The evidence says NO.

The bizarre and incompetent advice from medical academics never stops coming.
They are the people who said that Vioxx was the best drug for elderly, dehydrated people with broken hips.
They are the people who told you to eat vegetable oils that at the time were full of unlabelled trans-fats.
They are the ones who say that the solution to a high blood sugar is to eat more carbohydrate.
This is the profession that prescribes antidepressants to 1 in 10 Australians, one of the highest rates in the world.
And they are the people who say I should work standing up.

I'm not going to point out the obvious mathematical inadequacy of the original research on which that advice was based. (unless someone pays me to do so) Most doctors only read the abstract of such research, so couldn't tell.
Suffice it to say that if you don't include all confounding factors in such a study, you can prove just about anything. And if you parametrise activity in time units, you are not going to get the right answer. An hour spent chatting and stretching at the gym does not expend nearly as much energy as the hour I spent racing in the mountain run yesterday.

Lets look at the research that better adjusts for the problem of confounding.

First, there was the Whitehall II study. More than 80,000 person-years of follow-up and 450 deaths, showed NO effect of sitting on mortality. It also pointed out inadequacies of previous research and chided policy makers for over-interpretation of poorly controlled research.

More recent research (doi: 10.1186/s12966-016-0349-y) showed a trend towards better health outcomes people who sit at work, even after allowance for income/SES differences. Of course that does not prove that sitting is better, for the same reason of inadequate adjustment of confounding, but makes it unlikely that it is worse.

So don't just do something, sit there.

Thursday, 12 May 2016

Bizarre ACT Health Laws - more illegal maths

ABC radio did a story this morning on bizarre laws from around the country, so I thought I would chip in with another.
Protection of confidential data by altering just some of the numbers is a technique that is used and accepted around the world. See the example below. But is it accepted inCanberra?
The technique means that the recipient is unable to determine which values have been altered, and are unable to tell whether a specific datapoint is true or false. However, because most values are intact, the recipient can glean useful summary information such as the average of certain values.
But a little-known ACT law apparently makes it an offence to transmit false health data.
This would make it illegal to create a hypothetical teaching scenario where a patient did not want some of their private details revealed to students.
Even fictional data, which is declared as such, seems to be caught by the breadth of this law.

Stay tuned for an update on the legality in the ACT of this standard statistical method.

Tuesday, 10 May 2016

The reason for my success. Is it because I am "prescribed a range of steroids, including prednisolone .. to manage (my) Type 1 diabetes"?

Canberra's medical investigators may have stumbled on the reason why I have been so successful at managing Type 1 diabetes.
Certainly I am pleased with my results of late. Recently running 5km in 20 minutes and 20 seconds is faster than I have run since I was 19. That was 37 years ago. ( 76% for Parkrunners)
That equates to a VO2max of nearly 50, which is an excellent prognostic factor.
How have I improved this much?
Those Canberra doctors have suggested that I use a range of steroid, including prednisolone, hydrocortisone and fludrocortisone to manage my Type 1 diabetes.

No, this is not a mistake. Those doctors were given ample opportunity to amend or retract this statement, but chose to repeat it.

In any case, why would I self-prescribe medications that are essential for me to stay alive? It would only be necessary for me to do that if my own doctor had NOT prescribed them. In which case it is my doctor who should be investigated, not me.

And what was the evidence I self-prescribed? Allegedly it is in my blog. Huh? Read for yourself. My blog says no such thing, and I promise I have not deleted anything on this.

Clearly this is a vexatious action by Canberra doctors who are desperate to discredit anyone who claims success from LCHF, or any other alternative approach, to diabetes.

Monday, 9 May 2016

Alteration of insulin dose - does it constitute illegal self-prescription? Legal clarification at last.

Following threats made against me by AHPRA for allegedly self-prescribing drugs, I sought legal clarification on the issue of patients using doses of insulin and steroids other than those prescribed by their doctor from various State Health Departments and State diabetes organisations.

The only organisation to provide a detailed response to this question was the WA Department of Health, whose reply stated that not only was dose alteration acceptable for those drugs, but self-prescription of insulin and prednisolone was also perfectly legal.

Why then the threats against me by AHPRA? It couldn't possibly be retribution for the embarrassment my blog posts have caused to some of its committee members, could it?

(WA Health also noted that although self-prescription of insulin and standard Addison's drugs are legal, this does not apply to any Schedule 8 drugs, or to any Schedule 4 medicines classified as "specified drugs" under the Poisons Act)

Thursday, 5 May 2016

Can you believe why Calvary Hospital is the second most expensive in Australia?

Can you believe why Calvary Hospital is the second most expensive hospital in Australia?
According to the Health Minister "Specialist services, such as open-heart surgery, some complex brain surgery, bone marrow transplantation, and some high-level care for babies offered in the ACT do not have the same economies of scale possible in larger jurisdictions."
Calvary does NOT do open-heart surgery, complex brain surgery, bone marrow transplants, or have a high-level neonatal ICU.
How can a politician get away with such a statement? Because voters let him. Canberra people get the politicians they deserve, and the health system, and the funding cuts in other areas to pay for ACT Health incompetence.

And if you think expensive health care means good service look at the KPIs of the clipboard army.

Of course, none of this will be any surprise if you have read my previous blog posts. And if you think all that money means state-of-the-art equipment look at what happened when a surgeon repeatedly complained that the operating theatre was too hot, and the manager kept saying it was fine. Eventually, the manager brought along their thermometer to show the surgeon they were wrong.
After procuring a polystyrene cup, water and ice from the tea room, the thermometer was found to read minus 4.6 degrees C in ice water. Theatre temperature was then adjusted to what it should have been. Battle won. War goes on.

Using maths to optimise steroid regimens

Efficient solution of the most difficult Sudokus requires an appreciation of the conditions under which numbers are exchangeable, or at least the learning of rules of thumb that can be derived from such an appreciation.
Exchanging steroids, a necessity for many patients who do not thrive on a particular regime (see BMJ ref. in a previous post), also requires an understanding of the parameters that need to be matched. Merely exchanging based on daily dose equivalence is insufficient.
Perhaps that is why so many Australian patients with Addison's disease are reporting poor treatment outcomes on social media, and, unlike other countries, so few are reporting any sporting achievement.
And rather than believe those ignorant doctors who say that social media does not constitute evidence, check out the peer reviewed research publication showing that useful information on disease patterns in society can be determined from tweets, (Lee et al J Am Med Inform Assoc. 2015)

Number gnomes have hidden the middle of this standard puzzle, but not to worry. They have actually helped you by showing where you don't need to look to find the next cell value. Do you see the pattern?

17.5.16 Another.