Organ Donation (Wales)

A BBC report last week (http://www.bbc.co.uk/news/uk-wales-politics-20583179) detailed the plans by the Welsh Assembly to bring in an opt-out scheme for organ donation instead of the current opt-in scheme. This means that if you die and you have not stated whether you would or would not like your organs to be donated then you will be taken to be a willing organ donor.

"If passed by the Welsh Assembly it could come into force by 2015" (as above). This move would mean that in the situation where your wishes have not been stated your family would not be able to decide against you having your organs donated as it was never changed in your lifetime.

"The main reason families stopped organs being taken was because they did not know what their relatives' wishes were." Therefore it has been encouraged that these conversations are had at home to discuss the idea of 'presumed consent' and come to a decision on whether to opt-out of the organ donation process.

However, although the general thought is that it will increase the numbers of organ donors in Wales; "there are lower rates of organ donation in some countries that have already implemented presumed consent so it's important that this scheme is not seen as the only way to increase donation rates." This enforces the argument that this issue needs to be openly talked about and publicity increased in Wales but also across the whole of the United Kingdom.

A BMJ article (http://www.bmj.com/content/340/bmj.c2188) published in 2010 says that "in practice, even when people have expressed their willingness to donate by either carrying a donor card or, since 1994, signing up to the computerised NHS Organ Donor Register, their relatives are always asked for consent and relatives’ refusal overrides the deceased would-be donor’s decision." This is clearly wrong as it goes against the wishes of the deceased person and it is the hope that this new law, as well as brining in a presumed consent scheme, will act to stop the overriding that occurs by the relatives of the deceased.

The BMJ article also says that "in 2008, Prime Minister Gordon Brown asked an Organ Donor Taskforce to consider the potential effect of an opt-out system for organ donation in the UK." The Taskforce then did research and collected data on "the effect of presumed consent on organ donation rates" but contrary to the data that they collected they "recommended no change to current policy but renewed effort to increase the number of donors opting in."

In their report (http://tinyurl.com/32y8ktp) they set out 14 recommendations that "taken together, would create a structured and systematic approach to organ donation in the UK" but they also state that "the wishes of the potential donor or their family are ascertained and respected." But as I mentioned earlier this is where the issues are coming in, the overriding by the family of the potential donor.

What really needs to be focussed on are checkpoints 4.47-4.50 of the report under the heading ('public recognition and promotion of donation'). These underline the issues of publicity of organ donation, the lack of donation amongst certain communities, the risks that some communities face and the necessity of people from that same community donating organs.

However the most shocking statistic (as of 2008 when this report was created) is that "it is still the case that nationally, the relatives of 40% of potential donors refuse consent for donation." Therefore this Bill tabled by the Welsh Assembly is trying to dramatically decrease this percentage and make sure that people think about the huge benefits to other people's lives (sometimes saving lives) by giving their organs after death.




 

ottobock.

"In developed nations, stroke is the most frequent cause of long-term disabilities. Each year 150,000 people in the UK suffer from a stroke; with a dramatic increase expected over the next few years due to current demographic developments and the ageing of the so-called baby boomers." (http://tinyurl.com/cxv878r)

Otto Bock was a man who "founded a company to supply thousands of war veterans with prostheses and orthopaedic products" (http://tinyurl.com/bmxt89e). His company now have a huge range of products aimed at those affected by strokes and aiding in "reintegrating patients into their professional and social environments" (http://tinyurl.com/cxv878r).
 

Statistics from the Otto Bock website state that after suffering a stroke "one quarter of all people are still bound to a wheelchair; two thirds of all people have restriction of the ability to walk. Approximately one-third of all people complain of a total loss of arm functionality, and daily dexterity is significantly impaired in a further 50% of cases" (http://tinyurl.com/cxv878r). These statistics show the huge effects on daily life of a stroke, which is itself a life threatening medical condition.

"Like all organs, the brain needs the oxygen and nutrients provided by blood to function properly. If the supply of blood is restricted or stopped, brain cells begin to die. This can lead to brain damage and possibly death" (http://tinyurl.com/3py5b32). Strokes can be caused by a blood clot in the brain which leads to the blood supply being stopped and thus oxygen supply being reduced. This is known as "ischaemic (accounting for over 80% of all cases)" (http://tinyurl.com/3py5b32). The other main cause of a stroke is "haemorrhagic: a weakened blood vessel supplying the brain bursts and causes brain damage" (http://tinyurl.com/3py5b32).

"There is also a related condition known as a 'transient ischaemic attack' (TIA), where the supply of blood to the brain is temporarily interrupted, causing a 'mini-stroke'" (http://tinyurl.com/3py5b32).

Ischaemic strokes are caused by the build up of deposits, plaques, on the blood vessel walls causing an increased blood pressure, reduced space in the vessel and also stiffening of the walls. These factors later result in a blockage when a plaque breaks off and gets stuck in the blood vessel becoming fully blocked and causing a loss of blood supply and thus oxygen supply to the brain.

The risk of a stroke occurring can however be reduced "through a healthy lifestyle [such as] consuming a healthy diet, taking regular exercise, drinking alcohol in moderation and not smoking. Lowering high blood pressure and cholesterol levels with medication also lowers the risk of stroke substantially" (http://tinyurl.com/3py5b32).

Treatment of a stroke most often comes in the form of medical drugs for example in the case of ischaemic strokes "using a 'clot-busting' medicine called alteplase, dissolves blood clots. A regular dose of aspirin (an anti-platelet medication) [will also be administered] as this makes the cells in the platelets in the blood, less sticky, reducing the chances of further blood clots occurring" (http://tinyurl.com/d25mo6l). Other drugs are used, known as anticoagulants which also reduce the chances of blood clots by thinning the blood.

Blood cholesterol levels may also be an issue, if the LDL (low-density lipoprotein) cholesterol ('bad cholesterol') count is high then this could be part of the cause of the stroke as they stick to the blood vessel wall and form the plaques (restricting blood flow and reducing the elasticity of the blood vessel walls). "Statins reduce the level of cholesterol in your blood by blocking an enzyme (chemical) in the liver that produces cholesterol" (http://tinyurl.com/d25mo6l).

In terms of treatment for haemorrhagic strokes "emergency surgery is often needed to remove any blood from the brain and repair any burst blood vessels. This is usually done using a surgical procedure known as a craniotomy.

During a craniotomy, a small section of the skull is cut away to allow the surgeon access to the cause of the bleeding. The surgeon will repair any damaged blood vessels and ensure there are no blood clots present that may restrict the blood flow to the brain. After the bleeding has been stopped, the piece of bone removed from the skull is replaced.

Following a craniotomy, the patient may have to be placed on a ventilator. A ventilator is a machine that assists someone with their breathing. It gives the body time to recover by taking over its normal responsibilities, such as breathing, and it will help control any swelling in the brain.

The patient will also be given medicines, such as ACE inhibitors, to lower blood pressure and prevent further strokes from occurring." (http://tinyurl.com/d25mo6l).

This type of surgery is extremely dangerous and the risks and benefits to the patient must be assessed before any surgery takes place.

THIS IS A SURGICAL VIDEO
This video shows a procedure not for a craniotomy for stroke but for a tumour. (http://www.youtube.com/watch?v=CoDT9o01L08)

This brochure shows the product range for Otto Bock healthcare and displays the huge innovation in their products. http://www.ottobock.co.uk/cps/rde/xbcr/ob_uk_en/799_Stroke_Product_brochure_A4_FINALJAN.pdf

More information on stroke and the heart can be found at the websites in this post but also on the British Heart Foundation website at http://www.bhf.org.uk/#&panel1-2.





 

The Thumb

Reason for this bizarre topic.....?! I may have cracked/damaged the ligaments in my thumb and was wondering what could be the consequence of dislocated/breaking my thumb!

-Thumb Dislocation
"A dislocation is a separation of two bones where they meet at a joint. Joints are areas where two bones come together" (http://www.nlm.nih.gov/medlineplus/ency/article/000014.htm). In terms of the anatomy of the thumb, look below.



http://www.ski-injury.com/specific-injuries/thumb
 

Therefore a dislocation in the case of a thumb concerns the metacarpal bone and the bone below it or the metacarpal with the proximal phalanx. "In the case of a serious dislocation, the joint becomes unstable, and the function of the thumb is definitely altered. The joint of the thumb, between the metacarpal and the first phalanx, has two major ligaments (ulnar collateral ligament and dorsal collateral ligament) which may suffer from trauma and even rupture" (http://www.hand-clinic.com/pop_emergency/thumb_dislocation.htm).

-Treatment of a thumb dislocation.
Non-surgical treatment such as "orthopaedic treatment: immobilisation with a fixed plaster cast or resin to block the metacarpophalangeal joint of the thumb, with the wrist released. This immobilisation should be kept for three weeks. After removal of the immobilisation, the patient will gradually regain thumb motion, and should take care for two months. A few rehabilitation sessions [may] be needed" (http://tinyurl.com/btmf36n).

However surgical treatment may be necessary depending on the extent of damage;

As can be seen from the diagram above (http://tinyurl.com/btmf36n) an incision can be made (on the inside of the thumb in this case) and a screw can be put in place to hold the two bones together.



-Broken Thumbs (Fracture)
"Broken thumb injuries are highly debilitating and a common cause of thumb pain and hand swelling" (http://www.orthoped.org/broken-thumb-injury-symptoms-and-treatment.html).

"The thumb, being a vital part of the hand, dictates the necessity to achieve a nearly perfect reconstruction of a broken thumb" (http://tinyurl.com/d5eod44).  The options involve  "thumb joint replacement, and artificial thumb reconstruction" (http://tinyurl.com/d5eod44) or as we saw above, using 'orthopaedic bone screws'. The impact of this surgery can be seen in the patient below.



However "the common protocol, is to bring the broken ends of the bones or ligaments to their natural alignment as much as possible, with or without surgery. The next step is to keep them immobilised in this position until the fusion of the broken ends" (http://tinyurl.com/d5eod44).

I am very glad that I have neither of these but I do have the pain symptoms and swelling usually associated with both. the swelling is a "delayed symptom of thumb injury due to insufficient space in the thumb to accommodate the inflammatory fluids" (http://tinyurl.com/d5eod44).
 

Polypill

Student BMJ- The polypill: a magic bullet against cardiovascular disease?(http://student.bmj.com/student/view-article.html?id=sbmj.e6386)

The polypill is "a pill containing a number of medicines that all treat the same condition" (Oxford Dictionary) from 'poly', meaning many.

 

"Cardiovascular disease remains the leading cause of mortality in developed countries, and has been described as a “global epidemic.” In 2003, Wald and Law proposed a new polypill: six drugs combined into one tablet that would work to reduce cardiovascular risk. They proposed the polypill as a way of targeting modifiable cardiovascular risk factors, both for adults with pre-existing cardiovascular disease (secondary prevention) and, more controversially, for adults over 55 years old without cardiovascular disease (primary prevention)."

"Wald and Law argued that over 80% of myocardial infarctions and strokes could be prevented if this strategy was adopted. The polypill would contain six ingredients: three blood pressure lowering drugs (a thiazide diuretic, a β blocker, and an angiotension converting enzyme (ACE) inhibitor), a statin, aspirin, and folic acid. Their idea ignited great debate in the medical community regarding its potential to reduce the global burden of cardiovascular disease" (BMJ reference above).

How well does the pill work?
"By using the right combination of active medicines, the Polypill can reduce the risk of a heart attack or stroke by two thirds. The key objectives of the medicines are to reduce blood pressure and cholesterol."

"In July 2012, the results of a Polypill trial conducted at the Wolfson Institute of Preventive Medicine, were published. The trial was conducted among individuals aged 50 and over without a history of cardiovascular disease and without selection on the basis of blood pressure or cholesterol. The reductions in blood pressure and cholesterol were recorded and compared with those predicted from published estimates of the effects of the individual components.
84 participants took a single Polypill (containing amlodipine, losartan, hydrochlorothiazide and simvastatin) each evening for 12 weeks and a placebo each evening for 12 weeks in random sequence (a randomised cross-over trial).

In this trial, participants and doctors did not know whether the Polypill or the placebo was taken during each period (double-blind). The reduction in blood pressure and cholesterol at the end of the Polypill period was compared with the levels at the end of the placebo period. The allocation of the placebo or the Polypill is coded, and is only revealed at the end of the study. This study design provides more precise and accurate estimates of the blood pressure and cholesterol lowering effects of the Polypill than other kinds of study. Systolic blood pressure was reduced by an average of 17.9 mmHg (12%) on the Polypill, diastolic blood pressure by 9.8 mmHg (11%), and LDL cholesterol by 1.4 mmol/L (39%). The results were almost identical to those predicted; 18.4 mmHg, 9.7 mmHg, and 1.4 mmol/L respectively" (https://www.polypill.com/evidence-for-polypill.html).

The two graphs below (https://www.polypill.com/evidence-for-polypill.html) show the effect that the polypill has on diastolic blood pressure and cholesterol respectively both lowering to almost the levl of a 20 year old.

 

Whilst showing a reduction in diastolic blood pressure and LDL (low density lipoproteins) cholesterol in the graphs, this considerably lowers the risk of coronary heart disease and also the risks of stroke (http://tinyurl.com/9ykwvnp and http://tinyurl.com/9uvkr6z).

 

"If people took the polypill from age 50, an estimated 28% would benefit by avoiding or delaying a heart attack or stroke during their lifetime" (http://www.bbc.co.uk/news/health-18883163).
 

However "The British Heart Foundation called for more research and said pills were not a substitute for a living a healthy life." (http://www.bbc.co.uk/news/health-18883163). This study was also a very small study of just "84" (BBC) over 50 year olds, a much larger study would have to be carried out to provide solid data and evidence to become valid and broadly used.



 

Medical Mash Up

BBC- NHS and US health system 'should share ideas' (http://www.bbc.co.uk/news/health-19913437)

Before reading the article you would think that it was a good suggestion to share ideas and learn from different mistakes made. However to compare the two nations proves difficult in the size of the population and also their distribution between built up and rural areas.

The Telegraph Online website shows the population densities of the UK: http://tinyurl.com/cq5gh2o and the USA: http://tinyurl.com/9a2xdf4 with the USA clearly showing that it has large areas of very low population density compard to the UK which has a very high population density across the whole country.

Specifics that one could learn for the other include "NHS, which is in the middle of a £20bn savings drive in England, could learn from the transparency and analytical rigour provided by bodies such as the Congressional Budget Office in the US. And lessons learned from the NHS's rollout of universal electronic health care records could prove helpful to the US, which is much further behind on the issue."

"But both countries are under pressure to get more value out of health care spending and reduce growth in expenditure to sustainable levels and are consequently experimenting with new ways to encourage clinicians, patients and institutions to help achieve this." But maybe not copying another system is the way to do this, maybe ingenuity is needed?

BBC-Kaylee Davidson-Olley marks 25 years with new heart (http://www.bbc.co.uk/news/uk-england-tyne-19915904)

"She said: 'I cannot believe that I am fit and healthy 25 years after my transplant. This was only made possible because of the generosity of a family who made that important decision about organ donation, a decision that saved my life. Without that family discussing organ donation, I simply would not be here.'"

"In total, 112 babies aged under a year have received new hearts in the UK during the past 25 years."

And...one of the most inpirational stories I have seen in a while! http://www.bbc.co.uk/news/world-middle-east-19914444...incredible!
 

Electronics for the Body

US scientists have created "ultra-thin electronics that dissolve inside the body" (http://www.bbc.co.uk/news/health-19737125). As can be seen from the video on the BBC website (link above), the electronic 'plate' appears to 'melt' away. "The components are made of silicon and magnesium oxide, and placed in a protective layer of silk. The speed of melting is controlled by the silk. The material is collected from silkworms, dissolved and then allowed to reform. Altering the way the dissolved silk crystallises changes its final properties - and how long the device will last" (http://tinyurl.com/cog5642).

These electronics are classed as "transient electronics" (http://tinyurl.com/cog5642). The aim is for the electronics to "function for medically useful time frames but then completely disappear via resorption [reabsorption] by the body" due to the "remarkable feature of modern silicon electronics  and its ability to remain physically invariant, almost indefinitely" (http://www.sciencemag.org/content/337/6102/1640.abstract).

In terms of medical uses the team of researchers are finding uses for the technology having testing in "rats a device that heats a wound to kill off bugs. There are also ideas around using the technology to slowly release drugs inside the body or to build sensors for the brain and heart. John Rogers, a mechanical science and engineering professor at the University of Illinois, said: 'Infection is a leading cause of readmission, a device could be put in to the body at the site of surgery just before it is closed up'" (http://tinyurl.com/cog5642). Another huge benefit is that "medical implants will never need to be surgically removed" (http://www.medicalnewstoday.com/articles/250791.php) meaning that surgery does not need to be repeated to remove what may have been out in place. So, the electronics can be programmed to completely disintegrate once they have performed their task.

"As for concerns of toxicity, they say the materials are non-toxic and that in one device they used less of the mineral magnesium than is found in a multivitamin" (http://tinyurl.com/cjyps88).


 

ME and CFS

ME and CFS "Myalgic Encephalopathy and Chronic Fatigue Syndrome" (http://www.meassociation.org.uk/?p=1001) respectively.

These are just two of the names assigned to an illness which affects a "currently estimated 250,000 people in Britain, but is an illness of uncertain cause. All types of people at all ages are affected" (as above) which means that it has a serious affect on people in all walks of life from young people in education or work to those who are beyond both education and work. "The predominant symptom of ME/CFS is usually severe fatigue" (http://www.meassociation.org.uk/?page_id=1685) and can occur with "painful muscles and joints, disordered sleep, gastric disturbances, poor memory and concentration" (first link). The illness therefore has a huge impact on people's day-to-day lives, as expressed by the writer of this blog (http://www.chronicfatiguesyndromesupport.me.uk/), a sufferer of CFS who says;

"Think back to the worst dose of flu you’ve ever had - not a bad cold but the real thing. I’m talking about the sort of flu that makes it almost impossible to get out of bed in the morning - sometimes it IS impossible. I’m talking about the sort of flu that leaves you totally exhausted and ill when all you’ve done is walk a few yards. I’m talking about the sort of flu that overwhelms your joints and muscles with excruciating pain, the sort that fills your head with cotton wool so that if you try to read a book, the words mingle confusingly then swim off the page, leaving you feeling dizzy and sick.

Imagine these symptoms not lasting seven or ten days as with the flu, but for year after miserable year."

  

People try to adapt to the illness to minimise the effect that it has on their lifestyle and relationships. People who wish to carry on with work or with education are generally advised to "apply the principles of pacing" (http://www.meassociation.org.uk/?page_id=1693). This is so as not to put a huge demand or stressful workload on the sufferer. Others "find a relaxation technique of benefit and try to couple this with a form of gentle exercise" (http://tinyurl.com/ceh63e3).

 

Having given a very brief overview of the illness and a few treatments to do with therapy and active management, drug treatments (although not specialist for curing the illness) are also available, varying by case. It is clear to see that it affects the life of the sufferer very severely. As well as the diffuclties faced by the sufferers there are complications that arise in diagnosis due to there being "no examination findings which can confirm the diagnosis. There has to be a process of elimination (the exclusion of other conditions) before a diagnosis of ME/CFS can be made" (http://tinyurl.com/cjuo8v9). This therefore makes it very difficult for doctors in terms of action plans/active management and may rely on taking time and trying different methods to understand what actually is wrong. This could be a very stressful and worrying time for those who are suffering from the illness but have no diagnosis or plan to deal with the symptoms. 

Singing for Dementia

Reading an out of date New Scientist (22 May 2010) I found a story about dementia saying that "singing to elderly people with dementia helps them form new memories" (22 May 2010 pg12 by Nora Schultz). It has also been proved that "people with Alzheimer's disease are better at remembering events from their past when music is played" (same reference).

The breakthrough in this story (or was a breakthrough back in 2010!!) is that sufferers of dementia find it extremely difficult to remember things that have happened very recently i.e. what they have had for lunch, but can remember past events that mean a lot to them/ well in the past when stimulated.

A trial was carried out by "Brandon Ally and his team at Boston University" who were "inspired inspired by the report of a man with Alzheimer's who could recall current events if his daughter sang the news to him to the tune of familiar pop songs" (same reference).

What they found from their trial of "13 people with Alzheimer's" that by giving "the lyrics from 40 unfamiliar children's song to read, half accompanied by the actual song and half by spoken word" and the results showed that "those with Alzheimer's were able to recognise 40% of the original lyrics that had been accompanied by song but only 28% of those read to them."

Granted that this isn't a huge increase in the percentages it is a significant difference of 12%. But it was also reported that "we don't yet know why singing should help, but Ally said that music engages areas of the brain, including subcortical regions, that are typically spared until later on in dementia."

But singing has also been used in other ways for dementia sufferers such as in getting patients to "cope better with their symptoms and improve their quality of life" (http://tinyurl.com/cem7tpc).

Tendinopathy

"Tendonitis is a term often used to describe an inflamed and painful tendon. However, tendon pain can also be caused by small tears in the surrounding tissue or the gradual deterioration of a tendon where it connects to the bone. This type of tendon pain is often referred to as 'tendinopathy'." (http://www.nhs.uk/conditions/Tendonitis/Pages/Introduction.aspx) where the term tendinopathy is used to describe "tendon injuries collectively" (as above). These injuries can include tendonitis, tenosynovitis and deterioration of the tendon.

Tendosynovitis is a condition where "the sheath surrounding the tendon, rather than the tendon itself, becomes inflamed" (http://tinyurl.com/97qozs9).

Specifically one of the types of tendonitis that can occur is "Achilles tendonitis (heel)" (http://tinyurl.com/97qozs9) and is "commonly caused by a sports injury" such as walking or running where you may be "wearing shoes that do not fit or support the foot properly" (http://tinyurl.com/97qozs9).

To minimise the damage that could be caused "you should stop doing the exercise or activity that caused your symptoms. Self-help techniques, such as rest, painkillers and ice packs, can often help relieve tendonitis. More persistent cases of tendonitis may need to be treated with physiotherapy, corticosteroid injections or shock wave therapy." (http://tinyurl.com/yjz3rjh)

And to ease the pain of tendonitis whilst doing sport if you already have it "you should warm up properly before you start to prepare your body for more vigorous activity and help avoid injury. It is also important you cool down and stretch after you finish." (http://tinyurl.com/yjz3rjh).

There is a short video and a lot more information on the NHS website http://tinyurl.com/yjz3rjh which also gives an informative animation of tendonitis and gives a good overview of inflammation and the difference between tendocynovitis and tendonitis.



 

Sports Drinks

I found an article about sports drinks in THE WEEK 4th August 2012.

The article ran like this:

"The sports drink market is worth £1bn a year in Britain. But according to an article in the British Medical Journal, in most cases, people would do just as well, if not better, to drink water. The review of 104 popular brands found that although manufacturers make many grand claims for the effectiveness of their often calorie-laden drinks - whether in boosting performance or aiding recovery - there is a "striking lack of evidence" to back up most of them.

For instance, Lucozade Sport, the UK's bestselling sports drink, is said to have "an isotonic performance fuel to make you faster, stronger, for longer". But when Dr Carl Heneghan, director of the University of Oxford's Centre for Evidence-Based Medicine asked manufacturer GlaxoSmithKlise (GSK) if they could assess the research on which these claims rest, he was given what scientists call a "data dump" - 40 years' worth of research which included 176 studies. His team managed to examine 101, before concluding that "the quality of the evidence is poor, the size of the effect is often minuscule and it certainly doesn't apply to the population at large who are buying these products". They were similarly sceptical about claims that branched-chain amino acids - found in some of GSK's protein drinks - can enhance performance and recovery. One nutrition expert, Professor Mike Lean of the University of Glasgow, described the evidence for amino acids improving muscle strength as "absolute fringe", and in any case "totally irrelevant" in the context.However, GSK stands by it's claims, which it insists are backed up by science."

This article seems to play down the use of sports drinks branding them as a waste of money because there is no proof of their ability to increase performance or aid recovery. I then dug around in PubMed and on the BMJ to try to find some of the research papers where the data had come from and found this: http://tinyurl.com/cyzt7lp, a paper talking about the birth of sports drinks their use because of dehydration rather than thirst.

"The researchers also contend that much of the science behind sports drinks is biased or inconclusive and that empty calories from sports drinks are major contributors to childhood obesity and tooth decay" (http://tinyurl.com/coye356). So here we can see that there societal issues to do with the consumption of these drinks, although how many would one have to drink to lead to childhood obesity?

A BMJ article states that "Healthcare professionals should be encouraged to talk with patients about the calorific content of SSBs [sugar sweetened beverages] when discussing lifestyle modification to manage overweight and/or obesity . . . Consumption of water in preference to other beverages should be highlighted as a simple step towards healthier hydration: recommending 1.5 to 2 litres of water daily is the simplest and healthiest hydration advice you can give.” (http://www.bmj.com/content/343/bmj.d4280) So this article also agrees with the obesity issue arising from the consumption of sports drinks.

However I think that the killer argument came from the BMJ when Powerade were quoted on their website saying “water doesn’t have the performance benefits of a sports drink,”—but it does not go on to quantify what those benefits are" (http://tinyurl.com/cyzt7lp).

If you read the BMJ article (http://tinyurl.com/cyzt7lp then you can make up your own mind based on the evidence/lack of evidence of whether they actually are beneficial..?!
 

Seymour Medical Practice W/E

I had another two days of work experience last week at another General Practice in Bristol but this time in Easton rather than Hartcliffe.

It was very ineteresting to see the difference between the two Practices in terms of the way that they were run but also the cohort of patients that they had on their books. In Easton the patients were mainly of Caribbean, Central African or Indian origin opposed to the white cohort in Harcliffe. The issues that arose from the patients were also very different in Easton with less depression and long term illness but more cancers and varied illnesses. Due to there being a large number of African and Caribbean patients there was a lot of Prostate Cancer in the male patients, as the incidence of prostate cance is higher in black men than those of other ethnicities (http://seer.cancer.gov/statfacts/html/prost.html) with a lot of men coming in for the latter end of their courses of injections to control the cancer. 

There were a number of ethical situations raised in my time there. For example there were issues to do with the taking of medication and one man had not been taking it for some weeks, ignoring the doctors advice that it would be beneficial to his health. As it is not possible to force someone to take their tablets the doctor therefore gave a balanced argument for and against why he should take his pills and gave him the choice based on the data from drug trials and the discussion that they had had as to whether he should now continue with the drugs.

Another example was where someone was suspected of having lung cancer having spread from another part of his body, which he had already had operations for. It was then discussed whether he would like to attempt another operation to remove this next tumor which could soon be fatal. But he wished not to have any more surgery for the time being and wanted to try alternative herbal medicines. He thought that maybe this would be better than conventional medicine, as he had once seen someone get better on them and also believed in miracles. The doctor once again gave a balanced argument as to the benefits and risks of these medicines and gave the facts of the lack of data to suggest that they work efficiently and effectively in all patients.

I also spent time with one of the practice nurses who was in charge of the 'Stop Smoking' programme at the practice and consultations to do with malaria tablets and the options available and also asthma check ups.

It was just like Hillview Medical Practice in terms of the volume of patients through the doors every day and the number of patients on the books, but it was very evident as to the differences between the two practices in terms of the people that attended and the different sort of issues that they brought with them.

Vietnam and Laos

Recalling the 'Legionnaires' Disease' post back in February, it was reported that "the total number of confirmed cases is 52, while the number of suspected cases is at 48" (http://tinyurl.com/7tebrer) in Edinburgh.

I am travelling to Vietnam and Laos for a month with my school and thought I would look into two of the illnesses that can be caught from spending time in these countries (Japanese Encephalitis and Rabies).

Japanese Encephalitis. This "can be a serious illness causing inflammation of the brain, caused by a virus" (http://tinyurl.com/dys8sc7) and is transmitted by "the bite of infected mosquitoes, not transmitted between humans" (http://tinyurl.com/dys8sc7). The vaccine is recommended for travelling to East Asia as can be seen on this map http://emedicine.medscape.com/article/233802-overview which shows the predominant area where it occurs (there is also more information about the virrus itself on this website.

I mentioned that it 'can be serious' and this is because it is "usually a mild illness with no symptoms, only around 1 in 200 having the serious illness" (http://tinyurl.com/dys8sc7) where  "encephalitis (inflammation of the brain) occurs. This can cause permanent brain damage and is fatal in some cases" (http://tinyurl.com/dys8sc7).

Rabies. As most of you know it is passed on from the bite or scratch of an animal infected with the rabies virus. "The virus passes through the cut skin and travels (gradually) into the nervous system. It causes spasms, fear of water, madness, paralysis and usually death" (http://tinyurl.com/d6bw8n4). It is therefore a very serious illness, just like Japanese Encephalitis in the cases where it does cause encephalitis. To immunise yourself from rabies there is a series of injections which "stimulate your body to make antibodies against the rabies virus" (http://tinyurl.com/d6bw8n4). If you are bitten then it is recommended that you "clean the wound thoroughly and seek medical help" with "symptoms usually starting 2-8 weeks after however, symptoms may occur months or even years after" (http://tinyurl.com/d6bw8n4).

Both of these illnesses are serious and are worth considering for immunisation before travelling, especially if travelling to the areas where they occur, such as South East Asia. Whatever the illness or wherever you are travelling you should always research the diseases/illnesses from that country so that you can go to your doctor with an idea of the immunisations you will need to have/discuss having. A very good website for finding out about illnesses is http://www.patient.co.uk/.

As I am away for a month this will be the last before I get back but I have work experience on the two days after I get back so will update you then.

EuroSCORE

EuroSCORE stands for "European System for Cardiac Operative Risk Evaluation" (http://www.euroscore.org/what_is_euroscore.htm) and it is used in cardiac surgical theatres for "calculating predicted operative mortality for patients undergoing cardiac surgery" thus "a good measure of quality of cardiac surgical care" (http://www.euroscore.org/what_is_euroscore.htm). Effectively it calculates the risk of survival/death of the patient undertaking a cardiac operation based on 17 items of information in three categories "patient-related, cardiac-related and operation-related factors" (http://www.euroscore.org/euroscore_scoring.htm). These are then all taken into account and a formula is used (http://www.euroscore.org/logisticEuroSCORE.htm) to calculate the EuroSCORE for the patient.

All of the factors contribute to a final score/percentage chance of death and is used in a huge number of hospitals across the UK and Europe.

The data used to calculate the score was developed from studying "nearly 20 thousand consecutive patients from 128 hospitals in eight European countries. Information was collected on 97 risk factors in all the patients. The outcome (survival or death) was related to the preoperative risk factors. The most important, reliable and objective risk factors were then used to prepare a scoring system" (http://www.euroscore.org/what_is_euroscore.htm); which is a huge number of people and body of risk factors to develop a scoring system based on a patients risk relative to what has happened in the past.

News Bias

"Can spending less time sitting down add years to your life?"

The first paragraph of this BBC report (http://www.bbc.co.uk/news/health-18767278) on whether spending time sitting down actually increases your risk of death or not appears misleading to the research that has actually been produced. They say "limiting the time we spend sitting to just three hours a day could add an extra two years to our life expectancy." The key word in this sentence is the word 'could'. Later in the report it is reported that "experts say the US estimates are too unreliable to predict personal risk" and even that "the researchers themselves acknowledge there are flaws that make its findings less than reliable." So why have the BBC published this report and why do other news corporations publish research in their papers/websites that doesn't appear to give a conclusion? For example, I found another website that published this story but had a completely different angle that seemed to suggest it was firm. The website (http://tinyurl.com/bmbwxot) did not publish anything about the fact that the research may have had flaws and only suggested that it was unreliable was when they stated "they used the data to extrapolate the effects of sitting down on the health of an entire population" but to the eye of someone who doesn't understand the term extrapolation in terms of data this would mean nothing and would presume that the data was in fact reliable.

But why would 'Healthcare Today' take to the side of the argument that the data is reliable? What is their motive for giving a bias to the data? Going to the root of the data, the actual paper itself from BMJOpen, I found that Dr Peter Katzmarzyk, the man who conducted the research, came to the conclusion that "reducing sedentary behaviours such as sitting and television viewing may have the potential to increase life expectancy in the USA" (http://tinyurl.com/d4jlx8w) and that the rise in life expectancy is in the bounds of "1.39 and 2.69 years for sitting and 0.48 and 2.51 years for television viewing" (as above). This is a published piece of research and it is now the job of other scientists to research this further and test the conclusions of Dr Katzmarzyk, so in the future we will see the validity of the data.

But the point I was trying to illustrate was that you should never take the first news story you see as truth, always try to get opinion from lots of news corporations to account for all of the sides of the story that they are trying to portray. This means that you can build a picture of the story and the different angles to it. The best items to read would be the paper itself so that you get the pure data and can draw your own opinion. I learnt this by reading a book called 'Bad Science' by Ben Goldacre who shows how to get past the media angle and at the data and opinions that are valued in the science community i.e. leading researchers/scientists.

Chest Drain

I saw quite a few chest drains on the respiratory ward and also in ITU (intensive care unit) whilst in the hospital so thought I would find out what they do. A chest drain is "a hollow, flexible tube in the chest, acting like a drain" (http://www.nlm.nih.gov/medlineplus/ency/article/002947.htm). They are used to drain fluids from the body such as  "blood, fluid or air from around your lungs, allowing the lungs to fully expand" (http://tinyurl.com/d37r3ur), so it is mainly used when the lungs have been compressed, thus decreasing the size of the lungs and causing reduced efficiency. The chest x-ray below (http://tinyurl.com/cw6cy96) shows a 'pleural effusion' (shadow on the right side of the picture (left lung))-the "buildup of fluid between the layers of tissue that line the lungs and chest cavity" (http://tinyurl.com/3e5hnul) which is the area where the chest drain takes fluid from, in "the space between the inner lining and the outer lining of your lung" (http://tinyurl.com/d37r3ur).

The "body produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the thin tissue that lines the chest cavity,surrounds the lungs. A pleural effusion is an abnormal, excessive collection of this fluid" (http://tinyurl.com/3e5hnul).

It is inserted and guided to the right area by 'numbing the area where the drain will be inserted, it is then inserted through a cut in your skin between your ribs' (http://tinyurl.com/d37r3ur) as can be seen below (http://www.umm.edu/patiented/articles/000618_2.htm).

The tube, once in the right position (as above), then removes the fluid from the lining of the lung using suction. It is then removed once no more fluid comes out of the drain as there is no need for the drain anymore. An x-ray is then carried out again to see the improvement and the lung should look almost normal, with almost all of the fluid removed.

Video of the procedure: http://www.youtube.com/watch?v=fp1uBR8Lvn4.

BRI Work Experience

Haven't posted for a while...sorry about that! So i'm going to make it up to you all and do a few posts in the next few weeks..

A short one for now. Just finished three days of work experience at the BRI (Bristol Royal Infirmary). I had a day on a cardiac ward which dealt with some pre-op patients and other patients with severe heart issues leading to other issues in the body and I witnessed a number of extremely ill patients. I also spent a day in cardiac theatre, observing two open heart operations as in the 'Cardiothoracic Surgery' post, one of which was to replace the mitral valve (left atroventricular valve) of the heart and the other was to remove and replace a section of the Aorta. Both of these were extremely tricky operations but carried out with great skill by the surgeons.

In theatre there is a huge amount of teamwork required for a successful operation. The two surgeons require a surgeons assistant to pre-empt what the surgeon will need in terms of tools, and will then ask for the tools off the nurses who are in the non-sterilised zone. Then there is the anaesthetist and his/her assistant and also someone who is in charge of the cardiopulmonary bypass machine, which takes over heart and lung function in the operation whilst the heart is stopped.

On the third day I spent time on a different ward mainly involved in respiratory illness where I met some fantastic foundation doctors, training doctors and consultants. Talking with them and just observing them was so interesting and gave me such an insight into what to expect in the first few years of being a qualified doctor and beyond that and have acted as role models for me to aspire too in the future.

One news story, found it in The WEEK (9th June 2012 issue 872 page 16), bit of a funny one!
"Doctors in India have operated to remove a live fish from the lung of a 12-year-old boy. Anil Barela accidentally inhaled the 9cm specimen while playing a fish-swallowing game with fiends on the banks of a river!!"

Student Debt

Top news story on the BBC today was student debt who ran with the headline "Debt 'putting off' medical students, BMA warns" (http://www.bbc.co.uk/news/health-18128637).

Let me do the maths for you.
Every medical course at a British Universities will cost £9,000 per year for tuition fees by next year (September 2012). A medical course, for an undergraduate who has the correct A-levels and does not need to do a Foundation year, can last either 5 or 6 years depending on whether an intercalated degree is undertaken.

The NHS provide financial support whereby "from year five onwards, tuition fees will be paid by the NHS Student Bursary Scheme" (http://www.nhscareers.nhs.uk/details/default.aspx?id=557), so year five and year six of the degree will be paid for. Therefore in terms of tuition fees it will be £36,000 for the course. Of course the living costs at different universities varies so you could be looking at vast differences; for example London and Aberystwyth. Lets say a general £500-£600 per month which is £6000-£7200 per year.

Tuition: £36,000
Expenditure (Accommodation and Food):£36,000-£43,200 (6 years) OR £30,000-£36,000 (5 years)
Total Cost (in the region of) £75,600 (6 years) OR £69,000 (5 years)

From these figures (don't quote me on the expenditure figures because they depend entirely on location and the student lifestyle) we can see that it is indeed very expensive to attend medical school; but I wouldn't let it put you off and you will see why.

1. I was informed on a conference I attended that it costs around a £250,000 to put a student through medical school so the cost payed for tuition is not even 15% of the total cost of the degree.
2. If you want to become a doctor then surely there is nothing that will stop you doing what you most want to do in your life and inevitably is what you will spend the rest of your life doing.
3. When you pay back your student loan, even though it is a huge amount of money and you may be paying it back for a lot of your working life, they won't take so much away that you cannot live or sustain yourself. They also don't start taking money out of your pay until you reach a threshold of £21,000 and if you don't end up paying it off it is wiped at the age of 68.

But if your not convinced and you don't think it is right to be paying so much then there are other options. You could study abroad where the fees are less, for example Holland or other European countries but be aware that the British student loan companies do not provide loans for students studying abroad. But if you don't fancy that then you can do a different course such as a Biomedical degree that you can do Medicine afterwards/not at all. But also be aware that student loan companies do not provide loans for your second degree.

Dissolvable Polymers

These sorts of polymers have become extremely useful in hospitals for washing soiled linen and hospital clothing. When linen is replaced from beds in hospitals there is an issue for the cleaners/nurses because they have to touch the linen and replace it whilst putting the linen out of patient contact due to risks of infection or illness. It then needs to be sent down to the washing rooms to be cleaned, but how can you stop so many people coming into contact with it?

So, hospital laundry bags are now made out of dissolvable polymers; the cleaner/nurse can put the soiled clothes/linen into a laundry bag straight away, put it in a big trolley bin and then close it, thus protecting the patients from infection. When the trolley gets to the laundry room the bags can be removed, thrown straight into the washing machine and dissolved, coming out with clean linen. This means that anyone who comes into contact with the bag has a much reduced risk of infection.

The plastic used in the bags is "poly(ethenol), made from another plastic, poly(ethyl ethanoate), by the process of ester exchange" (http://www.4college.co.uk/as/poly/Dissolve.php).

Polymers are made up of hundreds of monomers, assembled by repeating units, but for the conversion of monomers into repeating units there are double bonds that must be broken to join the units together in a chain. For example, below left (http://tinyurl.com/cry9r5l) is an image of the repeating unit in poly(ethenol) (n represents a huge number) but the monomer (that produces the repeating unit) is ethanal, an aldehyde containing with carbonyl functional group or more specifically ethenol (below right; http://tinyurl.com/cry9r5l).

The mechanism of turning the ethanal into the repeating unit and thus the polymer poly(ethenol) is a complicated one which involves turning ethanal (above) into ethenol (above) which as can be observed above is "unstable; then made (into poly(ethenol)) though ester exchange rather than polymerisation" (http://tinyurl.com/cry9r5l). Polymerisation is the usual mechanism for making polymers.

The reason why the polymer is able to dissolve in water is due to the hydrogen bonding present in water and poly(ethenol); which occurs when hydrogen is bonded covalently to a highly electronegative element compared to itself, such as Oxygen, and also, when Hydrogen has a lone pair to align with such as one of the two lone pairs on the Oxygen atom in water (as below-http://tinyurl.com/bl3rjqr).


So the "-OH group on poly(ethenol) can interact with the -OH group in water" (http://tinyurl.com/cry9r5l), form hydrogen bonds, and therefore water dissolves poly(ethenol). But as can be observed in the table at the bottom of (http://tinyurl.com/cry9r5l), the solubility of the polymer depends on "the percentage of ester groups which have been removed". But all of the figures show that the polymer is highly soluble in water.

Another use of the dissolvable polymer is in "surgical stitching; this means that the stitches don’t have to be removed" (http://tinyurl.com/cry9r5l).

Colonic (Bowel) Polyps

I found an interesting video on YouTube and tried to find out what it was and ended up learning about polyps! Hope you enjoy. 


The "colon is also called the large intestine" (http://www.webmd.com/digestive-disorders/picture-of-the-colon) and is responsible for the removal of "water, salt, and some nutrients forming a stool" (same website; where there is a good image of the colon and where it sits in the body). 


Polyps, generally speaking; "are small growths: some develop into cancer, but it takes a long time" (http://www.webmd.com/digestive-disorders/picture-of-the-colon). More specifically; 'colonic polyps' are "benign (non-cancerous) tumors or growth which arises on the inner surface of the colon and; like a piece of pipe, the colon is hollow and the inner surface is normally smooth. The cause is not known, but the incidence of polyps increases with age" (http://tinyurl.com/c52u7dl). The risk of developing cancer from the polyps depends on "the type of cell that forms the polyp which varies and is important in determining its potential for developing into a cancer" (http://www.netdoctor.co.uk/diseases/facts/colonpolyps.htm).

Symptoms; "most colon polyps do not cause symptoms. If you have symptoms, they may include blood on your underwear or on toilet paper after a bowel movement, blood in your stool, or constipation or diarrhea lasting more than a week" (http://www.nlm.nih.gov/medlineplus/colonicpolyps.html).


You may be wondering then: 'how they are removed or even how they detect whether they are there or not if there aren't any symptoms?' There are certain groups of people who come under a 'larger risk' category; these people include "those over the age of 50, those who have had polyps before, have had a family member with polyps or have had family history of colonic cancer" (http://www.nlm.nih.gov/medlineplus/colonicpolyps.html). This does not mean that younger people cannot develop colonic polyps, but the chance increases with age. Therefore; to prevent the development of colonic polyps and then colonic cancer, "experts recommend routine colon cancer testing for everyone age 50 and older who has a normal risk for colon cancer. People with a higher risk, such as African Americans and people with a strong family history of colon cancer, may need to be tested sooner" (http://tinyurl.com/cgsn9ht). There has been research carried out into the idea that African Americans hold a higher risk of developing colonic cancer from colonic polyps as shown in a huge study at this website: http://www.research.va.gov/news/research_highlights/polyps-092408.cfm.

Location and removal of the colonic polyps can be carried out though a procedure known as a "colonoscopy (telescope examination of the whole large bowel starting at the rectum)" (http://www.netdoctor.co.uk/diseases/facts/colonpolyps.htm)  "a thin, flexible, telescope. It is about as thick as a little finger. It is passed through the anus and into the colon" (http://tinyurl.com/clfd5jh) and this is what the video that I found on YouTube shows (http://www.youtube.com/watch?v=vVqgtUHP2z8) with an informative voice over of the whole procedure, starting with the location of the polyp then the 'snaring'. The second polyp removal shows a better picture of what is left afterwards 'a clean base'.

Genetic Disorders and Prenatal Testing

There are hundreds of genetic disorders that have been diagnosed and have also been linked to specific mutations in the DNA. There are some common genetic disorders that occur more frequently than others; for example because "people in an ethnic group often share certain versions of their genes, which have been passed down from common ancestors; therefore if one of these shared genes contains a disease-causing mutation, a particular genetic disorder may be more frequently seen in the group" (http://ghr.nlm.nih.gov/handbook/inheritance/ethnicgroup). This can be seen in genetic disorders such as "sickle cell anaemia, which is more common in people of African, African-American, or Mediterranean heritage" (http://ghr.nlm.nih.gov/handbook/inheritance/ethnicgroup). There are also other common disorders such as cystic fibrosis, Down's syndrome, haemophilia and colour blindness.

I will do short introductions on what down 's syndrome, haemophilia and cystic fibrosis are, and then discuss the ethical sides of  the diagnostic testing that is available to pregnant women and also the ethics of abortion.

Down's Syndrome: "someone with Down's syndrome has an extra copy of chromosome 21 in the cells of their body. This is known as trisomy 21 (trisomy means there are three copies of a chromosome - in this case, chromosome 21). Because there is an extra chromosome 21, there is extra genetic material in the body" (http://www.patient.co.uk/health/Pre-natal-Screening-and-Diagnosis-of-Down''s-Syndrome.htm). It also explains on that website the typical features of down's syndrome, but also explains that "anyone can have a baby with Down's syndrome but a woman's risk increases as she gets older" (same website).

Cystic Fibrosis: occurs in places where mucus is produced and is caused by a mutation in the CFTR gene, which codes for the CFTR protein. The CFTR protein performs in a complicated mechanism that regulates the movement of chloride ions, sodium ions and water movement in and out of the mucus. When the mucus becomes too sticky for the cilia (hairs on epithelial cells) to move the mucus to where it needs to be (i.e. in the bronchus up to the mouth) the water needs to be drawn into the mucus to make it less viscous but when the CFTR is no longer present the chloride ions cannot get into the mucus to draw the water in via osmosis. This leads to blockages and damage to the lungs, reproductive system and other mucus dependent areas of the body. Sadly, because of the bacterium getting caught in the mucus, it is then dragged down into the lungs and destroys the alveoli and bronchioles, reducing the surface area and eventually suffocating the sufferer. For a more detailed explanation see http://www.patient.co.uk/health/Cystic-Fibrosis.htm which explains the effects on the other parts of the body as well, very interesting genetic disorder.

Haemophilia: (2 types; A and B, which only vary due to "problems with different clotting factors) is a genetic (inherited) condition that affects the blood’s ability to clot, normally, if you cut yourself, proteins called clotting factors combine with blood cells called platelets to make the blood sticky. This makes the bleeding stop eventually. However, in haemophilia, there are not as many clotting factors in the blood as there should be. Therefore, someone with the condition will bleed for a longer time than usual" (http://www.nhs.uk/conditions/Haemophilia/Pages/Introduction.aspx). This means that people with haemophilia can be subjected to a greater volume of blood loss (both internal and external) than should normally occur which can be dangerous for the person with the disorder. It is also interesting that it "almost always occurs in males" (http://www.nhs.uk/conditions/Haemophilia/Pages/Introduction.aspx).

There are a number of  tests that can be carried out to ascertain whether your child will have a genetic disorder; "prenatal testing provides information about your baby's health before he or she is born and, based on screening test results, your doctor might suggest diagnostic tests. Diagnostic tests confirm or rule out health problems in you or your baby" (http://www.nlm.nih.gov/medlineplus/prenataltesting.html).

1) Amniocentesis: carried out at 15-17 weeks of pregnancy where a needle is inserted into the amniotic fluid to collect cells that have fallen off the embryo which are then tested for known genetic disorders. It is "usually only offered to women when there is a significant risk that their baby will develop a serious condition or abnormality. This is because the procedure is quite invasive and has a small associated risks of miscarriage; estimated to be 1 in 100" (http://www.nhs.uk/conditions/Amniocentesis/Pages/Introduction.aspx).

2) Chorionic Villus Sampling: this is where placental tissue is removed (around 8-12 weeks) via "transabdominal CVS-a needle is inserted through the abdomen, or, transcervical CVS – a tube is inserted through the cervix (the neck of the womb)" (http://www.nhs.uk/conditions/Chorionic-Villus-sampling/Pages/Introduction.aspx). "The risk of CVS causing complications, such as miscarriage or birth defects in the baby, is higher if it is carried out before week 10 of the pregnancy" (as above).

So what are the implications of getting results from these tests? Well, if the results are negative then the family will probably decide to continue with the pregnancy as intended, but what if they come back positive?

1) The couple will receive guidance from their GP and will be given access to a whole host of people who can help them to make their decision and prepare for the child or to have an abortion, but either way, it will be an informed decision, that is best for everyone involved.
2) An argument that is often used is from those who believe in life beginning at conception, so they would say that an abortion is not the correct option, since that child now has a life ahead of him.
3) Others would say that life begins at birth and that the child is not conscious in the womb, so would argue against number three, but both arguing about human rights and when they are granted.
4) It also depends on the severity of the genetic disorder because if it is haemophilia then there is a good chance that the child will have a long life ahead of him that he can prosper in. But with cystic fibrosis it is very difficult for the child because of the treatments they must undergo regularly and also the suffering that they go through.

Please feel free to add to the list by leaving a comment and starting a discussion!

Hillview Medical Practice W/E

I have just finished three days of work experience at a General Practice in Hartcliffe (South Bristol) called Hillview Family Practice. It has been a very interesting and informative few days because of the huge variation in what I have seen, and it is hard to think about how varied a GP's day is when you just visit for a 10 minute appointment.

There were a number of things that made the days so good, as well as the diversity of cases that the patients brought in, such as being able to sit in with one of the GP's and observing the way that she carried out an examination on patients and realising the small amount of time in which a GP has so many things to carry out. They have to receive the patient and try to get down to the problem as quickly as possible, trying to get past the things in the patients story that don't actually have any relevance and get to the things that need to be dealt with. For example if a patient comes in with leg pain and a cold, the GP has to get past the fact that they have a cold, even though the patient talks about it as tha main part of the story (thinking that they are linked), and needs to focus on the leg pain, which could be a development of arthritis or a pulled muscle...

What I also noticed was the sheer volume of people that come through the door of the practice every day. There isn't much time in the day and all the free areas on the timetable at the beginning of the day for 'on call', quickly become filled with home visits or more appointments for people who need to be seen. There is also a large amount of 'admin' that needs to be performed to do with prescriptions for patients and so on which means that timings can become quite irregular.

I also took the chance to talk to some patients of the practice and I asked them what they thought of the service that the practice prosuces; one man replyed that the service has been fantastic and that he could not have asked for more. I have also furthered my understanding that some people choose to take free healthcare for granted, after observing a statistic on reception that over 300 people did not attend their appointments in a month and also the reluctance of some patients to comply with the best advice that they could be offered (from someone in the medical profession).

I spent some time in the treatment room in the practice where they take blood samples, analyse urine samples and administer vaccinations for babies; among other things. The blood that they take is sent off and can be tested for a number of different things, while the urine is also tested for a number of things such as glucose levels, pH etc. which can lead to further examinations.

On Thursday I went on a visit with one of the GP's to the MHA care home based in Hartcliffe, which is the older of the two MHA care homes in Bristol. It was very interesting to see the differences between the MHA care home that I volunteer at and the Hartcliffe MHA. What I noticed most of all was the extra floor space of this care home, set up in a different style to Horfield Lodge and seemed to make the place feel bigger. However the colours of the corridors were a lot darker (purples and creams) compared to Horfield Lodge (whites and reds). This made it feel as if there was no natural light and a bit enclosed from the outside world, even though more spacious.

On the whole I enjoyed my time at Hillview Family Practice, it was a great opportunity to observe how a General Practice works and how intense it can be at times; but it will also be interesting to see how it differs from another General Practice placement that I have planned for in August, based in Easton, which has a very different socio-economic standing to Hartcliffe.

Malaria RTS,S Vaccine

I recently did some private study on malaria and the development of the RTS,S vaccine which is "the first malaria vaccine candidate to ever reach large-scale Phase III clinical testing"  (http://tinyurl.com/cm6q6zx). You can find about the outline of clinical trials on the 'Clinical Trials' page.

What I found was that although there are currently ways of preventing malaria or treatments that are available once malaria is contracted, a lot of them take time to teach people how to use them and other solutions have to be replaced after a certain time period. For example; I looked at LLIN's and ITN's and the comparison between them. I found that LLIN's (long-lasting insecticide-treated mosquito nets) were of a better standard than ITN's (insecticide-treated mosquito nets) because they last around 3 years opposed to 12-18 months. This means that the distributor (mainly the WHO) does not have to go back to the same place every year but can distribute further afield or spend time funding other projects.

Another solution are antimalarial drugs, but mosquitoes are becoming/have become resistant to certain drugs; as was reported today; "scientists have found new evidence that resistance to the front-line treatments for malaria is increasing" (http://www.bbc.co.uk/news/health-17628172).

IRS (indoor residual spray) is another option but there are issues to do with the component of the spray; DDT (Dichlorodiphenyltrichloroethane) which is thought by many to have environmental impacts and also health impacts, although the WHO disagrees and; "announced that this intervention will once again play a major role in its efforts to fight the disease; Dr Anarfi Asamoa-Baah, WHO Assistant Director-General for HIV/AIDS, TB and Malaria said; DDT presents no health risk when used properly” (http://www.who.int/mediacentre/news/releases/2006/pr50/en/).

Therefore, the newest development in the fight against malaria to prevent the disease that affects millions of people every year is the RTS,S vaccine. It has been under development for 25 years and is the most clinically advanced malaria vaccine there has ever been and there has been a huge amount of investment in the development by a number of huge companies.

Results from the Phase III trials were released in 2009 by the "New England Journal of Medicine". On their website there are a number of interesting tables and graphs to show the effectiveness/efficacy of the vaccine and the methods of trialling it, who they administered it too and the effects that the vaccine had. One table that I found very interesting was to do with 'serious adverse effects' (7th table on the right hand side (http://www.nejm.org/doi/full/10.1056/NEJMoa1102287#t=articleResults)). The results look shocking when you see how many more adverse effects there were in the malaria group than the control drug, but then I noticed that the group that it was administered was double that of the control in both the '6-12 week' and '5-17 month' test groups. This seems to point towards the age groups that this drug will be administered in and leads to the question of safety for the children that it is being tested in; but as the tables data shows (and the other data), it appears to be a very safe vaccine.  

In terms of issues of cost, organisation, transportation to the areas where the vaccine is needed i.e. sub-Saharan Africa and administering the vaccine to the patients; I think that these will all be overcome by the co-operation between GlaxoSmithKline Biologists and organisations such as the WHO but also through the governments of the countries that need the vaccine for their people. The amount of people that will be saved by this vaccine in the future is worth more than the effort that is needed for organisation of producing and distribution of the vaccine itself. 

I would say that the RTS,S vaccine is a very good solution to the issue of malaria control. I think that it would be very effective if used in combination with other alternative malaria controls such as LLIN’s (which I feel would be a lot more successful than ITN’s) and also IRS. I think that GlaxoSmithKline Biologicals and other biological companies should continue their work and strive to develop a second generation malaria vaccine that performs even better than the first generation RTS,S vaccine.

Hip Surgery and Prescriptions

Odd combination but I haven't done a post for a while, so I thought I would do a couple of topics together.

Earlier in the year it was reported that thousands of pounds were lost to the NHS due to prescriptions every year i.e. in Wales where prescriptions are free (as in Scotland and Northern Ireland) it was reported that "people in Wales received an average of 22 items on prescription last year, costing the NHS £594m" (http://www.bbc.co.uk/news/uk-wales-politics-14738797).

But the news is that the cost of the prescriptions have risen in England (while the other UK nations stay free). I'm not going to list figures because that would be boring and that's not what matters here really, it's still a fairly low price to pay; but yes, the price has has gone up and that may be an issue for some people i.e. those who have long term conditions who need constant prescriptions. Maybe there should be funding schemes set up to help these people, but then again there is so much funding being lost these days it would be hard to see that happen.

The question is, why can't England have free prescriptions like the rest of the United Kingdom? Well; "The government says abolishing prescription charges in England would leave the NHS £450m short each year" (http://www.bbc.co.uk/news/health-17576096), which is a fair argument but they aren't dealing with the losses they are making in Wales (as illustrated earlier). There were a number of opinions expressed in the comments on the BBC website. Some were for the rises but others were unhappy with the rises and thought that it was 'unfair' (a very common term used in the report). What I suggest is that we be thankful for the NHS and what they do for us for free and we just accept these extra payments. If you are in a critical condition and on the brink of death they will perform life saving surgery without asking any questions, how about that for healthcare. I've been to other countries and seen their standards of healthcare where they can barely put up all the people in a hospital who need treatment. What are people suggesting? That we go private? Then things will be ten times more expensive because healthcare will no longer be good practice, it will be a business, charging people to live because they know that people want one thing; and they will pay anything to keep their lives. Honestly, what do people think is the alternative to what services we have?!

In terms of the hip surgery story, it is much like the PIP breast implant story; "surgeons have been warned to stop using a particular type of metal-on-metal hip implant because it has an 'unacceptably' high failure rate" (http://www.bbc.co.uk/news/health-17590832). The BBC reported that over a 4 year period "10.7%" had to be replaced which is almost 29 out of the "270" who have been given the "Mitch TRC and Accolade" hip replacements. There is a lot of investment and research put into things like hip replacements and other structures that are put into the body. This is because it has to be accepted by the body and also try to act as if it is natural/meant to be there; for example making sure the bones can move with it in place or making sure the metal doesn't rust in the body.

One way of performing hip replacement surgery is to do 'anterior approach' which is said to be better because "rehabilitation is simplified and accelerated, dislocation risk is reduced, leg length is more accurately controlled, and the incision is small" (http://www.hipandpelvis.com/patient_education/totalhip/intro.html). It was interesting to find that (written in a report in 2007) it wasn't the preferable choice of hip surgery in the USA because apparently "there are several reasons: lack of familiarity, traditional teaching, and lack of the necessary instrumentation and equipment" (as above). However the techniques may have improved since the report was written.

Although this is a very long surgical video (almost 2 hours) detailing the whole procedure, if you flick through it you can see the basic outline of how the anterior approach surgery is carried out with a small incision.

To finish, back to the H5N1 story which is raging on in America at the moment; news is out that a "US panel has approved the publication of two controversial H5N1 bird flu studies, after they were revised" (http://www.bbc.co.uk/news/world-us-canada-17569494). There was controversy over whether to release the publications in case bioterrorists got hold of them. But the "panel said the publications no longer revealed details that could lead to abuse by terrorists" (link as above).