This is an excerpt from "Fluids and Electrolytes Made Incredibly Easy! 1st UK Edition" by William N. Scott. For more information, or to purchase your copy, visit: http://tiny.cc/Fande. Save 15% (and get free P&P) on this, and a whole host of other LWW titles at lww.co.uk when you use the code MEDUCATION when you check out!
The chemical reactions that sustain life depend on a delicate balance – or homeostasis – between acids and bases in the body. Even a slight imbalance can profoundly affect metabolism and essential body functions. Several conditions, such as infection or trauma, and certain medications can affect acid-base balance. However, to understand this balance, you need to understand some basic chemistry.
Understanding acids and bases requires an understanding of pH, a calculation based on the concentration of hydrogen ions in a solution. It may also be defi ned as the amount of acid or base within a solution.
Acids consist of molecules that can give up, or donate, hydrogen ions to other molecules. Carbonic acid is an acid that occurs naturally in the body. Bases consist of molecules that can accept hydrogen ions; bicarbonate is one example of a base.
A solution that contains more base than acid has fewer hydrogen ions, so it has a higher pH. A solution with a pH above 7 is a base, or alkaline.
A solution that contains more acid than base has more hydrogen ions, so it has a lower pH. A solution with a pH below 7 is an acid, or acidotic.
Getting your PhD in pH
A patient’s acid-base balance can be assessed if the pH of their blood is known. Because arterial blood is usually used to measure pH, this discussion focuses on arterial samples.
Arterial blood is normally slightly alkaline, ranging from 7.35 to 7.45. A pH level within that range represents a balance between the concentration of hydrogen ions and bicarbonate ions. The pH of blood is generally maintained in a ratio of 20 parts bicarbonate to 1 part carbonic acid. A pH below 6.8 or above 7.8 is usually fatal.
Under certain conditions, the pH of arterial blood may deviate significantly from its normal narrow range. If the blood’s hydrogen ion concentration increases or bicarbonate level decreases, pH may decrease. In either case, a decrease in pH below 7.35 signals acidosis.
If the blood’s bicarbonate level increases or hydrogen ion concentration decreases, pH may rise. In either case, an increase in pH above 7.45 signals alkalosis.
Regulating acids and bases
A person’s well-being depends on their ability to maintain a normal pH. A deviation in pH can compromise essential body processes, including electrolyte balance, activity of critical enzymes, muscle contraction and basic cellular function. The body normally maintains pH within a narrow range by carefully balancing acidic and alkaline elements. When one aspect of that balancing act breaks down, the body can’t maintain a healthy pH as easily, and problems arise.
Objective To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present, with the aim of reducing current massive overdiagnosis and overtreatment of malaria.
This is a teaching resource that aids the student in memorisation of the Cranial Nerves, their anatomical path and function.
Additionally, it stimulates a clinical approach to the functions of the Cranial Nerves, with some 'not to be missed' signs.
As part of my post retirement ob & gyn activities, I spent two years in the early nineties, working at the Aga Kahn Medical School in Karachi, Pakistan. That is a most modern facility with excellent staff and resources and great medical students. One can imagine that the majority of obstetricians and gynecologists in a muslim country, like Pakistan, are female and that male ob & gyn might encounter some difficulties It was my distinct impression that often it is not the woman herself who objects to being examined and treated by a male, but rather the husband. An anecdote of a real situation which I encountered will illustrate this.
One day I was sitting in my office next to the labor and delivery suite as one of the more junior female residents came running into my office, quite excited. “Doctor Le Maire, could you please come quickly? One of the laboring patients has some very major drop in the baby’s heartbeat. I am worried but cannot reach her private doctor and the doctor on call is in the operating room.”
I ran over to the delivery suite with the resident and into the patient’s room. She was obviously in much discomfort and her husband was at her side. One of the first things an obstetrician may do when a woman in labor shows signs of some problem with the undelivered baby as evidenced by a drop in the baby’s heart rate, is to examine the woman vaginally. In doing so, the he or she can determine if the baby can be quickly delivered or if there is a reason for the drop in the baby’s heart rate, such as a loop of the umbilical cord being compressed by the head, in which case an immediate C- Section might be necessary.
So I immediately put on a pair of sterile gloves and got ready to examine the woman. She herself was perfectly ready to let me do this, but her husband stopped me and told me that he objected to his wife being examined by a male. This was even in the face of a serious situation with potential for harm to his unborn baby. There was no time to be lost trying to reach one of the female attendings, so I did the next best thing and told the very junior resident to take the patient into the operating room and examine her there and let me know the findings, while I was getting the operating room organized to do a C-Section, if called for.
The strange thing is that the husband would have let me do a C- Section on his wife, but not a vaginal exam. As it turned out, by the time the patient ended up in the operating room, her private doctor had been located and was in attendance. The outcome was good and a healthy baby was delivered soon after. However the situation could have been quite different and catastrophic.
Even stranger to me was that the woman’s husband was not a lay person but actually a chief resident in anesthesiology in the same hospital, with whom I had worked together in the operating room on a number of occasions. I would never have thought that an educated person and a medically educated person at that, would jeopardize the well being of his unborn child and wife, based on cultural and religious beliefs. Later on in the year this same anesthesiology resident came to ask me for a letter of recommendation as he wanted to apply for a specialized fellowship in the USA. I hope that the reader can understand why I politely (perhaps not so politely) refused.
Those interested can read more about my experiences in an e book, entitled "Crosscultural Doctoring. On and Off the Beaten Path." One can down load it for free to the reader device of your choice from Smashwords at: http://smashwords.com/books/view/161522. Or just Google Crooscultural Doctoring.
In NeuroPsychiatry it might be difficult to locate its territory, and find its niche. This might be an uneasy endeavour as its two parent branches neurology and psychiatry are still viable, also it siblings organic psychiatry, behavioural neurology and biological psychiatry are also present. This blogpost attempts to search for the definition and domains of neuropsychiatry.
Neuropsychiatry can be defined as the 'biologic face' of mental health (Royal Melbourne Hospital, Neuropsychiatry unit). It is the neurological aspects of psychiatry and the psychiatric aspects of neurology (Pacific Neurpsychiatry Institute). It is not a new term. Many physicians used to brand themselves as neuropsychiatrists at the rise of the twentieth century. It has been looked upon with a sense of unease as a hybrid branch. Also, it was subject to pejorative connotations, as the provenance of amateurs in both parent disciplines (Lishman, 1987). The foundational claim is that 'all' mental disorders are disorders of the brain' (Berrios and Marková, 2002). The American NeuroPsychiatric Association (ANPA) defines it as 'the integrated study of psychiatric and neurologic disorders' (ANPA, 2013). The overlap between neuropsychiatry and biological psychiatry was observed (Trimble and George, 2010) as the domain of enquiry of the first and the approach of the second will meet at point. Berrios and Marková seemed to have focused on the degree of conversion among biological psychiatry, organic psychiatry, neuropsychiatry and behavioural neurology. They stated that they share the same foundational claims (FCcs): (1) mental disorder is a disorder of the brain; (2) reasons are not good enough as causes of mental disorder; and (3) biological psychiatry and its congeners have the patrimony of scientific truth. They further elaborated that the difference is primarily due to difference in historic origins. (D'haenen et al., 2002). The American Neuropsychiatric Association (ANPA) defines neuropsychiatry as the integrative study of neurological and psychiatric disorders on a clinical level, on a theoretical level; ANPA defines it as the bridge between neuroscience and clinical practice. The interrelation between both specialities is adopted by The Royal Australia and New Zealand College of Psychiatrists as it defines it as a psychiatric subspeciality. This seems to resonate the concept that 'biologisation' of psychiatry is inevitable (Sachdev and Mohan, 2013). The definition according to Gale Encyclopedia encompasses the interface between the two disciplines (Fundukian and Wilson, 2008). In order to acknowledge the wide use of the term 'neuropsychiatry'; the fourth edition of Lishman's Organic Psychiatry, appeared and it was renamed as 'textbook of neuropsychiatry'. The editor stated that the term is not used in its more restrictive sense (David, 2009).
Ostow backtracked the origin of biological causes for illness to humoral view of temperament.In the nineteenth century, the differentiation between both did not seem to be apparent. The schism seems to have emerged in the twentieth century. The difficulties that arose with such early adoption of neuronal basis to psychiatric disorders are that they were based on on unsubstantiated beliefs and wild logic rather than scientific substance. (Panksepp, 2004). Folstein stated that Freud and Charcot postulated psychological and social roots for abnormal behaviours, thus differentiating neurology from psychiatry. (David, 2009). The separation may have lead to alienation of doctors on both camps and helped in creating an arbitary division in their scope of knowledge and skills. The re-emergence of interest in neurospsychiatry has been described to be due to the growing sense of discomfort in the lack of acknowledgment of brain disorders when considering psychiatric symptoms (Arciniegas and Beresford, 2001).
There is considerable blurring regarding defining the territory and the boundaries of neuropsychiatry. The Royal College of Psychiatrists founded section of Neuropsychiatry in 2008. The major working groups include epilepsy, sleep disorders, brain injury and complex neurodisability. In 1987 the British NeuroPsychiatry Association was established, to address the professional need for distinction, without adopting the concept of formal affiliation with parent disciplinary bodies as the Royal College of Psychiatrists. The ANPA was founded in 1988. It issued training guide for residents. The guide included neurological and psychiatric assessments, interpretation of EEG and brain imaging techniques. With regards to the territory, it included delirium, dementia, psychosis, mood and anxiety disorders due to general medical condition. Neurpsychiatric aspects of psychopharmacologic treatments, epilepsy, neuropsychiatric aspects of traumatic brain injury and stroke. The diagnosis of movement disorders, neurobehavioural disorders, demyelinating disease, intellectual and developmental disorders, as well as sleep disorders was also included. The World Federation of Societies of Biological Psychiatry (WFSBP) was established in Buenos Aires in 1974 to address the rising significance of biological psychiatry and to join local national societies together. The National Institute of Mental Health (NIMH), is currently working on a biologically-based diagnosis, that incorporates neural circuits, cells, molecules to behavioural changes. The diagnostic system - named 'Research Domain Criteria (RDoC) - is agnostic to current classification systems DSM-5 & ICD-10. Especially that the current diagnostic classficiations are mostly based on descriptive rather than neurobiological aetiological basis. (Insel et al., 2010). For example, the ICD-10 F-Code designates the first block to Organic illness, however, it seems to stop short of localisation of the cause of illness apart from the common prefix organic. It also addresses adverse drug events as tardive dyskinesia but stops short of describing it neural correlates. Also, psychosocial roots of mental illness seem to be apparent in aetiologically-based diagnoses as Post-Traumatic Stress Disorder, acute stress reaction, and adjustment disorders, the diagnostic cluster emphasise the necessity of having 'stress'. Other diagnoses seem to draw from the psychodynamic literature, e.g. conversion[dissociative] disorder.
The need for neuropsychiatry, has been increasing as the advances in diagnostic imaging and laboratory investigations became more clinically relevant. Nowadays, there are tests as DaT-Scan that can tell the difference between neurocognitive disorder with Lewy Bodies and Parkinson's Disease. Vascular neurocognitive disorders warrant imaging as the rule rather than the exception, vascular depression has been addressed is a separate entity. Frontal Lobe Syndromes have been subdivided into orbitofrontal and dorsolateral (Moore,2008) Much training is needed to address this subspeciality.
The early cases that may have stirred up the neurological roots of psychiatric disorders can be backdated to the case of Phineas Gage, and later, the case H.M. The eearlier fruits of adopting a neuropsychiatric perspective can be shown in the writings of Eliot Slater, as he attempted to search for the scientific underpinnings of psychiatry, and helped via seminal articles to highlight the organic aspect of psychiatry. Articles like 'The diagnosis of "Hysteria", where Slater, challenged the common wisdom of concepts like hysteria and conversion, rejecting the social roots of mental illness, and presenting a very strong case for the possibility of organicity, and actual cases of for which 'hysteria' was a plain misdiagnosis was way ahead of its time prior to CT Brain. Slater even challenged the mere existence of the concept of 'hysteria. (Slater, 1965) Within the same decade Alwyn Lishman published his textbook 'Organic Psychiatry' addressing the organic aspects of psychiatric disorders. Around the same time, the pioneers of social/psychological roots of mental illness became under attack. Hans Eysenck, published his book 'Decline and Fall of the Freudian Empire'. Eysenck stated clearly that the case of Anna O. seems to have been mispresented and that she never had 'hysteria' and recovered she actually had 'tuberculous meningitis' and she died of its complications (Eysenck, 1986).
To summarise, it seems difficult and may be futile to sharply delineate neurpsychiatry, biological psychiatry, organic psychiatry and behavioural neurology. However, it seems important to learn about the biological psychiatry as an approach and practice neuropsychiatry as a subspeciality. The territory is yet unclear from gross organic lesions as stroke to the potential of encompassing entire psychiatry as the arbitary distinction between 'functional' and 'organic' fades away. Perhaps practice will help to shape the domain of the speciality, and imaging will guide it. To date, the number of post-graduate studies are still low in comparison to the need for such speciality, much more board certification may be needed as well as the currently emerging masters and doctoral degrees.
This post is previously posted on bmj doc2doc blogs
Eysenck, H.J., Decline and Fall of the Freudian Empire, Pelican Series, 1986
German E Berrios, I.S.M., The concept of neuropsychiatry: A historical overview, Journal of Psychosomatic Research, 2002, Vol. 53, pp. 629-638
Kieran O’Driscoll, J.P.L., “No longer Gage”: an iron bar through the head, British Medical Journal, 1998, Vol. 317, pp. 1637-1638
Perminder S. Sachdev, A.M., Neuropsychiatry: Where Are We And Where Do We Go From Here?, Mens Sana Monographs, 2013, Vol. 11(1), pp. 4-15
Slater, E., The Diagnosis of "Hysteria", British Medical Journal, 1965, Vol. 5447(1), pp. 1395–1399
Thomas Insel, Bruce Cuthbert, R.H.M.G.K.Q.C.S.P.W., Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders, American Journal of Psychiatry, 2010, Vol. 167:7, pp. 748-751
Organic Psychiatry, Anthony S. David, Simon Fleminger, M. D. K. S. L. J. D. M. (ed.), Wiley-Blackwell, 2009
Neuropsychiatry an introductory approach, Arciniegas & Beresford (ed.), Cambridge University Press, 2001
Biological Psychiatry, Hugo D’haenen, J.A. den Boer, P. W. (ed.), John Wiley and Sons, 2010
Gale Encyclopedia of Mental Health, Laurie J. Fundukian, J. W. (ed.), Thomson Gale, 2008
Biological Psychiatry, M. Trimble, M. G. (ed.), Wiley-Blackwell, 2010
Textbook of Neuropsychiatry, Moore, D. P. (ed.), Hodder Arnold, 2008
Textbook of Biological Psychiatry, Panksepp, J. (ed.), John Wiley and Sons, 2004
The American Neuropsychiatric Association Website www.anpaonline.org
The Royal Melbourne Neuropsychiatry Unit Website http://www.neuropsychiatry.org.au/
The British Neuropsychiatry Association website www.bnpa.org.uk
The Royal College of Psychiatrists website www.rcpsych.ac.uk
The World Federation of Societies of Biological Psychiatry website www.wfsbp.org
When is it medically advisable to eat some one else's poo? When you need a poo transplant.
Poo transplants could be the solution to one of the biggest problems facing the NHS today- the bacterial infection Clostridium difficile. C.diff, as it's known to its friends, infects about 18,000 people in England and Wales every year and is involved in the deaths of about 2000 people.
C.diff typically arises due to imbalances in the normal gut bacteria. The gut is like a city, a city with about 100 trillion bacterial residents happily munching away on a banquet of bowel contents. The average person has about 1000 different types of bacteria in their gut, and about 3% of healthy adults have C.diff in that mix. The C.diff doesn't cause them any problems because its numbers are kept in check by the other gut bacteria. However treatment with broad spectrum antibiotics such as clindamycin, cephalosporins, ciprofloxacin and co-amoxiclav, can disrupt this happy community- killing off vast swathes of bacteria but crucially not the C.diff. Given free rein the C.diff multiplies rapidly and produces toxins which damage the gut. In some people this causes mild diarrhoea and abdominal pain, in others it can lead to torrential diarrhoea, perforation of the colon and death.
Traditional treatment includes stopping any broad spectrum antibiotics and possibly prescribing antibiotics which target the C.diff such as metronidazole or vancomycin. However with antibiotic use comes the risk of resistance. Moreover our current approach isn't entirely effective and about 22% of patients treated suffer a recurrence. This can result in a cycle of illness and hospital admission which is costly to the patient and the hospital.
So it's time to start thinking outside of the box. Cue the poo transplant. The thinking goes like this- if the cause of the problem is disruption to the normal community of gut bacteria, why not just pop those bacteria back in to crowd out the C.diff? Simples. Practically, the first step is to identify a donor, usually a close relative of the patient, and screen them for a range of infectious diseases and parasites. It's also advisable to make sure they haven't recently consumed anything the intended recipient is allergic to, before asking them to make their "donation". You then pop it in a household blender and blitz it down, adding saline or milk to achieve a slurry consistency. Next you need to strain your concoction to remove large materials- one medic in the UK uses coffee filters. Top tip. Then you're ready to administer it- about 25ml from above (e.g. via nasogastric tube), or 250ml from below.
Now, its important to note that poo transplants are still an experimental treatment. To date only small case studies have been carried out, but with 200 total reported cases, an average cure rate of 96% and no serious adverse events reported to date, it's worth carrying out a large trial to assess it thoroughly.
Poo transplants- arguably the ideal treatment for a cash strapped NHS. It's cheap, plentiful and it seems to work. Now to convince people to consume someone else's poo... Bottoms up!
FYI: This was first posted on my own blog.
Image Courtesy of Marcus007 at de.wikipedia [Public domain], from Wikimedia Commons
Ironically, it seems the health products with the least evidence are coming with the greatest assurances. A few years ago, a package holiday company advertised guaranteed sunny holidays in Queensland (Australia). The deal went something like this: if it rained on a certain percentage of your holiday days, you received a trip refund. An attractive drawcard indeed, but what the company failed to grasp was that the “Sunshine State” is very often anything but sunny.
This is especially so where I live, on the somewhat ironically named Sunshine Coast. We had 200 rainy days last year and well over 2 metres of rain, and that was before big floods in January. Unsurprisingly, the guaranteed sunny holiday offer was short-lived.
There are some things that really shouldn’t come with guarantees. The weather is one, health is another. Or so I thought…
“Those capsules you started me on last month for my nerve pain didn’t work. I tried them for a couple of weeks, but they didn’t do nothin'.”
“Perhaps you’d do better on a higher dose.”
“Nah, they made me feel kinda dizzy. I’d prefer to get my money back on these ones an’ try somethin’ different.”
“I can try you on something else, but there are no refunds available on the ones you’ve already used, I’m afraid.”
“But they cost me over 80 dollars!”
“Yes, I explained at the time that they are not subsidised by the government.”
“But they didn’t work! If I bought a toaster that didn’t work, I’d take it back and get me money back, no problem.”
“Medications are not appliances. They don’t work every time, but that doesn’t mean they’re faulty.”
“But what about natural products? I order herbs for me prostate and me heart every month and they come with a 100% satisfaction guarantee. You doctors say those things don’t really work so how come the sellers are willing to put their money where their mouths are?”
He decided to try a “natural” treatment next, confident of its likely effectiveness thanks to the satisfaction guarantee offered.
Last week I had a 38-year-old female requesting a medical certificate stating that her back pain was no better. The reason? She planned to take it to her physiotherapist and request a refund because the treatment hadn’t helped. Like the afflicted patient above, she didn’t accept that health-related products and services weren’t “cure guaranteed”.
“My thigh sculptor machine promised visible results in 60 days or my money back. Why aren’t physios held accountable too?”
Upon a quick Google search, I found that many “natural health” companies offer money-back guarantees, as do companies peddling skin products and gimmicky home exercise equipment. I even found a site offering guaranteed homeopathic immunisation. Hmmm…
In an information-rich, high-tech world, we are becoming less and less tolerant of uncertainty. Society wants perfect, predictable results — now! For all its advances, modern medicine cannot provide this and we don’t pretend otherwise. Ironically, it seems the health products with the least evidence are coming with the greatest assurances. A clever marketing ploy that patients seem to be buying into — literally and figuratively.
I think we all need to be reminded of Benjamin Franklin’s famous words: “In this world, nothing can be said to be certain except death and taxes.” We can’t really put guarantees on whether it will rain down on our holidays or on our health, and should retain a healthy scepticism towards those who attempt to do so.
This blog post has been adapted from a column first published in Australian Doctor http://www.australiandoctor.com.au/articles/11/0c070a11.asp
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/