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Foo20151013 2023 1nuvntv?1444774080
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891

Obesity Part 1 – Fat Kid in a Fat Society

Introduction to Obesity One of my favourite past-times is to sit in a bar, restaurant, café or coffee shop and people watch. I am sure many of you reading this also enjoying doing this too. People are fascinating and it is intriguing to observe: what they do; how they act; what they wear and what they look like. My family and I have always observed those around us and discussed interesting points about others that we have noticed. When I first came up to visit Birmingham University my family all sat in a coffee shop in the centre of Birmingham and noticed that on average the people walking past us looked much slimmer than what we were used to seeing back in south Wales. Now, when I go home it is more painfully obvious than ever that the people in my home region are much, much heavier than they should be and are noticeably bigger than they used to be even a short number of years ago. This change in the population around me is what first made me seriously think about obesity, as a major problem affecting the world today. Nowadays obesity is all around us! It is noticeable, it is spreading and it should worry us all. Not just for our own individual health but also for the health of our society. Obesity affects everything from the social dynamic of families, to relationships at school or work, to how much the NHS costs to run. Obesity is a massive problem and if we as a society don’t start getting to grips with it, then it will have huge implications for all of us! I am currently in my 5th year at medical school. While I have been here I have taken a keen interest in obesity. The physiology, the psychology, the anatomy, the statistics and the wider affects on society of obesity have all been covered in curriculum lectures and extra curriculum lectures. I have taken part in additional modules on these subjects and sort out many experts in this field while on hospital placements. Obesity is fascinating for some many reasons and I thought that it would be a great topic to write some blogs about and hopefully start some discussions. Warning For my first blog on the topic of obesity I quickly want to write a bit about myself and my battle with weight. Everyone’s favourite topic is themselves, but I like to think that’s not why I have written this and I hope it doesn’t come across as a narcissistic ramble. I don’t intend to try and make myself come off well or suggest that I have all the answers (because I know very well that I don’t) and I hope it doesn’t come across like that. I want to write a bit of an autobiography because I wish to demonstrate how easy it is to go from a chunky kid to a technically obese teenager to a relatively fat adult without really realising what was happening. Chunky Child to Fat adult While planning this blog I realised that my Meducation profile picture was taken when I was at my all time fattest. At the graduation ceremony at the end of my 3rd year at university after completing my intercalation I was over 19 stones. At 6 foot 2” this gave me a BMI of >33 which is clinically obese. I had a neck circumference of >18”, a chest circumference of 48”, a waist of >40”, a seat of >52” and a thigh circumference of >28” per leg. Why do I know all of these rather obscure measurements? Partly because I am quite obsessive but mainly because I had to go to buy a tailor made suit because I could no longer buy a suit from a shop that I could fit into and still be able to move in. The only options left to me where massive black tent-suits or to go to a tailors. After the graduation I sat down at my computer (whilst eating a block of cheese) and compared my face from the graduation photos to pictures I had taken at the start of university and the difference in shape and size was amazingly obvious. I had got fat! I realised that if I had a patient who was my age and looked like me with my measurements then I would tell him to lose weight for the good of his health. So, I decided that finally enough was enough and I that I should do something about it. Before I describe how I got on with the weight management I will quickly tell the back story of how I came to be this size. I have always been a big guy. I come from a big family. I have big bones. I had “puppy fat”. I was surrounded by people who ate too much, ate rubbish and were over weight themselves, so I didn’t always feel that there was anything wrong with carrying a bit of tub around the middle. When I went to comprehensive school at age 12 I had a 36” waist. I thought I carried the weight quite well because I was always tall and had big ribs I could sort of hide the soft belly. Soon after arriving at the new school I had put on more weight and for the first time in my life I started to get bullied for being fat! And I didn’t like it. It made me really self-aware and knocked my confidence. Luckily, we started being taught rugby in PE lessons and I soon found that being bigger, heavier and stronger than everyone else was a massive advantage. I soon got my own back on the bullies… there is nowhere to hide on a rugby field! This helped me gain my confidence and I realised that the only way to stop the bullying was to confront the bullies and to remake myself in such a way as that they would be unable to bully me. I decided to take up rugby and to start getting fit. I joined a local club, starting playing regularly, joined a gym and was soon looking less tubby. Reflecting (good medical jargon, check) on my life now I can see that my PE teachers saved me. By getting me hooked on rugby they helped get me into many other sports and physical activity in general and without their initial support I think my life would have gone very differently. Rugby was my saviour and also later on a bit of a curse. As I grew up I got bigger and bigger but also sportier. I started putting muscle on my shoulders, chest and legs which I was convinced hid how fat I actually was. I developed a body shape that was large but solid. I was convinced that although I was still carrying lots of excess weight I no longer looked tubby-fat. When I was 14 my PE teachers introduced me to athletics. They soon realised that I was built for shot putt and discuss throwing and after some initial success at small school competitions I joined a club and took it up seriously. At this age I had a waist of about 38” but was doing about 3-4 hours of exercise almost everyday, what with rugby, running, gym, swimming and athletics – in and out of school. My weight had by now increased to roughly 15 stones and my BMI was over 30. I was physically fit and succeeding at sport but still carrying quite a lot of fat. I no longer thought of myself as fat but I knew that other people did. Between the ages of 14 and 18 I started to be picked for regional teams in rugby and for international athletic competitions for Wales. My sporting career was going very well but the downside of this was that I was doing sports that benefited from me being heavier. So the better I got the heavier I wanted to become. I got to the stage where I was eating almost every hour and doing my best to put on weight. At the time I thought that I was putting on muscle and being a huge, toned sports machine. It took me a while to realise that actually my muscles weren't getting any bigger but my waist was! By the time I had completed my A-levels I was for the first time over 18 stones and had a waste of nearly 40”. So, at this point I was doing everything that I had been told that would make me more adapted for my sport and I was succeeding but without noticing it I was actually putting on lots of useless excess weight that in the long term was not good for me! During my first year of university I gave up athletics and decided that I no longer needed to be as heavy for my sports. This decision combined with living away from home, cooking for myself and walking over an hour a day to and from Uni soon began to bear fruit. By the summer of my first year at Uni, aged 19, I had for the first time in my life managed to control my weight. When I came to Uni I was 18 stone. After that first year I was down to 14 stone – a weight I had not been since I was 14 years old! I had played rugby for the Medical school during my first year but as a 2nd row/back row substitute. These positions needed me to be fit and not necessarily all that heavy and this helped me lose the weight. During my second year I began to start as a 2nd row and was soon asked to help out in the front row. I enjoyed playing these positions and again realised that I was pretty good at it and that extra weight would make me even better. So between 2nd year and the end of 3rd year I had put on nearly 5 stone in weight and this put me back to where I started at my graduation at the end of 3rd year. The ironic and sad thing is about all this that the fatter, less “good looking” and unhealthier I became, the better I was adapted for the sports I had chosen. It had never occurred to me that being good at competitive sports might actually be bad for my health. The Change and life lessons learnt At the beginning of my 4th year I had realised that I was fatter than I should be and had started to pick up a number of niggly injuries from playing these tough, body destroying positions in rugby. I decided that I would start to take the rugby less seriously and aim to stay fit and healthy rather than be good at a competitive sport. With this new attitude to life I resolved to lose weight. Over the course of the year there were a number of ups and downs. I firstly went back to all the men’s health magazines that I had stock piled over the years and started to work out where I was going wrong with my health. After a little investigation it became apparent that going running and working out in the gym was not enough to become healthy. If you want to be slim and healthy then your diet is far more important than what physical activity you do. My diet used to be almost entirely based on red meat and carbs: steak, mince, bacon, rice and pasta. Over the year I changed my diet to involve far more vegetables, more fibre, more fruit, more salad and way less meat! The result was that by Christmas 2012 I was finally back below 18 stones. The diet had started to have benefits. Then came exams! By the end of exams in April 2013 I had gone back up 19 stones and a waist of >40”. I was still spending nearly 2 hours a day doing weights in the gym and running or cycling 3 times a week. Even with all this exercise and a new self- awareness of my size, a terrible diet over the 3 week exam period had meant that I gained a lot of fat. After exams I went travelling in China for 3 weeks. While I was there I ate only local food and lots of coffee. Did not each lunch and was walking around exploring for over 6 hours a day. When I got back I was 17.5 stone, about 106kg. My waist had shrunk back down to 36” and I could fit into clothes I had not worn in years. This sudden weight loss was not explained by traveller’s diarrhoea or any increased activity above normal. What made me lose weight was eating a fairly healthy diet and eating far less calories than I normally would. I know this sounds like common sense but I had always read and believed that if you exercised enough then you could lose weight without having to decrease your calorie intake too much. I have always hated the sensation of being hungry and have always eaten regular to avoid this awful gnawing sensation. I had almost become hunger-phobic, always eating when given the opportunity just in case I might feel hungry later and not because I actually needed to eat. The time in China made me realise that actually I don’t NEED to eat that regularly and I don’t NEED to eat that much. I can survive perfectly ably without regular sustenance and have more than enough fat stores to live my life fully without needing to each too much. My eating had just become a habit, a WANT and completely unnecessary. After being home for a month I have had some ups and downs trying to put my new plans into action. Not eating works really easily in a foreign country, where it’s hot, you are busy and you don’t have a house full of food or relatives that want to feed you. I have managed to maintain my weight around 17.5 stones and kept my waist within 36” trousers. I am counting that as a success so far. The plan from now on is to get my weight down to under 16.5 stones because I believe that as this weight I will not be carrying too much excess weight and my BMI will be as close to “not obese” as it is likely to get without going on a starvation diet. I intend to achieve this goal by maintain my level of physical activity – at least 6 hours of gym work a week, 2 cardio sessions, tennis, squash, cycling, swimming and golf as the whim takes me. BUT MORE IMPORTANTLY, I intend to survive off far fewer calories with a diet based on bran flakes, salad, fruit, nuts, chicken and milk. I am hoping that this very simple plan will work! Conclusion Writing this short(-ish) autobiography was quite cathartic and I would really recommend it for other people who are trying to remake themselves. Its helped me put my thoughts in order. Over the years I wanted to lose weight because I wanted to look better. This desire has now matured into a drive to be not just slimmer but healthier; I no longer want to be slimmer just for the looks but also to reduce the pressure on my joints, to reduce the pressure on my cardiovascular system, to reduce my risks of being fat when I am older, to hopefully reduce the risk of dying prematurely and to some extent to make life cheaper – eating loads of meat to prevent hunger is expensive! I hope this blog has been mildly interesting, but also informative of just how easy it is for even a health conscious, sporty individual to become fat in our society. I also wanted to document how difficult it is to lose weight and maintain that new lower weight for any prolonged length of time. At some point I would like to do a blog on the best methods for weight loss but that may have to wait until I have found what works for me and if I do actually manage to achieve my goals. Would be a bit hypercritical to write such a blog while still having a BMI yo-yoing around 32 I feel! Thought for the day 1 - Gaining wait is easy, becoming fat is easy, losing fat is also technically easy! The hard part is developing AND then maintaining a healthy mental attitude towards your weight. The human body has evolved to survive starvation. We are almost perfectly made to build up high density fat stores just in case next year’s crops fail and we have to go a few months on broth. I will say it again – We are designed to survive hard conditions! The problem with the modern world and with modern society is that we no longer have to fight to survive. For the first time in human history food is no longer scarce… it is in fact incredibly abundant and cheap (http://www.youtube.com/watch?v=-Z74og9HbTM). It is no surprise that when a human body is allowed to eat want and how much it craves and then do as little activity as possible, that it puts on fat very quickly. This has to be one of the major ironies of our age – When the human race has evolved society enough that we no longer need to have fat stores in case of disaster, that we are now the fattest humans have ever been! 2 – The best bit of advice I was ever given is this: “Diets ALWAYS fail! No matter what the diet or how determined you are, if you diet then within 2 years you will be the same weight or heavier than you are now. The only way to a healthy body is through a healthy LIFESTYLE CHANGE! You have to make changes that you are prepared to keep for a long time.”  
jacob matthews
over 8 years ago
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Dr Mark Newbold “Why Should Doctors Get Involved in Management – Understanding the Problems” - Birmingham Medical Leadership Society Lecture 3

The Birmingham Student’s Medical Leadership Society (MLS) held it’s third and final lecture of 2013 on Thursday December 5th. The final lecture was given by Dr Mark Newbold CEO of the Heart of England NHS Foundation Trust and was a particularly enlightening end to our autumn lecture series on why healthcare professionals should become involved in management and leadership. In contrast to the previous talk by Mr Tim Smart this lecture did not focus on why doctors would be suitable for management roles but rather on why clinical leadership is absolutely necessary to tackle the fundamental problems in our hospitals today. Once again, the Birmingham MLS heartily thanks Dr Newbold for giving up his valuable time to speak to us and we must also thank Michelle and Angie for video recording this event as well. Fingers crossed, the recordings of both of our last events should be available fairly shortly. The lecture began with a brief career history of why and how Dr Newbold became involved in hospital management, from front line doctor, to department lead and on to chief exec of a major NHS foundation trust. The second part of the lecture was a brief history of the recent NHS beginning with the Labour years. Between 1997 and 2010 NHS funding increased enormously, which was a good thing. Targets increased proportionally with the funding, not necessarily a good thing. Expectations to meet the targets at all costs and punishments for failure also increased, not a good thing. Focus became diverted from providing the best possible care to ensuring that the hospital didn’t go bankrupt from failing to hit it’s targets. The “budget culture” was an unintended consequence of overzealous central target setting. This system did have some major successes, such as overall reduced waiting times and new specialist urgent cancer referral pathways. However, these successes did not necessarily transform into better patient care or higher patient satisfaction. This came to ahead as well all know with the Mid-Staffs Enquiry, the Francis report and the Keogh review. The recent NHS reforms have tried to change the NHS management culture away from target driven accounting and more towards affordable, yet excellent patient care – a “quality culture”. The NHS structural reforms have been well meaning but messy and complicated. The NHS culture change has begun, but trying to change something as huge as the NHS is like trying to steer an oil tanker, it takes time for the tiniest change in direction to be noticed. Add to this list of changes, an ever ageing population, an ever growing population, an increasingly chronically ill, co-morbid population and a relative freeze in budget and you can start to see why NHS managers are having such a tough time at the moment. How can NHS managers adopt this culture? Put their priorities in order. Quality care + Patient satisfaction > Waiting lists > Budgets Engage with the public in a more meaningful way. Have a social media presence so that you, your hospital and its staff are more than just a faceless organisation. Have a twitter account and write blogs about your challenges and successes. This will increase patient satisfaction with your hospital. Ask for and listen to patient reviews regularly. Make sure these reviews are public and this will help ensure that any changes made are recognised. Better articulate why you are changing a service, e.g. you are not shutting a local A/E to save money but to save lives! Specialist centres have been shown to have better patient outcomes than smaller, less specialised centres. The London stroke service reforms are an excellent example of this principle. Realise that a budget is a constraint, not an aim! Create a dialogue with doctors about which targets are important and why they are important. If doctors don’t agree with the targets then they will not try to improve the measures. For example, the A/E 4 hour waiting time target annoys a lot of healthcare professionals, who see it as a criticism of their work. However, this target is in fact not a measure of A/E efficiency but actually a measure of FLOW through the entire hospital. If the 4h target is missed then there is a problem within the hospital system as a whole and the doctors needed to be aware that their service is reaching capacity and that this may affect their practice. They should also consider why the 4h target was missed and what can they do to increase the patient flow through the hospital – are they needed in an understaffed department? The essence of this part of the lecture can be summarised by saying that “poor hospital performance has consequences for that hospital and its staff, these consequences affect clinical care and therefore, healthcare professionals need to care about the bigger picture otherwise it will affect frontline care”. The next part of the talk went on to outline some of the recent problems that Dr Newbold has been made aware of and how this affects his hospitals performance. 35% of patients who present to the A/E department have at least 1 chronic condition. 12% of patients are re-admitted within 30 days. Did they receive suboptimal care the first time? Patients who are re-admitted have a far higher mortality rate than other patients. Once, a patient has been in hospital for longer than 5 days their mortality rate begins to rise drastically. Being in a hospital is bad for your health and patients are often not discharged as soon as they should be. A hospital of 1500 people needs to discharge over 200 patients a day just to maintain its flow of patients. If this discharge rate decreases then the pressure on the system increases and beds are no longer available, which starts to decrease the services a hospital can provide, such as elective operations. Hospitals tend to be managed on 4 layers of alert. When the hospital is on top alert i.e. the most under pressure, mortality rates can be up to 8% higher than when the hospital is at its least pressured. By not discharging patients promptly, doctors are increasing the pressure on the system as a whole with awful unintended consequences for the patients. By admitting patients to the wards, who do not necessarily require in-patient care, doctors are also increasing the pressure on the system. Bed blocking has consequences for the patients, not just the budgets. The list above demonstrates how unintended consequences of frontline staff decisions affect patient outcomes. That is why it is critical that frontline staff are involved with helping to improve some of these problems. Does that patient really need to be admitted to an already full hospital? Does that patient really need to stay on the ward until Friday? Did that man with an exacerbation of asthma get the best acute treatment and has a plan been made for his long term management that will decrease the chance of him re-admitting? Healthcare staff can help by adjusting their practice to the situation and by helping to change the systems overall, so that the above consequences are less likely to occur. This part of the lecture was really quite sobering. It spelled out some hard facts about how such a complex system as a hospital operates. But more importantly it helped clarify just what needs to be done in the future to make hospital care the best it can be. Dr Newbold quoted the RCP report “Hospitals are not the problem, they have a problem” to highlight his believe that in the future the health service needs to change to be less focussed on acute crises and more focussed on exacerbation prevention. Hospitals should be a last resort, not a first choice. Hospitals themselves need to change how they deliver care. NHS staff need to explore ways of providing their services in an ambulatory fashion, so that patients don’t need to stay on the wards for any pre-longed period of time but come and go as quickly as possible. This will involve a major shake up in how hospital trusts fund care. They will need to increase their funding for the provision of more services at home. They need to get their employs out of the hospital and into the community. They need to work more closely with GP’s and with local social services. As the previous Chief Medical Officer said “Good Health is about team work”. Only when GP’s, community staff, hospital staff and social services work as a team will patient care really improve. At the present The University of Birmingham Students Medical Leadership Society is in contact with the FMLM and other similar groups at the Universities of Bristol, Barts and Oxford. We are looking to get in contact with every other society in the country. If you are a new or old MLS then please do get in touch, we would love to hear from you and are happy to help your societies in any way we can – we would also love to attend your events so please do send us an invite. Email us at med.leadership.soc.uob@gmail.com Follow us on Twitter @UoBMedLeaders Find us on Facebook @ https://www.facebook.com/groups/676838225676202/ Come along to our up coming events… Wednesday 22nd January 2014 LT3 Medical School, 6pm ‘Has the NHS lost the ability to care?’ – responding to the Mid Staffs inquiry’ By Prof Jon Glasby, Director of the Health Services Management Centre , UoB Thursday 20th February LT3 Medical School, 6pm ‘Reforming the West Midlands Major Trauma Care” By Sir Prof Keith Porter, Professor of Traumatology, UHB Saturday 8th March WF15 Medical School, 1pm “Applying the Theory of Constraints to Healthcare” By Mr A Dinham and J Nieboer ,QFI Consulting  
jacob matthews
almost 8 years ago
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Extolling the benefits of learning plans

“You’re a boring whore! Fix it.” The barked criticism came like a slap in the face. The director of Les Miserables was right, though. I was a boring whore. Actors need to immerse themselves in their roles, shed inhibitions and squelch embarrassment. I was not managing to do this while rehearsing the Lovely Ladies prostitute scene. My performance was overly self-conscious and restrained. Three days later I found myself at a medical education conference, attending a session discussing learning plans. A popular tool in adult education generally, and a training requirement for all GP registrars, learning plans are actively disliked by many. Done purposely and thoughtfully, they can be of great benefit; completed hastily or reluctantly because they are compulsory, they are next to useless. I have to confess that, as a registrar, my own learning plans were dashed off with little thought, submitted and then promptly forgotten. I’d never thought this technique would work for me. At the conference, the attending educators were instructed to each write a learning plan that addressed an aspect of their non-medical lives. We were asked to choose something that we genuinely wanted to improve. I instantly knew what I’d write about, and completed the task with seriousness and sincerity. The facilitator randomly picked a few participants to read out their learning plans. The topics were predictable: “I want to exercise each morning”, “I want to get at least seven hours of sleep a night” and the like. Yes, you can see where this is leading ... I should have anticipated being called upon, but when the “We have time for one more, how about you?” came, along with direct eye contact and a kindly smile, I momentarily panicked. Surveying the room of mostly middle-aged, male faces, many of whom I didn’t know, I considered making something up on the spot. Instead, I stood up, took a deep breath and read out: “I want to be a more exciting whore.” I then outlined my proposed methods for achieving this objective and how I intended to measure my progress. Without explanation, I then sat down. Silence. Not a sound. Most eyes were glued to me, the others looking anywhere but. The atmosphere was thick with shock, amusement, confusion, suspense and fascination. I didn’t leave them hanging for too long. After my disclosure as to why I chose the topic and the context in which I was “whoring”, there were audible sighs of relief and a sprinkling of laughter throughout the room. It was memorable for those present. Four years later, I still get the occasional question about my “whoring” when I run into certain educators at conferences. I am pleased to report that my learning plan well and truly achieved its aim. I enacted my plan exactly as written and practised diligently. I knew I had been successful when the director instructed me to “Tone it down a bit. This is a family show, you know!” I now feel a lot more comfortable extolling the benefits of learning plans to unconvinced registrars. I tell them: “I used to think that I wasn’t a learning plan-type person either but I’ve discovered that if you choose a relevant and important objective and spend time and effort working out how to achieve it, the technique can really work.” I tend to leave out: “It didn’t do much for my medicine, but it turned me into a fabulous whore.” This blog post has been adapted from a column first published in Australian Doctor. Dr Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com/  
Dr Genevieve Yates
over 7 years ago
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A Modest Man

The registrar's face was taking on a testy look. So enduring was the silence our furtive glances had developed a nystagmic quality. “Galactosaemia” came her peremptory reply. Right on queue the disjointed chorus of ahs and head nods did little to hide our mental whiteboard of differentials being wiped clean. At the time conjugated bilirubinaemia in children only meant one thing: biliary atresia. A fair assumption; we were sitting in one of three specialist centres in the country equipped to treat these patients. Ironically the condition has become the unwieldy yardstick I now measure the incidence of paediatric disease. Biliary atresia is the most common surgical cause of neonatal jaundice with a reported incidence of 1 in 14-16ooo live births in the West. It is described as a progressive inflammatory obliteration of the extrahapatic bile duct. And Dr Charles West, the founder of Great Ormond Street Hospital, offers an eloquent description of the presenting triad of prolonged jaundice, pale acholic stools and dark yellow urine: ‘Case 18...It was born at full term, though small, apparently healthy. At 3 days however, it began to get yellow and at the end of 3 weeks was very yellow. Her motions at no time after the second day appeared natural on examination, but were white, like cream, and her urine was very high coloured.’ 1855 was the year of Dr West's hospital note. An almost universally fatal diagnosis and it would remain so for the next 100 years. The time's primordial classification of biliary atresia afforded children with the 'noncorrectable' type, a complete absence of patent extrahepatic bile duct, an unfortunate label; they were beyond saving. Having discovered the extent of disease at laparatomy, the surgeons would normally close the wound. The venerable Harvardian surgeon, Robert E. Gross saved an enigmatic observation: “In most instances death followed a downhill course…” K-A-S-A-I read the ward’s board. It was scrawled under half the children's names. I dismissed it as just another devilishly hard acronym to forget. The thought of an eponymous procedure had escaped me and in biliary atresia circles, it's the name everyone should know: Dr Morio Kasai. Originating from Aomori prefecture, Honshu, Japan, Dr Kasai graduated from the National Tohoku University School of Medicine in 1947. His ascension was rapid, having joined the 2nd department of Surgery as a general surgeon, he would assume the role of Assistant Professor in 1953. The department, under the tenure of Professor Shigetsugu Katsura, shared a healthy interest in research. 1955 was the landmark year. Katsura and Kasai operated on their first case: a 72 day old infant. Due to bleeding at the incised porta hepatis, Katsura is said to have 'placed' the duodenum over the site in order to staunch the flow. She made a spectacular postoperative recovery, the jaundice had faded and there was bile pigment in her stool. During the second case, Katsura elected to join the unopened duodenum to the porta hepatis. Sadly the patient's jaundice did not recover, but the post-mortem conducted by Kasai confirmed the development of a spontaneous internal biliary fistula connecting the internal hepatic ducts to the duodenum. Histological inspection of removed extrahepatic duct showed the existence of microscopic biliary channels, hundreds of microns in diameter. Kasai made a pivotal assertion: the transection of the fibrous cord of the obliterated duct must contain these channels before anastomosis with the jejunal limb Roux-en-Y loop. This would ensure communication between the porta hepatis and the intrahepatic biliary system. The operation, entitled hepatic portoenterostomy, was first performed as a planned procedure for the third case at Tohoku. Bile flow was restored and Kasai published the details of the new technique in the Japanese journal Shujutsu in 1959. However, news of this development did not dawn on the West until 1968 in the Journal of Pediatric Surgery. The success of the operation and its refined iterations were eventually recognized and adopted in the 1970s. The operation was and is not without its dangers. Cholangitis, portal hypertension, malnutrition and hepatopulmonary syndrome are the cardinal complications. While diagnosing and operating early (<8 weeks) are essential to the outcome, antibiotic prophylaxis and nutritional support are invaluable prognostic factors. Post operatively, the early clearance of jaundice (within 3 months) and absence of liver cirrhosis on biopsy, are promising signs. At UK centres the survival after a successful procedure is 80%. The concurrent development of liver transplantation boosts this percentage to 90%. Among children, biliary atresia is the commonest indication for transplantation; by five years post-Kasai, 45% will have undergone the procedure. On the 6th December 2008, Dr Kasai passed away. He was 86 years old and had been battling the complications of a stroke he suffered in 1999. His contemporaries and disciples paint a humble and colourful character. A keen skier and mountaineer, Dr Kasai lead the Tohoku University mountain-climbing team to the top of the Nyainquntanglha Mountains, the highest peaks of the Tibetan highlands. It was the first successful expedition of its kind in the world. He carried through this pioneering spirit into his professional life. Paediatric surgery was not a recognized specialty in Japan. By founding and chairing multiple associations including the Japanese Society of Pediatric Surgeons, Dr Kasai gave his specialty and biliary atresia, the attention it deserved. Despite numerous accolades of international acclaim for his contributions to paediatric surgery, Dr Kasai insisted his department refer to his operation as the hepatic portoenterostomy; the rest of the world paid its originator the respect of calling it the ‘Kasia’. Upon completion of their training, he would give each of his surgeons a hand-written form of the word ‘Soshin’ [simple mind], as he believed a modest surgeon was a good one. At 5 foot 2, Kasai cut a more diminutive figure one might expect for an Emeritus Professor and Hospital Director of a university hospital. During the course of his lifetime he had developed the procedure and lived to see its fruition. The Kasia remains the gold standard treatment for biliary atresia; it has been the shinning light for what Willis J. Potts called the darkest chapter in paediatric surgery. It earned Dr Kasai an affectionate but apt name among his peers, the small giant. References Miyano T. Morio Kasai, MD, 1922–2008. Pediatr Surg Int. 2009;25(4):307–308. Garcia A V, Cowles RA, Kato T, Hardy MA. Morio Kasai: a remarkable impact beyond the Kasai procedure. J Pediatr Surg. 2012;47(5):1023–1027. Mowat AP. Biliary atresia into the 21st century: A historical perspective. Hepatology. 1996;23(6):1693–1695. Ohi R. A history of the Kasai operation: Hepatic portoenterostomy for biliary atresia. World J Surg. 1988;12(6):871–874. Ohi R. Morio Kasai, MD 1922-2008. J Pediatr Surg. 2009;44(3):481–482. Lewis N, Millar A. Biliary atresia. Surg. 2007;25(7):291–294. This blog post is a reproduction of an article published in the Medical Student Newspaper, April 2014 issue.  
James Wong
over 7 years ago
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Emergency Medicine UK: Working, Training and Standards

UK Emergency Medicine site: CEM, EMTA and FASGEM. This website gives information about working, training and standards of care in emergence medicine in Britain.  
rcem.ac.uk
over 6 years ago
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2
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Differences in Mechanosensory Discrimination Across the Body Surface - Neuroscience - NCBI Bookshelf

The accuracy with which tactile stimuli can be sensed varies from one region of the body to another, a phenomenon that illustrates some further principles of somatic sensation. Figure 9.4 shows the results of an experiment in which variation in tactile ability across the body surface was measured by two-point discrimination. This technique measures the minimal interstimulus distance required to perceive two simultaneously applied stimuli as distinct (the indentations of the points of a pair of calipers, for example). When applied to the skin, such stimuli of the fingertips are discretely perceived if they are only 2 mm apart. In contrast, the same stimuli applied to the forearm are not perceived as distinct until they are at least 40 mm apart! This marked regional difference in tactile ability is explained by the fact that the encapsulated mechanoreceptors that respond to the stimuli are three to four times more numerous in the fingertips than in other areas of the hand, and many times more dense than in the forearm. Equally important in this regional difference are the sizes of the neuronal receptive fields. The receptive field of a somatic sensory neuron is the region of the skin within which a tactile stimulus evokes a sensory response in the cell or its axon (Boxes A and B). Analysis of the human hand shows that the receptive fields of mechanosensory neurons are 1–2 mm in diameter on the fingertips but 5–10 mm on the palms. The receptive fields on the arm are larger still. The importance of receptive field size is easy to envision. If, for instance, the receptive fields of all cutaneous receptor neurons covered the entire digital pad, it would be impossible to discriminate two spatially separate stimuli applied to the fingertip (since all the receptive fields would be returning the same spatial information). Figure 9.4Variation in the sensitivity of tactile discrimination as a function of location on the body surface, measured here by two-point discrimination. (After Weinstein, 1969.)  
ncbi.nlm.nih.gov
about 6 years ago
10
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14

The PressureWire fractional flow reserve measurement system for coronary artery disease | Advice | NICE

The PressureWire FFR devices measure FFR, a physiological parameter used to assess the severity of stenoses in the coronary arteries.  
nice.org.uk
about 6 years ago
Preview
2
35

Brain imaging reveals autism in boys

Researchers at Linköping University and the University of Gothenburg have developed a new brain imaging measure to identify autism in boys. The method opens up new possibilities to track progress and improve treatment.  
liu.se
over 5 years ago
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1
28

NHS death rates 'should be ignored' - BBC News

A key measure of hospital death rates should be ignored, according to the expert who is leading the NHS review into them.  
BBC News
almost 8 years ago
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1
28

Physiology Tutorial - Blood Flow

The task of maintaining an adequate interstitial homeostasis (the proper nutritional environment surrounding all cells in your body) requires that blood flows almost continuously through each of the millions of capillaries in the body. The following is a brief description of the parameters that govern flow through a given vessel. All bloods vessels have certain lengths (L) and internal radii (r) through which blood flows when the pressure in the inlet and outlet are unequal (Pi and Po respectively); in other words there is a pressure difference (ΔP) between the vessel ends, which supplies the driving force for flow. Because friction develops between moving blood and the stationary vessels walls, this fluid movement has a given resistance (vascular), which is the measure of how difficult it is to move blood through a vessel. One can then describe a relative relationship between vascular flow, the pressure difference, and resistance (i.e., the basic flow equation):  
vhlab.umn.edu
over 7 years ago
Www.bmj
1
38

What is the most effective operation for adults with severe and complex obesity?

Accessing, undergoing, and achieving a successful outcome from surgery for “severe and complex obesity” is difficult and requires determination and effort. Here, we consider “severe and complex obesity” to mean that an individual’s health is compromised by his or her weight to the extent that surgery can be considered to be an appropriate option.1 Surgery may be offered to adults with a body mass index (BMI) of ≥40, or a BMI of ≥35 with an obesity related disease, and it can be very successful. An average 50% of excess weight may be lost in the first few years after surgery, and if this is sustained it is associated with long term reduction in overall mortality and decreased incidences of diabetes, myocardial infarction, stroke and cancer.1 2 This treatment, however, requires careful consideration and serious commitment, with the need to demonstrate full engagement in a structured weight loss programme, to have tried all appropriate non-invasive measures of weight loss, and persevered for referral to a specialist surgical team.1 Once surgery is approved it is necessary to choose which operation to undergo.  
bmj.com
over 7 years ago
Www.bmj
1
31

What is the most effective operation for adults with severe and complex obesity?

Accessing, undergoing, and achieving a successful outcome from surgery for “severe and complex obesity” is difficult and requires determination and effort. Here, we consider “severe and complex obesity” to mean that an individual’s health is compromised by his or her weight to the extent that surgery can be considered to be an appropriate option.1 Surgery may be offered to adults with a body mass index (BMI) of ≥40, or a BMI of ≥35 with an obesity related disease, and it can be very successful. An average 50% of excess weight may be lost in the first few years after surgery, and if this is sustained it is associated with long term reduction in overall mortality and decreased incidences of diabetes, myocardial infarction, stroke and cancer.1 2 This treatment, however, requires careful consideration and serious commitment, with the need to demonstrate full engagement in a structured weight loss programme, to have tried all appropriate non-invasive measures of weight loss, and persevered for referral to a specialist surgical team.1 Once surgery is approved it is necessary to choose which operation to undergo.  
bmj.com
over 7 years ago
Preview
1
35

Painful diabetic neuropathy

Diabetes is a worldwide epidemic, and associated neuropathy is its most costly and disabling complication. Given the rising prevalence of painful diabetic neuropathy, it is increasingly important that we understand the best ways to diagnose and treat this condition. Diagnostic tests in this field are evolving rapidly. These include the use of skin biopsies to measure small unmyelinated fibers, as well as even newer techniques that can measure both small unmyelinated fibers and large myelinated fibers in the same biopsy. The main treatments for painful diabetic neuropathy remain management of the underlying diabetes and drugs for the relief of pain. However, emerging evidence points to major differences between type 1 and type 2 diabetes, including the ability of glycemic control to prevent neuropathy. Enhanced glucose control is much more effective at preventing neuropathy in patients with type 1 diabetes than in those with type 2 disease. This dichotomy emphasizes the need to study the pathophysiologic differences between the two types of diabetes, because different treatments may be needed for each condition. The impact of the metabolic syndrome on neuropathy in patients with type 2 diabetes may account for the difference between the two types of diabetes and requires further study. Finally, neuropathic pain is under-recognized and undertreated despite an ever evolving list of effective drugs. Evidence exists to support several drugs, but the optimal sequence and combination of these drugs are still to be determined.  
www.bmj.com
over 7 years ago
Preview
1
25

Painful diabetic neuropathy

Diabetes is a worldwide epidemic, and associated neuropathy is its most costly and disabling complication. Given the rising prevalence of painful diabetic neuropathy, it is increasingly important that we understand the best ways to diagnose and treat this condition. Diagnostic tests in this field are evolving rapidly. These include the use of skin biopsies to measure small unmyelinated fibers, as well as even newer techniques that can measure both small unmyelinated fibers and large myelinated fibers in the same biopsy. The main treatments for painful diabetic neuropathy remain management of the underlying diabetes and drugs for the relief of pain. However, emerging evidence points to major differences between type 1 and type 2 diabetes, including the ability of glycemic control to prevent neuropathy. Enhanced glucose control is much more effective at preventing neuropathy in patients with type 1 diabetes than in those with type 2 disease. This dichotomy emphasizes the need to study the pathophysiologic differences between the two types of diabetes, because different treatments may be needed for each condition. The impact of the metabolic syndrome on neuropathy in patients with type 2 diabetes may account for the difference between the two types of diabetes and requires further study. Finally, neuropathic pain is under-recognized and undertreated despite an ever evolving list of effective drugs. Evidence exists to support several drugs, but the optimal sequence and combination of these drugs are still to be determined.  
www.bmj.com
over 7 years ago
Preview
1
22

Painful diabetic neuropathy

Diabetes is a worldwide epidemic, and associated neuropathy is its most costly and disabling complication. Given the rising prevalence of painful diabetic neuropathy, it is increasingly important that we understand the best ways to diagnose and treat this condition. Diagnostic tests in this field are evolving rapidly. These include the use of skin biopsies to measure small unmyelinated fibers, as well as even newer techniques that can measure both small unmyelinated fibers and large myelinated fibers in the same biopsy. The main treatments for painful diabetic neuropathy remain management of the underlying diabetes and drugs for the relief of pain. However, emerging evidence points to major differences between type 1 and type 2 diabetes, including the ability of glycemic control to prevent neuropathy. Enhanced glucose control is much more effective at preventing neuropathy in patients with type 1 diabetes than in those with type 2 disease. This dichotomy emphasizes the need to study the pathophysiologic differences between the two types of diabetes, because different treatments may be needed for each condition. The impact of the metabolic syndrome on neuropathy in patients with type 2 diabetes may account for the difference between the two types of diabetes and requires further study. Finally, neuropathic pain is under-recognized and undertreated despite an ever evolving list of effective drugs. Evidence exists to support several drugs, but the optimal sequence and combination of these drugs are still to be determined.  
www.bmj.com
over 7 years ago
Preview
1
56

Painful diabetic neuropathy

Diabetes is a worldwide epidemic, and associated neuropathy is its most costly and disabling complication. Given the rising prevalence of painful diabetic neuropathy, it is increasingly important that we understand the best ways to diagnose and treat this condition. Diagnostic tests in this field are evolving rapidly. These include the use of skin biopsies to measure small unmyelinated fibers, as well as even newer techniques that can measure both small unmyelinated fibers and large myelinated fibers in the same biopsy. The main treatments for painful diabetic neuropathy remain management of the underlying diabetes and drugs for the relief of pain. However, emerging evidence points to major differences between type 1 and type 2 diabetes, including the ability of glycemic control to prevent neuropathy. Enhanced glucose control is much more effective at preventing neuropathy in patients with type 1 diabetes than in those with type 2 disease. This dichotomy emphasizes the need to study the pathophysiologic differences between the two types of diabetes, because different treatments may be needed for each condition. The impact of the metabolic syndrome on neuropathy in patients with type 2 diabetes may account for the difference between the two types of diabetes and requires further study. Finally, neuropathic pain is under-recognized and undertreated despite an ever evolving list of effective drugs. Evidence exists to support several drugs, but the optimal sequence and combination of these drugs are still to be determined.  
www.bmj.com
over 7 years ago
Preview
1
17

Painful diabetic neuropathy

Diabetes is a worldwide epidemic, and associated neuropathy is its most costly and disabling complication. Given the rising prevalence of painful diabetic neuropathy, it is increasingly important that we understand the best ways to diagnose and treat this condition. Diagnostic tests in this field are evolving rapidly. These include the use of skin biopsies to measure small unmyelinated fibers, as well as even newer techniques that can measure both small unmyelinated fibers and large myelinated fibers in the same biopsy. The main treatments for painful diabetic neuropathy remain management of the underlying diabetes and drugs for the relief of pain. However, emerging evidence points to major differences between type 1 and type 2 diabetes, including the ability of glycemic control to prevent neuropathy. Enhanced glucose control is much more effective at preventing neuropathy in patients with type 1 diabetes than in those with type 2 disease. This dichotomy emphasizes the need to study the pathophysiologic differences between the two types of diabetes, because different treatments may be needed for each condition. The impact of the metabolic syndrome on neuropathy in patients with type 2 diabetes may account for the difference between the two types of diabetes and requires further study. Finally, neuropathic pain is under-recognized and undertreated despite an ever evolving list of effective drugs. Evidence exists to support several drugs, but the optimal sequence and combination of these drugs are still to be determined.  
www.bmj.com
over 7 years ago