Category: Sicklecell

Re: International medical graduates and quality of care: What if quality of care in developing country is better than UK’s?

Re: International medical graduates and quality of care Aneez Esmail, Julian Simpson. 356:doi10.1136/bmj.j574 International Medical Graduates and quality of care: What if quality of care in developing country is better than UK’s?

The excellent Editorial [February 6 2017] of Professor Aneez Esmail and Julian Simpson, hemmed in as it is to comparing and contrasting UK health care [1] with that of the USA vis-à-vis foreign trained doctors, was not expected to address the question: What if certain aspects of the quality of care in a developing country, say Ghana, is better than that in the UK? What is a doctor trained in Ghana by UK-trained doctors to do when he/she sees something taught at home is contradicted by UK practice with disastrous results?

JUST SEE WHO MY GREATEST TEACHERS IN MEDICINE WERE!
I dare to ask 21st Century Clinicians to compare themselves with those who taught me, and state honestly whether apart from the CT Scans, Ultrasound machines, MRI’s, and microsurgical techniques, they boast better clinical acumen than these grand-teachers?. I was trained at London University’s Westminster Hospital School of Medicine by the world’s greatest – Sir Clement Price-Thomas, Surgeon of King George VI, Sir Richard Bayliss Physician of Queen Elizabeth II, Sir Stanford Cade, World Number One in cancer surgery assisted by Charlie Westbury MS MRCP FRCS, then Professor J Pulvertaft (Pathology), Sir Arthur Bell Obs/Gynae, etc. and at the Post-graduate level Malariologist Professor Brian Maegraith, Liverpool University School of Tropical Medicine, Sir John Dacie, Haematologist at Hammersmith Hospital where Professors John Goodwin (Cardiology) and J McMichael assisted by Dr Celia Oakley taught me Cardiology, and where I first met Dr Geraint James who introduced me to his wife Professor (later Dame) Sheila Sherlock [2 3] of Royal Free Hospital, where I worked with the Artificial Kidney King of Europe Dr Stanley Shaldon. All these were Clinicians with the “History-Inspection-Palpation-Percussion-Auscultation” (HIPPA) approach to patient care which was what I taught my undergraduate and post-graduate students in Ghana. Then at Cambridge University I was very fortunate to be instructed in Haemoglobinopathy and G6PD Enzymopathy by Professor Hermann Lehmann FRS the Doyen of Abnormal Haemoglobins.

Back home in Ghana my Mentors were Colonial Physician Dr Albert Hawe MD FRCP [4] and Ghanaian Dr Silas Dodu MD FRCP DTMH who had collected most of the prizes at the University of Sheffield.

BUT WHY THIS CATALOGUE OF NAMES? ANSWER:
When the National Foundation and the March of Dimes paid for a 6-week tour of 11 leading Medical Institutions in the USA 45 years ago, and I did Grand Rounds at Cornell, George Washington University Hospital, Columbia University, Johns Hopkins, Yale, Howard, Tennessee, Indianapolis etc, and I often made Haemoglobin phenotype diagnoses without X-rays and Lab results but by just examining the patient using HIPPA
the Professors were so astounded they asked how I did it, and I just said “It’s the British Undergraduate Exercise that prepared me for the bush”.

THEN BACK TO THE UK FOR QUESTIONABLE MEDICAL CARE
The situation in the UK has drastically changed. Ghanaian doctors we taught would end up in the UK and be introduced to practice that looked at the blood of the patient before looking at the patient – quite opposite to what we taught them, preferring to look at Protocols hung up on a wall without realising that what is good for one patient may be poison for another. Or that what is recommended by NICE Guidelines could be killing patients [5-7]. How many British doctors, I wonder, are aware that I said 42 years ago in The Lancet that blood transfusion precipitated sickle cell crises? [8] Or that Graham Serjeant described a sickle cell anaemia lady he had never transfused but who going to the USA on holiday from Jamaica, checked into a Clinic for routine tests, was found to be anaemic and promptly transfused, only to die within 48 hours? [9] Or that I have described an “SS” man who would go into sickle cell crisis whenever Haemoglobin level rose above 9 grams per deci-Litre? [10]? I once referred one such patient to Professor Lucio Luzzatto at London’s Post-Graduate Medical School Hammersmith Hospital to venesect her every 6 months to bring Hb below 9 grams lest she went into sickle crisis. Sadly, with dogged determination British doctors would follow a Protocol that said Hb should not fall below 11.0 grams per deci Litre [11]. How many British Doctors would persist with Morphine and Diamorphine even when NCEPOD Report damned the Opiate Culture? [12-19]. Yet NICE continues to recommend intravenous Opiates? [5-7 12-19].

Even when a Nigerian Consultant Haematologist in a UK Teaching Hospital, himself “SS,” wrote a BMJ Editorial on Hydroxyurea saying “patients had been voting with their feet due to side effects” [20 21] clinicians continued to prescribe it.

KONOTEY-AHULU SICKLE CELL DISEASE PATIENT MANAGEMENT APPROACH
My immediate elder brother, my immediate younger brother, and the 5th of my parents’ 11 children had sickle cell disease [22]. I know the disease first hand. Having grown tired of criticising other clinicians about their mismanagement of patients with sickle cell disease I am offering doctors, nurses, patients and their relatives a real alternative to what the rest of the world (apart from Graham Serjeant [23] in the West Indies) prescribes [24]. My approach brings hospitalisation to a minimum, preferring patient management to disease treatment [25-29]. My kascdispatma (spelt fully above) produces PATIENT ACHIEVERS who use their non-abnormal haemoglobin genes inherited from the same parents to achieve things that their siblings without the disease have not achieved [30 31]. G6PD status of patients, meaningful genetic counselling with voluntary family size limitation [32], avoidance of harmful received wisdom underline the Common Sense Public Health Approach that is the defining feature of kascdispatma When Professor Helen Ranney of Albert Einstein University College of Medicine New York says “There is no single clinical experience in the United States comparable to that of Dr Konotey-Ahulu “[33] should not serious clinicians and parents struggling to look after sickle cell disease patients try my kascdispatma?.

Felix I D Konotey-Ahulu FGA MD(Lond) FRCP(Lond & Glasg) DTMH(L’pool) FGCP FWACP FTWAS

Conflict of Interest: None Declared felix@konotey-ahulu.com www.sicklecell.md

1 Aneez Esmail, Simpson Julian. International medical graduates and quality of care. BMJ 2017; 356: j574 (6 February 2017) doi:https://doi.org/10.1136/bmj.j574

2 Konotey-Ahulu FID. Konotey-Ahulu FID. Dame Sheila Sherlock’s Third World Dimension. BMJ rapid response 20 Jan 2002 http://www.bmj.com/content/324/7330/174.1.extract.reply#bmj_el_18859

3 Konotey-Ahulu FID. David Geraint James: Great Champion of Overseas Postgraduates. 18 Nov 2010 [Response to BMJ 341:doi.1136/bmj.c6400] See Ref 170 on Dame Sheila Sherlock 20 Jan 2002. http://www.bmj.com/content/341/bmj.c6400.full/reply#bmj_el_244903 | http://www.bmj.com/content/324/7330/174.1.extract.reply#bmj_el_18859

4 Konotey-Ahulu FID. Some personal encounters with a remarkable physician. (Tribute to Dr Albert Joseph Howe, OBE, CBE, MD, FRCP, DTMH). Ghana Med J 1979; 18: 88-90.

5 Gillis VL, Senthinathan , Dzingina M, Chamberlain K, Banks K, Baker MR, Longson D [Guideline Development Group]. Management of an acute painful sickle cell episode in hospital. Summary of NICE Guidance. BMJ 2012; 344: e4063 [doi:101136/bmj.e4063]

6 Konotey-Ahulu FID. UK drug related deaths are still rising: So where is NICE? Sept. 6 2009 BMJ Rapid Response to Susan Mayor on “UK drug related deaths are still rising 2 reports say” BMJ Sep 6. http://www.bmj.com/cgi/eletters/339/sep01_1/b3536#219836

7 Konotey-Ahulu FID. Management of an acute painful sickle cell episode in hospital: NICE guidance is frightening1 Sept 7 2012 www.bmj.com/content/344/bmj.e4063/rr/599158 [42 references]

8 Konotey-Ahulu FID. Sicklaemic human hygrometers. Lancet 1965 May 8; 1(7393): 1003-1004. http://www.pubmedcentral.nih.gov/picender.fcgi?artid=1846286&blobtype=pdf

9 Serjeant GR. Blood transfusion in sickle cell disease: A cautionary tale. Lancet 2003; 361: 1659

10 Konotey-Ahulu, FID. The Sickle Cell Disease Patient. Macmillan Education Ltd London 1991/1992. Foreword by Roland B Scott, MD (Howard University) – 36 chapters with 4,500 references, 643 pages. ISBN: 0-333-39239-6 & Konotey-Ahulu FID. The Sickle Cell Disease Patient, Watford: Tetteh-A’Domeno Co, 1996 Reprint of 1991 Macmillan book] http://www.sicklecell.md/aboutscd.asp [Hb > 9.0 grams >crises, p.482 Case History 21]

11 Claster Susan, Vichinsky Elliott P. Managing sickle cell disease. BMJ 1997; 327: 1151-1155. Doi:10.1136/bmj.327.7424.1151.

12…NCEPOD (National Confidential Enquiry into Patient Outcome and Death). Sickle: A Sickle Crisis? (2008) [Sebastian Lucas (Clinical Co-ordinator), David Mason (Clinical Co-ordinator), M Mason (Chief Executive), D Weyman (Researcher), Tom Treasurer (Chairman) info@incepod.org

13 …Konotey-Ahulu FID. Poor care for sickle cell disease patients: This wake up call is overdue BMJ Rapid Response May 28 2008 BMJ 2008; 336: 1152 to Susan Mayor “Enquiry shows poor care for patients with sickle cell disease” on National Confidential Enquiry into Patient Outcome and Death (NCEPOD) REPORT “SICKLE: A Sickle Crisis? (2008) http://www.bmj.com/cgi/eletters/336/7654/1152a#196224 | http://www.info@ncepod.org

14 Konotey-Ahulu FID. Inquest into diamorphine deaths: Does NCEPOD sickle patients report warrant a similar inquest? BMJ Rapid Response March 7 2009 http://www.bmj.com/cgi/eletters/338/mar03_3/b903#210208

15 Konotey-Ahulu FID. Opiates for sickle-cell crisis? Lancet 1998; 351: 1438. [“The question that puzzles me is: why do west African and West Indian patients with sickle-cell disease who did without morphine in their countries have to be given morphine pumps during sickle-cell crises when they come to the UK?”]

16 Konotey-Ahulu FID. Opiates for sickle-cell crisis. Lancet 1998; 352: 651-652. [In response to David Bevan’s criticism (in Lancet 1998; 351: page 1965) of white physicians who agree with Dr Konotey-Ahulu that opiates have created addicts in their hospital – “When I say routine opiates for sickle crisis are not the way to bring out these patients’ best potential in the long term I am glad to hear white physicians say the same…White physicians who, at the risk of being misunderstood by Bevan, voice their displeasure at what they see happening on their wards deserve commendation, not condemnation.”]

17 Konotey-Ahulu FID. Current “hit and miss” care provision for sickle cell disease patients in the UK. BMJ Rapid Response 22 July 2008 http://www.bmj.com/cgi/eletters/337/jul11_2/a771#199135

18 Konotey-Ahulu FID. Management of sickle cell disease versus management of the sickle cell disease patient. BMJ Rapid Response 17 September 2008 http://www.bmj.com/cgi/elettrs/337/sep08_1/a1397#202088

19 Konotey-Ahulu FID. Management of sickle cell disease patient in the community BMJ Rapid Response 13 April 2014 [90 References] to Brousse V, Makali J, Rees DC: Management of sickle cell disease in the community. BMJ 2014; 348: g1765 doi:10.1136/bmj.g1765 http://www.bmj.com/content/348/bmj.g1765/rr/694233

20 Olujohungbe A, Cinkotai KI, Yardumian A. Hydroxyurea therapy for sickle cell disease in Britain. BMJ 1998; 316: 1689 (6 June)

21 Konotey-Ahulu FID. Management of patients with sickle cell disease. African Journal of Health Sciences 1998; 5: 47[ Commenting on article of Sally Davies and Lola Oni (BMJ 315: 656 -60) “what I feel is more important in the day to day management of patients with a view to keeping them out of hospital, is clinical epidemiology which includes the circumstances of crises. Two examples suffice to ilustrate what I mean: … I fear Davies
and Oni’s statement that ‘The Central Middlesex management protocol uses morphine infusions’ will make morphine the accepted drug for sickle crisis management. The consequences of such an approach are dire, especially when some UK hospitals are already making diamorphine their first choice”.]

22 Konotey-Ahulu FID. The Human Genome Diversity Project: Cogitations of An African Native. Politics and the Life Sciences (PLS) 1999, Vol 18: No 2, pp 317-322. [Invited Commentary on Professor David Resnik’s article: The Human Genome Diversity Project: Ethical Problems and Solutions. [Chart “Sickle Cell Disease in Successive Ghanaian Generations for Three Centuries”]

23 Serjeant GR. Sickle Cell Disease. Oxford. Oxford Univ. Press (2nd Edition) (632 pages)

24 Davies SC, Oni L. Management of patients with sickle cell disease. BMJ 1997; 315: 656-660.

25 Konotey-Ahulu FID. The inheritance of Sickle Cell Disease. New African January 2000, pp 40-43 http://www.konotey-ahulu.com/pdfs/sicklecell_jan2001.pdf

26 Konotey-Ahulu FID. The Person with Sickle Cell Disease. New African March 2001, pp 38-39.http://www.konotey-ahulu.com/pdfs/sicklecell_mar2001.pdf

27 Konotey-Ahulu FID. Teenager with Sickle Cell Disease. New African. June 2001, 41-42 http://www.accessmylibrary.com/coms2/summary_028627289580_ITM http://www.konotey-ahulu.com/pdfs/sicklecell_jun2001.pdf

28 Konotey-Ahulu FID. Adult with Sickle Cell Disease. New African Sep. 2001, pp 40-43. http://www.konotey-ahulu.com/pdfs/sicklecell_sep2001.pdf | http://www.questia.com

29 Konotey-Ahulu FID. Sickle-cell disease and the patient. Lancet 2005; 365(9457): 382-83 January 29-February 4. [Commenting on Marie Stuart & Ronald Nagel’s “Sickle-cell disease” Seminar in Lancet 364: 1343-60, and Michaela Buckner’s “Sickle-cell disease: from Sierra Leone to southeast London” Lancet 364: 1361, it is pointed out that “Stuart and Nagel missed something out of their Seminar, which Michaela emphasizes – circumstances.”

30 Konotey-Ahulu FID. Sickle cell achievers’ conference. SICKLE CELL News Review 1995; Summer Edition: 5.

31 Omaboe Letitia, Konotey-Ahulu FID. The Second International Conference On The Achievements of Sickle Cell Disease Patients. Accra 19th July 1995 Conference Brochure 19pp

32 Konotey-Ahulu FID. Sickle Cell and Allied Haemoglobinopathy: The Genetics That Touches You and Me – University of Cape Coast, Ghana, GOLDEN JUBILEE MESSAGE. (Sept 19 2014) http://bit.ly/1w3BuvM

33 Ranney Helen. “There is no single clinical experience in the United States comparable to that of Dr Konotey-Ahulu”. In Summary of Symposium on Sickle Cell Disease – Diagnosis, Management, Education, and Research – In Sickle Cell Disease, Editors Abramson, JF Bertles, Doris Wethers (C. Mosby & Co) 1972, page 320.

Competing interests: No competing interests

Dr Margaret McCartney highlights something most doctors ignore [1] Her “seams of multiple misinformation” become disinformation when deliberate, as when “Journal agrees to retract paper after university found study was never done” [2].

“EVIDENCE” AND “TRUTH” ARE WORDS NEEDING CAREFUL SCRUTINY#

“There is no real evidence that e-cigarettes do any harm”, is interpreted as “e-fags are harmless”. No evidence is increasingly used as evidence [3]. Prefix “scientific” to “truth”, and Einstein expects integrity. [4] When three doctors confessed that tests they published had been done were in fact not done I concluded letter to BMJ Editor Dr Martin Ware:

“Your readers, Sir, are interested in scientific truth. I am one of them, and the very least I am entitled to expect is that if evidence obtained from my own country cannot be scientific it should at least be true. – I am etc., F I D KONOTEY-AHULU” [5]

BUT WHAT IF TWO OR MORE EXPERTS DISAGREE ON WHAT IS TRUTH?

Lord Solly Zuckerman FRS said in his excellent article “Pride and Prejudice in Science” that disagreements about truth were often coloured by prejudice, and sometimes fraud. [6] I’ve discussed elsewhere experts’ disagreements. [7]. That Ethics is deprecated and Science re-defined by some scientists is sad. Two examples: (a) Design in nature is now not science [8]. (b) Programmes to genome-sequence whole populations anonymously [9 10] against which I have protested, indicating how dangerous this is in an “Anti-truth world” [11]. Had James Watson been genome-sequenced anonymously would the truth have come out?

NOBEL LAUREATE PROFESSOR JAMES WATSON IS AFRICAN

James Watson announced that the current global genome-sequencing exercise would show that Africans were less intelligent than other “races” [12], using the term “race” just as Charles Darwin had done: “The Origin of Species By Natural Selection – Or The Preservation Of Favoured Races In The Struggle For Life” [13]. Watson’s three to four trillion DNA bits in his genome were sequenced only to discover that his great-grandparent was African [14]. Convinced he belonged to the “favoured white race” he in fact had a great-grand parent from the African “un-favoured race”. I commented: “Watson, still alive today in the USA, was thus brutally reminded not only that there is but one human race, but also that African genes contributed to the Nobel Prize in ‘Physiology or Medicine’ which he jointly won with Francis Crick and Maurice Wilkins in 1962 on the DNA Double Helix” [15]. James Watson’s opinion was taken as scientific truth because Nobel Laureates are not supposed to be economical with the truth. The Human Genome Project became suspect [11 16 17], and this exposes the
real problem with research in Human Sciences including IQ, Linguistics and even History. Researchers wax eloquent about “Evolutionary Ethics”, making ex cathedra statements like “The capacity to develop ethics is a product of biological evolution” [18]. Such Evolutionary Fundamentalism is considered “scientific truth” while “GOD commanded, and universe materialized” [19] is ridiculed?

EVOLUTION PROFESSORS J Z. YOUNG AND PAUL R. EHRLICH

Three events in a Lecture Series on Evolution by J Z Young FRS at University College London [20] convinced me that Darwin’s Evolution by Natural Selection never took place. It was more than 3 decades later that another Fellow of the Royal Society Professor Fred Hoyle would confirm my judgement: “How has the Darwinian theory of evolution by natural selection managed, for upwards of a century, to fasten itself like a superstition on so-called enlightened opinion? Why is the story still defended so vigorously?” [21] First event (a): J Z Young was comparing the brain of a new-born human baby with that of an adult chimpanzee [20]. His words “I do not know …” stunned me and Shirley Knight sitting together. (b) One student’s question “Why …?” brought the answer: “’Why?’ questions are not permitted here” (c) J Z Young kept saying “Theory of Evolution” over and over again. This world-authority on the human brain [22] who taught me not only “what to think” to pass exams, but also “how to think” to enable me criticise my teachers, led me to the conclusion I found Professor Fred Hoyle arriving at 3 decades later, namely that Darwin’s Evolution Emperor has no clothes! But then comes Paul Ehrlich [18] sprinkling his 531-page Evolution book with “Why?” questions that he blithely proceeds to answer with ex cathedra pronouncements!

DR MARTYN LLOYD-JONES’ BOOK “TRUTH UNCHANGED UNCHANGING” [23]

This Welsh Genius [24] proved some “Truths” to be supra-scientific. [23]. I once wrote: “There is a vast area of man’s experience called the spiritual realm which neither Freudian psychoanalysis nor the scientific method can fathom” [25] Dr Lloyd-Jones’ books “Spiritual Depression” [26] and “Conversions Psychological and Spiritual” [27] support this. Because “approaches to scientific truth and spiritual truth are different” [25] one scientist will read Spiritual Depression “with much profit while another, with the same qualifications, will find it unintelligible” [25]. Dr Lloyd-Jones totally dismisses Darwin’s “races”. He recognises only intra-racial marriages: Google “Felix and Rosemary” [28].

INTERNET’S MINUS AND PLUS WITH REGARD TO TRUTH

Misinformation that Margaret McCartney mentions [1] can be counterbalanced using the same Internet when editors refuse to publish corrections [29]. Are Margaret’s two prescriptive suggestions [1] capable of identifying scientific liars [30-32] and lying journalists who suppress truth about Statins or whatever? [29]

PERSONAL QUEST FOR TRUTH

“Did that happen?” is my best question to unravel truth. Was I born on a Saturday? Was I struck by lightning on a Friday 2 days before Christmas? Science can never be used to substantiate the truth behind these events [3 33-36], so why do we defer to Science to verify infinitely more important events defining Christmas? History beats Science [37]. Dismiss me as a creationist sermonizing, and I respond: a creationist is ‘a c’; I prefer to reverse the letters and be known as ‘C a’ – “CREATOR acknowledger” whose MILLENNIUM Hymn http://bit.ly/cRrZ0s spells out supra-scientific Truth [38] about The PERSON who said “Before Abraham was I AM” [39].
Conflict of Interest: Believer in The Lord Jesus Christ [Nuntsɔ Yesu Kristo]
Felix I D Konotey-Ahulu FGA MD(Lond) FRCP(Lond) FRCP(Glasg) DTMH(L’pool) FGCP FWACP FTWAS Kwegyir Aggrey Distinguished Professor of Human Genetics University of Cape Coast Ghana & Former Consultant Physician Genetic Counsellor in Sickle Cell and Other Haemoglobinopathies, 9 Harley Street, London W1G 9AL.
felix@konotey-ahulu.com Twitter@profkonoteyahul

References
1 McCartney Margaret. Evidence in a post-truth world. BMJ 2016; 355: 16363 November 28, 2016
2 Dyer Clare. Journal agrees to retract paper after university found study was never done. BMJ 2013; 347: f55
3 Konotey-Ahulu FID “Private Thoughts: There is no evidence that I was born on a Saturday. Postgraduate Medical Journal of Ghana 2012; 1: 32-33 33” which often proved superiority of history over science in arriving at truth.
4 Einstein Albert “Science can be created only by those who are thoroughly imbued with the aspiration toward truth and understanding” In EINSTEIN: Life and Universe, by Walter Isaacson, New York 2007, Simon & Schuster, page 390 of 675 pages.
5 Konotey-Ahulu FID. Sickle cell and altitude. BMJ 1972; 2: 231-232.
6 Zuckerman Solly. Pride and Prejudice in Science. Aerospace Medicine 1974. 45: 638-647. (Also republished in Ghana Medical Journal 1975; 14: 52-60)
7 Konotey-Ahulu FID. Clinicians facing conflicting recommendations: Use Common sense? BMJ Rapid response Dec 5 2008 www.bmj.com/cgi/eletters/337/nov28_2/a2530#205677
8 Sarfati Jonathan. By Design – Evidence for Nature’s Intelligent Designer – The God of the Bible. Creation Book Publishers 2008 Atlanta Georgia, USA www.creationbookpublishers.com [260 pages]
9 Wise Jacqui. Consortium hopes to sequence genome of 1000 volunteers. BMJ 2008; 336: 237 (2 February)
10 Announcement: http://www.1000genomes.org/files/1000Genomes-NewsRelease.pdf International Consortium Announces the 1000 Genomes Project. Major Sequencing Effort Will Produce Most Detailed Map of Human Genetic Variation to Support Disease Studies. (Tuesday January 22 2008)
11 Konotey-Ahulu FID. 24 Konotey-Ahulu FID. Sequencing genome of 1000 volunteers: Why do this anonymously? African Journal of Health Sciences 2011; 18: 37-52 www.ajhsjournal.or.ke/admin/current/914vpjkSBOS.pdf
12 Watson James in Sunday Times: Racial differences in intelligence: James Watson, Nobel Prize winning geneticist persecuted for scientific truth. He claimed that black people were less intelligent than white people and the idea that “equal powers of reason” were shared across racial groups was a delusion. Human-Stupidity (Admin) March 14 2010. http://www.independent.co.uk/news/science/fury-at-dna-pioneers-theory-africans-are-less-intelligent-than-westerners-394898.html
13 Darwin Charles R. Origin of Species by Means of Natural Selection, or The Preservation of the Favoured Races in the Struggle for Life. John Murray, London 1859.
14 Verkalk Robert. Revealed: Scientist who sparked racism row has black genes/The Independent www.independent.co.uk > News> Science 9 December 2007
15 Konotey-Ahulu FID. There is but one human race. New African (London) December 2009, Number 490, page 4.
16 Konotey-Ahulu FID. The Human Genome Diversity Project: Cogitations of an African Native. In POLITICS AND THE LIFE SCIENCES, September 1999, Vol. 18(2), pp 317-322.
17 Konotey-Ahulu FID. Why should Africans fear any human genome project? Africawatch. November 2010, pages 34-36.
18 Ehrlich Paul R. Human Natures – Genes, Cultures, and the Human Prospect. Island Press/Shearwater Books, Washington DC 2000, page 308.
19 Holy Bible. (a) Psalm 30 verses 8 & 9: Let all the earth fear JEHOWAH. Let all the inhabitants of the world stand in awe of HIM. For HE spoke and it was done. He commanded, and it stood fast & (b) Hebrews chapter 1 verses 1 &2: God …has in these last days spoken to us by His SON, Whom HE has appointed heir of all things, through Whom also HE made the worlds & (c) Colossians chapter 1 verses 16 & 17 For by Christ all things were created that are in heaven and that are on earth, visible and invisible …all things were created through HIM and for HIM & (d) St John chapter 1 verses 1 to 3: In the beginning was the Word, and the Word was with God, and the Word was God. All things were made through Him, and without Him nothing was made that was made.
20 The God Delusion title devalues sensible discourse BMJ Rapid Response Oct 19 2016
www.bmj.com/content/335/7629/1099.1/rr-0
21.. Hoyle Fred. The Intelligent Universe. Michael Joseph, London, 1985, page 25
22 Young JZ. Philosophy and the brain. New Yok, NY, US Oxford University Press 1987, viii 233 pp.
23 Lloyd-Jones DM. Truth Unchanged Unchanging. Crossway Books March 31 1993. ISBN-10 0-89107-706-5 www.crossway.org Foreword www.truthforlife.org>fore>Alistair Begg ..
24 Murray Iain (2013). Life of Martyn Lloyd-Jones 1899-1980 Banner of Truth Trust Edinburgh. [This doctor qualified from St Bartholomew’s Hospital London University with First Class Honours and Distinction in Medicine & Therapeutics. Proceeded Doctorate in Medicine with his MD Thesis on Subacute Bacterial Endocarditis. Assisted Lord Horder, Physician to King George V, then suddenly announced retirement from Clinical Medicine and became a preacher. Those not allergic to Christian Worship may wish to listen to Dr Martyn Lloyd-Jones MD MRCP. Listen to one of his messages at Westminster Chapel on 24th November 1963, Sunday after assassination of President Kennedy: Go to www.soundcloud.com/dawid1 and click on JFK. I was there that never to be forgotten Sunday evening. Christians will cherish Dr Martyn Lloyd-Jones’ 15-minute-long extempore prayer after the second hymn, plus his never to be forgotten long sermon after the 3rd hymn “In the cross of Christ I glory”. When he stepped down from the pulpit drenched in sweat, having expounded Galatians 6 verse 14, and after the last hymn “Abide with me” and Benediction, we just sat there, stunned!] Dr Martyn Lloyd-Jones preached more than 1600 sermons. Jonathan Catherwood has all the details – jonathan@mljtrust.org
25 Konotey-Ahulu FID. The spiritual and the psychological in Clinical Medicine. (Personal View) BMJ 1977; 1: 1595 www.bmj.com/cgi/reprint/1/6076/1595.pdf doi:10.1136/6076/1595 June 15.
26 Lloyd-Jones DM. Spiritual Depression: Its Causes and Cure. (ISBN 9780802813879) Amazon’s Book Store www.amazon.co.uk>Spiritual-De [One of top 100 Millennium books]
27 Lloyd-Jones DM. Conversions Psychological & Spiritual https://www.amazon.co.uk>Co 9780851100098 December 1 1959. Critique of Dr William Sargant’s Battle for the Mind
28 Konotey-Ahulu Felix & Rosemary – 50 Years.mov – YouTube https://www.youtube.com 50th Wedding Anniversary [Dr Martyn Lloyd-Jones marries them Easter Monday April 23 1962]
29 Konotey-Ahulu FID. Sickle Cell Trait: As with Statins When leading editors disagree please give principles same weight as details – September 2016 http://www.sicklecel.md/blog/index.php/2016/09/statins-when-leadingl-editors-disagree-please-give-principles-same-weight-as-details/
30 Laine C. Scientific misconduct hurts. Ann Intern Med 2016. doi:10.7326/M16-2550. pmid:27951591.
31 Dyer O. Peer reviewer stole article and published it as his own. BMJ 2016; 355:i6768. doi:10.1136/bmj.i6768. 3
32 Huang Wel. Peer reviewer stole article and published it as its own BMJ 2016; 355:i6768 doi:10.1136/bmj.i6768 :
33 Konotey-Ahulu FID. Born on a Saturday? Science vs History On The Origin and End of the World. Creation 38(4):2016 CREATION.com
34 Konotey-Ahulu FID. Case of lightning burns. BMJ 1963; 1: 1547. June 8. doi:10.1136/bmj. 1.5344.1547 http://www.bmj.com/cgi/reprint/1/5344/1547.apdf
35 Konotey-Ahulu FID. Superstition and phenomena in Africa Personal View. BMJ 1969; 2:48 http://www.bmj.com/cgi/reprint/3/5664/235.pdf doi:10.1136/bmj.2.5648.48 April 15
36 Konotey-Ahulu FID. The supra-scientific in clinical medicine: a challenge to Professor Know-All. doi:10.1136/bmj.323.7327.1452 Brit Med J 2001; 323(7327): 1452-1453 (22-29 Dec) http://www.bmj.com/cgi/reprint/323/7327/1452.pdf
37 Konotey-Ahulu FID. History versus Limits of Science: Is Solomonic Genius a Y Chromosome Phenomenon? J Genet Disorders Genetic Reports 2014; 3: 2
http://bit.ly/1wyq5H5 [Quoted Konotey-Ahulu FID (2012) “Private Thoughts: There is no evidence that I was born on a Saturday. Postgraduate Medical Journal of Ghana 1: 32-33 33” which often proved superiority of history over science in arriving at truth].
38 Konotey-Ahulu FID. MILLENNIUM Hymn – TIME WAS CREATED. http://bit.ly/cRrZ0s 2000 http://www.youtube.com/watch?v=4hconD91uNs .(Seven verses with Music)
39 Holy Bible: St John chapter 8 verse 58 – JESUS said to them “Most assuredly, I say to you: before Abraham was, I AM”.

Dangerously flawed diagnosis of sickle cell trait in compartment syndrome rhabdomyolysis article 

I find it astonishing that Lancet that once published “Beware of symptomatic sickle cell traits” 1 published this article of Ali Rhida et al 2 where sickle cell trait was diagnosed purely on the patient’s say so without as much as a sickle cell test nor haemoglobin electrophoresis to quantify abnormal haemoglobin fractions.

Questions that require answering are

(a) Who passed this article for publication?
(b) What is the G6PD status of this patient? (Galtrey and Passansali described a Kenyan in whom “a diagnosis of G6PD deficiency and rhabdomyolysis was made”) 3
(c) Why did it not occur to the authors that their mention of “suspected sickle cell crisis” 2
should have alerted them to the fact that they were dealing most probably with sickle cell
haemoglobin C disease, “SC” phenotype and not sickle cell trait, “AS” phenotype (with ‘A’ greater than ‘S’)?
(d) Will Lancet Editor be kind enough to request that Ali Rhida and colleagues produce
details not only of all haemoglobins including “A2” and of “F” fractions but also of quantified G6PD level by recalling the patient and conducting these tests they should have done before?

Why is all this extremely important? ANSWER: Because Insurance Companies in the USA are queueing up to load the Premium of anyone called “Sickle Cell Trait”, using as the reason for doing so articles such as we read here. So serious has been the misinformation and disinformation on Sickle Cell Trait that when the Martin Luther King Jr Foundation Award honoured some 20 of us worldwide (including Linus Pauling, Hermann Lehmann, Max Perutz, Roland Scott, Bela Ringelhann, Helen Ranney, Doris Wethers, James Bowman, Charles Whitten, Graham Serjeant, Samuel Charache, A C Allison, J V Neel and others) for outstanding contribution to Sickle Cell Research I, who then ran the largest Sickle Cell Clinic in the world at Korle Bu Teaching Hospital in Ghana was asked to give the Keynote Address on “The Vital Difference between Sickle Cell Trait and Sickle Cell Disease”, and because I produced facts that Sickle Cell Traits had run and won Olympic Gold Medals at Mexico City 7000 ft above sea level only to come to ground level in New York for Insurance Companies to load their Premium, proving to the hilt that sickle
cell disease was being called sickle cell trait deliberately, or through ignorance I was given 4 bodyguards for all the 4 days I was in Philadelphia.4

I do not have to tell Lancet’s Editor what to do, but this article of Ali Rhida et al 2 is nothing short of dangerous, as the references I have accumulated on this matter demonstrate 5.

I declare no competing interests

Felix I D Konotey-Ahulu

Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast, Ghana and Recent Consultant Physician Genetic Counsellor in Sickle Cell and Other Haemoglobinopathies, 9 Harley Street Ltd., Phoenix Hospital Group, London W1G 9AL
1 Konotey-Ahulu F. Beware of symptomatic sickle cell traits. Lancet 1992; 339: 555
www.the.lancet.com/journals/lancet/article/PII0140-6736(92)90377-F/fulltext

2 Rhida A, Khan A, Al-Abayechi S, Puthenveetil V. Acute compartment syndrome secondary to rhabdomyolysis in a sickle cell trait patient. Lancet 2014; 384:2172

3 Galtery Clare M, Pathansal R. New onset diabetes complicated by haemolysis and rhabdomyolysis: a case report and review of the literature. Journal of Medical Case Reports 2008; 2: 159 www.jmedicalcasereports.com/content/2/1/159

4 Konotey-Ahulu FID. Four bodyguards and the perils of unmasking scientific truths.BMJ 2007; 335: 210-211 www.bmj.com/cgi/reprint/335/7612/210.pdf

5 Konotey-Ahulu FID. (a) Blaming sudden death on sickle cell trait? http://bit.ly/1Eutn19
(b) Sickle Cell Trait Misinformation and Disinformation http://bit.ly/1CqYHib (c)
Further Communication on Sickle Cell Trait Misinformation and Disinformation http://bit.ly/1Gm4gNp Respectively (a) Sept 19 2011 (b) Nov 30 2011 (c) June 19 2012.

PERSONAL VIEW – British Medical Journal

TAFRACHER! – An Invaluable Ghanaian word

View as a PDF click here.

Re: Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study
Re: Association of hip pain with radiographic evidence of hip osteoarthritis: diagnostic test study Nancy E Lane, Thomas M Link, Steven Vlad, Irina Tolstykh, et al. 351:doi 10.1136/bmj.h5983

Rapid Response by Felix I D Konotey-Ahulu (8 January 2016) http://www.bmj.com/content/351/bmj.h5983/rr-2

Hip pain and radiographic signs of osteoarthritis: Sickle cell & other haemoglobinopathy differential diagnosis 

Dr M J Nieuwenhuijse and Professor Rob G Nelissen’s Editorial [1] linked to Kim and colleagues’ paper (doi:10.1136/bmj.h5983) is probably more suited for developing countries where MRI is often unavailable for investigating hip pain and “osteoarthritis” than for the UK, yet the authors appear to have only a Caucasian audience in mind for their message. We know that haemoglobinopathy is the commonest cause of hip pathology in Africa as I pointed out in The Lancet in “Hip disease in Africans” [2]

1 IN 3 WEST AFRICANS HAS SICKLE CELL OR HAEMOGLOBIN C GENE

With every third West African at home and abroad possessing a beta-globin gene variant as Sickle Cell Trait (‘AS’) or Haemoglobin C Trait (‘AC’) we proved conclusively in Ghana that 3 out of every 100 births will have Sickle Cell Anaemia (‘SS’) or Sickle cell Haemoglobin C Disease (‘SC’) [3-9], thereby confirming veracity of the Hardy Weinberg gene frequency Equation p + q + r =1 producing phenotypes p2 + q2 + r2 +2pq + 2pr + 2qr =1 (the square of the gene frequencies) which was exactly what we observed on investigating 1,000 and 13,000 consecutive babies born at Korle Bu Hospital in Accra.[4 5]. Many of these babies grew to develop hip problems that often confused some radiologists [7], and which needed differentiating from Perthes’ disease [10]

TERMINOLOGY INADEQUATE TO HIGLIGHT PAITENT’S REAL NEEDS

Dr Nieuwenhuijse and Professor Nelissen are right to use phraseology like “clinical symptoms suggestive of degenerative hip joint disease” and “asymptomatic degenerative changes” [1] – terms that describe many patients with haemoglobinopathy [7 8]. The authors’ advice “Treat patients, not radiographs” also needs to be heeded because too often we clinicians refer patients for investigation without examining them, using the term “osteoarthritis” when osteo-arthropathy was better. Few Resident Doctors these days on both sides of The Atlantic practice the five cardinal “Introductory Course” drill before sending patients for investigations. These 5 are: 1. History 2. Inspection 3. Palpation 4. Percussion 5. Auscultation. Therefore, in answer to the authors’ question “How should we respond to patients presenting with hip pain?” [1] my first answer would be history: “Do you have hereditary rheumatism?”, using tribal names for sickle cell disease (chwechweechwe, ahututuo, nwiiwii, lakuragbee, etc) [6 7 8]. For many patients HISTORY alone gave me the diagnosis of hip pain. INSPECTION – Before he/she sat down I had observed the limp, and then I looked for jaundice and estimated straight leg raising, leg shortening, and elicited pain on hip rotation. PALPATION – I noted Corrigan’s pulse in my sickle cell anaemia patients and looked for abdominal signs, before pressure for groin tenderness. PERCUSSION: Liver enlarged? Spleen? AUSCULTATION – Precordial systolic bruit made me advise radiologists to comment on heart size, “cod fish vertebra”, and splenic calcification.

GENETIC CAUSES OF HIP PAIN

There is phenotype variation in incidence [11]: Sickle Cell Disease, ‘SC’ phenotype, has more frequent hip pain than Sickle Cell Anaemia (‘SS’) for the reasons explained elsewhere after personally surveying over 1,200 consecutive patients of all ages [6]. Seventeen of 600 consecutive Hb ‘SS’ ie 2.8% and 40 of 603 consecutive Hb ‘SC’ patients ie 6.6% with hip pain and limp had femoral head problem (p<00.1) [6 7 8 11 12]. Arthritic hip incidence in Sickle Cell Trait (‘AS’) is not different from that in the rest of the population with no ‘S’ gene, unless one’s definition of Sickle Cell Trait was the seriously flawed definition common in American publications where sickle cell disease ‘SC’ was often called Sickle Cell Trait merely because the mother of the patient with symptoms had Negative Sickling Test. Brilliant haematologists have been known not to proceed to haemoglobin electrophoresis when sickling test was negative, thereby missing Hb ‘C’ which, combined with Hb ‘S’ is sickle cell disease, ‘SC’ phenotype. In my 36 consecutive Haemoglobin ‘CC ’patients just the 35th presented with hip pain [7].

COHORT STUDIES OVER RATED IN CLINICAL VALUE

Results from cohort studies with varying degrees of expertise cannot be better than careful observation of consecutive patients over many years by the same clinician as in Ghana [7] and West Indies [13]. Both this Editorial [1] and Kim and colleagues’ paper it is linked to (doi:10.1136/bmj.h5983) mention cohort studies which fail to take into account the numerous non-Caucasians as well as white Mediterranean people with sickle cell disease whose hip pain has not alerted doctors to haemoglobinopathy. An exception was Professor Malcolm Milne who once asked me on a postgraduate ward round to examine a Greek patient.

INSPECTION: – Slight icterus. Nails pale. Right shoulder muscle wasting giving angular contour. Straight leg raising – only 450 from the bed on the left side, with pain on hip rotation. PALPATION: Murphy’s sign positive. Corrigan’s sign positive. AUSCULTATION: Precordial systolic bruit. I then announced: “This patient has Sickle Cell beta-Thalassaemia, with gall stones and articular bone necrosis of the right humeral head and left femoral head”. Professor Milne gave me full marks and showed us the detailed blood results from Professor J G Humble confirming the phenotype. But why did I not say Sickle Cell Anaemia (‘SS’), which was also very common in Greece? ANSWER: Because the patient’s nails and conjunctivae were not as pale as I had known them to be in Sickle Cell anaemia. I then announced to the impressed gathering that I knew much about sickle cell disease before I went to Medical School. My parents were among the 1 in 3 very healthy Ghanaians with Hb ‘S’ or ‘C’ Trait, and they produced 11 of us of whom 3 had sickle cell disease. Growing up in the Manya Krobo Tribe I was surrounded by close and distant relatives born with chwechweechwe-hemkom, and who walked with a limp [14]. No cohort studies were needed for my education.

Conflict of Interest: None declared.

felix@konotey-ahulu.com and Twitter @profkonoteyahul
Felix I D Konotey-Ahulu FGA MD(Lond) FRCP(Lond) FGCP, DTMH(L’pool)

1 Nieuwenhhuisje MJ, Nelissen RG. Hip pain and radiographic signs of osteoarthritis. BMJ 2015; 351:h6262 (03 December 2015)

2 Konotey-Ahulu FID. Hip disease in Africans. Lancet 1970; 1: 999

3 Ringelhann B, Konotey-Ahulu FID. Hemoglobinopathies and Thalassaemia in Mediterranean areas and in West Africa: historical and other perspectives 1910-1997 – A Century Review. Atti del’Accademia della Science di Ferrara 1998; 74: 267-307.

4 Gbedemah KA, Acquaye CTA, Konotey-Ahulu FID, Reindorf CA. Haemoglobin phenotype patterns in more than 1,000 consecutive new-born babies in Ghana. Ghana Med Journal 1976; 15: 253-256.

5 Bonney GE, Walker M, Gbedemah K, Konotey-Ahulu FID. Multiple births and visible birth defects in 13,000 consecutive deliveries in one Ghanaian hospital. In Proceedings of the Second International Congress on Twin Studies Part C. Ed Walter Nance. Progress in Clinical and Biological Research 1978; 24B: 105-108.

6 Konotey-Ahulu FID. The Sickle Cell Diseases: Clinical manifestations including the Sickle Crisis. Archives of Internal Medicine 1974; 133: 611-619.

7 Konotey-Ahulu FID. The Sickle Cell Disease Patient: Natural History from a Clinico-epidemiological study of the first 1550 patients of Korle Bu Hospital Sickle Cell Clinic. The Macmillan Press Ltd, London 1991 & 1992 and T-A’D Co Watford 1996.

8 Konotey-Ahulu FID. Pattern of Sickle Cell Disease in Accra (A STUDY OF 1,550 PATIENTS): A THESIS PRESENTED FOR THE DEGREE OF DOCTOR OF MEDICINE (MD) IN THE UNIVERSITY OF LONDON. 1971

9 Ringelhann B, Dodu SRA, Konotey-Ahulu FID, Lehmann H. A survey of haemoglobin variants, thalassaemia, and Glucoose-6 Phosphate Dehydrogenase Deficiency in Northern Ghana. Ghana Medical Journal 1968; 7: 120-124.

10 Konotey-Ahulu FID. Perthes’ Disease versus Sickle Cell Disease hip. October 24 2014 BMJ Rapid Response www.bmj.com/content/349/bmj.g5584/rr/778350 or http://bit.ly/1tGmuYm

11 Konotey-Ahulu FID. The spectrum of phenotypic expression of clinical haemoglobinopathy in West Africa. New Istanbul Contribution to Clinical Science 1978; 12: 246-247.

12 Konotey-Ahulu FID. Effect of environment on Sickle Cell Disease in West Africa: epidemiologic and clinical considerations – In SICKLE CELL DISEASE: Diagnosis, Management, Education and Research, Editors Harold Abramson, John F Bertles, Doris L Wethers. Saint Louis 1973 The C V MOSBY Company, pages 20-38.

13 Serjeant GR. Sickle Cell Disease. Oxford, Oxford University Press, 1992.

14. Konotey-Ahulu FID. Sickle Cell Disease in Successive Ghanaian Generations For Three Centuries (Manya Krobo Tribe) 1670 to 1970 – The Human Genome Diversity Project: Cogitations of an African Native. In Human Genome Diversity Project. POLITICS and The LIFE SCIENCES 1999; 18: 317-322.

Competing interests: No competing interests 08 January 2016
Felix I D Konotey-Ahulu Kwegyir Aggrey Distinguished Professor of Human Genetics University of Cape Coast, Ghana Consultant Physician Genetic Counsellor in Sickle Cell & Other Haemoglobinopathies Phoenix Hospital Group, 9 Harley Street, London W1G 9AL
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