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Hot Topics Blog
Subclinical Hypothyroidism in the Elderly - A Small Victory in Addressing OverdiagnosisRob Walker - 12 Oct, 2017
New England Journal of Medicine June 2017
Florence is 82. She's starting to get a bit frail, lives out in the countryside and getting to the surgery can be difficult. She's on a couple of antihypertensives and a couple of inhalers for her COPD and has had some blood tests for mild cognitive impairment. She sleeps a bit more in the day time (so will I if I get to 82). Her TSH comes back at 7.5 with a normal T4. What do we do? First thought 'rats, why did I do the TFT in the first place'.
I'm sure we have all been reading a lot about overdiagnosis and overtreatment over the past cou- ple of years, and one of the aspects that has really hit home with me is the idea of the 'treatment burdens' we place on patients. Not just medications, but testing, appointments etc. We have for many years been pushed down the path of ever increasing testing, monitoring and treatment, mainly based on evidence that was often not really applicable to the real world patients we are seeing in General Practice. We have known for some time we are just doing too much 'stuff' to our patients for minimal gains but have felt duty bound to 'follow the guidelines'.
However, the recent NICE guideline on multimorbidity has been a total game changer in my view. It has given us the backing to make those judgement calls on whether testing or treating the patient in front of us is really going to improve their quality of life or not. One of the difficulties though is that the evidence base on when NOT to treat is still in it's infancy.
However, one small victory came in the shape of an RCT published in the NEJM in June 2017 looking at subclinical hypothyroidism in the elderly. Richard Lehman in his blog nicely suggested that 'the thyroid gland could be described as the playground of overdiagnosis'. It was an RCT of >700 patients >65 years old with subclinical hypothyroidism (TSH 4.6 to <20 with normal T4). They were randomised to treatment aiming for normal TSH levels, or placebo (which also had sham blood tests and dose adjustments). At 1 year there was no difference in either hypothyroid symptom score or tiredness score.
So back to Florence and what we do about her subclinical hypothyroidism. Previously I would have been tempted to treat it just in case it was causing the cognitive impairment, but let's be honest, it's much more likely to be age related and/or vascular as she was a heavy smoker. Given the backing of the multimorbidity guideline I'm now not going to increase her treatment burden by adding more pills, and the hassle of another half a dozen appointments for blood tests and follow- ups, for something that is highly unlikely to improve her quality of life. I'm going to suggest we just watch and wait and check it again as part of her annual review next year.
Rob Walker
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The Slow Art & Science of Healing Leg UlcersLucy Hamilton - 18 Oct, 2017
Getting Mary Back to Goa
It is great when patients show their appreciation and they often do, but sometimes the difference that we have made is tangible. It took about 4 months to heal Mary's leg wound and when it healed I was as pleased as she was. She gave me a hug and some tomatoes and courgettes from her garden. She is 80 years old and a widow, full of life and adventure. She had injured her leg in Goa while on holiday, a traumatic wound from an accident as she stepped onto a boat, an L shaped skin flap laceration that stretched from below her knee to just above the ankle. She presented about 10 days after the accident with black sutures, like liquorice bootlaces holding the wound together.
My colleague called me in to have a look, with her back to the patient she pulled a face that suggested 'OMG!' The sutures were holding the vertical part of the wound but the horizontal was covered with black eschar and beginning to gape, a number of the sutures were flapping about doing nothing. The wound didn't look infected but the leg was swollen. I told Mary that I wasn't sure we could heal this in primary care and that plastics might be an option. I explained to Mary that I thought we should try to treat this with compression, it didn't look like a venous leg ulcer but I was hopeful that the mechanism that allowed compression to heal venous leg ulcers might work here. Mary, bless her, had faith in us!
The doppler result gave us an ABPI of 0.9 so, with the sutures out, we started short stretch compression, over a simple non adhesive dressing with some padding to absorb the exudate. We were seeing her twice a week. After four weeks we had some improvement but the lower part of the wound was sloughy and the black eschar, although reduced ,in size was still there. Actiform Cool® (marmalade to Mary) helped hydrate the eschar and de slough the wound. It took weeks but there was a little improvement each time. We got to a point when the exudate was minimal and we changed to the Activa® hosiery kit which give the same amount of compression as a two layer bandage but meant Mary could share the management of the wound but more importantly enabled her to shower without an ungainly cover to protect her leg. We moved to weekly appointments with Mary replacing the primary dressing and stockings in between. The Venus IV study (2014) found that this hosiery kit healed ulcers at the same rate as 4 layer compression and that recurrence rates were lower.
Progress was painfully slow and although Mary didn't say that she was discouraged her face let us know. Then finally the day came, my colleague who had shared the management of this wound with me called me in for Mary to declare that her wound was healed. This is when we got the garden produce and the hug. "By the way' said Mary ' I have booked to go back to Goa next year!"
Lucy Hamilton
Nurse Practitioner and Educator on the NB Medical Primary Care Nurses Course
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Ex-Texans GM Brian Gaine back with Bills scouting department
Fired as general manager by the Texans in June, Brian Gaine is back with the Buffalo Bills.
Gaine was hired by the Bills on Tuesday as a senior personnel advisor.
A former New York Jets tight end, Gaine was the Bills' director of player personnel in 2017 before rejoining the Texans.
JOHN McCLAIN: A pair of breakout stars for Texans
Gaine has previous stints as a personnel department executive with the Jets, Dallas Cowboys and Miami Dolphins.
Gaine replaced former Texans general manager Rick Smith in January 2018 when Smith took a leave of absence to care for his wife, TIffany, who later died of cancer.
Recommended Video:
Gaine's tenure with the Texans was short-lived, though. He was fired following the NFL draft on June 7.
JOHN McCLAIN: What to expect at Texans training camp
The Texans haven't replaced Gaine. They made an unsuccessful run at New England Patriots executive Nick Caserio, briefly drawing a tampering charge that was dropped when they ended their pursuit of Caserio.
The Texans are currently operating without a general manager, relying on coach Bill O'Brien, senior vice president of football administration Chris Olsen, team president Jamey Rootes, vice president of team development Jack Easterby and personnel department executives Matt Bazirgan, James Liipfert and Rob Kisiel.
NEWS WHEN YOU NEED IT: Text CHRON to 77453 to receive breaking news alerts by text message | Sign up for the only newsletter for the Houston sports superfan.

subset: commoncrawl


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"Dr. Haiwan" sent me this via e-mail. Thought it was a "jolly good yarn" (this seems to be a common Kiwi phrase :-) ) and would pass it on. Nice "feel good" motivational story though I think the concept of using this dog to "preach that even without a perfect body, one can have a perfect soul' (???) is overdoing things.
This is 'Faith'
This dog was born on Christmas Eve in the year 2002. He was born with 3 legs - 2 healthy hind legs and 1 abnormal front leg which need to be amputated. He of course could not walk when he was born. Even his mother did not want him.
His first owner also did not think that he can survive. Therefore, he was thinking of 'putting him to sleep'. By this time, his present owner, Jude Stringfellow, met him and wanted to take care of him.
She was determined to teach and train this dog to walk by himself. Therefore she named him 'Faith'.
In the beginning, she put Faith on a surfing board to let him feel the movements. Later she used peanut butter on a spoon as a lure and reward for him to stand up and jump around. Even the other dog at home also helped to encourage him to walk. Amazingly, only after 6 months, like a miracle, Faith learned to balance on his 2 hind legs and jumped to move forward. After further training in the snow, he now can walk like a human being.
Faith loves to walk around now. No matter where he goes, he just attracts all the people around him. He is now becoming famous on the international scene. He has appeared on various newspapers and TV shows.
There is even one book entitled 'With a little faith' being published about him. He was even considered to appear in one of Harry Potter movies.
His present owner Jude Stringfellew has given up her teaching post and plans to take him around the world to preach that even without a perfect body, one can have a perfect soul'.


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Hot Sale Flexible Uhmwpe Plastic Sheets - Chinaprice: check with company for price
hot sale flexible uhmwpe plastic sheets Ultra High Molecular weight polyethylenen, it is commonly abbreviate UHMWPE, is a subset of thermoplastic engineering plastic, it has extremly long chains with a molecular mass usually between 2-6 million.
UHMWPE retains key physical properties and high impact strength, even at low temperaturers down to -200°C .This excellent general purpose plastic with self lubricating properties offers noise reduction and low friction surface.
Company Contact:
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- Phone: 13963917933
- Address: NO.1558,jinghua road, dezhou, shandong , China
- Email:
- Website: http://www.sdhasy.com
Published date: October 17, 2016 - Modified date: October 17, 2016
- Business Description: Established in 2008, Huao has become the largest manufacture. Our UHMWPE products are mainly including uhmwpe sheet , uhmwpe rod , uhmwpe strip, uhmwpe block , uhmwpe fender facing pads , uhmwpe bearing , uhmwpe cutting boards , uhmwpe suction box cover , uhmwpe chain guides , uhmwpe machining block ,uhmwpe conveyor impact bar and other uhmwpe machined parts with all kinds of grades and color .
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Over 100 BYV members join BJP
The youth workers were inducted into BJP in the presence of Union Minister Dharmendra Pradhan.
Bhubaneshwar: More than hundred Biju Yuva Vahini (BYV) members joined the Bharatiya Janata Party (BJP) here on Tuesday. The youth workers were inducted in the party in the presence of Union Minister Dharmendra Pradhan.
Pradhan also took to his Twitter handle to welcome the newly inducted members in the party fold and asserted that they have "deserted BYV to work towards development agenda."
"Inducted Sanjay Patra and hundreds of Youth Leaders from Biju Yuva Vahini belonging to Jaydev Assembly Constituency into BJP Odisha today. Deserting BYV, they have joined BJP to work towards Narendra Modi's and Amit Shah's development agenda to build a New Odisha," he tweeted.
Yesterday, Prime Minister Narendra Modi had inaugurated developmental projects worth Rs 14,523 crore in Bhubaneswar under the Centre's 'Purvodaya' vision.


text: Diabetes is one of the most significant diseases facing the world today, and it creates a considerable economic burden for patients, families and society as a whole. Despite progress being made in treatments, projections continue to rise for diabetes, particularly in urban areas. It is for this reason that cities are our key interest point and where we need to take action to hold back the alarming rise of this condition.


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The classic hydrating lip liner is Givenchy Lip Liner, which contains vitamin E oil for extra hydration, but we've also used the Dior Rouge Contour Lip Liner, and it's great for matte color that's not dehydrating. The very best thing, though, honestly, is just to use Make Up For Ever Lip Line Perfector as a hydrating base and then put your favorite liner right on top.
Have another go-to? Let us know below.