The Crippen Diaries 2007 (24)
The repercussions of the press presentation of stem cell surgery for dry macular degeneration continue. A lot of patients are coming in to ask about it.
George had just been to the hospital eye clinic. He said that he had asked about the surgery, and been advised it was not available locally. So he wanted me to refer him down to London, to Moorfields. Sadly, it is not available there either.
The he asked me if I would prescribe some more I-Caps for him. The hospital specialist had started him on them and said they might help.
I know three things about I-Caps. They are not available on prescription, they have been heavily and successfully advertised and they are expensive. As they cannot be prescribed, and as I cannot imagine the eye specialist paying for George's I-Caps himself, there can be only one explanation. The manufacturers of I-Caps must have kindly given the hospital a free supply of the drugs for distribution to the patients. Such generosity. I really must stop being rude about Big Pharma.
Let us change the subject completely for a minute, and look at two happy, smiling people with white teeth.
A picture of good looking people with very white teethI do not know why they are so happy. Maybe they are pleased with their dental cosmesis. But back to the topic under discussion.
Expensive or not, I-Caps must be good because Chris Steele recommends them. And Chris Steele is a doctor. A famous doctor. He is famous because he is sometimes on telly.
Not only does he appear on telly, and in his own web site, but he also appears in the I-Caps advert. If you click on his name in the advert, the following pops up:
Dr Chris Steele is the resident GP on ITV’s This Morning programme. In 2006 he ran a feature about common eye conditions and mentioned his mother had recently had some treatment.Great stuff, Chris. I hope mum is well. Did she take the tablets?
She was advised by her Ophthalmologist that she should consider taking I-Caps, a dietary supplement which contain the antioxidants Lutein and Zeaxanthin.
Antioxidants are important and can contribute in helping to maintain eye health.
Despite Chris, and his mum, Dr Crippen is still not sure why I-Caps work. Fortunately, there is an option in the I-Caps advert entitled “why I-caps work”. Heavens, they must have seen me coming. I clicked on it immediately. This is what it says:
- High potency vitamins and essential minerals including zinc
- Lutein and Zeaxanthin – natural carotenoids found in the macula
- Contains the important vitamins A, C and E
- Provides raised serum concentrations of Lutein, which can be related to increased macular pigment density
- Sustained release formula for greater absorption and less stomach irritation
- Best-tolerated zinc source with one of the highest levels of absorption
Fortunately, those nice people at I-Caps have managed to persuade eye clinics to give out free samples. That is how George got his. And because he got them from the eye “specialist” he knows that they must be good. Sadly, I cannot prescribe them for him. But he can buy them himself from, for example, Eyecare Plus:
ICAPS Eye Vitamins 3 x 60 tablets : £39.40
Bundle contains sufficient for 3 months dosage
Bundle contains sufficient for 3 months dosage
What a bargain.
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Tuesday 12th June
Amanda is fourteen and arrived today with her mother. Amanda attends one of the local private schools, a school which is always high in the league tables, and prides itself on academic excellence and “value added” as well.
Amanda has not been doing very well academically and the school have raised the question of “dyslexia” or, as Amanda’s mother puts it, “mild” dyslexia. From the medical point of view Amana is fit and well, and excels at sports. If she were in a comprehensive school, she would I suspect be in the higher academic streams. But she is not in the comprehensive school. She is in the private school and has been deemed to be "struggling".
Amanda’s parents are professionals, and not short of a few bob. They want to have Amanda assessed by an educational psychologist to see if this diagnosis of “mild” dyslexia is correct. I suspect it will be. It nearly always is. I cannot recall a private psychological assessment for dyslexia reaching the conclusion that the child shows no evidence of the problem.
“She’s very intelligent, doctor, but she is dyslexic.” I struggle with this concept.
A layman’s definition of intelligence – and I happily admit to being a layman on this – is “the ability to understand and process information.” Just as it is no longer acceptable for children to fail exams, it is no longer acceptable to label them as being of lower intelligence. Instead, we sub-divide intelligence into a number of categories and look at each one individually. Let us suppose that Amanda is very poor at analysing data presented to her in words and is labelled as dyslexic. Surely this means that one area of her intelligence is poor or, in to put it in simple terms, she is not as intelligent as she might be.
Because we have the label “dyslexia” Amanda will be given extra time for her GCSEs. Why do we not identify all children who are, for whatever reason, less intelligent and give them all extra time to do their exams? Indeed, taking this to the logical conclusion, we could assess all children’s global intelligence and give them examination times inversely proportional to their IQ.
Why not?
Why should it just be middle-class Amanda who gets preferential treatment?
What happens to all these children with “mild” dyslexia when they leave school? Will they be prepared for the realities of life? You do not get “extra time” in the real world.
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Thursday 14th June
Andrew is in his late thirties, and still plays an occasional game of veteran’s rugby. I keep suggesting that it is time he took up golf but he will not hear of it. A few weeks ago, in an end of season game, he hurt his back during a tackle. He does not have a previous history of back trouble. He told me today that the pain was so bad that he took himself to an osteopath who told him that he had a problem with a displaced lumbar vertebra. This sounds serious to me. The only context I have come across displaced vertebra is after a visit to that nice Mr Pierrepoint. It took the osteopath three sessions to get the vertebra back in place.
Andrew is still in pain, though better than he was. The history and signs were suggestive of residual sciatica. Not much to be done. Reassurance and analgesia. But what do osteopaths mean by saying that a vertebra has been “displaced”?
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The community pharmacist has identified all out patient who are on atorvastatin rather than simvastatin. Simvastatin is about four times cheaper. One of my partners has been struggling with the right form of words to use when explaining to the patients that their medication is being changed. She has hit on a winning formula. She is telling patients that “simvastatin is the industry standard.” To the extent that it means anything – the vague suggestion that simvastatin is the “industry standard” because it is better – it is dishonest. But in fact it does not mean anything at all. It is pure Blairspeak - from the land of “cotton rich” and “organic” and “corn fed”.
I have started saying to patients that I am changing them to simvastatin because it is four times cheaper. This has the merit of honesty. Surprisingly, most patients accept that. A few do not. Tough. It is time everyone learnt the cost of health care, and this is a small start.
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I had to do a medical report today on a women who is in her mid-thirties. The company who are employing her asked for details of “all consultations with the doctor over the last year” – that was easy, there had only been one for contraception; for details of “all certified absence from work in the last three years” – even easier, none; and for “a summary of all significant past medical problems.”
She had not had much. Two children. A fractured wrist. That was about it. Except, when she was twenty, she was treated for a gonoccoal throat infection. An unexpected finding on a throat swab when she was a student. She had presented with a persistent sore throat, which was not responding to OTC aspirin.
Is this a “significant” medical problem?
Medically it is not a big deal but not perhaps something that women want on their medical c.v. which, with computerisation, can be accessed by the world and his wife. In the old days, I might well have “lost” a page of the untidy Lloyd George notes. You cannot do that with a computer. Even if I took it off, there is an audit trail.
I phoned her and told her that I would have to put it on the medical report. She laughed. She really was not bothered.
Perhaps I am turning into an old prude. It really is not a big deal. But I would not want it on my medical summary.
I put “severe throat infection” on the medical report. Why should I trouble her company with details of the bacteriology?
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Friday 16th June
The morning started badly. I was seeing the third patients when I heard screaming and shouting coming form the reception area. There were a lot of swear words mainly starting with “f” or “c”. I excused myself and went outside. There were already two of the younger female doctors there, trying to persuade an incandescently angry middle aged woman to calm down.
What had happened?
Mabel is in her mid-forties. She had arrived at reception shortly after 8.00 am and asked for an appointment to see a specific doctor. That doctor is away on holiday. “She is always on effing holiday…” started Mabel and from there it got worse. She was offered an appointment to see one of the other doctors at 10.00 a.m. That was not good enough. Mabel wanted to be seen immediately. She was not prepared to wait an hour and a half and she was not prepared to come back.
The receptionist stood her ground. There were no appointments free until 10.00 a.m. and in any normal sphere of life the offer of an appointment within two hours would be regarded as good service. Not in the NHS. At this stage, Mabel completely lost it. Her language became appalling.
The two female partners who had come out finally managed to calm Mabel down, and took her off to a consulting room. Why had she demanded an immediate appointment? She wanted a prescription for some co-codamol which she takes from time to time for low back pain. She has suffered from low back pain for years. There are no abnormalities to find examining her. She has had physiotherapy – unhelpful. She has had an X-Ray and an MRI Scan – both normal. The orthopaedic consultant who saw here suggested more physiotherapy. It did not work the first time when we had arranged it, and it did not work the second time.
Mabel lives alone. She is unmarried. She stacks shelves in a local supermarket. She smokes too much. She drinks a bit but not excessively. She is lonely and sad and does not cope with life. It is easy to “medicalise” people like Mabel, to conjure up some sort of psychiatric diagnosis but she is not psychiatrically ill. She is a sociopath who is unable to cope with life. She has often been difficult in reception before, but never like this.
We spend far too long at lunchtime discussing what to do about Mabel. The two female doctors who dealt with her felt guilty about letting the reception staff down. They do not want to give the message that abuse works and will get you an appointment. Mabel’s foul language was such that, in the absence of mental illness, we would normally remove a patient like this from our list. Mabel is not mentally ill. She is in the no man’s land between “mad” and “bad” an area where the NHS normally does not go.
We decided in the end that we would discuss it with the staff. I went off to talk to two of the senior receptionists. You may think they are battle axes.
I said, “Do you want us to chuck her off?” We talked a little. One of them said, “Mabel doesn’t have much, does she?”
So Mabel was reprieved.
64 Comments:
Well that answers my question about whether lutein and zeaxanthin are popular across the pond! It would also appear that your advertisers are just as, er, good as ours.
The hypothesized benefit is that they reduce oxidative and light-induced damage. The body does seem to like concentrating them in the macula, and some research has shown beneficial effects on macular degeneration. (And the disagreeing research shows they are no worse than placebo.)
Hmm - that product has been discontinued in favour of Viteyes with 6mg of Lutein and £47 for 3 months or the Viteyes Advanced with 10mg of Lutein at £62 for 3 months. To be fair, the distributors do mention that the 6mg product should also be supplemented up to 10mg/day with the Pure Focus Sublingual Lutein Spray which is £18.95 and good luck sorting out the dosages with that. This would probably be a decent question in the new physics exam.
If this spray delivers 10mg Lutein via 6 sub-lingual sprays, but you already supplement 6mg from another source - how many sprays do you need to top up to 10mg? Just how do you deliver a partial spray?
Are there any important differences in bioavailability to note? The advertising text for the spray mentions that only 25% of the "orally ingested Lutein is absorbed it [sic] into the bloodstream. By using the under-the-tongue sublingual route 95% of the Lutein directly passes into the bloodstream and onwards to the eye".
In fact, that page is a joy - it explains that: "One bottle of Pure Focus Spray contains 120 x 2.05mg applications ( 4 weeks )". But - I though that 6 sprays of 2.05 = 12.30mg rather than 10mg.
Of course, the same site points out that the very latest of the LAST studies deprecates the benefit of lutein in favour of Meso-Zeaxanthin - which you can purchase, in the form of Macu-Shield. "MZ is synthesized in most people’s bodies from L [lutein] and it is now thought that some individuals may lack the converting enzyme. Until now (Dec 2006) MZ has not been available as a single pill supplement."
Macu-Shield is £59 for a 3 months supply.
So, I hope that the above is clear. You only obtain 25% of any Lutein that you take in a supplement - but they don't highlight on the pages whether the studies used oral supplements or sub-lingual sprays. Lutein now seems to be deprecated for MZ in AMD but you need to take lutein anyway.
Whatever you do, the supplements work out at around £60 for 90 days.
High potency vitamins and essential minerals including zinc
Lutein and Zeaxanthin – natural carotenoids found in the macula
Contains the important vitamins A, C and E
Provides raised serum concentrations of Lutein, which can be related to increased macular pigment density
Sustained release formula for greater absorption and less stomach irritation
Best-tolerated zinc source with one of the highest levels of absorption
Reminds me of http://www.dhmo.org Dr C. Enjoy.
Aphra.
- sigh -
One of the reasons it is so difficult talking people out of taking daft alternative supplements sold over the net by fairly transparent charlatans...
...is that large consumer product companies with scientific names use exactly the same sales pitches and tactics.
Except they find it easier to get on TV and produce endorsements from real doctors.
In fact, it is getting to seem more like a continuum, with the Pharma companies at one end, outfits like Alcon (who make various eye products, including I-Caps) in the middle, and the myriad over-the-net vitamin and supplement sellers at the other end.
I just feel sorry for desperate patients with serious illnesses (few non-deadly things can be as frightening as the prospect of losing your sight) who are being taken to the cleaners to make businesses richer.
I;m sure you've already done this, John, but just in case there is a Cochrane review of vitamin therapy in AMD at:
http://www.cochrane.org/reviews/en/ab000254.html
"The evidence as to the effectiveness of antioxidant vitamin and mineral supplementation in halting the progression of AMD comes mainly from one large trial in the USA. The generalisability of these findings to other populations with different nutritional status is not known."
Human nature isn't too different to how it was when all these pretty bottles were sold.
Well, given that exams are an artificial exercise depending very much on the ability to read and write quickly, it would seem a little unfair to disadvantage people with a fixed inability to do the very first part of the exercise, which is supposed to test something else entirely. In the real world, most of these people will not need to read and write quickly, but will need the skills the exams are actually intended to test.
Re dyslexia - I think a couple of years ago there was a Dispatches TV program that made a fairly convincing case that instead of using the word dyslexia (and all that that implies about it being a medical condition) you could instead just use the phrase "not very good at reading and writing". I would love to know if this stands up.
Clare Wilson
Among the many things that irritate me about the ICaps site - it is not particularly accessible to screen-readers (as used by people with vision problems or dyslexia (even) to 'read' a computer screen) if you run it through a web accessibility analysis tool. The alt tags are missing which means that people don't know what is in the images, including any text that they contain. Bad enough for the images, a disaster for any menu buttons that do this.
I'm complaining about this because not only are they a firm whose market is vision impaired people (with a similar diagnosis) but I see that they display the RNIB See it right logo on the bottom left of the page - without an alt tag, of course...
On a related note, John, did you happen to catch the Indy's extended front page advertorial for the new Grazax sublingual hay fever vaccine, which the kindly ran yesterday?
http://news.independent.co.uk/health/article2646292.ece
I also managed a little fisk of my own that you may find interesting -
http://www.ministryoftruth.org.uk/2007/06/12/why-is-the-indy-shilling-for-big-pharma/
Oh the nerve, what with me being neither a doctor or an economist, merely someone with a pronounced bullshit allergy.
“She’s very intelligent, doctor, but she is dyslexic.”
I think my husband is one of the few people I know for whom this might apply (with the obvious change in gender!). He excels at mathematical subjects (As at A level, back in the days...and with no extra time allowance) and holds further degrees and research fellowships in engineering, but his spelling...bizarre is the only word. He languished at the bottom of the class all through primary school until he got to upper school, where, providentially, a teacher started a chess club. My husband soon proved himself an excellent player and it was duly discovered (initiated by this same teacher) that he was also unusually good at problem solving, maths and physical sciences and that he had definite 'tracking' difficulties when reading text left to right, jumbling up words and letters. So, a happy ending but it could easily have been otherwise as his parents could never have afforded private education.
Dear John,
I think that you are being unfair on I caps and similiar supplements. The supplement Ocuvite-preservision was used in the AREDS study, a 4000 patient randomised double masked placebo controlled study over seven years. This is the study cited by the Cochrane review board. The reason that there is only this study that meets the highest standards of scientific evidence is the scale of the study.
There is much other evidence in less perfect studies and epidemiological research of varying qualities.
The relavent reference is:
From
Archives of Ophthalmology
October 2001 (Volume 119, Number 10)
A Randomized, Placebo-Controlled, Clinical Trial of High-Dose Supplementation With Vitamins C and E, Beta Carotene, and Zinc for Age-Related Macular Degeneration and Vision Loss
The Age-Related Eye Disease Study Research Group
Archives of Ophthalmology. 2001;119(10):1417-1436
This arm of the Age-Related Eye Disease Study (AREDS), an 11-center double-masked clinical trial, evaluated the effects of vitamin supplementation on the development of age-related macular degeneration (AMD). Patients were enrolled if they had extensive small drusen, intermediate drusen, large drusen, noncentral geographic atrophy, pigment abnormalities in 1 or both eyes, or advanced AMD in 1 eye. Visual acuity had to be 20/32 or better in 1 eye. Patients were randomized to receive either antioxidants (500 mg of vitamin C, 400 IU of vitamin E, and 15 mg of beta carotene), 80 mg of zinc with 2 mg of copper, antioxidants plus zinc, or placebo.
Participants were monitored with ETDRS visual acuity and retinal photography. Average follow-up after enrollment was 6.3 years. Compared with placebo, those with advanced AMD receiving antioxidants plus zinc had a statistically significant odds reduction for progression (odds ratio 0.72). The rate of progression of those with extensive small drusen, nonextensive intermediate drusen, or pigment abnormalities had a very low rate of progression over 5 years (1.3%). Zinc and antioxidants plus zinc reduced the development of advanced AMD in the higher-risk group.
Now if any other medication was shown to reduce the rate of blindness by 27% in a randomised clinical trial of this scale run by Johns Hopkins Hospital would you doubt that it would be supported?
While hypersupplementation with vitamins does have a whiff of quackery and has been demonstrated to be ineffective in many conditions, in Macular disease the evidence is to the contrary.
The study involved middleclass americans with higher than average vitamins at baseline supplemented with doses of 5 times RDA of the relavent vitamins, so is a true trial of hypersupplementation.
You may be interested to know that the trial is being rerun with a preperation involving Leutins as theese werent in common use in the early 90s when the AREDS study started.
As to cost when one considers that a years treatment with Lucentis will cost circa 12000 pounds then preventing this at a cost of 10 pounds per month seems a bargain, even when you count the number needed to treat.
Read the paper in archives John, Its not quackery, though the claims for Bilberry extract etc may be...
Dr James
not many kids on council estates appeal their exam grade either, these upgrades only ever go to the pushy middle classes
what with extra time due to dyslexia they may as well be given a straight 40% upgrade from the beginning
and the catchment area schnanigans
probably these least fair society we have ever had, dont u love nu labour?
I certainly wouldn't paint it with broad a brush, but there is some truth to your concerns about altering the testing/learning environment for dyslexics.
I have had some patients who were given considerations of various sorts to manage to graduate, then go on to get college degrees, but in the end seemed unemployable, or at least never seemed to hang on to a job for various performance reasons.
I just wonder if it fosters the idea in their minds that they will always get special consideration throughout their lives.
At the same time there are many dyslexics who have succeeded, it seems because they weren't given special consideration, and therefore had to cope in some way with the reality of it.
Sorry but i can't find Dr Crippen's e mail address anywher eon the site.
I have a couple of things i would like to e mail him for Brit Meds.
Can anyone help?
Click on dr john crippen which takes you to the profile. The email address is there
John
So if someone has an asthma attack, it should just mean "They're not very good at breathing"?
Or - If someone has a spinal injury, or even carpal tunnel to the extent that they cannot actually handwrite or are bad at it, they should not be given support in the form of dragon software, or even the opportunity to submit word processed work, for example?
As you might say, "Where does it end?" But people have gone off in the wrong direction here. The girl concerned (or whatever conglomerate of patients she actually represents) can't afford the sort of GP attitude described here. She might have some sort of neurological deficit affecting a number of cognitive functions. It doesn't matter if she's middle, working or underclass. She should be tested (and if necessary helped in whatever ways are available, with current/future knowledge and 'best available evidence'). Or should she just be left with some half-baked notion of 'not very good at reading and writing' following her to her grave, smothering her potential?
Right, anyone interested in exploring the idea that dyslexia simply means "poor at reading" should check out the article on the Dispatches website, at http://www.channel4.com/news/microsites/D/dyslexia_myth/dyslexia.html
and also look at the webchat with the producer (link on the right-hand side).
It was provocatively called: "The Dyslexia Myth" but don't prejudge it. The producer himself has dyslexia/"is a poor reader".
Clare Wilson
laughing cow you miss the point
there is whole industry grown up to provide advice and services to an every growing numbers of "dyslexics" diagnosed
this is self fulfilling
and it is a good way for the pushy middle class parent to get little johnnie perks such as more time to complete the exam, etc etc
the system is already completely biased against the genuine hard working kid brought up on a council estate and going to a sink comprehensive, i really dont think the middle classes need any more perks of pushydom
yes there maybe a few genuine dyslexics out there, but i know for sure there are a whole bunch more for whom it is just an excuse
too much political correctness, too little fairness
no one
Dr. James - it looks more like £20 a month going by the above calculations. But your point holds if the available supplements are an accurate facsimile of the formulation used in the studies. They have possibly done themselves no favours by adding in the Bilberry etc.
On the plus side, I think that the distributors do mention that the best advice for smokers is to stop smoking and it has a note about the potential problems of beta-carotene supplementation for smokers.
"As you might say, "Where does it end?" But people have gone off in the wrong direction here. The girl concerned (or whatever conglomerate of patients she actually represents) can't afford the sort of GP attitude described here. She might have some sort of neurological deficit affecting a number of cognitive functions. It doesn't matter if she's middle, working or underclass. She should be tested (and if necessary helped in whatever ways are available, with current/future knowledge and 'best available evidence'). Or should she just be left with some half-baked notion of 'not very good at reading and writing' following her to her grave, smothering her potential? "
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You have entirely missed the point.
This is not a question of "this sort of GP attitude".
The point here is that this is a middle class girl who does NOT have any neurological deficit, who will have an ed. psych. assessment (no suggestion that she will not) and most likely the assessment will not show anything apart from some problems with "words".
Obviously if it were to show other things, that is a different matter.
The school in question, which my daughters attend, is consistently in the top ten of the league tables for GCSEs and A levels.
My daughter has just done her AS levels. 10 of the 20 girls in her class (50%) had extra time because of "tracking disorders" and/or dyslexia.
It is a load of bollocks.
And it they don't get the grades that their parents expect they will shell out more money for remarks.
It is a load of bollocks.
Meanwhile, five miles down the road at the local comprehensive, they don't "do" dyslexia and tracking disorders, and they don't "do" extra time for exams. Why not? Because they don't have precious pushy middle class parents behind them.
Yes, as someone said above, I paint with a broad brush to make the point, but the point is valid.
And we have not added in the additional 5% added to the marks because the goldfish died.
I do not believe in sticking children in the corner with a dunce's cap and I except entirely that a few children have significant dyslexia.
But 50% of the year in top performing school
Bollocks!
John
hey dr john we agree totally for once
no one
Do look at the Channel 4 report recommended on Haloscan:
The Dyslexia Myth
By David Mills
Introduction | Why the silence? | The future of defining dyslexia
Introduction
As a current affairs producer, every story you tell brings surprises. No story I have ever been involved with before though has produced as many eye-openers as the Channel 4 Dispatches programme The Dyslexia Myth.
There were numerous small revelations: ranging from the discovery that dyslexic children do not reverse their letters any more than younger children reading at the same level, to the discovery that the Government has so far introduced no fewer than 650 different initiatives in primary schools.
Then there were even more dramatic discoveries: poor readers with high IQs, usually seen as dyslexic, respond in exactly the same way to help with their reading as poor readers with low IQs who are rarely labelled as dyslexic.
The biggest shock was that the 'dyslexia myth' story which sounded so controversial when I first started the research, turned out not to be controversial at all to the experts. The idea that the common understanding of dyslexia is a myth was startling when I first heard it. Yet I found it was a view shared by every academic that I talked to. The scientific consensus about it is overwhelming.
This poses two questions, both of which trouble me still, even though we did not deal with them in the documentary. I am raising them here in more detail. The first question is why has the story not been reported before? The second is what is the future of the term dyslexia?
Why the silence?
The expert knowledge that the popular understanding of dyslexia as a 'myth', has been around for at least ten years. The research findings, taken collectively, are devastating. Yet they have never been properly reported to the public. Perhaps the reason for this is the inadequacy of the journalistic profession.
Or perhaps it reflects perhaps a bigger problem: a natural reluctance on the part of researchers to simplify and popularise the findings of other investigators. Although academics understand the big picture, few feel comfortable about dragging together all the different research findings about a complex subject, simplifying them and putting them together to provide a simple overview. Academics are rated on their ability to come up with their own findings, not on how effective they are at popularising other people's research.
The future of defining dyslexia
The question of how dyslexia could be defined generated a lot of controversy in the run up to the documentary. The reason we did not deal with it in the documentary is that there is simply too much disagreement about it. There are at least five major views about the future use of the term 'dyslexia':
View 1
The term dyslexia should be dropped completely.
It is said that dyslexia carries so many wrong associations, and is understood in so many different ways by so many different people, that it serves no useful scientific or therapeutic purpose. It should be replaced by 'reading problems' or in more severe cases 'reading disability'.
I have a lot of sympathy with this view. As a journalist I like to know what words mean. There are problems though. The term dyslexia is so ingrained that a lot of people would still go on using it. There is also the fact that 'dyslexia' is a handy term for those trying to focus attention on the needs of those with reading problems.
View 2
'Dyslexia' can be redefined to describe all children who find it difficult learning to read because of phonological problems.
This would provide a clear definition which would identify children who have a sufficient problem detecting the smallest sounds in words which make learning to read difficult. It would thus identify children who will need additional tuition in a small group or even one-to-one help.
This could result in labelling up to one fifth of children as 'dyslexic'. Do we really want to suggest that so many children are in some way 'disabled'? Given that so many children have problems learning to read, we should look upon difficulty in learning to read as an entirely normal experience for quite a lot of children.
View 3
'Dyslexia' should only be used to describe children with the severest problems.
These children will need not only small group teaching but also often skilled one to one assistance to overcome their problem.
Such a definition has the merit that it would help institutions like the Dyslexia Institute focus attention on such children. Yet it would still label children as dyslexic who, with the right teaching at school, will learn to read perfectly well. It may also suffer from the difficulty of arriving at a cut off point. So on one side of this line a child would be labelled dyslexic, while on the other, a very similar child would not be.
View 4
'Dyslexia' should be used only for the 1-2 per cent of children with a long-term reading problem who do not respond to the best school teaching currently possible.
There is no doubt that these children need far more help than individual schools can provide, including diagnostic tests and long term support.
This view is supported by many leading researchers. It would mean that 'dyslexia' defines a clear group of children who are significantly disabled and for whom special help is both needed and justified.
View 5
'Dyslexia' should no longer be really associated with reading problems nor defined in relation to reading.
The argument is that there is a pattern disability, much wider than mere reading problems, which can be used to define who is, and who is not dyslexic.
The problem is, that as far as I am aware there is, precious little agreement on whether such a pattern exists or if it does exist, how at present it might be defined. There are indications that some adults who have suffered long-term reading disability do often share other problems, such as poor memory or poor organisational skills, but whether this could be used to redefine dyslexia seems, on the evidence, problematic.
So what do I think after all the research that I have done? I am tempted by the definition in View 3, that dyslexia should be used to define children with the severest problems. However in the end I think I would come down in favour of View 4, reserving the term 'dyslexia' for the 1-2 per cent of children, whose problems, on present evidence, are unlikely to be resolved by even the latest 'state of the art' school teaching. It would be a rigorous definition and focus attention on those who suffer most. They need all the help we can give them.
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The University system with dyslexia is just like schools, John. Though the prevailing view among University academics can be shorthanded in jokes like:
- Middle class kids have "mild dyslexia". Working class kids can't write or spell.
- Middle class kids have "mild dyslexia". Working class kids are just thick.
- Dyslexia diagnosis: the middle-class parent's educational insurance policy for your kids.
We have seen a vast increase in the number of students with a dyslexia diagnosis at my University. It is now running at something around 1 in 10, across all courses.
All these students get various kinds of special measures and support, including extra time in exams. We are also told to give them lecture notes in advance if they so request (detailed notes, not just the summary hand-outs or Powerpoint presentations we normally use/distribute), extra help in tutorial work and group discussions/ seminars (er? how exactly...?), etc etc. Students with "severe" dyslexia diagnoses get other sorts of help, even including computers with special software to write exam answers on.
These instructions usually come from the "Faculty Disability Support Officer", almost all of whose workload relates to dyslexics.
It is now a thriving industry, in other words.
I worry about diagnoses from private for-fee Educational Psychology practitioners. A diagnosis of severe dyslexia from a pukka Educational Psychologist who works for an LEA (or whatever they are called now) is one thing. A diagnosis of mild dyslexia / "trouble with spelling and grammar" from a private practitioner who is being paid to diagnose exactly that makes me twitchy. But educational institutions are pretty much obliged to take them both at face value. Otherwise we would have to go down the route of hiring our own Ed Psych assessors and potentially contesting what the other Ed Psych person has said, with the potential for it all ending up in court.
So in the end, I feel the support for students is how it has to be, though sometimes it can grate a bit. If a student in our place has a difficulty, like dyslexia, we will do all we reasonably can to help them cope with it, give them the appropriate support etc. (Contrary to some popular stereotypes, academics really do care about their students, a bit like doctors and their patients). And then we will judge them by the same academic standards we apply to all students, so that the degree we hand out hopefully means what it says on the tin.
Doc:
My very middle-class, privately-educated brother was diagnosed with dyslexia (at the moderate-to-mild end of the spectrum) when he was 10 or 11.
The purpose was not to gain extra time during exams, but to identify a problem that could be solved. With a couple of years of special tuition at lunchtime, his reading and writing scores increased markedly. His spelling is still not great, but that's the only sign now that he used to have "a problem".
(And yes, he's scarily smart, has the prestigious Maths degree, the high-paying job and the rest of it. He sounds quite a lot like hcw's husband, except he's crap at chess...)
Sam
don't get me wrong.
I do not suggest for a moment that people with reading difficulties, or any other difficulties for that matter should not get help
Of course they should
But I become cynical that,as someone said above, it is predominantly middle class children who get the help.
Working class children are just thick
John
Regarding the AREDS study, ICAPS has a lower level of lutein than the supplement that was tested AND a lower level than the recommended daily minimum to have any impact.
At the same time, there are concerns about the potential toxicity of high quantities of other vitamins in ICAPS.
No RCT has been done, and there is precious little evidence to suggest ANY food supplement is of much benefit beyond placebo effect.
Interested in what Dr James said above about the Arch Ophth antioxidant trial for AMD. If he is still around.. a few Qs:
1. The trial was published 2001, so if it worked why was is there not more subsequent trial data?
2. How does the risk trade-off work with the lately-published potential risks of high dose antioxidant supplements?
3. Has there been a decent trial of simply eating more foods rich in the relevant things?
[As a life-long cynic about the efforts of the vitamin-pushers, I had the impression that eating foods rich in "things that are good for you" was usually at least as good, if not better, than chomping expensive supplements.]
- and 4. if the people with early AMD are smokers, are overweight, have borderline BP, have badly controlled diabetes, have high-ish cholesterol (any and all of the above) and so on, does altering these "modifiable risk factors" reduce the AMD risk more than the supplements? ..not to mention making them healthier all around.
The freebie "starter course" from the doctor is an old PharmaCo marketing trick, of course. Donate the pills free, hope the doctor starts the patients started on it, and then they will understandably want to keep popping them and demand same from their GP.
Yer don't get owt fer nowt, as we say in Yorkshire.
John, Icaps are allowed on prescription - I dispense a fair number each month and haven't had a script back with 'disallowed' on it.
I know the drug tariff is overly complex, but any drug, food, cosmetic or supplement is allowed on FP10 unless it is blacklisted (part XVIIIA). Icaps are not blacklisted (you can check at http://www.ppa.org.uk/edt/June_2007/mindex.htm) and so are allowed.
If you're ever not sure whether something is allowed on FP10 you can always ask you local pharmacist.
I agree with UK community pharmacist, I-Caps are theoretically allowed on FP10, even though they are a load of old balls.
One of our local consultants is recommending it, and our GPs have been brow-beaten into prescribing it (Mostly by patients who have seen that smug tit on "This Morning")
I agree with UK community pharmacist, I-Caps are theoretically allowed on FP10, even though they are a load of old balls.
One of our local consultants is recommending it, and our GPs have been brow-beaten into prescribing it (Mostly by patients who have seen that smug tit on "This Morning")
I-caps ARE allowed?
Strewth! I really did not know that.
I will have to look into that with my partners tomorrow.
That is going to pose some interesting and difficult questions.
Thanks for that, community pharmacist; I wonder if ignorance would have been more blissful though!
John
I attended university to do my MSc a few years ago. I needed to apply for Disabled Students Allowance (£6000 per year) as I am physically disabled, and have severe neurological problems. Unfortunately by the time the DS advisor had dealt with all the 'dyslexics' (3 out of 10 on some courses!) then there was little time left to deal with anyone else. In fact there was only token support for anyone not 'dyslexic'. Blind and deaf students only had very limited help, physically disabled students were not given extra time or study accomodation. yet laptops were handed out like sweeties to 'dyslexics', and they had up to 50% extra time for coursework and exams, audio-dictation equipment, and assistants to take notes!
Oh and oddly enough, the 'dyslexics' were the only ones who didn't have to undergo a demeaning, exhausting, 3hr assessment at the regional DS assessment centre.
I ended up quitting, because while Johnny and Jilly Cant-Read were getting thousands of pounds, free computers, transport to and from lectures, cut-price accomodation and personal assistants , I got a floppy disc allowance of £5 a month (ha ha!) and up to 10 taxi rides a year, that I had to pay for myself then could claim back if they thought my condition justified it! Useless.
Why is it that all the middle-class kids have tracking disorders, dyslexia, attention deficits etc. while housing estate kids are just naughty and thick?
If became unfortunate enough to have a wet macula problem and was refused optimum NHS treatment, I would probably seek private treatment with Avastin at "only" £85 a shot, plus fees.
Dr C,
You are spot on with your observations about dyslexia. I have referred many adults for dyslexia assessments and have never had the diagnosis discounted. If this was true of any other investigation I would be fearful of under-referring; as it is I am convinced it is because there is a perverse incentive at work for the 'right' diagnosis.
It seems illogical that attempts are made to level the playing field for those who are at the extreme end of functioning (i.e. really thick) rather than simply mediocre. A test of academic ability is inevitably discriminatory (er.. that's the point) and if anyone is unable to accept that perhaps they shouldn't bother doing the test?
Oh, there is extra time in the 'real world'. It's available as a 'reasonable adjustment' under disability legislation and many under-performing employees who have met a friendly psychologist and been given the desired label would extract adjustment of this sort from their employer.
The put-upon working class kid he went to school with, and who had a job in the same office, would then probably end up doing some of his work. Modern Britain; great isn't it?
re "I-caps ARE allowed?" from the patients point of view this exposes one of the biggest problems with the nhs model, the gp acting as gatekeeper to everything else depends on having a gp who knows what he is doing, understands what he can prescribe, where he can refer, what strings he can pull, general politics of the job as much as ability, and the patients with frankly crap gp's get a very bad deal, and even in relatively trivial areas like this how well the nhs attends to you depends completely on that one individual gatekeeper - which just reinforces my view that we should be able to self refer to consultants like you can in belgium, italy et al
i am that put upon working class kid! what with this crap, womens networks in place to ensure womin get positive discimination, and failed sales folk from public school at the top ... its a hard slog
yep the uk is stuffed
I have a dyslexic friend who is a teacher. Every time he gets a new class, he spends a reasonable amount of time educating the dyslexics that they are not going to be getting away with anything. Hmmm.
anon said womens networks in place to ensure womin get positive discimination
AHAHAHAHAAAAH. Don't make me laugh so hard, I'm asthmatic, er, I mean breathing impaired
Oh *wipes away a solitary tear*
You'll be saying that black people never get arrested, and that gays are allowed to adopt as many kids as they want next.
Oh anon, anon, anon. You have cheered me up so much that I'd buy you a drink if you weren't such a chauvinist piglet.
Dr Crippen said Dyslexia " It;s a load of bollocks"
Well Doc, I'm Dyslexic and you might well be correct because my testosterone is under 8 nmol/l in the clinical range 10.5-30 nmol/l
Would you or any or the others prescribe Tostran (2% gel)?
Incandenza says that I caps contain less lutein than the supplements in the Areds study.
This is not true, Leutin was not in the AREDS supplement at all, therefore it is impossible for the I caps to have less.
As per my previous post the trial is now being re-run with a leutein containing supplement. This is the AREDS2 trial, also a large multicentre randomised trial based at Johns Hopkins Hospital, Wilmer Eye institute, generally recognised as the leading US academic ophthalmology institution. Large scale studies like this take years, the AREDS took more than seven, so results should be out in the next year or two.
The patients in the study were well nourished middle class white americans, with basal vitamin levels higher than the USA average, and significantly more than the UK, and the effect was present even in these healthy eaters, so it seems that on the best evidence Hypersupplementation does help macular degeneration, despite your and my suspicion of quackery. If it was any other Rx would it be doubted.
Both treatment and placebo arms had a lower death rate than the USA average with no significant differrence between them. Retinol supplementation has been linked to osteoporosis, hence Beta Carotene was used as this is not so linked, though it does seem to increase the death rate in smokers. Smoking is a BAD THING.
In summary eating healthy foods does not seem to be enough, supplemenmts do have additional benefit.
I know some practices are willing to prescribe I caps, others not. I tell patients that they will probably have to pay themselves. Ocuvite preservision is less availible in the UK than I Caps, and looks like Horse Pills, so most take I caps or Vitex, both of which have slightly lower vitamins than Ocuvite, but also have leutins.
In the AREDS study Zinc 80mg (given with 2mg copper as otherwise might induce copper deficiency) was very nearly as effective as the Ocuvite supplement, and is perhaps a reasonable alternative particularly in recalcitant smokers.
Dr James
Re dyslexia, sure enough some individuals use the label as a shield and blame everything that's ever gone wrong in their lives on the fact that "the words jump around the page" but I don't agree with it being a synonym for being thick. It may be a significant problem when reading and writing are required but it's no barrier to creativity and open thinking. A friend of a colleague recently found out they were severely dyslexic but is reading English and consistenly achieving 2:1s and 1sts in their essays. They came to the conclusion she was intelligent enough to subconciously overcome the obstacles the dyslexia provided. Another severely dyslexic colleague has just secured a place at a prestigious art and design university. Both come from working class families. Both went to state schools, one was given the option of extra time in exams. Dyslexia isn't some bollocks thing middle-class parents use to skim over the fact that their child isn't quite as clever as Mr & Mrs Jones' child, it's something which is putting a lot of people at a major disadvanage. 20, 30 years ago, dyslexics would go into trades such as bricklaying and factory work where reading and writing wasn't required so much because "they weren't very good at school". Now that New Labour is so determined to get 50% of school leavers into university, it's now being picked up more and more frequently. The majority of these people are capable of obtaining a university degree and go on to do so successfully (yes, usually with the extra time in exams). So, unfortunately this "dyslexia=stupid" thing just doesn't cut it with me.
Sublingual means under-the-tongue?
Darn.
Almost a medic -
We weren't denying dyslexia exists. Just suggesting it is grossly overdiagnosed by a set of people who make a living diagnosing it for fees. And mostly on behalf of middle class parents who are seeking extra insurance for their kids. It's cheaper than hiring a tutor.
I would say the severely and truly dyslexic are likely to get "lost in the wash" in education, when one in ten students in my University are rather laughably labeled dyslexic.
My personal view: based on the 18-21 yr olds whose writing I read regularly at (a Russell group) University, schools no longer teach most chidren how to spell or to write grammatical English. And remember I am seeing the "top echelon" of what schools turn out, with A level grade As. It may not be all the schools' fault, because a lot of the kids I know aged 11-15 have never read anything past the age of about 5 that wasn't text on a PC screen. The internet is not, on the whole (pace Dr Crippen), a place to find literate and clear writing.
the real problem isnt that genuine dyslexics get help, or extra time in exams
the problem is that it is way more diagnosed in the chattering middle class kids with pushy parents than it is amongst working class kids in sink comprehensives
it is being used as another lever to ensure little johnnie gets the best chance in life possible
Aging academic cynic - I totally agree with you on the poor standards of English at university. I'm a postgrad student at another top university, and I'm required to help run lab classes, and mark the lab reports afterwards. I was with the third years this year; remember, many of these guys will be graduating in a week or two, but the standard of grammar in particular was terrible in some cases. One chap had put an apostrophe before every single terminal s. They don't get any marks for spelling and grammar, but I make a point of correcting it anyway. Actually I wasn't taught much grammar at school, which was a problem when they tried to teach us French and German grammar! I picked up a lot of my English language skills from reading lots of books.
My impression of dyslexia has been that it is a specific learning difficulty for reading and writing, independent of the rest of a child's IQ. The child can be dull, average or bright, and still be dyslexic.
hcw - I have a similar story - I have a relative who can barely write his name, but can discuss science and logic perfectly well, and scores in the top 1% on IQ tests. One assessment was done by the educational psychologist who came to his state comp.
I've known a few other dyslexics - I think they were all genuine, except for one family (coincidentally, or perhaps not coincidentally, they were also the richest) where I thought the kids were plain thick.
It could also be that I am not quite posh enough to know the sort of people who'd fake it.
Why is the problem automatically with the middle classes?
We all know that health in the lower social classes is generally poorer, partially because they take longer to present (or don't at all).
So is the problem about middle class parents asking for assessment and treatment, or is it lower class parents not supporting their kids?
Never mind dyslexia, here's one for you.
A classmate of mine (fourth year medical student) has managed to get thousands of pounds worth of equipment including a laptop, digital camera, minidisc player and PDA - all top of the line - because of a "disability."
What's wrong with him? He had asthma as a child/adolescent, for which he no longer takes any medication. No matter how severe the condition, he is apparently eligible for this "support" from some big pot of money somewhere.
He fully admits himself that it's a total scam, as do (more or less) the people responsible for giving him the stuff but, hey, the money's gotta be spent...
Hmmm..I hope your classmate realises how difficult proving that he's fit to practice may be if he has any health issues.
He wouldn't get that sort of equipment for asthma; my guess is that he has some sort of learning difference that he doesn't want to share with people (as the people who give him the stuff don't have to dole out all of the money, at least if you're talking about a UK student).
Dyslexia is on a par with ME or CFS or fibromyalgia and previously low back pain or neurasthenia.
Yes, probably something wrong in some of the cases, yes badly managed by conventional medicine but yes also, often used as a bloody good excuse for personality traits/reactions to situations or a ticket to an easier life or extra considerations
Re. anon 12.21-
The Dispatches programme, if I recall correctly, explained that the label of dyslexia was given to those who had literacy/numeracy problems but nevertheless had a reasonable/high IQ. If you couldn't read or write well and also had a low IQ then you were just generally a bit slow.
The only logic to discriminating between the two groups would be if one needed a different type of educational approach to the other. You might predict that they would; that the bright ones would respond far better to intensive reading/writing tuition and should be targeted accordingly.
But they don't. All poor readers/writers benefit from additional tuition to the same extent, and separating those with high IQ from those with low IQ is of no practical benefit.
Hence the programme's main question; why bother with the label? I suppose the suggestion that kids who can't read or write very well need extra help with these activities just isn't complex enough for the boffins paid very well to baffle the rest of us with psychometrics.
Re. anon 9:36:00 PM - why bother with the label? Hmm, I dunno. So you're saying that this show said that you can't tell the difference between a dull child with dyslexia, and a ordinary dull child who takes longer than an ordinary cleverer child to learn to read? They don't need anything different? Or is it saying that dyslexics of all IQs need the same help learning to read, so no point distinguishing on basis of IQ? Or both?
ni gp - re ME/CFS fakers, roll on diagnostic test!
What happens to all these children with “mild” dyslexia when they leave school? Will they be prepared for the realities of life? You do not get “extra time” in the real world.
A good question Dr C. I come across "dyslexic" medical students every day, being allowed all sorts of concessions such as extra time in exams and waived fines on library books. The mind boggles. That's not to say that genuinely dyslexic people should be denied a bit of help, but if an individual is considered unable to manage minor things like returning books, I fail to see how they should be allowed to become a doctor!
The data is pretty clear, supplemental antioxidants don't reduce all cause mortality.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17327526&ordinalpos=46&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Maybe you see short term effects, but in the long term those on placebo fair slightly better.
My hypothesis is that it is a "setpoint" issue. That food choice is part of the "oxidative stress setpoint", and that if your body calls for high oxidative stress, it will direct you to eat "rubbish" so as to not to consume all those antioxidants which it must then destroy by generating more and more superoxide (which eukaryotes have virtually unlimited capacity to do).
All the diet studies showing protective effects of fruits and vegetables have been retrospective where people ate a self-selected diet. It may be that state of health determines food choice, not food choice determining state of health.
Dear Dr Crippen,
I was under the impression that simvastatin was the weakest of the statins dose for dose. If you bump up the dose to make it equivalent to say 40 of atorvastatin you run into the dreaded side effects. By changing everyone to simva do you then run the risk of worse cholesterol control? Then if their control is worse, will you then get a few more MIs/Strokes/etc per year and will these events be more expensive to the PCT than using the "better" statin at the start?
All that aside most of the statin trials seem to be sponsored by drug companies. Especially the head to head trials.
Dr Sniper
Anon 9:52 -
I don't claim to be an expert, but my understanding is that the diagnosis of dyslexia is reserved for those with poor numeracy/literacy skills but who have good general intellect. If the child is generally not the sharpest tool in the box then they tend not to attract the diagnosis. In reality discriminating between the two groups is like nailing jelly to the ceiling, aand other factors (principally pushiness of parents)play a large role in whether the diagnosis is given or not.
But the key point is that both groups benefit from more intensive tuition, and to the same degree (which is a bit counter-intuitive). So why go to the trouble if identifying a sub-group of poor readers/writers (who happen to have an otherwise good IQ) when there is no evidence that they should be treated any differently?
Happy to admit limitations of my knowledge; this was my recall of the Dispatches episode. It all made sense at the time....
I tutor in the evenings to pay my way through medical school; the nature of the work means that except when I do pro bono work, I'm dealing with pretty solidly middle/upper-middle class kids. As the good doctor suggests, an enormous number of them seem to have "dyslexia", and although I have come across one girl whose report had come up negative (I took the edpsych's name so I could recommend him), my favourite has to be a boy called David. He was 12 when I started working with him, and really exceptionally intelligent in the sort of gifted, hardworking way that's best summed up with plain old "bright".
His parents had had an edpsych do a report on him which they gave to me to read; this I duly did.
As I read I had an overwhelming sense of deja vu, and sure enough, midway through the report the author went from saying: "David has..." to "Tom has...".
He hadn't bothered to change the names from the last time he'd used his middle-class dyslexia form.
Pfizer - Lipitor: not first among equals?
Ed at Pharmalot has a few choice words about this one!
Not to mention the WSJ Health blog.
http://pharmagossip.blogspot.com/
Dr Sniper,
you are correct that simvastatin is not as potent as atorvastatin. 10mg atorvastatin is equivalent to 20-40mg simvastatin (some PCTs advise 20mg simva, others 40mg simva for 10mg atorva). However, how many people actually need 40mg atorvastatin? Not many.
You might want to have a look into the evidence around statins. I suggest you start with HPS (http://www.ctsu.ox.ac.uk/~hps/), and NPC have lots of good info on statins (http://www.npc.co.uk). Basically there is a huge amount of evidence to support use of simva 40mg in patients with diabetes, angina, CHD, PVD.
Lots of drug studies are sponsored by industry. Some of them are useful, some of them are not. You just have to look at them in the same way as any other study: what where their inclusion and exclusion criteria, what was their comparator, what did they actually find (ARR & NNT, not RRR).
My copy of the World Health Organisation's details of requirements to make a diagnosis of developmental dyslexia (in ICD-10) has 7.5 pages of explanation and guidelines. It's quite hard to tick enough boxes for clinicians to make a formal diagnosis of dyslexia.
Working in Child & Adolescent services a lot of kids were referred but of the hundreds screened and referred with ?dyslexia, none had it.
I'm sure it exists, but it is over diagnosed.
Before even getting on to soft signs, a formal diagnosis (using ICD-10) specifies that 1 of 2 criteria has to be met :
A (1) a score of reading accuracy and/or comprehension that is at least 2 standard errors of prediction below the child's chronological age and general intelligence, with both reading skills and IQ assessment on an individually administered test standardised for the child's culture and educational system;
or
A (2) a history of serious reading difficulties, or test scores that meet criterion A (1) at an earlier age, plus a score on a spelling test that is at least 2 standard errors of prediction below the level predicted on the basis of the child's chronological age and IQ.
There are then further criteria to be met.
As taxpayers, if someone's claiming to have dyslexia but hasn't gone through this formal process, do we have a right to say their resource allocation os fraudulent? ;-)
Next time redirect Mabel to A&E.........on a Friday night.
Her behaviour would then be almost impossible to distinguish from a significant minority of the usual aherm/cough, clientele.
Hi A&E charge nurse
Yes, I know what you guys have to put up with in A and E, and in that context I feel precious mentioning Mabel.
We get something like this about three times a year; I know you see it weekly.
I don't have an answer.
Does a patient ever forfeit their right to medical care through bad behavior?
John
Dear UK Community Pharmacist,
Thanks for the pointer - I will go over the link in due course. Could I remind you of the old saw: There are lies, damned lies and statistics...... There is always someone clever than me to twist a figure beyond my meagre skills.
As to who needs high dose statins, and please bear in mind 40 of atorvo is middle of the road, I would answer than any NSTEMI/STEMI or ischaemic stroke need their cholesterol lowering hard. Initially, I was taught that for an unstable plaque you would add in high dose statin. This would then act as a plaque stabiliser. Now "guidelines" suggest making sure the patient gets a statin before they leave hospital. Generally, colleague based medicine (like evidence only much more personal) says that whatever the statin result you need to lower it after an atherosclerotic/thrombotic event. Clinically the higher you nudge up the dose; the more likely you are to run into a side effect.
Dr Sniper
Dr John Crippen - "Does a patient ever forfeit their right to medical care through bad behavior?"
But how much can we reasonably ask doctors and nurses and reception staff to endure? What degree of violence?
K
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