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Foo20151013 2023 1eqve0g?1444774030
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LWW: Case Of The Month - May 2013

This month’s case is by Barbara J. Mroz, M.D. and Robin R. Preston, Ph.D., author of Lippincott’s Illustrated Reviews: .Physiology (ISBN: 9781451175677). For more information, or to purchase your copy, visit: http://tiny.cc/PrestonLIR, with 15% off using the discount code: MEDUCATION. The case below is followed by a choice of diagnostic tests. Select the one lettered selection that would be most helpful in diagnosing the patient’s condition. The Case A 54-year-old male 2 pack-per-day smoker presents to your office complaining of cough and shortness of breath (SOB). He reports chronic mild dyspnea on exertion with a daily cough productive of clear mucus. During the past week, his cough has increased in frequency and is now productive of frothy pink-tinged sputum; his dyspnea is worse and he is now short of breath sometimes even at rest. He has had difficulty breathing when lying flat in bed and has spent the past two nights sleeping upright in a recliner. On physical examination, he is a moderately obese male with a blood pressure of 180/80 mm Hg, pulse of 98, and respiratory rate of 22. His temperature is 98.6°F. He becomes winded from climbing onto the exam table. Auscultation of the lungs reveals bilateral wheezing and crackles in the lower posterior lung fields. There is pitting edema in the lower extremities extending up to the knees.  Question Which if the following tests would be most helpful in confirming the correct diagnosis? A. Spirometry B. Arterial blood gas C. Complete blood count D. B-type natriuretic peptide blood test E. Electrocardiogram Answer? The correct answer is B-type natriuretic peptide blood test. Uncomfortable breathing, or feeling short of breath, is a common medical complaint with multiple causes. When approaching a patient with dyspnea, it is helpful to remember that normal breathing requires both a respiratory system that facilitates gas exchange between blood and the atmosphere, and a cardiovascular system that transports O2 and CO¬2 between the lungs and tissues. Dysfunction in either system may cause dyspnea, and wheezing (or bronchospasm) may be present in both cardiac and pulmonary disease. In this patient, the presence of lower extremity edema and orthopnea (discomfort when lying flat) are both suggestive of congestive heart failure (CHF). Elevated blood pressure (systolic of 180) and a cough productive of frothy pink sputum may also be associated symptoms. While wheezing could also be caused by COPD (chronic obstructive pulmonary disease) in the setting of chronic tobacco use, the additional exam findings of lung crackles and edema plus systolic hypertension are all more consistent with CHF. What does the B-type natriuretic peptide blood test tell us? When the left ventricle (LV) fails to maintain cardiac output (CO) at levels required for adequate tissue perfusion, pathways are activated to increase renal fluid retention. A rising plasma volume increases LV preload and sustains CO via the Frank-Starling mechanism. Volume loading also stimulates cardiomyocytes to release atrial- (ANP) and B-type (BNP) natriuretic peptides. BNP has a longer half-life than ANP and provides a convenient marker for volume loading. Plasma BNP levels are measured using immunoassay; levels >100 pg/mL are suggestive of overload resulting in heart failure. How does heart failure cause dyspnea? Increasing venous pressure increases mean capillary hydrostatic pressure and promotes fluid filtration from the vasculature. Excess filtration from pulmonary capillaries causes fluid accumulation within the alveoli (pulmonary edema) and interferes with normal gas exchange, resulting in SOB. Physical signs and symptoms caused by high volume loading include: (1) Lung crackles, caused by fluid within alveoli (2) Orthopnea. Reclining increases pulmonary capillary hydrostatic pressure through gravitational effects, worsening dyspnea when lying flat. (3) Pitting dependent edema caused by filtration from systemic capillaries, an effect also influenced by position (causing edema in the lower legs as in our ambulatory patient or in dependent areas like the sacrum in a bedridden patient). What would an electrocardiogram show? Heart failure can result in LV hypertrophy and manifest as a left axis deviation on an electrocardiogram (ECG), but some patients in failure show a normal ECG. An ECG is not a useful diagnostic tool for dyspnea or CHF per se. Wouldn’t spirometry be more suitable for diagnosing the cause of dyspnea in a smoker? Simple spirometry will readily identify the presence of airflow limitation (obstruction) as a cause of dyspnea. It's a valuable test to perform in any smoker and can establish a diagnosis of chronic obstructive pulmonary disease (COPD) if abnormal. While this wheezing patient is an active smoker who could have airflow obstruction, the additional exam findings above point more to a diagnosis of CHF. What would an arterial blood gas show? An arterial blood gas measures arterial pH, PaCO¬2, and PaO2. While both CHF and COPD could cause derangements in the values measured, these abnormalities would not necessarily be diagnostic (e.g., a low PaO2 could be seen in both conditions, as could an elevated PaCO¬2). Would a complete blood count provide useful information? A complete blood count could prove useful if anemia is a suspected cause of dyspnea. Test result BNP was elevated (842 pg/mL), consistent with CHF. Diuretic treatment was initiated to help reduce volume overload and an afterload reducing agent was started to lower blood pressure and improve systolic function.  
Lippincott Williams & Wilkins
over 8 years ago
Foo20151013 2023 1vfzxkt?1444774033
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547

My Top 5 Tips to Use Social Media to Improve your Medical Education

Introduction Hello and welcome! I am finally back to blogging after having a brief hiatus in order to take my final exams. Whilst the trauma is still fresh in my mind, I would like to share with you the top 5 social media tips that helped me through the dark days of undergraduate medicine. Some of you may have already read my old essay on 'How Medical Students should interact with Social Media Networking Sites' and this document deals with some of the problems with professionalism surrounding the use of social media. This blog will not cover such issues, but will instead focus on how you can use social media to benefit your learning/ revision processes. Top Tip 1: YouTube For those of you who are unaware, YouTube is a video-sharing website. Sometimes the site is overlooked as a 'social media' resource but if you consider the simple definition of Social Networking Sites as 'those with user led content,' you can quickly see how YouTube definitely falls into the social media category. It wasn't until I got to University that I realised the potency of YouTube as an educational tool. It has a use at every stage of medical education and it is FREE. If you are still in your pre-clinical training then there are a wealth of videos that depict cellular processes and 3D anatomy - very useful content for the visual learner. For the clinical student, there are a number of OSCE demonstration videos that may be useful in honing your examination skills. There are also a number of presentations on clinical topics that have been uploaded, however, YouTube has no quality control measures for these videos (to my knowledge) so it may be best to subscribe to a more official source if you like to use podcasts/ uploaded presentations for your revision. Another reason YouTube comes in as my number 1 top tip is because I find it difficult to procrastinate whilst using the site. Sure, you can start looking up music and videos that have nothing to do with medicine but personally I find that having a little bit of music on in the background helps me work for longer periods, which is a definite bonus during the revision period. On the other hand, there are many that find YouTube difficult to harness due to the draw of funny videos and favourite Vloggers (Video Bloggers) that can distract the unwary from revision for hours on end. At the end of the day, YouTube was created for funny videos (predominantly of cats it seems) and not for medical education, and this should be kept in mind if you choose to use it as a tool for your learning. Top Tip 2: Facebook Yes, the dreaded Facebook comes in at number two for me. Facebook is by far and away my largest source of procrastination when it comes to writing / working / revising or learning. It is a true devil in disguise, however, there are some very useful features for those who like to work in groups during their revision... For example, during the last six months I have organised a small revision group through Facebook. We set up a 'private page' and each week I would post what topics would be covered in the weeks session. Due to the nature of Facebook, people were obviously able to reply to my posts with suggestions for future topics etc. We were also able to upload photos of useful resources that one or more of us had seen in a tutorial in which the other students hadn't been able to attend. And most importantly, we were able to upload revision notes for each other via the Facebook 'files' tab. This last feature was invaluable for sharing basic notes between a few close colleagues. However, for proper file sharing I strongly recommend the file sharing service 'Dropbox,' which provides free storage for your documents and the ability to access files from any computer or device with internet. Coming back to Facebook, my final thoughts are: if you don't like group work or seeing what your colleagues are doing via their statuses or private messages then it probably isn't a useful resource for you. If you have the motivation (unlike myself) to freeze your Facebook account I can imagine you would end up procrastinating far less (or you'll start procrastinating on something else entirely!). Top Tip 3: Twitter Twitter is a microblogging site. This means that users upload microblogs or 'Tweets' containing useful information they have found on the internet or read in other people's tweets. Twitter's utility as an educational resource is directly related to the 'type' of people you follow. For example, I use Twitter primarily to connect with other people interested in social media, art & medicine and medical education. This means my home screen on twitter is full of people posting about these topics, which I find useful. Alternatively, I could have used my Twitter account to 'follow' all the same friends I 'follow' on Facebook. This would have meant my Twitter home page would have felt like a fast-paced, less detailed version of my Facebook feed just with more hashtags and acronyms - not very useful for finding educational resources. With this in mind, consider setting up two twitter accounts to tease apart the useful tweets about the latest clinical podcast from the useless tweets about what your second cousin once removed just had for lunch. A friend suggested to me that if you really get into twitter it is also possible to use one account and 'group' your followers so that you can see different 'types' of tweets at different times. This seems like a good way to filter the information you are reading, as long as you can figure out how to set up the filters in the first place. Like all Social Media Sites, Twitter gets its fair share of bad press re. online professionalism and its tendency to lure users into hours of procrastination. So again, use with caution. Top Tip 4: Meducation It would not be right to write this blog and not include Meducation in the line-up. Meducation is the first website that I have personally come across where users (students, doctors etc) upload and share information (i.e. the very soul of what social networking is about) that is principally about medicine and nothing else. I'm sure there may be other similar sites out there, but the execution of this site is marvellous and that is what has set it apart from its competitors and lead to its rapid growth (especially over the last two years, whilst i've been aware of the site). When I say 'execution,' I mean the user interface (which is clean and simple), the free resources (giving a taste of the quality of material) and the premium resources (which lecture on a variety of interesting clinical topics rather than sticking to the bread and butter topics 24/7). One of my favourite features of Meducation is the ability to ask 'Questions' to other users. These questions are usually asked by people wishing to improve niche knowledge and so being able to answer a question always feels like a great achievement. Both the questions and answers are mostly always interesting, however the odd question does slip through the net where it appears the person asking the question might have skipped the 'quick google search' phase of working through a tough topic. Meducation harnesses social networking in an environment almost free from professionalism and procrastination issues. Therefore, I cannot critique the site from this angle. Instead, I have decided to highlight the 'Exam Room' feature of the website. The 'Exam Room' lets the user take a 'mock exam' using what I can only assume is a database of questions crafted by the Meducation team themselves (+/- submissions from their user base). However, it is in my opinion that this feature is not up to scratch with the level and volume of questions provided by the competitors in this niche market. I feel wrong making this criticism whilst blogging on Meducation and therefore I will not list or link the competitors I am thinking of here, but they will be available via my unaffiliated blog (Occipital Designs). I hope the Meducation team realise that I make this observation because I feel that with a little work their question database could be improved to the point where it is even better than other sites AND there would also be all the other resources Meducation has to offer. This would make Meducation a truly phenomenal resource. Top Tip 5: Blogging Blogging itself is very useful. Perhaps not necessarily for the learning / revision process but for honing the reflective process. Reflective writing is a large component of undergrad medical education and is disliked by many students for a number of reasons, not least of which is because many find some difficulty in putting their thoughts and feelings on to paper and would much prefer to write with the stiffness and stasis of academic prose. Blogging is great practice for breaking away from essay-writing mode and if you write about something you enjoy you will quickly find you are easily incorporating your own personal thoughts and feelings into your writing (as I have done throughout this blog). This is a very organic form of reflection and I believe it can greatly improve your writing when you come to write those inevitable reflective reports. Conclusion Thanks for reading this blog. I hope I have at least highlighted some yet unharnessed aspects of the sites and resources people already commonly use. Please stay tuned in the next week or two for more on social media in medicine. I am working together with a colleague to produce 'Guidelines for Social Media in Medicine,' in light of the recent material on the subject by the General Medical Council. Please feel free to comment below if you feel you have a Top Tip that I haven't included! LARF Twitter Occipital Designs My Blog As always, any views expressed here are mine alone and are not representative of any organisation. A Worthy Cause... Also, on a separate note: check out Anatomy For Life - a charity medical art auction raising money for organ donation. Main Site Facebook Twitter  
Dr. Luke Farmery
over 8 years ago
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3896

An amazing incident

It's been a while since I've added any thoughts to this blog. In that time I have finished my Obs/Gynae placement, I have spent a week on labour ward, and done my first week of my 4th year surgical placement. All the while cramming in revision between various activities and general staying alive measures. This, I feel, is how most people who are sitting their final written exams are spending their time, so I don't feel so alone. I just want to bring to the attention one amazing incident that happened on my labour ward week. I was on a night shift, there wasn't a lot going on. Absolutely everyone was knackered, the registrar who'd been on nights for the past week was just chatting to me. I have never seen someone look so tired. The emergency alarm went off and a lady had a cord prolapse, which is an obstetric emergency with a high foetal mortality rate. Now I think it's amazing that the doctor went from nearly falling asleep to switched on 'surgical-mode' in an instant, successfully performed the C-section, delivering the baby in about a minute, then went back to being absolutely knackered and let the SHO close up the wound. It just really impressed me and I felt it was something worth sharing. Actually I was incredibly surprised that I enjoyed Obs/Gynae. Women's health was a placement I was dreading, it was my last major knowledge gap and I didn't have a clue what it was going to be like. If my tutor for the block does read this, thank you for all your help and getting me involved in everything. I would encourage other students who are going into it and feeling any level of apprehension to just throw yourselves into it and give 110% effort. It is a great placement for practicing transferable skills (this is important to remember, especially if you don't have any desire to go into it you CAN transfer and practice skills from elsewhere!) and getting heavily involved in patient care. Also I'd like to point out the Mother and Baby were fine :)  
Conrad Hayes
over 8 years ago
Foo20151013 2023 1nuvntv?1444774080
2
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
Foo20151013 2023 1juzlhe?1444774136
2
330

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
Foo20151013 2023 13vodzp?1444774194
9
174

Is ADHD a difficult diagnosis?

In a recent article in the BMJ the author wonders about the reasons beyond the rising trend diagnosing Attention Deficit Hyperactivity Disorder (ADHD). The article attempts to infer reasons for this. One possible reason was that the diagnostic criteria especially DSM may seem for some to be more inclusive than ICD-10. The speculation may explain the rise of the diagnosis where DSM is used officially or have an influence. In a rather constructive way, an alternative to rushing to diagnosis is offered and discussed in some details. The tentative deduction that the Diagnostic Statistical Manual (DSM) may be one of the causes of rising diagnosis, due to raising the cut-off of age, and widening the inclusion criteria, as opposed to International Classification of Diseases, 10th revision (ICD-10), captured my attention. On reading the ICD-10 diagnostic criteria for research (DCR) and DSM-5 diagnostic criteria, I found them quite similar in most aspects, even the phraseology that starts with 'Often' in many diagnostic criteria, they seem to differ a bit in age. In a way both classification, are attempting to describe the disorder, however, it sounds as if someone is trying to explain a person's behaviour to you, however, this is not a substitute to direct clinical learning, and observing the behaviour, as if the missing sentence is 'when you see the person, it will be clearer'. El-Islam agrees with the notion that DSM-5 seems to be a bit more inclusive than ICD-10. A colleague of mine who is a child psychiatrist and she is doing her MSc. thesis in ADHD told me, that DSM-5 seems to be a substantial improvement as compared to its predecessor. The criteria - to her - though apparently are more inclusive, they are more descriptive with many examples, and she infers that this will payback in the reliability of the diagnosis. She hopes gene research can yield in biological tests for implicated genes and neurotransmitters in ADHD e.g. DRD4, DAT, gene 5,6,11 etc. One child psychiatrist, regretted the fact that misdiagnosis and under-diagnoses, deprive the patient from one of the most effective treatments in psychiatry. It is hoped the nearest forthcoming diagnostic classification (ICD-11), will address the issue of the diagnosis from a different perspective, or else converge with DSM-5 to provide coherence and a generalised newer standard of practice. The grading of ADHD into mild, moderate, and severe seem to blur the border between disorder and non-disorder, however, this quasi-dimensional approach seems realistic, it does not translate yet directly in differences in treatment approaches as with the case of mild, moderate, severe, and severe depression with psychotic symptoms, or intellectual disability. The author states that one counter argument could be that child psychiatrists are better at diagnosing the disorder. I wonder if this is a reflection of a rising trend of a disorder. If ADHD is compared to catatonia, it is generally agreed that catatonia is less diagnosed now, may be the epidemiology of ADHD is not artefact, and that we may need to look beyond the diagnosis to learn for example from environmental factors. Another issue is that there seems to be significant epidemiological differences in the rates of diagnosis across cultures. This may give rise to whether ADHD can be classified as a culture-bound syndrome, or whether it is influenced by culture like anorexia nervosa, or it may be just because of the raising awareness to such disorders. Historically, it is difficult to attempt to pinpoint what would be the closest predecessor to ADHD. For schizophrenia and mania, older terms may have included insanity, for depression it was probably melancholia, there are other terms that still reside in contemporary culture e.g. hypochondriasis, hysteria, paranoia etc. Though, it would be too simplistic to believe that what is meant by these terms was exactly what ancient cultures meant by them, but, they are not too far. ADHD seems to lack such historical underpinning. Crichton described a disorder he refers to as 'mental restlessness'. Still who is most often credited with the first description of ADHD, in his 1902 address to the Royal College of Physicians. Still describes a number of patients with problems in self-regulation or, as he then termed it, 'moral control' (De Zeeuw et al, 2011). The costs and the risks related to over-diagnosis, ring a warning bell, to enhance scrutiny in the diagnosis, due to subsequent stigma, costs, and lowered societal expectations. They all seem to stem from the consequences of the methodology of diagnosis. The article touches in an important part in the psychiatric diagnosis, and classifications, which is the subjective nature of disorders. The enormous effort done in DSM-5 & ICD-10 reflect the best available evidence, but in order to eliminate the subjective nature of illness, a biological test seems to be the only definitive answer, to ADHD in particular and psychiatry in general. Given that ADHD is an illness and that it is a homogeneous thing; developments in gene studies would seem to hold the key to understanding our current status of diagnosis. The suggested approach for using psychosocial interventions and then administering treatment after making sure that it is a must, seems quite reasonable. El-Islam, agrees that in ADHD caution prior to giving treatment is a recommended course of action. Another consultant child psychiatrist mentioned that one hour might not be enough to reach a comfortable diagnosis of ADHD. It may take up to 90 minutes, to become confident in a clinical diagnosis, in addition to commonly used rating scales. Though on the other hand, families and carers may hypothetically raise the issue of time urgency due to scholastic pressure. In a discussion with Dr Hend Badawy, a colleague child psychiatrist; she stated the following with regards to her own experience, and her opinion about the article. The following is written with her consent. 'ADHD is a clinically based diagnosis that has three core symptoms, inattention, hyperactivity and impulsivity in - at least - two settings. The risk of over-diagnosis in ADHD is one of the potentially problematic, however, the risk of over-diagnosis is not confined to ADHD, it can be present in other psychiatric diagnoses, as they rely on subjective experience of the patient and doctor's interviewing skills. In ADHD in particular the risk of under-diagnosis is even more problematic. An undiagnosed child who has ADHD may suffer various complications as moral stigma of 'lack of conduct' due to impuslivity and hyperactivity, poor scholastic achievement, potential alienation, ostracization and even exclusion by peer due to perceived 'difference', consequent feelings of low self esteem and potential revengeful attitude on the side of the child. An end result, would be development of substance use disorders, or involvement in dissocial behaviours. The answer to the problem of over-diagnosis/under-diagnosis can be helped by an initial step of raising public awareness of people about ADHD, including campaigns to families, carers, teachers and general practitioners. These campaigns would help people identify children with possible ADHD. The only risk is that child psychiatrists may be met with children who their parents believe they might have the disorder while they do not. In a way, raising awareness can serve as a sensitive laboratory investigation. The next step is that the child psychiatrist should scrutinise children carefully. The risk of over-diagnosis can be limited via routine using of checklists, to make sure that the practice is standardised and that every child was diagnosed properly according to the diagnostic criteria. The use of proper scales as Strengths and Difficulties Questionnaire (SDQ) in its two forms (for parents SDQ-P and for teachers SDQ-T) which enables the assessor to learn about the behaviour of the child in two different settings. Conner's scale can help give better understanding of the magnitude of the problem. Though some people may voice criticism as they are mainly filled out by parents and teachers, they are the best tools available at hands. Training on diagnosis, regular auditing and restricting doctors to a standard practice of ensuring that the child and carer have been interviewed thoroughly can help minimise the risk of over-diagnosis. The issue does not stop by diagnosis, follow-up can give a clue whether the child is improving on the management plan or not. The effects and side effects of treatments as methylphenidate should be monitored regularly, including regular measurement height and weight, paying attention to nausea, poor appetite, and even the rare side effects which are usually missed. More restrictions and supervision on the medication may have an indirect effect on enhancing the diagnostic assessment. To summarise, the public advocacy does not increase the risk of over-diagnosis, as asking about suicidal ideas does not increase its risk. The awareness may help people learn more and empower them and will lead to more acceptance of the diagnosed child in the community. Even the potential risk of having more case loads for doctors to assess for ADHD may help give more exposure of cases, and reaching more meaningful epidemiological finding. From my experience, it is quite unlikely to have marked over-representation of children who the families suspect ADHD without sufficient evidence. ADHD remains a clinical diagnosis, and it is unlikely that it will be replaced by a biological marker or an imaging test in the near future. After all, even if there will be objective diagnostic tests, without clinical diagnostic interviewing their value will be doubtful. It is ironic that the two most effective treatments in psychiatry methylphenidate and Electroconvulsive Therapy (ECT) are the two most controversial treatments. May be because both were used prior to having a full understanding of their mechanism of action, may be because, on the outset both seem unusual, electricity through the head, and a stimulant for hyperactive children. Authored by E. Sidhom, H. Badawy DISCLAIMER The original post is on The BMJ doc2doc website at http://doc2doc.bmj.com/blogs/clinicalblog/#plckblogpage=BlogPost&plckpostid=Blog%3A15d27772-5908-4452-9411-8eef67833d66Post%3Acb6e5828-8280-4989-9128-d41789ed76ee BMJ Article: (http://www.bmj.com/content/347/bmj.f6172). Bibliography Badawy, H., personal communication, 2013 El-Islam, M.F., personal communication, 2013 Thomas R, Mitchell GK, B.L., Attention-deficit/hyperactivity disorder: are we helping or harming?, British Medical Journal, 2013, Vol. 5(347) De Zeeuw P., Mandl R.C.W., Hulshoff-Pol H.E., et al., Decreased frontostriatal microstructural organization in ADHD. Human Brain Mapping. DOI: 10.1002/hbm.21335, 2011) Diagnostic Statistical Manual 5, American Psychiatric Association, 2013 Diagnostic Statistical Manual-IV, American Psychiatric Association, 1994 International Classification of Diseases, World Health Organization, 1992  
Dr Emad Sidhom
almost 8 years ago
Foo20151013 2023 1u6up6r?1444774235
4
137

Keep on Truckin’

Shattered. Third consecutive day of on-calls at the birth centre. I’m afraid I have little to show for it. The logbook hangs limply at my side, the pages where my name is printed await signatures; surrogate markers of new found skills. Half asleep I slump against the wall and cast my mind back to the peripheral attachment from which I have not long returned. The old-school consultant’s mutterings are still fresh: “Medical education was different back then you see....you are dealt a tough hand nowadays.” I quite agree, it is Saturday. Might it be said the clinical apprenticeship we know today is a shadow of its former self? Medical school was more a way of life, students lived in the hospital, they even had their laundry done for them. Incredulous, I could scarcely restrain a chuckle at the consultant’s stories of delivering babies while merely a student and how the dishing out of “character building” grillings by their seniors was de rigeur. Seldom am I plied with any such questions. Teaching is a rare commodity at times. Hours on a busy ward can bear little return. Frequently do I hear students barely a rotation into their clinical years, bemoan a woeful lack of attention. All recollection of the starry-eyed second year, romanced by anything remotely clinical, has evaporated like the morning dew. “Make way, make way!...” cries a thin voice from the far reaches of the centre. A squeal of bed wheels. The newly crowned obs & gynae reg drives past the midwife station executing an impressive Tokyo drift into the corridor where I stand. Through the theatre doors opposite me he vanishes. I follow. Major postpartum haemorrhage. A bevy of scrubs flit across the room in a live performance of the RCOG guidelines for obstetric haemorrhage. They resuscitate the women on the table, her clammy body flat across the carmine blotched sheets. ABC, intravenous access and a rapid two litres of Hartmann’s later, the bleeding can not be arrested by rubbing up contraction. Pharmacological measures: syntocinon and ergometrine preparations do not staunch the flow. Blood pressure still falling, I watch the consciousness slowly ebb from the woman’s eyes. Then in a tone of voice, seemingly beyond his years, the reversely gowned anaesthetist clocks my badge and says, “Fetch me the carboprost.” I could feel an exercise in futility sprout as I gave an empty but ingratiating nod. “It’s hemabate....in the fridge” he continues. In the anaesthetic room I find the fridge and rummage blindly through. Thirty seconds later having discovered nothing but my general inadequacy, I crawl back into theatre. I was as good as useless though to my surprise the anaesthetist disappeared and returned with a vial. Handing me both it and a prepped syringe, he instructs me to inject intramuscularly into the woman’s thigh. The most common cause of postpartum haemorrhage is uterine atony. Prostaglandin analogues like carboprost promote coordinated contractions of the body of the pregnant uterus. Constriction of the vessels by myometrial fibres within the uterine walls achieves postpartum haemostasis. This textbook definition does not quite echo my thoughts as I gingerly approach the operating table. Alarmingly I am unaware that aside from the usual side effects of the drug in my syringe; the nausea and vomiting, should the needle stray into a nearby vessel and its contents escape into the circulation, cardiovascular collapse might be the unfortunate result. Suddenly the anaesthetist’s dour expression as I inject now assumes some meaning. What a relief to see the woman’s vitals begin to stabilise. As we wheel her into the recovery bay, the anaesthetist unleashes an onslaught of questions. Keen to redeem some lost pride, I can to varying degrees, resurrect long buried preclinical knowledge: basic pharmacology, transfusion-related complications, the importance of fresh frozen plasma. Although, the final threat of drawing the clotting cascade from memory is a challenge too far. Before long I am already being demonstrated the techniques of regional analgesia, why you should always aspirate before injecting lidocaine and thrust headlong into managing the most common adverse effects of epidurals. To have thought I had been ready to retire home early on this Saturday morning had serendipity not played its part. A little persistence would have been just as effective. It’s the quality so easily overlooked in these apparently austere times of medical education. And not a single logbook signature gained. Oh the shame! This blog post is a reproduction of an article published in the Medical Student Newspaper, February 2014 issue.  
James Wong
over 7 years ago
%3fr=0
2
121

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
%3fr=0
2
138

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
Www.bmj
0
13

Impact of smoking and smoking cessation on cardiovascular events and mortality among older adults: meta-analysis of individual participant data from prospective cohort studies of the CHANCES consortium

Objective To investigate the impact of smoking and smoking cessation on cardiovascular mortality, acute coronary events, and stroke events in people aged 60 and older, and to calculate and report risk advancement periods for cardiovascular mortality in addition to traditional epidemiological relative risk measures.  
feeds.bmj.com
over 6 years ago
Static.www.bmj
0
13

Randomised controlled trials: understanding effect sizes

Researchers assessed whether a multimodal group exercise intervention had physiological, functional, and emotional benefits for patients with cancer. A randomised controlled trial was performed. The intervention was supervised exercise comprising high intensity cardiovascular and resistance training, relaxation and body awareness training, and massage. The intervention was delivered for nine hours weekly for six weeks in addition to conventional care. The control treatment was conventional care alone. Participants were 269 patients with cancer undergoing adjuvant chemotherapy or treatment for advanced disease. The primary outcome was fatigue at six weeks as assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30); scores range from 0 to 100 and higher scores represent higher levels of fatigue. Secondary outcomes included measures of physical capacity, general wellbeing, physical activity, and quality of life.1  
feeds.bmj.com
over 6 years ago
Www.bmj
0
8

Reforming the Cancer Drug Fund

The Cancer Drug Fund was originally conceived as a temporary measure, until value based pricing for drugs was introduced, to give NHS cancer patients access to drugs not approved by NICE. Spending on these drugs rose from less than the £50m (€63m; $79m) budgeted for the first year in 2010-11 to well over £200m in 2013-14, and the budget for the scheme—now extended for a further two years—will reach £280m by 2016.1 The recent changes to the fund recognise the impossibility, within any sensible budget limit, of providing all the new cancer drugs that offer possible benefit to patients. More radical changes are needed to the working of the fund, given the failure to introduce value based pricing, so that it deals with the underlying problem of inadequate information on the effectiveness and cost effectiveness of new cancer drugs when used in the NHS.  
feeds.bmj.com
over 6 years ago
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41

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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0
6

Good bone, bad bone

Scientists explore a new parameter of bone quality that measures strength instead of...  
medicalnewstoday.com
over 6 years ago
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1

Study links brain anatomy, academic achievement, and family income

Many years of research have shown that for students from lower-income families, standardized test scores and other measures of academic success tend to lag behind those of wealthier students.  
medicalnewstoday.com
over 6 years ago
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Pathway known to suppress tumors may also reduce burden of neurodegenerative diseases

Findings shed light on quality control measures that help keep cells healthy and go awry in diseases like ALSA molecular pathway known to suppress tumors appears to...  
medicalnewstoday.com
over 6 years ago