ECHOLALIA - Issue 4 by Echolalia Magazine

ECHOLALIA THE OFFICIAL UON MEDICAL SCHOOL MAGAZINE

From plant to pill What is the nation’s fixation with natural products?

Issue 4 September 2014

Editorial

Sadly, this will be my last editorial as Editor-in-Chief of ECHOLALIA. Before I go on to tell you about all the fantastic articles that have been written for this issue I have a few people to thank. Mei and Anouska have not only been excellent people to work with, but they were also on the original committee that launched ECHOLALIA back in 2012. Their unending hard work and dedication have helped make ECHOLALIA a continuing success. Since 2012 we have had several new additions to the committee and I hope that the younger members continue to produce this amazing (I’m not at all biased!) publication with Joel Pryn at the helm. There is just one final mention to make before I get on with what I should be writing. In every single issue, we have had one writer that has written multiple articles, some of them the night before the printing deadline yet still of an excellent quality, so my final editorial could not go by without also mentioning Sam Quarton.

Cover illustration Natural Remedies by Mei-Ling Henry. This represents the drug digoxin and its production from natural derivatives of the foxglove plant, Digitalis lanata.

Anyway, enough posturing, and on with the job in hand. What has this issue got to offer? We have once again caught up with some of the sports and societies to see what they have been up to, and how you can get involved in the year to come (page 12). Along the same theme, we asked you what you thought about the Students’ Union. Turn to page 24 to see how everyone answered. With a general election looming, do you know who you are going to vote for? Read about party policies regarding health, the NHS and students to help you make up your mind (page 20).

What did you think of the SU? Turn to page 24 to find out.

Following last issue’s teaching to help you cross the minefield that are U&Es, we have followed it up to help you get your head around the almost as baffling LFTs so that you can shine when next on a ward round with a particularly pernickety hepatologist. Our case study will also help you find your way through the murky waters of abdominal pain, so put on your thinking caps and tell us why Mr Rogers is ‘busting a gut’. Go to the Essential Lecture Handouts section where you can also WIN £30 of Amazon vouchers with this issue’s prize crossword. After all this hard work, you need to kick back and relax. Check out the best places to eat in Nottingham (page 38) or what is on at the theatre (page 40). And finally, don’t miss this year’s medics’ musical, Sweeney Todd—The Demon Barber of Fleet Street, see the back page for all the details.

Ollie 2

Is the use of ‘natural’ ingredients in everyday products as good as it sounds? (Page 32).

In This Issue

News and comment Global News……………………………………………………………………… 4 A Conflict of Interests: Russia and Ukraine…………………………… 6 Ebola: A State of Emergency……………………………………………… 8

Societies Homed: Poverty in Nottingham………………………………………… 10 InFocus: MedSin………………………………………………………………11 Societies Round-Up……………………………………………………………12

Sports InFocus: Medics’ Cross Country………………………………………… 14

Features The Future of the NHS……………………………………………………… 16 Desperate Medical Students………………………………………… 18 Who should you vote for?………………………………………………… 20 The Origins of Chemotherapy…………………………………………… 22 Could the SU do more for you?…………………………………………24 Careers: The Academic Foundation Programme………………… 28 Student Insight: What it’s like to take time out for research… 29 The Use of Apps in Medicine………………………………………………30 Natural Selection……………………………………………………………… 32 Kick to the Head: Concussion in Football…………………………… 34

Arts and Culture

Don’t want to cook tonight? Take a look at our top foodie hotspots in Nottingham (page 38).

Films of 2014…………………………………………………………………… 36 Nottingham Foodie Hotspots…………………………………………… 38 What’s on at the theatre…………………………………………………… 40

Essential Lecture Handouts Interpreting LFTs…………………………………………………………… Reasons to love Colwick Cheese………………………………………… Puzzle Page…………………………………………………………………… Case Study: Busting a Gut………………………………………………… Acknowledgements and Answers……………………………………… —-

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ECHOLALIA is produced and written by students within the medical school. It is funded by advertising and sponsorship, so that it can be freely available to all students.

Echolalia—The Offical UoN Medical School Magazine @echolalia_mag

With the next general election looming, we’ve asked our writers to tell us how to best use our votes as healthcare students (Page 20).

echolaliasubmissions@gmail.com echolaliamagazine@gmail.com echolaliadesign@gmail.com issuu.com/echolalia_magazine

News and Comment

US—Ban Exfoliating Face Washes! There are a significant number of personal care products such as scrubs, toothpastes, and other cosmetic items that contain thousands of minuscule balls of plastic called microplastics or microbeads. These may feel good when you are using them, but these tiny plastic beads are bad news for the environment. Microbeads are normally less than 1 mm across, and slip through most water treatment facilities into the water supply, and eventually into the world’s water, reaching our lakes and seas.

GLOBA

Animals can mistake microbeads for food and end up swallowing them, causing blockages and even starvation. A recent report from the United Nations Environment Programme estimates that this plastic waste damages marine ecosystems every year worth US $ 13 billion. It’s good news then that Illinois has been declared as the first US state to ban the manufacture and sale of cosmetics containing plastic microbeads. New York, Ohio, and California are expected to follow suit. L’Oreal, Johnson & Johnson, and Colgate have already agreed to replace the hazardous plastic with more natural ingredients like oatmeal or sea salt. Other major companies that use microbeads are also following in the process of complying. In the meantime, there has been an app (Beat The MicroBead) developed for consumers to scan products to see whether they contain microbeads.

UK—GM mosquitoes as a biological weapon to tackle malaria. A new technique developed by a team at Imperial College, London, involves modifying the genes of mosquitoes to produce mostly male offspring, with the idea of inciting a population decline. Scientist hope this discovery will make a substantial contribution to eradicating malarial disease that kills more than 1 million people each year, mostly African children. The research is ambitious in supporting a vision that this genetic system will spread itself through the target population in the wild, causing favourable imbalances in the sex ratio that will lead to a population crash. The scientists injected a gene from slime mould into mosquitoes that attaches to their X-chromosome during the male’s sperm-making process and effectively shreds parts of the chromosome’s DNA. 95% of offspring were male, whereby the hope is that modified mosquitoes mate with wild ones, creating more males containing the modified gene and causing a decline in disease-inflicting female offspring.

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Health stories from around the world, brought to you by Mansi Shah.

L NEWS Netherlands—Diverse Viruses That Control Our Gut Bacteria A virus that has been discovered by researchers in Radboud University Medical Centre in Nijmegen, Netherlands’ is six times more abundant than all other known gut viruses. This virus is a bacteriophage, meaning it replicates by infecting a species of common gut bacteria. Its discovery supports the suggestion that these abundant gut viruses may be the masters of regulating the teeming bacterial communities that call our gut home; viruses that could be maintaining the biodiversity within us. Interestingly, each person’s viral signature is unique, regardless of where people live or what they eat. The lead researcher, Bas Dutilh, has stated that this finding can be harnessed for personal phage therapy, where specially designed bacteriophages can be inserted into the gut to kill or boost certain bacterial populations to promote the normal balance.

Syria and Gaza—Traumatised Children Battles in Ukraine, Gaza, and Syria have disrupted and disturbed societies that we watch from afar in media. Particularly, little is known as to how far the conflict has traumatised and interfered with the mental development and well being of young individuals. Under 18s are required to have special protection in periods of war according to the United Nations Convention on the Rights of the Child, a convention that celebrates its 25th anniversary this year. The convention, although lacking in enforcement, has provided a framework to plan the time and the resources required to provide ‘special protection’ to children. The young generation must be both mentally and physically fit in order to recover from war and rebuild as a society. Many humanitarian organisations exist that have become aware of the burden of mental illness that continues to develop with the conflict in Gaza. Poor, developing countries such as those in question simply do not have healthcare systems equipped to deal with paediatric mental health issues. This care is particularly

important, as research supports the theory that prolonged and severe stress can damage the developing brain. There can be no single approach to limiting the mental damage inflicted by war in different places. A more useful approach is intervention that intensely engages in the life experience of each individual affected. There is a great need for the countries blighted by conflict to develop their own capacity to help improve mental wellbeing of the affected young. For example, interventions in schools could help access large numbers of children and contribute to an educated generation that can promote redevelopment of society. These should be combined with longitudinal studies to track these disturbed children into adults, to see how the treatment has helped them.

News and Comment

A conflict The crisis in eastern Ukraine has been rumbling on for many months now; a worryingly enduring fixture in newspaper reports and television bulletins. However, after the dramatic events early in the conflict when every day conspired to bring us closer to a second Cold War or worse, the situation has (at least globally) seemed relatively stable and controlled for much of this time. Creatures of limited attention span that we are, to those of us without personal involvement, stories of rebel advances or government progress easily become background noise; we are aware of the situation, but in the form of a chronic condition rather than an acute life-threatening event. Chronic conditions can have exacerbations however, and recent times have seen an escalation in tensions not seen since the start of the conflict. In early September, after Russian troops became more openly involved in the conflict, Lithuania’s

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of interests

President declared Russia was ‘at war with Europe’. David Cameron invoked Godwin’s law, drawing comparisons with Hitler and the Sudetenland, and NATO began the creation of a 4,000-strong ‘spearhead’ force, designed for rapid deployment in Eastern Europe if required.

what was claimed to be Russian equipment, and the capture by Ukrainian forces of Russian paratroopers (who Moscow state were on leave) means this has been widely disputed for some time. Plausible deniability on behalf of Russia has recently become increasingly stretched. The Kiev government has So what triggered this recent flare of consistently maintained that Russia is rhetoric, and where are we now? Russian representatives have repeatedly claimed the pro-Russian rebel groups are acting entirely independently of Russian support, and while satellite imagery purporting to show Russian troops moving into Ukraine, the shooting down of Flight MH17 with

aiding the rebels with arms, supplies and troops. Earlier this month, in the face of significant advances by the Ukranian government, it appeared Moscow were becoming less concerned with hiding it. Clear pictures emerged of tanks among the rebel forces that are solely made in and used by Russia, and the Ukrainian military claimed to have identified units of Russian troops throughout the region of Donetsk. If this is true it would match the pattern of behaviour in the annexation of Crimea, in which Russia initially denied that unidentified soldiers occupying key strategic targets were Russian, before later becoming more open, reinforcing these positions with uniformed troops in the interests of stabilizing the situation. That the same soldiers were one of the key reasons the situation required stabilising was quietly forgotten. In this case, the additional Russian military support seems to have achieved its objectives in halting or reversing the recent Ukrainian gains, but at the expense of further widespread condemnation and sanctions against Russia.

Encouragingly, at the time of writing, Ukrainian President, Petro Poroshenko, has just announced a cease-fire, after reaching an agreement with Russia. However, with such conflicting ideas over the future of the region it is hard to see this leading to a lasting peace, and the Ukrainian Prime Minister’s response to news of the cease-fire (that ‘all previous agreements have been ignored or brazenly violated by Russia’, and that ‘Putin plans to destroy Ukraine and restore the Soviet Union’) certainly isn’t promising.

It is a continuing headache for western leaders. Military escalation would be disastrous, the only possible long-term solution is through negotiations between all parties, yet they are under increasing pressure to present a show of strength to Putin, hence David The question remains of how a solution Cameron’s recent comments warning of to this conflict can be reached, of how the dangers of appeasement and this chronic condition can be treated. referring to Neville Chamberlain in

1938. This does seem quite hyperbolic, but Cameron can be forgiven for feeling the shadow of the past - the whole affair feels oddly dated, with echoes of an era that many thought we, in the 21st century world of globalisation, were leaving behind. News articles (including this one) talk of movements made by ‘Russia’, of ‘Moscow’ or ‘Kiev’ making decisions, as if the nation-state were a living animal, rather than a region of land. When discussing the latest EU sanctions against Russia, articles talk of EU dependence on Russian energy as Putin’s ‘trump card’ or ‘ace up his sleeve’, with the meaning clear: This is a game we are playing. The Great Game. Except it’s not. Enough of the 19th century - we should remember that rather than simply abstract concepts jostling for power and influence, there are people involved. Roughly 3,000 people have died as a result of the conflict, at least quarter of a million have been made refugees, and hundreds of thousands have limited access to food, water and other basic necessities. This is not a game, and one gets the urge to tap Putin and other world leaders on the shoulder and show them the date. It’s 2014. We’ve never been more connected. A video of a cat uploaded in London can simultaneously make someone laugh in Kiev, Moscow, Beijing and New York. We have the UN, affordable international travel, and Facebook. Now can we have peace? Samuel Quarton

News and Comment 8 25

Ebola: A state of Emergency

Ebola, a viral haemorrhagic fever first discovered in 1976, and responsible for killing 280 people, has recently made a comeback. Declared an ‘international emergency’ by the WHO, the current outbreak has a death toll of 961 as of 9th August. Emerging from Guinea in March, the virus has now spread to multiple countries including Sierra Leone, Liberia and Nigeria, with no signs of stopping. This has led to a number of extreme measures being implemented to curb the disease. All schools in Liberia have been shut down, as well as a number of hospitals. Furthermore, a blockade has been imposed, preventing entry to the capital to those from regions affected by Ebola. In Sierra Leone, quarantines have been enforced on victims in order to limit its spread.

workers are therefore particularly at risk through needlestick injuries as well as indirect transmission occurring in contaminated areas. Because of this, they are sometimes shunned as communities believe that they are instrumental to disease spread. Add that to the fears of the disease itself and it is no surprise that a large number of the 6000 strong healthcare work force in Liberia are incredibly hesitant to continue working.

Besides healthcare workers, those attending burial ceremonies are also highly at risk due to close contact with recently deceased bodies. Therefore, it will be incredibly important to dissuade communities from practising their traditional burying rituals such as kissing the body immediately after death – when the body is at its most infectious. However, in other areas, In humans the virus spreads via direct fear of catching the disease has contact with the blood, secretions and resulted in infected bodies being bodily fluids of those infected. Health abandoned on the streets by family members. This led to protests in Liberia as there were corpses left uncollected by the government, which has ordered all infected bodies to be cremated.

A New Hope: The world has their eyes on a drug named ZMapp – an experimental treatment which has been given to two US aid workers when they contracted Ebola. Within an hour after being given the drug, the condition of one ‘improved dramatically’. However, since this experimental serum is still in the pre-human phase of clinical trials, it is unknown as to when it will be available for patients. Its use has unleashed a barrage of ethical dilemmas: in a crisis, is it okay to skip the drug testing pathway? Who should get first ‘dibs’ on the experimental treatments? For now, emphasis is very much on increasing public knowledge about transmission and the symptoms of the disease in order to recognise those infected and treat the condition immediately as well as to try to reduce transmission as soon as possible. It was found that patients have a better chance of survival if they are treated early. On top of this, there is also importance placed on quarantine in order to prevent spread of the disease. Fortunately, it has been reported that clinical trials on a vaccine which was found to be promising during tests on animals will start in September 2014, with the hopes of a vaccine being developed by the end of 2015. Ella Quintela

The unknown fight against homelessness in Nottingham A lot of us are unaware about the benefit delays. Additionally, debt grave problems that are hidden and low incomes drive people to away in the city we live in. We our food bank. A lot of people are happy and feel quite self- are in work but they simply can’t sufficient with the surroundings make ends meet’. For him of where we live around the homelessness is the end result

Societies

university campus, most of us in of government’s inability to tackle

Homed

helping?

HoMed is an organisation that attempts to bridge the gap between students and Nottingham’s homeless community. Once a week student volunteers from HoMed distribute food and

policies that increase deprivation experiencing homelessness are trapped in a cycle of deprivation among those most at risk.

needed listening ear to people who come along,

government policy is to blame; Dylan Williams ‘the main reasons people come to us are benefit changes and

the Beeston to Lenton strip. poverty. University life happens in a He warned that austerity has bubble; most of us largely go damaged the ability of local about our everyday work and councils to counteract activities, detached from the rest homelessness. ‘They’ve been of the city. Have you ever put in an impossible position – wondered if homelessness is a they can only provide what’s major problem in an established mandatory. Preventative groups city like Nottingham? That don’t get anything, even though someone in the streets nearby prevention is more economic in would go to bed hungry, cold, the long run’. without food? Centres like Emmanuel House, Preventing homelessness in an important point of support for Nottingham continues to be a the homeless community in priority. A report by the Joseph Nottingham, recently saw their Rowntree Foundation at the end funding slashed. In a speech to of last year found that students last semester its CEO, homelessness has risen by 34% Ruth Shelton, suggested they since 2010. The report criticises may ultimately be forced to close the government’s failure to tackle as a result. homelessness, citing insufficient than often those housing stocks and austerity More

that impacts their health, Nigel Adams is director of Hope wellbeing and life chances. It Nottingham, a Christian group, looks like a long road ahead providing a number of services to before we can completely homeless and impoverished eradicate and prevent people in the city, including a homelessness through the food bank. He told Echolalia ‘the concerted efforts of many number of food parcels we’ve organisations. distributed has doubled over the last year’. He believes

How

clothes to the homeless in Nottingham city centre. Rachel Haughton, HoMed Coordinator, said: “It’s important to break the stigma of homelessness and our soup-runs mean we can help to better understand homelessness and give back to society. As well as helping the homeless we empower students to take action locally, educate others and be part of the voice for a better future for healthcare in the UK.” Rachel said HoMed has seen a ‘two-fold increase” in services users over the last year’. She thinks this is due to a ‘lack of affordable housing, high levels of unemployment and a lack of help and support available for those in difficulty’. She also explained how HoMed attempts to tackle the marginalisation of homeless people in modern society. ‘We also provide a much as they often feel left behind by society. In addition, we’re able to signpost them to other local organisations who provide support and food on other nights of the week’.

How can one get involved? Rachel urged students interested in joining HoMed to contact the society at homednottingham@gmail.com, or join the ‘HoMed Nottingham’ Facebook group. Please note: opinions expressed in ECHOLALIA are those of the individual authors and not those of the magazine itself nor the Students’ Union or MedSoc.

In Focus: MedSin If I were to take a random sample of medical students and ask them their initial reason for wanting to study medicine, which would very likely trigger UCAS application-related memories, I would bet that the majority of people are going to mention, at least in part, their genuine want to help people; to make a difference. In addition to the latter, there may be other reasonable reasons like decent pay, social respect, scientific challenges, and job security, but there are other professions that equally provide these career aspects. I think deep down, a lot of us came into medicine as we had dreams and an inner calling of saving the world.

tackle inequalities in global and local the IFMSA activities, via exchange health through education, advocacy, programmes or getting involved in and community action. public health projects, Medsin is able to provide a powerful voice for global There’s no denying that large health. For example, tackling HIV inequalities exist - currently the involves both improving access to antideveloping world has 90% of the retrovirals in developing countries by world’s disease burden, but only 10% campaigning for a patent pool to allow of the world’s healthcare resources; for the provision of cheap generic Malawi has roughly one doctor for drugs, as well as good sexual every 50,000 people, compared to education for students and school about 1 for every 400 in the UK. More pupils here in the UK. locally, your postcode still affects your life expectancy and homeless people In Nottingham we hold regular events die an average of 30 years with expert speakers on earlier than the issues such as FGM, the war rest of on drugs, mental us. health in the

As the reality of medical school sets in, our high aims and aspirations of benefiting the human kind get more and more lost, as we are slowly swamped by the drudgery of However, biochemical pathways, log-books, and global health is not lectures with very little opportunity for about naïve, privileged interaction. westerners dictating solutions, Much of the time we are too focused with a bit of voluntourism thrown in for on completing tick-box activities; like good measure; but a recognition that the next OSCE, the next MACCS, and diseases, and other issues such as the next sign-off. As our world FGM, don’t stop at national borders. constricts we lose touch with the We live in a globalised, interconnected bigger picture of our dreams we world; it took the Black Death five initially had in our minds; but, there is years to spread across Europe in the a solution to the problem, and in my 14th century; SARS spread worldwide totally unbiased position as co- in a matter of weeks. President of Medsin, the solution is Medsin, as the UK member of the Medsin. International Federation of Medical Medsin (Medical Students Students Association (IFMSA, a part International Network) is a network of of the WHO), represents all UK students based at each medical medical students internationally. school throughout the UK aiming to Through engaging with and influencing

developing world, the NHS, health access for refugees and many more, as well as the work of our fantastic Medsin-affiliated activities such as Homed and Sexpression. This year we have an ‘Intro to Global Health’ course, a fantastic conference, lots more great workshops and, of course, plenty of free pizza. Keep an eye-out for shout-outs and posters. For more information, please visit facebook.com/MedsinNottingham . Samuel Quarton

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Societies

WAMS We are the Widening Access to Medicine Society (WAMS). For the third year running, we've successfully worked with the University's Widening Participation team on events such as a Medicine Buddy Day, visited schools with a WP background and held a Work Experience week for some Year 12s. We have lots more events coming up, including Mock Interviews, and our e-mentoring scheme for Year 11/12. We're always looking for volunteers and it's fun and really rewarding so get involved!

Societies sessions where all abilities are welcome, and we're currently preparing for a summer tournament against Leeds, Leicester and Sheffield. So if you like playing tennis with friends and meeting new people this is the perfect society for you! HEARTSTART increase students’ knowledge of homelessness through a series of talks and presentations from professionals within the area of homelessness. Ortho Soc

A brand new society for the year 2014! Orthopaedics society has been set up Join our facebook group ‘Medics to provide an insight (to boys and WAMS Volunteers’ and visit GIRLS) into the competitive speciality www.wamsnottingham.com to find out of orthopaedics. We hope to organise more. a series of talks, workshops and skills sessions throughout the year that will HoMed bring to light the skills and attitudes required to be an orthopod. This year HoMed has continued to provide food and drink to those who Tennis are homeless, through our weekly soup run. Next year we would like to We are a new flourishing society that provide sleeping bags and a regular aims to make tennis fun and accessible for everyone. Over the past supply of socks, gloves and hats year we've set up weekly tennis throughout the winter. We also aim to

HEARTSTART has expanded this year to teach BLS to more youth groups, sports clubs and even run sessions in conjunction with WAMS outreach programmes in deprived areas. We have also had a great year with recruitment, doubling our number of trained volunteers, with some volunteers completing their session leader certificates. Next year’s visit requests are already coming in and we have sessions planned to teach in halls of residence so we’re looking forward to welcoming new volunteers this autumn.

GP Soc GPSoc provides teaching in the key fundamental skills from effective history taking to safe prescribing. An inspirational talk regarding pre-hospital medicine generated so much enthusiasm that the highly acclaimed Community First Responders society has been generated. On the 10th September in conjunction with the Vale of Trent RCGP, there was a celebration of work done abroad by local GPs with the opportunity for students to get inspiration for electives.

Round up Vital signs Red Cross Society

Bumps and Bits

SCRUBS

We’re the Nottingham Red Cross Society and this year we’ve been focusing on raising awareness and money for the British Red Cross. Coming up this summer’ we’re having a barn dance! Come along if you fancy a bit of fun and raising money for an amazing cause.

We run mock OSCE sessions with top SCRUBS is the University of tips on passing your Obs and Gynae Nottingham Student Surgical Society! Over the past year we have organized exams. many successful events, recently A free Careers Day is planned for including our Surgical Careers Fayre. October, packed with fun practical In the year to come we are looking sessions, careers advice, certificates forward to starting up our new for your portfolio and a whole lot more! research network, and hosting our So why don’t you get in touch? inaugural national surgical skills competition!

NICE NICE Student Champions – a group of NICE affiliated students offering computer training to raise the awareness about the availability of invaluable NICE resources; podcasts, presentations, and notes we wish we’d had for exam preparation. Best of all is that you get all this free, with a certificate of attendance from NICE included.

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Sports

In Focus: Cross-Country “In the dark winter months when motivation is low and the temperatures outside are freezing, Medics’ Crosscountry is the one thing that stimulates me to get ready and get running!”

Running could be the sport for you and you can make what you want from it; whether you are looking to challenge yourself, get fitter, win medals, or even train for marathons.

We are a fairly new society that has Whatever your pace, you’ll find been set up for all abilities from social someone to run along with. Even if it’s morning joggers to marathon runners. never been your sport and you’re still suppressing memories of those Running can be an isolating sport; dreadful school cross-country lessons however, in our weekly training from long ago- all are welcome to join sessions we ensure that everyone gets our growing group! to know each other well, and we run together chatting and enjoying it. We have been taking part in a free

weekly 5km timed run, called ParkRun (www.parkrun.org.uk), that takes place across the entire world. Here in Nottingham, we have the opportunity to participate at four different, nearby locations, each within a short bike ride away from University Park, with a newly opened one in Beeston. This type of run has been a great way to interact with the local running community outside of the University. We run four very different tracks, with some being hillier than others. They are a great way to keep track of our performance and have been a lot of fun so far. Apoorva Khajuria

Calling all the keen medic runners! Email mzyak4@nottingham.ac.uk for more info or to join! We meet weekly for training and are hoping to book a few events and races this year in and around Nottingham.

Features

The NHS was founded in 1948 on the altruistic vision of providing quality healthcare free at the point of delivery. However, this vision is now threatened by unprecedented challenges. Owing to a toxic combination of factors like flat funding, rising costs and a burgeoning demand for NHS services, the future of the NHS is unlikely to be sustainable without prompt action.

Flat Funding With the current economic crisis, the coalition government tightened its public spending to reduce the budget deficit. Whilst the NHS budget was protected (all other public services faced 2.9% cuts), the HM Treasury’s 2010 spending review impacted on the NHS regardless. That is, the NHS budget has for the first time in its history remained flat in real terms, after factoring in inflation. Between 2011/12-2014/15, NHS funding has grown at only 0.1% per annum in real terms. This compares unfavourably to the generous 4% annual real terms funding growth of previous years. Meanwhile, funding pressures continue to rise steadily. This creates a funding gap that widens yearly as the difference between financial resources and costs grows. By 2014/15 this shortfall is projected to be around £16bn. To reconcile this gap, the NHS was instructed to make productivity improvements within acute care to meet a quarter of this shortfall (known as the QIPP challenge). The remaining gap is closed through a workforce pay freeze and improvements in the management of patients with longterm illnesses to reduce hospital costs.

Rising Costs: The costs of providing healthcare in the 21st century are rising. As the fifth largest employer in the world with a workforce of 1.7m employees across the four devolved nations, this applies particularly to the NHS. As such, most of its expenditure is accounted for by workforce pay. To put this into perspective, the NHS in England spends 70% of its budget allocation on staff.

Besides labour costs, there are capital costs associated with purchasing clinical and administrative facilities and equipment, infrastructure, ICT systems etc. Additionally, there is the rising cost of expensive new drugs, therapies and technologies as medicine Nonetheless, with funding pressures anticipated to and technology advances. Not to mention, these costs continue beyond 2014/15, an additional £34bn shortfall are subject to inflation, like most goods and services will exist by 2021/22. Even with extended efficiency savings beyond 2014/15, this would be too large a shortfall to meet, especially given that the workforce pay freeze is just a short-term measure.

The Future of the NHS: Is it Sustainable?

Growing Demands:

have risen by 1m since 2008. Crucially, the 30% of patients with one or more longterm illness account for £7 out of every £10 spent within the NHS.

The demand for NHS services has risen dramatically. Currently, the NHS deals with 1 million patients every 36 hours. In the last decade, A&E attendances have risen by 55% and hospital admissions from 11 million to 15 million, whilst outpatient attendances increased by 1m between 2011/12-2012/13 alone. In primary care, GP consultations It is pivotal to the future of the NHS to explore new are expected to rise from 5 to 8 annual consultations per innovative care and sustainability strategies. Moreover, this should not only include financial stability, but also person over the next several years. environmental protection and social empowerment as part This burgeoning demand is driven by population growth of a comprehensive sustainability package for the future. and ageing and an increase in the number of patients living With anticipation that flat funding in real terms will be with multiple longterm illnesses. Specifically, with the rise extended to 2021/22 and funding pressures continuing to in life expectancy, a current baby boom, and declining rise, it will be increasingly difficult to reconcile this funding mortality, the UK population is set to grow by 10m by the gap. The QIPP challenge has offered significant 2030s. Additionally, the number of people aged 65+ is opportunities for efficiency savings up to now, but since projected to rise by 7m over the same period, with 1 in 4 workforce pay is unlikely to remain frozen beyond the short predicted to be aged 65+ by 2050. The significance of this term, further unprecedented savings would be required. is that older patients account for two-thirds of hospital Only few other options remain: increasing taxation, further admissions, are more likely to require longer hospital stays cuts in other public services, government borrowing, or and readmission, and being the most intensive users of charging patients a fee for their healthcare, none of which healthcare, they account for the majority of health seem realistic. Besides these, the only longterm expenditure within the NHS, particularly with hospital care sustainable option is a fundamental change in the way our being the costliest form of healthcare. healthcare system is configured for the modern health, Finally, the increasing complexity of patients with longterm social and financial dimensions of today. illnesses is a huge strain on NHS services. In particular, Khalid Khan the annual cost of just one patient with multiple longterm illnesses is around £8000 - more than double the £3000 cost of those with a single longterm illness. Over the next few years the number of these ‘multi-morbid’ patients will

The Future:

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Features

Desperate Medical Students Funding has been a hot topic for students since the rise in fees. But, are medical students more affected than other students? Friends brush off my concerns, seemingly believing that we’ll all be in our GP jobs earning sixfigures before we’re 25. In my eyes the reality is that you could be living on as little as £3,500 worth of maintenance a year, dropping to £1800 in 5th year, and ending up with around £70,000 of debt by the time your five years are up. I know lots of medics are in the same boat, desperately ignoring their bank balance. I’m currently in second year, and work up to 30 hours a week. With this work I’m not only trying to pay my bills, but also scrambling to save for fourth and fifth year - when I wouldn’t have the summer holidays or free time during term to earn. Without relying too much on the bank of mum and dad, we have very few options. Working part time on top juggling our challenging studies with extra-curricular activities seems to be the scenario that too many of us are struggling with. Medical students have more timetabled hours, and their modules demand more studying time at home than probably any other degree (anyone who took MOM will understand my pain). An article in the student BMJ looked at the balancing act medical students faced, and concluded that working less than 16 hours a week was a realistic and possible amount. Rather worryingly, some students have resorted to sex work in order to pay their bills. Here’s what I did, and perhaps you can do too. Get as much financial support as possible from many sources.

funding, and the University’s own bursary scheme for its students. For example, if your household income is less than £42,000 you’re guaranteed a bursary from the University.

Further, ‘money4MedStudents’, (a project of the Royal Medical Benevolent Fund), and the BMA have some fantastic financial guides and resources for medical students to help you find your way through budgeting, to entitlements, loans, bursaries and the medical course is funded. It’s confusing enough being funded by charitable trusts. Student Finance for part and the NHS For those looking for healthcarefor the rest, let alone having to scrape related, temporary or part-time, job together enough money from parents opportunities, the NHS Professionals and work to pay your expenses. website is the way to go. Remember, Medical students are more likely to be that there are also many different employed after graduation than most employment agencies, like Reeds, that students, so the risk in lending us specialise in providing temporary or more money is greatly reduced. part-time staff. Be wise on your expenditures as you Some of the examples of the medically never know when you are going to related flexible roles one could do are: need that extra cash in your bank  Hospital auxiliary, account for something unexpected.  Healthcare assistant or care Louisa Hepworth worker (you can often obtain this work from a nurse bank or Not-to-be-missed finance agency), resources: 

Medical secretary,



Theatre technician,



Laboratory work in a hospital,



Research scholarship.

It’s good to keep your options open when looking for work, as there are many transferable skills that we have as medical students that fit into hospitality and retail work for example. You could also try consulting our University’s careers services—they have a plethora of invaluable resources to get you a sharp edge when it comes to hunting and applying for jobs. Additionally, look into becoming a student ambassador for the University.

It’s definitely worth looking into the University’s financial support services. Here I’ve offered some short term fixes They help by providing information for you in terms of money, but what we regarding governmental student really need is a re-evaluation of how 18

www.bma.org.uk/developing-yourcareer/medical-student/guide-tomedical-student-finance www.money4medstudents.org/ finding-money www.nottingham.ac.uk/ studentservices/financialsupport/ index.aspx Get started on a job: www.medicalcareers.nhs.uk/ medical_students/ summer_jobs_and_parttime_work.aspx www.e4s.co.uk/ www.reed.co.uk/ www.unitemps.com/ www.nottingham.ac.uk/careers/ students/index.aspx

Features

Conservative Party The Conservative party has worked successfully in Government over the last four years to secure a strong economic recovery for the UK. In the face of calls to increase borrowing and reckless spending, they reduced the deficit and created the market confidence that has inspired the current recovery. By facing up to difficult public spending choices, we are now in a strong position to support the public finances and the UK is one of the fastest growing economies in the Western world. They have surely proven to be the party that can be best trusted with the country’s economy. The Conservatives raised the threshold at which individuals pay income tax, to help the lowest paid in

Labour PARTY The Labour party rebuilt the NHS after years of Tory neglect, but under David Cameron’s administration there is now a growing crisis in our hospitals. The Conservative and Liberal Democrat coalition have caused chaos with a top -down reorganisation putting private profits before patient care. Thousands of nurses and other frontline staff have been made redundant since David Cameron became Prime Minister. As a result, the NHS has seen a crisis in A&E waiting times. In the last year alone, nearly a million people have had to wait for over four hours to be seen in hospital. Furthermore, more patients are having their operations

GREEN PARTY If you hold with the stereotypes of the Green Party then you’re probably wondering how tree hugging and lentil eating can possibly influence the NHS or your life as a medical student. ‘Green’ issues and the environment are certainly central to the Party’s agenda, however, they are considered part of a bigger picture. The Green Party stands for creating a healthier and more equal society. Regarding health, they are committed to maintaining a strong public service, including the NHS. It is an issue that Caroline Lucas, the first (and so far only) Green MP has publicly spoken

society. By simultaneously lowering the higher rate income tax, the UK has become a more attractive destination for investors. They are the only party that can realistically give you a referendum on the UK’s place within the EU – something Labour and the LibDems want to deny you. In terms of healthcare, the party firmly believes that doctors should be at the heart of NHS governance and clinical commissioning. Through the introduction of CCGs, GPs have been placed at the heart of the NHS budget. By reducing bureaucracy, more money can be better spent on patient care. Indeed, they have protected the NHS budget whilst in office and will continue to do so. Whereas Labour places its ideological belief in state centralisation first, the Conservatives seek to

maximise individual choice through competition. Importantly, they have also made Care Quality Commission an independent body, making it more difficult for systematic failures within the NHS to be covered up again. Vote for the Conservative Party to continue to empower doctors, promote patient choice, to protect the economic recovery, to have your say on the EU, and to continue rewarding success whilst still protecting the weakest in society.

cancelled and treatments like cataract and knee operations are being rationed. The coalition government has also made it more difficult to see your GP as the Labour party’s guarantee of a GP appointment within 48 hours was scrapped. Over the last two years there has been a 66% increase in the number of people aged 90 or over entering A&E departments via blue-light ambulances. Under Labour, elderly patients would have a named contact to oversee their care and be a first point of contact. The Tories rejected this proposal due to high costs, though it has been argued that these costs could have been covered if not for the

£3 billion spent on an unnecessary ideological top down reorganisation. In October 2012, hospitals were given the right to generate 49% of their income from private patients. The Conservatives and Liberal Democrats are privatising the NHS, with huge private health firms run by people who had donated £1.5m to the Tories, winning £1.5bn in NHS contracts. In conclusion, the Labour party created the NHS and only Labour can be trusted to fix the mess caused by the Conservative and Liberal Democrat Government.

out about. To this end, the Green Party campaigns and engages issues such as the selling off of NHS services for the profit of offshore companies. Additionally, they believe that health can be tackled by addressing underlying factors. These include access to green spaces, healthy eating and exercise. A specific aim is to extend the Scottish policy of free social care for the elderly to the rest of Britain. They also want to include dental and ophthalmic care with free NHS services and abolish prescription charges. They aim to address areas of inequality such as free access to higher education, which is something that would make life easier for many

medical students. I recently became a member of the Green Party when I realised how much of their manifesto chimed with me as a medical student, future doctor and future NHS employee. Perhaps you too believe that the way of facing hard financial times is to create a more equal society, rather than selling off public assets for private profit and taking away support from the most vulnerable. If so, I urge you to vote for the Green Party (tree hugging optional).

Liberal democrats The Liberal Democrats are traditionally one of the three major parties within British politics. As the name suggests, they are a ‘liberal’ party. Leader Nick Clegg summarised this as meaning ‘power is vested in people, not in states or institutions’. Their fundamental beliefs are increasing social mobility (i.e. a more equal distribution of wealth throughout society, through economic and statesponsored means). In 2010, the Lib Dems won 23% of the vote, and for the first time in recent history became part of government, in a coalition with the Conservatives. Although this was unpopular, with some questioning why a party that stands for social progress would form Dearest ECHOLALIA readers, I have a confession to make. My 18th birthday was the day after the last general election, so I have never had the chance to vote. As someone who would want to use my vote in an informed manner, this was actually something of a relief. I could avoid deciding what my political leanings were and put off trying to decipher what the different parties were saying they would do, let alone trying to second guess what they would really do. Shameful, I know. Women didn’t fight for the vote so that I could be

a coalition with the right-wing Conservatives. I feel this was necessary, as a Liberal DemocratLabour coalition would still have constituted less than 50% of MPs, meaning that opposition party support would be required to pass any bill, potentially resulting in a stagnant, impotent government unable to pass any laws for 5 years. Many students will be reluctant to vote Lib Dem again, following the infamous tuition fee rise. However, this was a Conservative policy and as a minor coalition partner, the Lib Dems could not have everything their own way. Nick Clegg isn’t the first, and certainly won’t be the last politician to break a pre-election promise but at least Clegg has the courtesy to apologise and campaigned to minimise the impact of relieved not to have to use it. However, with a general election imminent sometime in the next year, I think it’s time I grew up, as I am now most definitely of an age to vote. So next comes the big decision of who to vote for.

the changes by increasing grants to lower income students. With the 2015 elections still some time away, their final manifesto has yet to be finalised, but what exists so far can be found at www.manifesto2015.org. The Lib Dems, I feel, have shown themselves to be more than a protest vote, making a positive impact within the current government. With another coalition likely in the next election, the Lib Dems have a good chance of being able to enact change again.

Mei-Ling Henry Featuring contributions from Oliver Tomkins (Conservative), Labour Society, Joseph Hedgecock (Liberal Democrats) and Emma Chan (Green Party).

Being in fifth year, I reasoned that many of you are likely to be in a similar situation to me, so I asked for some help in choosing who I should use my vote for as a medical student.

Who should you vote for?

This is what our writers decided.

Key Party Policies

 Doctors at the heart of NHS governance.  Protection of NHS budget.  Promote patient choice.  Named contact to oversee elderly care.  Funding a high quality health service for ‘public not profit’.  Addressing the many areas inequality that impact on health.

 Implementing free social care for the elderly similar to that provided in Scotland.  Against privatisation of the NHS.  Increased emphasis on mental health.  Working to improve access to education.

through semen, thus having the ability to cause an allergic reaction.

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host of the radio show asked the listeners to send in their quarters and dollars to aid the anti-cancer fund and buy me a television. $200,000 flooded in and I was able to watch the Braves win the World Series that year on a controversial call involving my new friend Phil Masi. I suppose the money went some way to help the science too. The ‘Jimmy Fund’ was born and to this day is still linked with Boston’s baseball team. It became a household name and by 1952 Farber had set up the Jimmy Clinic, his own hospital for treating childhood cancers, replete with dolls, toys, books and a television – once referred to as ‘Disney World fused with Cancerland’. A renewed future for children at a hospital — chemotherapy treatment (above). Einar Gustafson as the original ‘Jimmy’ (below).

ORIGINS OF CHEMOTHERAPY — An Unlikely Fate

y name is Einar Gustafson. Until the blueberry harvest of the year I turned 12 (1948), my life was normal. I got tummy pain and had to go to hospital. They did surgery on my appendix but found an abdominal cancer. It was a ‘lymphoma’. I was forced to leave my parents’ farm in Maine and move to Boston, Massachusetts, where Dr Farber ran a small cancer unit. He was using ‘aminopterin’ to treat children with leukaemia and lymphoma. He desperately needed funding for his research, and hoped to build a haven for anti-cancer specialists. There are ways of raising money for science. When I was very young, President Roosevelt was figurehead of a polio research campaign, ‘March of Dimes’, and 2,680,000 dimes were sent to the White House

“

to fund Sabin’s and Salk’s vaccines. The Variety Club, who once visited Farber, adopted an abandoned child and raised her well. Their philanthropy made big news, proving an excellent business venture for the Philadelphian thespians. Farber selected me as his mascot. For anonymity, and ease, I was known as ‘Jimmy’. ‘Truth or Consequences’, a prominent primetime radio show, interviewed me as Jimmy. Following a host of questions about baseball, the reporter asked me if I’d ever met Phil Masi, of the Boston Braves – my favourite team. I replied no, and Phil Masi walked into my room! The rest of my favourites filed in afterwards, one by one. A piano was brought down and we sang the old tune.

Take me out to the ball game, Take me out with the crowd, Buy me some peanuts & Cracker Jack, I don’t care if I never get back…

“

Some of those there cried, focusing on the last line. The

I reached remission from my lymphoma soon after. I returned to my parents’ farm in Maine whilst Dr Farber, Mary Lasker and her ‘Laskerites’ continued to remind the public and politicians of our onus to ‘make war’ against cancer. Working as a trucker, I remained anonymous until 50 years after my first interview, in 1998. I was welcomed back to the Dana-Farber institute and spent 3 years supporting the Jimmy Fund with its slogan emblazoned on my truck – ‘Because it takes more than courage to beat cancer’. I died following a stroke in 2001, leaving 3 children, 6 grandchildren and a charity raising around $45 million every year for cancer treatments. Tim Mercer

Features

Could your SU be doing more for you?

ECHOLALIA investigates some of the reasons why the university of Nottingham students union is repeatedly rated poorly by students on the national student survey. Being a medical student it is very easy to feel isolated from the rest of the University; for those in preclinical years, the long days and early starts can limit social activities with friends on other courses, whereas for those in the clinical phases it is the lack of holiday and placements away.

‘I have sent [the SU] emails with a 'read report' before and received a notification that they were deleted without being read.’

ECHOLALIA wanted to find out if students, and UNAD (University of medical students did feel supported Nottingham at Derby) have a similar by the Students’ Union, and whether role in supporting the graduate entry there was any ‘It would be good to be medics until they more that could be join MedSoc in their able to contact the SU done to improve clinical years. more readily about services. The SU mission educational issues.’ As most people statement is ‘to know, MedSoc is the umbrella improve the experience of student life organisation that acts as an by providing quality services, intermediary between medical representation and development societies and the SU. MedSoc have opportunities for all of our students’. the task of supporting over 40 sports Sadly, every year in the National and societies purely for medical Student Survey final year medics do not rate the SU particularly highly, and we wanted to find out why this might be. Following our online survey the SU have provided information regarding the services that are currently available and those that they are currently improving.

‘Lacking knowledge or empathy for Medschool timetables, life or course structure.’ The online survey was completed by students across all five year groups, and the responses were wide

What do the numbers say?

91% of you knew that MedSoc is a branch of the SU that takes the role of being an umbrella organisation for medical student societies and welfare.

19 The number of societies that had a committee member respond to our survey.

28% of you feel adequately supported by the SU. 9% of you did not realise that MedSoc was part of the SU.

61% How many of you said that you had trouble contacting the SU.

2.4/5 The average rating of how well supported students felt by the SU.

72% of you have felt that the SU could be supporting you or your society more than at present.

12% knew that the B floor space was bookable for use.

88% of you did not realise that the SU space on B floor was available to students.

ranging. Members from most sports and societies responded, giving us the opinion of students with a wide range of interests. There was also a wide response from committee members of almost half the listed societies, in some cases more than one committee member responding on behalf of the same society. It is often the committee members of societies that have the greatest involvement with MedSoc and the SU, therefore responses from these members are useful in establishing whether the people that help run the societies are supported enough in their endeavours.

supported students felt within the level of support from 1 (not at all) to 5 medical school. As opinions vary (very). Turn over to see the results. according to the roles one plays we Of everyone that had ever tried to asked about support as just a ‘I was a GEM. Derby students contact the SU, 39% felt that medical student, get an intro speech about the their answer as a member of a SU being for everyone and was To gain a rough idea of how students society, and as unsatisfactory. one of the very little else. What's the felt about the SU, we asked how Many people committee print shop, for example?’ members of one of felt that ‘The Treasury and Print the many MedSoc affiliated societies. responses were slow, and often did shop are never open late We asked for students to rate the not answer the question asked, and

enough.’

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medical students knew when it was There is one thing that has become open specifically for them it may most apparent from our survey. Whilst the SU continue to improve access. This suggestion ‘I have used the print shop work to support us, has been passed for society reasons and both there is still a lot more the SU can do, on to the SU for times they have been helpful and ECHOLALIA consideration. and completed my order hopes, that following The service the responses to our quickly and efficiently’. provided by the survey, they enact Print Shop some of the suggestions. seems of a generally good standard; although, once again opening times do ECHOLALIA TEAM not take into consideration the longer sadly some people felt that they were hours worked by medical students. not valued by the SU staff and that at 71% of people felt the Students’ Union times staff were rude and extremely could be providing more support. All of unhelpful. That the suggestions The SU response said, 61% of made have been students were ‘Take time to understand how passed on to the SU We presented satisfied by medics work and support for consideration and these results to the Students’ responses given. them, rather than trying to fit ECHOLALIA hopes Union and this The Treasury us into the neat little boxes they will act upon the is the reply sent has always been suggestions made. by postgraduate they already have.’ Laura a contentious We hope that in the officer, issue amongst sports and societies future, if a similar questionnaire is sent Theobald. with 61% of people who responded describing the difficulties they had experienced when trying to access either the print shop or treasury. The main issue regarding the Treasury seems to be the opening times and levels of communication, some people have suggested later opening on occasions to facilitate access for those who are on clinical placement, even if it is not as regularly as once a week, if

responses will be more positive. As one respondent said, the SU should ‘take the time to understand how medics work and support them, rather than fit us into the neat little boxes they already have’.

‘Remember that we are also part of the university!!!’

‘The research is a great insight in to how some of the medical students are currently feeling and gives us more information on the areas where we can and are supporting students. Whilst there are some areas that need additional focus and attention, I’m pleased to say that we are already working on improvements and campaigns such as working with the council for free permits for students on clinical placements, Officers leading on a campaign against hidden course costs within the medical school, and continuing to lobby the University next year for improved hopper bus services especially for students on placements. We’ll also be introducing a mobile banking app for society funds, which will be available next February 2015 and working to improve the communication between medical societies by facilitating the creation of a MedSoc Groups Forum for presidents of societies and sports groups to attend and make suggestions and share best practice’

The room on B Floor is centrally bookable after 3pm through: Results: How you rated the SU. The average score for each showed that there was suroombookings@nottingham.ac.uk room for improvement in support offered to medical students.

Nottingham Medico Chirurgical Society Lectures 2014/15 The Nottingham Medico Chirurgical Society would like to welcome all medical students to this years programme of lectures held at the Postgraduate Education Centre, City Hospital. Lectures begin at 7pm but a buffet and drinks are available from 6.15pm for just £2.50 and we would love to see you there.

1st October 2014

12th November 2014

10th December 2014

Presidential address

A life of crime

Me and my career—a tale of serendipity, scandal and Satan.

Professor Richard Shepherd Bsc (Hons) MB.BS DMJ (Path) FRCPath

Determining the colour of dinosaurs Professor Mike Benton BSc PhD FRS

Dr Geoffrey Hulman MD FRCPat

Consultant in Forensic Pathology and Visiting Professor, Chester University

Consultant Histopathologist,

BART lecture

Professor of Palaeontology in the Department of Earth Sciences, University of Bristol

14th January 2015

4th February 2015

11th March 2015

Solar variability and climate change

Nottingham and other amazing Maggie’s centres

Incest and folk dancing; two things to avoid

Professor Joanna Haigh CBE FRS FInstP FRMetS

Piers Gough CBE RIBA RA

Professor Steve Jones FRS

Partner CZWG Architects Llp

Professor of Atmospheric Physics, Imperial College, London

Professor of Architecture, Royal Academy Schools

Emeritus Professor of Genetics, University College London

20th May 2015

22nd April 2015

Regulating the body clock—the unrecognised role of the eye Professor Russel Foster BSc PhS FRS Professor of Circadian Neuroscience, Oxford University BART lecture

www.medchi.org.uk

BART lecture

What causes wellness? Professor Sir Harry Burns FRSE Professor in Global Public Health, University of Strathclyde BART lecture

President—Dr Geoffrey Hulman FRCPath | 27

What is the Academic

Who should consider

Foundation Programme?

applying for the AFP?

The AFP is a variation of the standard programme that gives junior doctors exposure to research, teaching or leadership.

Features

Typically, academic work is one of the three rotations in F2. However AFPs in Newcastle have two academic rotations – one each in F1 and F2 – and Oxford integrate their academic training across the whole 2 years.

It is possible to apply for both the AFP and FP, with offers for the former made first. AFP candidates can apply to two Foundations Schools, with the Thames Schools combined into one (unlike for the FP). Shortlisted candidates are then interviewed and those receiving offers informed in late January. Competition ratios are typically 2:1 or 3:1, with London, Oxford and Cambridge over 7:1.

The AFP can be a stepping-stone to obtaining an Academic Clinical Fellowship, but definitely isn’t just for those wanting to become clinical academics. Getting your preferred training post or consultant job is increasingly dependent on research experience and publications. Even for those with less clear career goals can benefit from an AFP application – just getting an interview will help prepare you for ST1/CT1 interviews.

Careers The Academic Foundation Programme How can I improve my chances of being successful? 1) A high degree class in the BMedSci or additional degrees boost your educational score. 2) Unlike the FP, posters at non-student conferences and prizes still count towards the application. Essay prizes exist for almost every speciality, most of which receive few entries. 3) Ensure your basic clinical knowledge is strong; you will not be selected if interviewers think you won’t gain your clinical competencies in the 5 remaining clinical rotations. 4) INSPIRE run mock interviews and is piloting an initiative to link students to research projects within the University.

Tom Jackson is currently a 4th year and a member of the Academic Medicine Society, INSPIRE. For more information about the AFP go to the Foundation Programme website

Student insight

What is it really like to take a year out to pursue academic research?

Tomorrow’s Doctors stipulates that graduates must be able to ‘evaluate and integrate evidence critically’. This includes handling and understanding of statistics and detection of error and bias in papers. We are given a project and some teaching to cover the foundations of the research process and critical appraisal, but I feel that this is lacking in scope. Students across the UK are less involved with critical appraisal of research than previous years, and clinical research is sidelined towards specialist research graduates. Last year, I opted out of the medical course for one year to complete a Masters degree. As the news spread amongst the year, the response was polarised between delighted enthusiasms, to outright horror. However, the recurring theme from many was surprise. There are several ways to be involved in academic research at the University – INSPIRE provide funding for projects organized by students, and SCRUBS are promoting clinical audits developed and supervised by surgical clinicians. Why take a year out?

A Gantt chart for a simple research project. This visual representation was very useful in deciding how long each step should take. Finally, research provides a wealth of skills: those wishing to pursue an academic career will find their CV bolstered by a postgraduate degree (although it is not a necessity); communication skills from collaboration or presentations within the department or at conferences; time management while handling several projects at once; computer skills using within-department programs, and so on. A major boon to any research project is the flexibility. Many clinical academics are willing to have student involvement, if you ask nicely.

easy for several months to disappear with an average output. Thus, a recommendation is to plan using a Gantt chart. Additionally, having consistent meetings with your supervisor is especially helpful – 10 are the strict minimum, but this gives time to ask questions or meet deadlines for intended goals.

If you are shackled by endless procrastination, weekly workshops of ‘Shut Up and Write’ are available to postgraduates. These sessions allow four blocks of unimpeded silence so that you can plan, read or write in a On the way, I’ve picked up some great constructive environment. You are advice that has helped with my research rewarded with a free lunch. year. Academic research is an exciting A study thesis must form a sound opportunity to engage with clinicians argument, or the resulting research is and researchers, and provides much invalid. This can take time – but an more rounded development than just a agreed and planned method with your handful of points to your Foundation department or supervisor will smooth Application score. There are many ways Secondly, the choice was a personal the research process. Nothing is more to be involved, alongside or independent one. We are lucky in the UK to be daunting than trying again from scratch to your degree. allowed to study Medicine at 18 –the because of a methodological flaw. majority of Europe doesn’t permit until Secondly, statistical power of your you are 25 – and I was concerned that it Questions? Feel free to get in touch; research is very important, so always was not my intended direction. In short, email me at mzydk@nottingham.ac.uk collect significantly more data than this was a ‘gap year plus’. While this needed. Samples can get contaminated; may not apply to you, students may find data can get corrupted. that research provides a well-needed Dan Kent respite, if the thought of graduation and The hardest part of any project is the responsibility is looming. time management aspect, and it is very My reasoning was twofold. Primarily, it provided an opportunity to focus in a research environment that is independent to the medical course. My department was kind enough to provide a desk, a computer, and an access to the filter coffee machine! (N.B. The stereotype of the caffeine-laden researcher is, to the best of my knowledge, a fitting one). This setting allowed time to build a research question, analyse data, and draw conclusions without distraction.

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The use of apps in medicine

Apps and medical education

Whilst the array of medical apps is vast, some have become a staple in the medical student’s iPhone. Free anatomy apps such as Visual Anatomy Lite and Gray’s Anatomy provide guides to all things anatomical and are significantly lighter than the paper version! Both feature rotational models, muscle description, and high resolution images that are already revolutionising anatomy teaching.

Medscape mobile app from WebMD, that provides an extensive database of most diseases at our finger-tips, has become a firm favourite in US and is becoming increasingly popular here in the UK too. The apps available today make information more accessible than ever, and have the potential to create a whole new generation of more competent and knowledgeable professionals. Smartphone apps have the added

Smartphone apps are becoming increasingly more sophisticated day by day. These types of technological advance have gradually infiltrated into the expanding industry of healthcarewith the promise of benefits for both the medical professionals and the patients that they serve. Smartphone apps are revolutionising check-ups and examinations; they are transforming the way in which medical students learn and practice, as well as allowing patients greater autonomy in checking their symptoms and managing their own conditions.

advantage of allowing students to thoroughly test themselves before being unleashed on patients. For example, the BMJ’s revision app, OnExamination, contains countless multiple choice examination questions, giving students the chance to fine tune their response to clinical presentations.

Apps for clinical examinations Whilst the choice of apps for medical students remains extensive, it is perhaps the newer generation of interactive examination apps that are likely to transform the average check up. In 2013, AliveCorr issued an iPhone based ECG heart monitor available on prescription. The device takes the form of an iPhone case with 2 electrodes on the back. Patients can place their hands on the electrode to complete the electrocardiogram circuit, resulting in an ECG reading which can then be stored for analysis -providing a wire-free solution to ECGs. Not only will this technology improve the speed and accuracy of diagnosis of conditions such as atrial fibrillation, but will also allow patients to monitor their own conditions with ease.

which can then be saved and reviewed. Perhaps the most revolutionary iPhone app is the iStethoscope, which has already been purchased by millions of physicians since its release. One of the most important upsides to the app is the ability to record and listen back to patient’s heart sounds. Some have criticised the sound quality of the app, but with newer versions being released periodically it’s likely that this will be a mere glitch in the future of iStethoscope.

Another exciting development in the world of app examinations is that of the iExaminer iPhone adapter. The system used an iPhone case which aligns an ophthalmoscope to the iPhone camera, allowing a crystal clear image of the eye

iExaminer App

Apps for lifestyle management Patients with chronic conditions such as asthma or diabetes have an array of apps available in order to make their conditions easier to live with. The market for apps to manage diabetes has become particularly saturated, from sharing tips and stories with diabetics

Fooducate App

around the world (DiabeticConnect) to managing diet by scanning the barcodes of food (Fooducate). Apps such as Glucose Buddy allow diabetics to track their vital data with much greater ease. By entering blood glucose, insulin dosage and calorie intake, patients have greater autonomy and can take charge of their condition. The app has the added advantage of notifying the user when data input is needed and allows users to print and review their statistics online, creating an easier correspondence with healthcare professionals. Health and fitness apps have created a new generation of patients taking their well-being into their own hands.

Final Comments Many have argued that the rise in accessibility of self-diagnosis websites and apps such as WebMD has become harmful to patients. Whilst such symptom checker sites have the advantage of encouraging patients to be vigilant to changes in their health and motivated to educate themselves, there is a potential for the ‘cyberchondria’ effect. There is also an element of fear that comes with an over-reliance on such technology. For $119.99 a year, physicians can purchase Isabel Healthcare's diagnosis decisionsupport system app, an all-encompassing medical database matching over 6000 diseases with symptom checklists. Clearly such apps are useful for confirming diagnosis, but there is an ever present threat of a costly misdiagnosis from just one touch of a button. If used correctly, smartphone apps truly have the potential to transform the clinical practice in our healthcare system. The future of diagnostics is set to be quicker, more accurate, with more efficient treatment results. With a higher level of patient responsibility through the use of smartphone apps, conditions can be better managed and controlled. Perhaps the most important impact of such technology is the way in which patients and physicians interact. Smartphone apps clearly make important medical decisions much easier to communicate between patient and physicians, and may result in a generation of more compliant patients. Whilst medical education continues to evolve incorporating technology, the iPhone has become in many ways, anything but a simple means of communication, and could, quite literally, save lives. Sara Dawson 35 31 | 31

Features

he term ‘natural’ is used ubiquitously in contemporary society to sell. It has become a fashionable description deployed as a marketing strategy for innumerable goods, such as organic foods, cosmetics and alternative medicines. The word’s omnipresence and association with health has conditioned many consumers to mistrust anything which does not brandish its label. But are we too obsessed with the natural and is it wise to shun the artificial in its favour? Dr Norman Borlaug was an American scientist who earned the Nobel Peace Prize in 1970 due to his pioneering research into genetically modified crops. By artificially producing various strains of wheat and rice which was hardier and more resistant to disease, Dr Borlaug is credited with saving over one billion people from starvation. But despite this incredible feat, there are people who remain

wholeheartedly in opposition to GM food. Greenpeace, for example, is campaigning for the world to return to solely organic farming methods. But is GM food (or ‘Frankenstein food’ as one activist described it) worse for you than its more natural organic alternative? In 2008, Baron Krebs, former head of the Food Standards Agency (whose father elucidated the TCA cycle in 1937 to the eternal gratitude of generations of medical students), commented that there is no reliable evidence to suggest that organic food is any more safe or nutritious than non-organic food. This has recently been backed up by a systematic review published in the Annals of Internal Medicine. Food which has had its genes modified in the laboratory, rather than by selective breeding on the farm, has saved one billion people from death with no compromise on the safety or nutritional value of the final product.

Campaigning, then, to return to more ‘natural’ ways of farming seems rather immoral, and it’s likely that anybody who has sufficient free time to march with a placard would not be one of those affected by the subsequent shortage of food. The cosmetic industry also uses the ‘natural’ marketing strategy with vigour. It’s done to such an extent, in fact, that one could easily mistake their bathroom cabinet for a kitchen cupboard: face creams with honey, body washes with guava and moisturisers with cocoa butter are mundanely common. Some brands go to such extents to include natural and indulgent ingredients in their products that the results are laughable; one popular shampoo is laced with ‘diamond dust’, ‘cashmere’ and ‘ champagne extracts’! Any science-y sounding ingredients in these products are ignominiously demoted to the back of the bottle in

un-readably small font because of the favour of more natural (less effective) public’s mistrust of anything which is alternatives. But it is interesting to produced in the laboratory. consider why people have such mistrust for something produced by a But almost all cosmetics do have scientist rather than Mother Nature. ingredients manufactured in this manner. Even my Original Source It is commonly argued that we have shower gel, which is packed with not evolved to ingest man-made ’7,927 tingling real mint leaves’, products and should therefore avoid contains commercially prepared them. But this logic is flawed. ingredients – it is not juiced directly Evolution is not an infallible process from the herb into the bottle as the and frequently requires us to create branding may lead you to believe. artificial remedies in order to offset its This doesn’t matter, of course, failings. Our naturally evolved because the artificial ingredients are immune systems, for example, are in added for a reason. The preservative a constant arms race with bacteria sodium benzoate, for example, stops and may require the fire power of my shower gel ‘going off’ which unnatural antibiotics. In addition, means I’m not rubbing mould all over archaic and unsuitable evolved my face every morning and I can be responses can be the very reason assured that it is, in fact, the mint and why we have had to create synthetic not bacteria which is making my balls interventions. Our kidneys, for tingle. instance, have evolved to retain water in response to decreased Even in the medical world, patients perfusion. However, this can often turn their backs on exacerbate heart failure, so we treat conventional, scientific medicines in

this ailment with medicines that help the body dispose of excess fluid. The pills are unnatural, the diuretics are not plucked from trees and the ACE inhibitors are not dug from the earth, but they nevertheless grant extra beats to tiring hearts. Modern, manmade medicines mean we no longer need to relinquish our fate to a process of random trial and error. Contemporary society is everincreasingly embracing the natural whilst shunning the scientific. As future medical professionals it is important that we remain aware of this shifting attitude and encourage our patients appreciate the vast benefits of science and its byproducts. Otherwise, it may get to the point where we have to get used to prescribing homeopathy for patients unwilling to accept anything unnatural. And those doses would be a nightmare. Simon Wyatt

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A Free Kick to the Head:

Features

Concussion in football

The recent World Cup in Brazil showcased all the thrills and spills of a great sporting event – upsets, rising stars and goals galore. Unfortunately it’s also been in the news for a number of medical issues on the pitch (injured physiotherapists aside). Uruguay’s Maxi Pereira, Xavier Mascherano of Argentina, and German Cristoph Kramer all suffered blows to the head during matches and continued to play, despite all showing signs of concussion. Kramer, for example, stated no recollection of the first half of the world cup final. Maxi Pereira also appeared to persuade the attending doctor and his team physiotherapists that he was fit to continue after appearing to be knocked unconscious against England. The incidents have lead to calls from the players’ professional body FIFPro and branches of the media for a review of

the treatment protocols offered to delayed, which emphasises the need players in cases of concussion. for proper assessment before a player is allowed to continue. Even more The Fédération Internationale de poignant evidence from the American Football Association (FIFA) does have College of Surgeons suggests that a publically available ‘Recognise and fairly minor head injury secondary to a Remove’ guidelines for recognising concussion, can lead to a serious concussion that includes the signs, haematoma or cerebral oedema, thus symptoms and red flags to look out for. strengthening the argument for proper However, during recent World Cup sideline assessment. incidents these guidelines have clearly not been implemented robustly Current FIFA’s ‘return to play’ protocol enough, calling into question attitudes allows play to continue while a player towards player safety at an elite level, receives treatment on the sidelines, which in turn sets a bad example for with the affected team down a player attitudes towards concussion at the for the duration of treatment. A system grass roots. A recent article on the like ‘blood substitutions’ in rugby would subject by the Lancet raised the need allow players to be properly assessed for adequate assessment from an off the field without disadvantaging unbiased clinician so that a player or their team; whereby replacement team’s vested interest doesn’t affect players come on for the duration of the decision, as in the case of Pereira. treatment for a player to prevent the The article also suggests that acute affected team being a man short. symptoms of concussion can be

concussions, and in July of this year, the National Football League (NFL) agreed to remove a $675 million compensation cap for players who have suffered neurological conditions such as dementia and Lou Gehrig’s disease – these are judged to be as a result of the sport. The scale of the figures show how seriously the issue is being taken within American football, even without completely understanding the links between concussion and CTE. Though the risk of concussion complications will inevitably be greater in high impact sports such as boxing and American football, the growing evidence must at least point towards higher caution in cases of football concussions. Steps ought to be taken by FIFA to change attitudes to, and assessment of, concussions on the pitch. Similarly, because symptoms can sometimes be subtle, the proper education of officials and coaches at every level would be beneficial to players at all levels. Peter Hateley

Do you follow?

While the shorter-term effects of concussion are usually not severe and resolve spontaneously, the uncommon chronic effects are beginning to be better understood. From as early as the 1920s, the cumulative damaging effects of concussive blows in boxing were noticed by clinicians. Then called ‘punch drunk’ syndrome, or dementia pugilistica, it observed the neurological deterioration in prizefighter boxers. Today the condition is commonly known as chronic traumatic encephalopathy (CTE) and features pathological changes in tau proteins within the brain, which over decades is associated with neurodegenerative changes of varying severity, including personality changes, dementia and Parkinsonism, amongst other symptoms. Though boxing has long been linked to this condition, other impact sports such as American football are now acknowledging the effects that repeated concussions have had on players. CTE has been found post mortem in a number of exAmerican football players who have suffered multiple

Do you ever wonder what happens to all of the paperwork we generate in feedback forms, reflections, logbook signs offs and their carbon copies? I can’t imagine that some sorry meded type soul is forced to read every CP1 student’s ‘insights’ regarding IPL, nor do I believe that future historians will marvel over a meticulously archived collection of my preclinical tutor meetings. My theory is that everything we ever hand in is carefully collated in a skip before being burned to power the hospital. There is just so much paper, and as you progress, the volume of signatures and drivel you must collect increases in direct proportion to the amount of grief you get for missing something. So the final week of any placement becomes a desperate logbook chase, with slightly desperate looking students badgering the nurses to watch them test somebody’s urine, while others trek around the hospital looking for that podiatrist they sat in with but forgot to get a signature from. Then you hand the logbook in, complete barring one tick box that you just couldn’t get with the clinics they gave you, and a consultant who you have met once or twice (or even never) uses that missing tick as evidence that you have clearly learned nothing in your time here and subsequently cannot be signed off. Tick boxes and sign-offs are the only things that you need to take away from a placement, because they are clearly the only things that they care about. No consultant supervising you for the entire placement? Eh, email the module lead if you really care. Terrible teaching fellow? What do you expect us to do about it? Teaching rescheduled without notice… again? It’s clearly your fault for not checking your emails in the car while commuting. But what is this? You had to see this many patients with X and you saw one fewer? You’d better come back to clinic on the day of the exam to rectify your egregious mistake. Do you follow?

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BEST

2014

Arts and Culture Captain America:

The Edge of Tomorrow

The LEGO Movie

The Winter Soldier

Yes, I’m talking about the latest Tom Cruise film, and yes, I’m just as surprised about it as you are. Major Cage (Cruise) finds himself stuck in a time-loop after he dies whilst fighting an invading alien race. With the help of Sergeant Vrataski (Emily Blunt), he repeats the same day over and over, honing his combat skills as he gets closer to defeating the alien threat. It’s Groundhog Day with aliens; the action sequences are great and it’s surprisingly humorous, so the timeloop never seems repetitive. It’s a change of pace from Cruise’s usual roles – he’s a scared, inexperienced soldier rather than his usual smiling hero – and he does a great job with it, but Blunt is the one who’s truly outstanding.

Emmet (Chris Pratt) is just an ordinary Lego construction worker, but somehow the Master Builders believe him to be the prophesised ‘Special’, the only one capable of stopping President Business (Will Ferrell) from gluing all LEGO figures where they stand. Don’t be fooled; it’s a lot more than just a kids’ movie – it’s witty and compelling, and the live-action segment is truly heart-warming. Plus, the voice cast is excellent; Liam Neeson makes a great Bad Cop, and Will Arnett’s dark and brooding Batman will have you in stitches. Oh, and you’ll have the ‘Everything is Awesome’ song stuck in your head for days.

he latest film in The Avengers franchise and one of the best. We catch up with the Cap (Chris Evans) who, whilst trying to adjust to life in the 21st century, must uncover a conspiracy within SHIELD that threatens the whole world. The plot is completely gripping, with just the right mix of action, tension and character development, and there are a few twists thrown in for good measure. The supporting cast of Samuel L Jackson, Scarlett Johansson and Anthony Mackie (who plays the latest Avenger, Falcon) are excellent in their own right too. It’s a bit long at 2hr15min, but you’ll be thoroughly entertained throughout.

Looking for a good movie to keep your hall or housemates entertained for an evening? Katie Jeffs runs down some of the best and worst films of 2014 to help you choose!

FILMS

Honourable mentions: The Grand Budapest Hotel, The Double, Dallas Buyers Club

WORST FILMS

2014

Transcendence

The Amazing Spider-Man 2

Pompeii

It’s a real shame that Transcendence makes this list as it looked so promising. Dr Will Caster (Johnny Depp) is a researcher working to create a sentient computer. After he is shot by antitechnology extremists, his wife (Rebecca Hall) uploads his consciousness into his computer, but soon becomes concerned by the supercomputer’s rapidly growing intelligence. Unfortunately what could have been a great exploration of logic versus reality is instead a dull relationship story, filled with plot holes and meaningless technobabble. It’s hard to care about any of the characters either; not even Depp, who just acts lifelessly on a computer screen for most of the film. Johnny, we love you, but please stop making terrible films.

This one might be a bit controversial. In this instalment of the Spider-Man reboot, Peter Parker (Andrew Garfield) has to deal with new villains, old friends, the mystery surrounding his father’s death and his relationship with Gwen Stacy (Emma Stone). The problem is, it’s over two hours long and despite all the plotlines, the film never seems to go anywhere. Somehow it’s both rushed AND too slow – Peter and Harry Osborn become best friends within five minutes, but it takes forever to set up the fight scenes. Whilst Gwen and her chemistry with Peter are great, the rest of the characters are underdeveloped; Electro’s motives are weak, and Rhino is little more than a cameo. That said, it’s still better than Sam Raimi’s Spider-Man 3.

It’s beyond me why anyone would want to see a film where everybody obviously dies at the end (um, spoiler alert?), but the powers-thatbe evidently thought differently. In this ‘historical disaster’ film, slaveturned-gladiator Milo (Kit Harrington) must rescue the woman he loves from the evil clutches of Corvus (Kiefer Sutherland) before Vesuvius erupts and kills them all (again, spoilers?). Some people might find it a guilty pleasure, but really the whole thing just seems pointless. It’s disappointing as the cast list is decent (Carrie-Anne Moss and Emily Browning), but the script really should’ve warned them off. You know nothing, Jon Snow. (Dis)honourable mentions: The Legend of Hercules, Winter’s Tale, Need for Speed

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Restaurant Sat Bains. Lenton Lane.

Arts and Culture

A two-star Michelin restaurant and hotel in several converted barns near Clifton Boulevard. A 7 or 10 course tasting menu is available for lunch and dinner in the restaurant or at a chefâ&#x20AC;&#x2122;s table to see the food being prepared in the kitchen. Fantastic if you are into the whole dining experience. This is the most expensive restaurant on this list, so perhaps tone to visit after graduating, with your parents paying, of course.

Nottingham foodie hotspots

Iberico. The Shire Hall, High Pavement. Located in the old county gaol which also houses the Galleries of Justice, this restaurant serves a selection of traditional Spanish and innovative world tapas. The food is delicious, with a wide choice of dishes. This subterranean restaurant has a great atmosphere and with so much on offer, you will definitely try something that you have never eaten before (even if you are a regular customer).

World Service. Newdigate House, Castle Gate. Housed in a beautiful 17th century building, the decor is a fusion of British and Oriental. The food is varied and excellent, blending British and international flavours in a menu which changes frequently. I would also recommend the bar, where they are happy to make you a range of cocktails that you can enjoy in the Oriental garden.

The Larder on Goosegate. 16-22 Goosegate, Hockley. The Larder is located in a Grade II listed Victorian building used as Jesse Bootâ&#x20AC;&#x2122;s first apothecary in Nottingham. The apothecary eventually moved and became the national company Boots, but the restaurant still displays the apothecaryâ&#x20AC;&#x2122;s original cabinets and medicine bottles. The food is a mix of classic and modern British, very tasty and all locally sourced.

Harts. Park Row. This is the perfect place for an indulgent lunch or dinner, with a wide choice of high quality food. The dessert menu is inventive and the service is excellent. If the weather allows then definitely get outside for a drink in the terrace garden, which boasts a great view across The Park so you can appreciate some of the quirky architecture.

Delilah. 12 Victoria Street.

The Cod’s Scallops. 170 Bramcote Lane, Wollaton. Sometimes classic combinations just cannot be beaten. Recently included in The Times’ list of top 30 fish and chip shops in the country (number 18), this restaurant definitely serves the best fish and chips in the city. You can mix and match shellfish, or order a freshly cooked fish (battered or breaded) from the large fish counter. They also do takeaway!

Annie’s Burger Shack. 5 Broadway, Lace Market. Although this amazing burger restaurant used to move all over the city, it has recently settled permanently in the Lace Market. Annie’s combines a great selection of beers and real ales with the largest burger menu in the city. It has become well known for its flavour combinations and can be recommended to those who normally would never go to a burger restaurant.

Since upscaling to their new (bigger!) location, getting a seat at the bar is no longer a battle. This wonderful delicatessen sells a variety of food and wine but also serves great breakfast and lunch in the laid back atmosphere of a busy deli. The lunchtime specials board is well worth investigating for the sandwiches and antipasti. This is a perfect place to treat yourself to brunch at the weekend or to drop in for coffee and cake.

Memsaab. Maid marian way. The food tastes as good as the plush interior looks. Decadent, red and patrolled by suited and sari-ed staff, the excellent service will have you coming back again and again. A mixture of regional Indian, Pakistani and modern Indian cuisine makes this menu a lot more exciting than any student-targeting, cheap local curry house. This place is in a different league, so be adventurous when you order and it’ll pay off. Whilst not horribly pricey, you might want to reserve it for when family are visiting.

Saltwater. The Cornerhouse, Foreman Street. Rocket restaurant run this popular rooftop bar which offers beautiful views over the Nottingham skyline. Saltwater has frequently been included in lists of the best rooftop bars in the country (in winter it is best to stay inside). Although the food is good, the view is the real draw here, so it gets very busy in the evenings. Come here for a cocktail and to take in the city at night. Alice Armitage

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Arts and Culture

Tired of the Operating Theatre?

The Northen Ballet Dancers (above); CATS the Musical (top right); The Birmingham Hippodrome (bottom left) The Sheffield Crucible and Lyceum (middle right); The Nottingham Playhouse (bottom right)

n a rather warm (free heating!) swept along with the music, the have been known to do in previous night in Mansfield, when the dancing, the exquisite costumes and years but the Kite Runner is our next O student loan comes in and we’re makeup and the cheeky personalities venture at Nottingham Playhouse. away on placement there seems to be one thing our money seems to go on. Setting ourselves up for a term of fortnightly theatre trips to indulge in: plays, musicals, dance and art displays, operas and classical concerts. Ultimately spending the money all at once helps save the guilt and feelings of frivolity that might come later Last term saw us visiting musicals such as CATS, Tom’s Midnight Garden and Singin’ in the Rain. A short drive or train journey away, we found ourselves at the Sheffield Crucible and Lyceum. These theatres also had so much to offer from classics like Fame, to the new Beatles musical Let it Be.

in each cat. The poems take you through descriptions of each member of a tribe of cats, the Jellicles. With music, dance and poetry the show has been said to fuse together in a ‘bizarrely brilliant way’. ‘ Another interesting watch was Let it Be at the Sheffield Lyceum. Just a short drive up the M1, the Lyceum is a lovely 19th century theatre with a fantastic bar and foyer providing a truly exciting atmosphere. Let it Be is a show based on the music of the Beatles. However, it was not the musical we were expecting. The experience leaves you feeling like you’re at multiple Beatles concerts from their various albums through the ages. Whilst it wasn’t what we had anticipated, it was a brilliant show providing an evening with the Beatles like no other.

CATS is based on a book of poetry, so whilst it doesn’t have a story to follow, some theatre goers find this easier as you can take from it what With the prospect of my elective on you will. It requires neither a lot nor a the horizon, it is unlikely we’ll be able little imagination and you can get to frequent the theatre as much as we 40

Other possibilities in the next year are; The Great Gatsby by Northern Ballet, Shrek, The Curious Incident of the Dog in the Nighttime, Jeeves and Wooster, and One Man, Two Guvnors (one not to be missed), all at the Theatre Royal Nottingham. If you can bear to venture further west, the Birmingham Hippodrome is hosting some fantastic productions this year, with Wicked having toured there already and Blood Brothers coming in the near future. Next year also sees Matthew Bourne’s Edward Scissorhands amongst some other great Ballets and dance productions. If it’s for a romantic date, an evening with friends, or a break from revision, get yourself something at the theatre booked, save the guilt when you feel you have no money, and have a fantastic time! Alexandra Maslen

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Essential Lecture Handouts

Interpreting

LFTs The liver: an overview

Liver function tests (LFTs) are a staple investigation for most patients on admission, as well as a stock answer to any examiner or consultant who wants you to come up with a plan of action on the spot (“FBCs, U&Es and LFTs!” we exclaim in response to any presenting complaint). Knowing what all the acronyms stand for is important but interpretation is crucial. It is an essential part of providing good care at any level of your career from student to consultant. This short guide will hopefully break down LFT’s for you.

To understand the LFT results in front of you, you have to understand two simple principles: not tes 1. LFTs do

tion ses, t liver func inotransfera m a e th lly LFTs;

ld actua ts of componen rase; shou fe e s n m y ra z lt n y e to the lutam The se and λ-g n. Damage o ta ti a c h n p fu s t o o h n alkaline p c enzymes ng damage ese hepati as measuri th f f o o t h e g s u a o le be th the non es re stem induc LFTs. Even y s n o ry n a o ili ti c -b sent dete hepato that repre ubsequent ; s in d n m a u d lb o a d into the blo . The liver ilirubin an insensitive onents; b p ly e m v o ti c la e re quate are enzym aintain ade of the liver, m n n o ti a c c n d fu n a synthetic nal reserve g. ing functio z a m ite a beatin a u q n n a e k ta has s a h it nction until synthetic fu

2. Derang ed (abnor mal) LFTs not always do mean live r disease 1 in 6 of the

population asymptom has an atic deran g e ment of th due to fatty e ir LFTs change. Many conditions that derangeme cause nt have no LFT liver involv ement.

Tested molecule

Normal range

Location

AST

0-30iU/L

Hepatocytes, heart muscle, skeletal muscle, RBCs

ALT

0-35iU/L

Hepatocytes (mostly)

ALP

40-130iU/L (non-pregnant adults)

Biliary cells, bone and placenta

GGT

0-40iU/L

Biliary cells, pancreas, intestines and renal tubules

Albumin

30-50g/L

Bilirubin

0-21µmol/L

RBCs, liver, biliary tract

Aminotransferases (AST and ALT) means hepatic y located in hepatocytes, this These enzymes are primaril e amounts of larly hepatitis, will release larg parenchymal damage, particu test ALT as it is so most laboratories will just g, thin e sam the t tes h Bot them. and red blood in significant amounts in muscle more reliable. AST is found elated to the liver, can be raised in conditions unr it and le) tab ve abo e (se s cell is and haemolysis. such as post-MI, rhabdomyolys T: ALT ratio. This combined to produce the AS Sometimes, both results are t is >2 suggests diagnosis. An AST: ALT tha can be helpful in guiding the oholic disease is a ratio of <1 means that non -alc alcoholic liver disease, whilst hosis develops, ALT is higher than AST until cirr likely. In chronic liver disease, omes true. at which point the reverse bec

LFTs are taken in a yellow vacutainer for clinical chemistry.

Alkaline phosphatases

Many students mak e the mistake of us ing albumin in interpretation of ac ute presentations. Do n’t. It has a long half-life and m ay remain high desp ite significant acute damage. It ca n also be lowered by a variety of acute non-hepatic illnesses too. Use it instead as a marker of chronic liv er disease progress ion. W hen presented wi th hypoalbuminaem ia, consider;  Reduced productio n – caused for exam ple by chronic liver disease or extreme malnutritio n.  Increased protein los s – caused for exam ple by nephrotic synd rome or proteinlos ing enteropathies.

λ-glutamyltransferase (GGT) n e to haemoglobi n in the blood du tio uc od e pr er th its From cytes, ation in hepato ug nj co its to m th r in e catabolis ology can occu th pa re he w s te are many si raised bilirubin ubin. Seeing a lir bi of n tio uc prod source. Is it investigate the to u yo pt om pr should duced liver ), hepatic (re is ys ol m ae (h prehepatic or posthepatic liver damage) or n tio nc fu it is a rise in ishing whether bl ta Es )? is as st (chole localise the ated will help ug nj co un or conjugated lesion.

It might seem intuitive that long term liver disease should demonstrate significant LFT derangement. This, in reality, is not the case. Chronic liver disease, especially with cirrhosis, where the causative agent has been treated shows minimal LFTs abnormalities. An ex-alcoholic with

alcoholic liver disease whilst remaining tee-total may have no LFT abnormality at all! In cases such as this, serial measurements of albumin or prothrombin time (markers of synthetic function) will show a more representative picture.

1. Lowth M. Abnormal liver function tests http://www.patient.co.uk/ doctor/abnormal-liver-functiontests: EMIS; [cited 2014 19th July]. 2. Marshall W, Bangert S. Clinical Chemistry. 6th ed: Mosby Elsevier; 2008. 3. Prince M, Clark P. Interpreting abnormal liver function tests. Student BMJ. 2012.

Extra Reading

A final note on chronic liver disease

Bilirubin

Albumin

inflammation biliary obstruction/ ic ss cla e th of e be due to ALP is on ion the ALP could lat iso in d ise ra if , markers. But, tural bone growth e. For example na us ca ed lat P. re AL ne d a bo cause raise Paget’s disease all uced by bone fractures or d ALP as it is prod ise ra es us ca o als Pregnancy the placenta.

GGT is used to differentiate between bone causes of rais and hepatic ed ALP. A high A LP and GGT is su biliary disease. ggestive of A raised GGT alone may indi induction due ca te to drug ingestio enzyme n. This is com alcohol but ot monly caused her drugs such by as rifampicin, phenobarbital co -amoxiclav, and griseofulv in can raise GG T too.

A summary of liver disease by LFT derangement Condition Acute hepatitis

Chronic hepatitis

Cirrhosis

Cholestasis

Malignancy and infiltrations

N to ↑↑

N to ↑

↑ to ↑↑↑

↑↑↑*

↑

N to ↑

N to ↑↑

↑↑↑

↑↑

Albumin

N to ↓

γ-Globulins

↑

N to ↑

Test Bilirubin Aminotransferases Alkaline phosphatase

Prothrombin time

Thomas Oliver

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Essential Lecture Handouts

3F reasons to love Colwick cheese!

ollowing this month’s article on the best places to eat in Nottingham, I’m showcasing some local produce. High quality local produce includes Colton Basset Stilton, Melton Mowbray pork pies and Castle Brewery beer. But, the local product I’m really going to rave about is the recently relaunched Colwick cheese.

Originally from the village of Colwick, just east of Nottingham, Colwick cheese is handmade using milk from rare breeds, resulting in a very soft texture (somewhere between brie and cream cheese) and a refreshing flavor. The launch has been a huge success following an appearance on Jamie Oliver’s Friday Night Feast. It’s available to buy at local delis, Fred Hallam, Beeston; Delilah, Victoria Street and The Cheese Shop, Flying Horse Walk. It’s a versatile cheese so can be used in almost any recipe that calls for a soft cheese; here are three ideas to get you started.

Colwick Bagel 1. Toast a bagel. 2. Spread with butter/margarine. 3. Add a generous helping of Colwick. To make this treat extra special you could add a slice of bacon, raisins, a drizzle of syrup or my personal favorite, a dash of balsamic vinegar.

Colwick & Apple Salad 1. 2. 3. 4. 5.

Slice an apple and place in a bowl of water with a dash of lemon juice (this will stop it browning). Make a dressing by mixing 3 teaspoons olive oil (the foodies amongst you might want to try English Rapeseed oil instead) with 1 teaspoon of balsamic vinegar, and add salt and pepper to taste. Make the salad with whatever leaves you have in, I think it is best with a bitter leaf such as chicory (red makes the salad look good) or radicchio. Mix the leaves and apple chunks with some walnuts and chunks of Colwick. Stir in the dressing.

- For a more substantial meal try this salad with some toasted fresh bread.

Colwick Squash 1. 2. 3. 4. 5.

Mix 1 teaspoon of cumin seeds, 1 teaspoon of dried chilli and 1 teaspoon of ground coriander with some salt and pepper. Spread this spice rub over large chunks of butternut squash or pumpkin, then drizzle in olive oil. Roast in the oven at 200°C until soft (around 40 minutes). Remove from the oven and sprinkle with chunks of crumbled Colwick. Serve with some grilled meat, the flavors in a pork chop or steak compliment the Colwick perfectly. George Hulston

Prize crossword

Unscramble to the highlighted letters and send the hidden word to us via Facebook ‘Echolalia – The Official UoN Medical School Magazine’ for a chance to win £30 worth of Amazon vouchers. Across

Down

1. 9. 10. 11. 12. 14. 16. 18. 19. 20. 22. 25. 27.

2. 3.

Endocrine organ (11) Main artery (5) Astonish (5) Burn with hot iron (5) Garden pipes (5) Revenue (5) Number (3) Slowly (music) (6) Unblock (6) Recede (3) Vacuous (5) Distribute (5) Titan who held up sky (5) 28. Reason (5) 29. Ring-shaped reef (5) 30. Doctors’ ‘hearing tubes’ (11)

1 1

10 11 13

14 16

19 20

27 28

Puzzle page 7