Midlands Medicine May 2016 by netinspire

MIDLANDS MEDICINE MAY 2016

VOLUME 28 - ISSUE No 1

EDITOR’S NOTES

RATIONAL RATIONING

JAW JAW IS BETTER THAN WAR WAR

WHY JUNIOR DOCTORS SHOULD STRIKE

MOTHERS AND DAUGHTERS: EXPLORING KNOWLEDGE ABOUT, AND ATTITUDES TOWARDS, CERVICAL SCREENING AND HPV VACCINATION

MAJOR BLEEDING COMPLICATIONS FOLLOWING ACUTE MYOCARDIAL INFARCTION: SITE, FREQUENCY AND IMPACT

TISSUE ENGINEERING APPROACHES TO TREAT EMPHYSEMA

AN ACCOUCHEUR’S FINANCIAL STRIFE IN THE 19TH CENTURY

AWARD WINNERS

A VIEW FROM THE WARDS DURING THE JUNIOR DOCTORS’ STRIKE

QUIZ NIGHT

WORDPLAY 14

INTERESTING IMAGES

QUIZ ANSWERS AND EXPLANATIONS

INDEX TO VOLUME 27

Midlands Medicine is the journal of the North Staffordshire Medical Institute, whose purpose is to promote postgraduate medical education and research. The journal was first published in 1969 as the North Staffordshire Medical Institute Journal.

COVER IMAGE

A piece of postal history on which Vera Cartlinâ&#x20AC;&#x2122;s piece An Accoucheurâ&#x20AC;&#x2122;s Financial Strife in the 19th Century is based.

Midlands Medicine

MIDLANDS MEDICINE

CONTENTS

Dr D de Takats

Editor’s notes

ASSISTANT EDITOR

Rational Rationing Ian Thornflesh

Jaw Jaw is Better than War War Paul Laszlo

Why Junior Doctors Should Strike Matthew Tabinor

EDITOR

EDITORIAL

Mr C Bolger

EDITORIAL BOARD Mr D Gough Dr I Smith K Stevenson Mr D Griffiths Helen Inwood Dr B Davies Professor R Chambers Clive Gibson Professor Bob McKinley Tracy Hall

ORIGINALS Mothers and Daughters: Exploring Knowledge About, and Attitudes Towards, Cervical Screening and HPV Vaccination Susan M Sherman, Emee Estacio, Emma Nailer , Claire Cohen, Jennifer Taylor & Charles W E Redman Major Bleeding Complications Following Acute Myocardial Infarction: Site, Frequency and Impact Mamas Mamas, Kelvin Jordan &Umesh Kadam

EDITORIAL ASSISTANT Spencer Smith

THE NORTH STAFFORDSHIRE MEDICAL INSTITUTE President: Mr B Carnes Chairman: Professor S O'Brien Honorary Secretary: Mr J Kocierz Honorary Treasurer: Mr M Barnish

Tissue Engineering Approaches to Treat Emphysema Tina P Dale, Wa’el Osman, Monica A Spiteri, Mohammed F Haris, Alicia J El Haj, Ying Yang & Nicholas R Forsyth

An Accoucheur’s Financial Strife in the 19th Century Vera Cartlin

REPORTAGE

Please forward any contributions for consideration by the Midlands Medicine Editorial Board to the Editor c/o Spencer Smith, Editorial assistant. By email: spencer@nsconferencecentre.co.uk Or by post: North Staffs Medical Institute, Hartshill Road, Hartshill, Stoke-on-Trent ST4 7NY Views expressed are solely those of the author(s) and do not reflect the views of the Midlands Medical Journal. All material herein copyright reserved, Midlands Medicine ©2016.

Volume 28, No 1, May 2016

Award Winners

A View from the Wards During the Junior Doctors’ Strike Paul Laszlo

ENDPIECES

Quiz Night Oluseyi Ogunmekan

Wordplay 14 Dominic de Takats

Interesting Images

Quiz Answers and Explanations

Index to Volume 27

EDITOR'S NOTES Welcome to this slightly later Spring issue of Midlands Medicine, the first of a new volume, number 28. The lateness is in part due to some disruptions wrought by various Junior Doctors’ Strikes which have now taken place on three separate occasions, and also due to a desire to be up-to-date with very recent developments in the dispute between the junior doctors represented by the BMA and the government represented by the Secretary of state for Health, Jeremy Hunt. We’ve done well in capturing the moment. There are a couple of articles on the dispute from an older head but, key to the relevance of a journal such as this, we have a clear exposition of what the strike is really about from someone who should know: one of the striking doctors in training, Matt Tabinor. If you have time, read all three pieces; if you just don’t get it, read Matt’s helpful explanation; if you want to know how it may end, read Jaw Jaw is Better than War War by Paul Laszlo.

grants and prizes. This was made possible by some very generous benefactions and the institute and the awardees are most grateful. Our riches, in this issue are that we can read in some detail and digest the different, ambitious and important medical research that the institute is supporting right now. I’ll refrain from outlining the papers here: you can read about the awards in the appropriate section and I urge you to read the papers in the Originals section. And then a complete change of pace: something historical. Starting with a simple artefact, a 19th Century letter, Vera Cartlin opens a window into medical practices of the past. A question that occurs to me is whether anything in the human behaviour aspects of professionalism have changed at all, or is it merely the structures in which we function, and our science and technology that have advanced?

We conclude with the usual fare, Oluseyi Ogunmekan, provides another entertaining yet educative quiz and Snuck in at the back of the Editorial section, occasional there is a diagnostic tale contained in some simple contributor Ian Thornflesh argues that there’s no point plain radiographs, as if of old. worrying about the arrival of rationing into the NHS as budgetary constraints tighten, because it’s already Once again, apologies for the delay in this edition here and we’ve been living with it for a while and on a reaching you, but in view of the need to capture for daily basis. Perhaps he has a point! posterity the recent events, I hope you’ll understand the need for this. Until next issue, Happy Reading! The Junior Doctors’ strike is important and historical, and has delayed this issue until May, but there is, PS, all respectable journals need to mark Leicester as usual, very much more herein: Last autumn the City’s remarkable conquering of the football premier NSMI, as part of its 50th anniversary celebrations gave league for the 2015-16 season. Ours is subtle, but away bumper grants totalling £500K beyond the usual definitely present, on the front cover.

Bertrand Russell

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Good life is inspired by love and guided by knowledge

Midlands Medicine

RATIONAL RATIONING IN THE NHS Ian Thornflesh, commentator

Whether you recognise it or not, healthcare rationing is a daily reality in the NHS. If you think about it for a moment, how could it be otherwise? As we are well aware, finite resources, both staffing and financial, face up to increasing demand from an ageing population and rising expectations of not only what can be done, but also what should be done - it seems many younger folk have not quite yet reached a mature view on a time for a natural end to life which need not railed against (though older folk often have a more philosophical and resigned acceptance of what nature intends, but not always).

National Institute for Health and Care Excellence (NICE), originally set up in 1999 as the National Institute for Clinical Excellence, now emphasises its role in making sure that treatments procured by the NHS have a satisfactory evidence base, but it is widely understood that a major part of any NICE assessment of medication, procedures or equipment is a good dollop of health economic analysis, in short, a valuefor-money assessment. And how can it be otherwise if we are to be subject to responsible government? After all, if you squander “a billion here, a billion there, pretty soon you’re talking serious money.”*

By several estimates the UK economy is the fifth largest in the world. We have been spending 9% of Gross Domestic Product (GDP) on healthcare in recent years, according to the World Bank1, which, as a proportion, is similar to countries including Afghanistan (8%), Australia (9%), Brazil (8%), Croatia (8%), Israel (8%), Namibia (9%) and Nicaragua (9%). It is not as low as Zambia (5%), Saudi Arabia (5%), Pakistan (3%) or Eritrea (3%) but it is not nearly as much as the US at 17%. Clearly there are some statistical oddities at play here, with a country such as Saudi Arabia able to have a very well endowed health service without the expenditure representing a such a large slice of national income, and the relatively high healthcare costs in the USA (some would argue inefficiencies, others that medical staff are over-remunerated). However you look at it, though, the absolute amount we spend is significant. At the same time, we chose as a society to spend 91% of our GDP elsewhere (Education, Social Services, Leisure, Military spending, and so forth).

The NHS is a combination of sate-delivered and stateprocured healthcare. This is provided on the basis of need to citizens, and residents, generally free at the point of use. At least that’s true when considering medical or surgical needed care, but dental and eye care have slipped from that overall embrace so that although basic dental and eye care are state funded, there is a general two tier approach whereby basic needs are met for all at little or no cost but the bulk of activity is privately provided with the NHS subsidising access to private business for the public: think dental practices run by large firms, think high street opticians. Basic needs are covered for all with dental check-ups and eye tests ‘freely’ available but teeth whitening and designer frames require a discretionary handing over of cash; if you want more than the basics you can have whatever you can afford.

This has become more than just acceptable, it is normal to us now. Yet we think a little differently when we come to body healthcare. Though we make Our 9% spend represents an important change from a distinction between cosmetic work, which is clearly a previous 7% GDP spend which embarrassed Tony for the private sector, we don’t think in terms of a two Blair when he discovered that the UK percentage was tier approach to needed healthcare for the body, except far below the European average. He made a promise perhaps the public understanding regarding rare to get the UK healthcare spend up to that European cancer treatments such as comes through awareness average and made good on the promise.2 of Facebook pages dedicated to raising money to get a child abroad for treatment not available on the NHS†. In round terms the NHS in England has £100 billion to spend annually.3 Huge as it may seem, that is a You could, should you wish to, pursue needed medical finite number, and when a finite resource comes up treatment privately for serious conditions and major against significant, varied and elastic demand, some illnesses, but you would need to be either generously sort of allocation of resources has to take place. The insured or independently wealthy to make a successful Volume 28, No 1, May 2016

go of that; for the majority of citizens, local primary and secondary care, regional tertiary care and national centres within the NHS are all they can hope to avail themselves of. It is in this context that the Critical Care outreach team operate. They perform a helpful advisory role on general wards helping sick patients to be monitored and cared for appropriately. Additionally, however, there is a gate-keeping function which it would be disingenuous to deny. Critical Care always have an eye to the utility of transfer to one of their beds; even when there is no problem over bed availability there is due consideration of the likelihood of success. There are scoring systems, there’s experience, account is taken of pre-morbid functional status; more subtly there’s an assessment of the potential support in convalescence mediated via the family’s opinions. The elderly, multi-morbid, patients, particularly with significant respiratory disease, with poor prior functional status are often turned down. A sympathetic clear explanation of the fact a move to a critical care setting isn’t sufficiently likely to yield the desired outcome to justify the transfer is often accepted and understood, at least by the distressed and fazed family in the moment. The pill is sweetened by, not entirely unjustified, talk of kindness, humanity, dignity, peace. Sometimes it is well explained that much good care can be delivered appropriately in the ward setting, but that if such care is met with further deterioration, then the next level of care is simply too unlikely to work to support such a move. Occasionally some patients pull through decisions of that nature; those who die because a ‘ceiling of care’ has been put in place and they have deteriorated and can no longer reasonably be expected to benefit from active treatment can, at least, be positively palliated, and their families be given valuable time to say goodbye, in calm, even peace. Of course, there often is a limited number of beds available in Critical Care, in which case the outreach team can find themselves in the unenviable mindset of trying to ‘pick winners’; those patients likely to benefit most/most likely to benefit from Critical Care management. The very fact that there’s a dual phrase with a slash starts to tell you how complex this is: the patients who might benefit most are not necessarily the same as those most likely to benefit, so the task is to identify those who are most likely to fare badly if not transferred to Critical Care and amongst them, those most likely to benefit from transfer, and amongst 6

those the ones likely to benefit most. Difficulties must obviously arise when the number of patients on that crafted and considered list exceeds the number of beds available. Fortunately, options exist to temporarily expand the number of beds available for Level 3 care to try to ensure equitable access to Critical Care across time as demand varies, but the case is clear that Critical Care beds are generally a limited resource and access to them needs appropriate careful management for best patient level and service level outcomes. In the US, neurosurgeons might consider that a 1% chance of recovery after devastating brain injury is a reason to ventilate all such cases in a triumph of hope over expectation, arguing an ethic that it’s right to go with a chance, however small, of recovery: ‘where there’s life there’s hope’; in England our neurosurgeons and intensivists would look at the 99% chance of nonrecovery, the competition for ventilated beds, the spectrum of quality of recovery encompassed within the 1% chance and the vulnerability of being accused of ventilating with a view to organ harvesting rather than with a view to recovery, and they’d walk away. That is rational rationing.

REFERENCES 1 http://data.worldbank.org/indicator/SH.XPD. TOTL.ZS/ 2 GriffinA UK nears European average in proportion of GDP spent on health care BMJ (2007) Vol 334 p442 doi: http://dx.doi. org/10.1136/bmj.39140.341736. DB 3 http://www.nhs.uk/NHSEngland/thenhs/ about/Pages/overview.aspx

* Quote commonly misattributed to Illinoisan Republican Senator, Everett Dirksen. † More technically correctly, not in the UK; there is an important private oncology market in the UK so it isn’t always necessary to go abroad to obtain treatment not funded by the NHS. Midlands Medicine

JAW JAW IS BETTER THAN WAR WAR Paul Laszlo, Consultant Physician

of the 1950s. Ironic that she (particularly as a woman in British parliamentary politics) was part of the In the month in which the first full withdrawal establishment whilst the long-haired, bearded, whiteof labour by junior doctors takes place, it seems coated (largely) men, the junior doctors rallied against apposite to reflect on how we come to be here. What her, were the unionised public sector employees. They follows below is pure opinion, just one person’s view were truly in the British industrial relations sprit of the concerning the state of play between Secretary of State 1970s, in turn owing much to the preceding century, for health and the Junior Doctors of England. with the exception of those periods of pulling together for the greater national good, generally occasioned by BACK THEN a World War, or similar event. The last time there were strikes by doctors was in Ironic again that the present government, the first 1975. Barbara Castle was taking the Government’s majority Conservative government in the 21st Century, part and was trying to get doctors to be more seems to see their dispute with doctors in the training committed to the NHS and to do less private practice. grades through the prism of 1970s' class structures Consultants ‘worked-to-rule’ in January to April of (struggles). This time they are rightly (and rightfully, that year. Mollifying accommodations were reached as they perhaps see it) cast as the establishment whilst and things settled for a while. But in November that the junior doctors, all born knowing no different in the year the Juniors went on strike for a month before last 70 years of socialised medicine as the norm, are a settlement was reached. (Officially the dispute seen for the unionised public sector workers that they started on 12th October 1975 and was not closed are. Amongst the younger Tories the miners’ strike is until September 1976, but the sharp end was just that probably regarded in a positive light, Thatcher taking month of November.) At that time union militancy on the militant NUM, and winning. Perhaps amongst and industrial unrest were common. Something of them, Jeremy Hunt. But up and down the land there a generational divide was evident with Consultants are many who seethe passionately at the memory of being regarded as establishment, and essentially allied those times and deeds. And perhaps some junior more on the right of the British political spectrum doctors will romantically associate themselves with whereas the Junior Doctors thought of themselves as the miners’ side. unionised public sector workers. The BMA of the day originally accepted a deeply unfavourable contract HERE on behalf of the juniors who then rejected the BMA’s acceptance and took up the case for themselves, So to declare my credentials: I was a junior doctor in bringing the BMA round in their wake rather than hospital and research settings for some 16 years and have been working at Consultant level as a physician being led by the BMA. for over a decade. In my time as a junior I was Barbara Castle didn’t see any distinction between involved with rota (re-)organisation and understood the grades of doctors, after all today’s juniors are a degree of militancy among my peers. To be fair, that tomorrow’s seniors, and generally took a dim view has appeared continually from one generation to the of doctors wielding power. Memories lingered of next, and is often clearer to see and far more vehement Aneurin Bevan having stuffed the mouths of doctors at around the time of contract negotiations. And yet, with gold in order to secure their cooperation in the in all those years, no junior doctors’ strike. setting up of the National Health Service in 1946, part of a social safety net, dubbed The Welfare State, AND NOW underpinning society’s vulnerable from cradle to grave; a social contract from the labour party to the Bound up in a fantasy notion, a disguise, a distraction working people of Britain in recognition and reward that is contained within the sound bite “a truly seven for the sacrifices made by the less well off majority in day NHS”, is the idea that the same workforce can two World Wars. Boy did Barbara resent the need for deliver an unvarying 7-days-a-week service for the doctors to be paid so well, and she was keen to see that same money and with no increase in hours worked. they weren’t. In 1975 she was living the class struggles What is truly fanciful is the idea that this will improve PREAMBLE

Volume 28, No 1, May 2016

standards by providing better cover at weekends but will not worsen standards on Mondays-Fridays when reduced staffing will inevitably result. Look, it really is this simple: if lower levels of cover at weekends are the cause of poorer outcomes for patients admitted at weekends, then it is reasonable to want to improve the situation by increasing staffing at the weekend. Roughly, so as not to increase hours per worker, an increase in personnel of 2/5 (or 40%) would be needed. In fact, it would be less than this as there is already some weekend cover, not none, but it is minimal. So a 30%, or if really stretching things, a 25% increase in total NHS funding might fund a lifting of Saturday and Sunday NHS activity (Service, resource, call it what you like) to the level seen in the week and achieve the seven day service desired. However, in these times of austerity, we must do things differently: spread the existing workforce across seven days and abolish, so far as practically possible, any increases in tariff or any barriers to that so the whole thing can be achieved ‘within the same cost envelope’. This will, if it is implemented (sorry: introduced), achieve at least the objective of allowing rotas to be constructed which take little or no account of what day of the week it is (though, in fact, in the real world it hasn’t gone nearly so far at all), which in turn could lead to equity of junior cover across the seven days of the week. However, given that it’s the same pool of juniors doing the same total hours for the same pay, this can only happen if weekday cover is reduced. If the equation: a certain amount of junior doctor time, care and attention = a measurable quantity of healthcare delivered, then this will eliminate the difference in outcome between weekdays and weekends, and that will be a fulfilment of a stated political intention. But it’ll be achieved by taking that weekend shortfall in cover and distributing it equally across the days of the week. So the difference will be eliminated as much by reducing the quality of care slightly over the weekdays as by improving it at weekends. As long as we accept that’s what’s going to happen because the democratically elected government providing a wholly publicly funded health service have politically decided it so, then that’s what should happen. In the making it happen there’s a new Junior Doctors’ Contract to be successfully negotiated. These are complex talks. The government is embodied in the person of one Jeremy Hunt, Secretary of State for Health, successor to one Andrew Lansley, and carrying on the same great baton (Oh well!), the NHS employers are interested parties and the BMA is the trade union and manifests its presence in the form of Johann Malawana, chair of the BMA Junior Doctors’ Committee. 8

The Juniors doctors are making an interesting argument, saying that it really isn’t about holding onto decent terms and conditions for their own sake: rather they’re saying that if doctors in training are not treated with respect, valued and given decent working conditions then there will be an exodus from the training grades to foreign fields, doing rather more than decimating the ranks, and that cannot be any good for the future of the NHS. (See Matt Tabinor’s accompanying piece.) Following failure to reach final agreement on a proposed new contract, emergency cover was withdrawn over several days. Then Jeremy Hunt responded not by returning to negotiations but rather by stating that the contract would be imposed (sorry: ‘introduced’). To try to force him to talk again, a full withdrawal of labour is proposed. If that doesn’t work then there’s little left in the tank but escalation, and the only really heavy weapon left is an all out indefinite strike. So that’s where we are. Fine. Or not so fine. It occurs to me that the strike as a bargaining tool is at its most potent when not used. It is a threat to be held up, flashed about, and played, but not undertaken. Because now we know that a hospital will survive a day or two without juniors and that Consultants will find themselves obliged to bridge the gap. And with a reasonable number of young appointees over the last few years they’re not so old as to have forgotten all their bedside clinical skills, so the wards still run. And out in primary care there’s not such a great dependence on juniors and all the GPs are capable of doing without their support. (Some surgeries might even run more smoothly without the need to supervise trainees!) This all means that although the strikes are a shame and an inconvenience to many, they’re really only just that, an inconvenience, no great shake. Targets may be missed and waiting times may go up, but we’re only at the beginning of the second year of a fixed five year term, so there’s plenty of time to repair any damage in the 12-18 months running into the next election. There’s another very important timetable at work too: the first Wednesday in August. Any Junior Doctor starting anew in August will automatically be on the new contract, or they’ll have no job at all. The government has already asked trusts to draw up plans for a phased introduction of the new contract at the different training grades over the coming months and years: so far as the government is concerned this is a done deal. It is that apparent intransigence that makes me fearful: the only weapon left to the BMA is to escalate action, culminating in an all out indefinite strike. But these Tories remember the miners. That is their last such war against unionised labour. The lessons they draw from Midlands Medicine

that are that the government should robustly hold its line and not budge, awaiting first the crumbling and then the total collapse of the strike. And in this case there’s not even an indefinite timescale to consider: in August the tectonic plates shift, a new cohort enters at the bottom (on the new contract), a tier leave at the top as grace expires and many in the middle move around, so destabilising any coherency of Juniors’ response.

THE FUTURE

Consultant Contracts, GP Contracts. Here we go. Again, a simplistic view: at the moment I’ll put in 16 hours at a weekend and work about 1-in-10 weekends in addition to a full working week, and I’m remunerated for the additional time. This means 10 stretches a year of working 12 days in a row. If the government wants more weekend time out of me and I cannot imagine an all out indefinite strike of Junior to save money too, that would be easily done: instead Doctors being all that widely supported for months of remunerating me for weekend working, give me on end (for one thing they cannot afford the loss of the time back the following week. I’d be paid a little income) which means the government are more likely less, but I’d have more time for other things, and in the to get their way than not. Given that we can predict week when it’s slightly more useful; overall, my quality that now, it would be better to return to talking, by of life would likely improve slightly despite pay falling hook or by crook, than to pursue a path of escalation. a little. Jeremy, give that a thought.

Volume 28, No 1, May 2016

Jeremy Hunt, 26th April 2016, live on The Today Programme Radio 4

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Talking is the way to end this.

WHY JUNIOR DOCTORS SHOULD STRIKE Matthew Tabinor, ST2 Trainee in Medicine, Academic Fellow in Nephrology, UHNM Today is the 26th April 2016. This next forty-eight hour period will go down in history as the first time junior doctors in the NHS have totally withdrawn their labour from all areas of the hospital, including those areas providing emergency care. This is an incredibly sad time, and naturally our thoughts at this time are with those patients who have been directly affected by recent events. As a professional body, we are sorry that you, our patients, have had to go through this, and please be assured that many of us have, individually, made every effort to ensure there will be sufficient consultant cover in the wards and departments we work in prior to agreeing to take this action today. And yet, as a profession, we are increasingly exasperated by the failure of politicians to listen to the concerns of those at the frontline of NHS service delivery. Despite numerous rounds of negotiation between the BMA and the government, our concerns, not only about the junior doctor contract, but also about the wider context of NHS service delivery, are not being addressed. It is on this backdrop that we feel this dispute is not only about our current working conditions, but ultimately about the shape of junior doctor training, recruitment and retention, and how we as junior doctors will provide care in the future. As such, whether we like it or not, this dispute is not just a dispute about junior doctor working conditions, but ultimately about the ability of the NHS to provide safe and effective care in the future.

vacancies between 2013 and 2015. Additionally, although the number of consultants increased by 17% between 2009 and 2014, the latest data suggests that, disconcertingly, vacancy rates in consultant posts in many specialities are also increasing; particularly emergency medicine and paediatrics. As a result, from FY1 to consultant level, there are rota gaps every day and, as a result, doctors are being increasingly overstretched and, ultimately, suffering from increasing levels of burnout. (2) It is widely considered that the NHS has been chronically under-funded. Now, as of 2016, most NHS trusts are in deficit … the latest figures from December 2014 stating that, collectively, NHS providers in England were £800 million in deficit. Furthermore, 53% of trust finance directors recently stated that care in the local area had worsened in the past year as a result of such financial constraints. A significant problem, reflecting current levels of doctor shortages, is the increasing costs of locums. In 2010, the Royal College of Surgeons estimated the cost to NHS trusts for all locum shifts was approximately £750 million per year. Although no further estimates have been made since 2010, we can predict this cost is significantly more than £750 million, and across all trusts, this is proving to be a significant financial stressor. If junior doctors walk away because of the new contract, this can only become ever more of a problem; there is a danger of a vicious cycle setting in: we want to stop the damage now, before it’s too late.

Let me put my decision to take industrial action myself, and to support the action taken by my colleagues, into context for you. There are three major problems today in the NHS, which we as junior doctors are being (3) The third significant issue from the junior doctor perspective is that NHS staff, from porters particularly affected by: to consultants, feel increasingly under appreciated (1) We ALREADY have a shortage of doctors in the and micromanaged. This is leading to low morale NHS. Ask any doctor in the NHS today about the amongst the workforce. These stressors are leading state of their rota and about staff shortages within to increasing levels of staff sickness, demotivation their department, and I guarantee you there will be and, ultimately, increasing numbers of staff leaving gaps. Numerous factors, including better working conditions abroad, mismatched recruitment rates the NHS. Most shockingly of all, a recent assessment from medical school through to speciality training, of NHS working culture revealed that up to 24% of as well as increasing restriction on the use of non-EU staff surveyed felt bullied in the workplace. For a doctors, means that our junior doctor population is more comprehensive survey of this, please check not sufficient to meet current clinical demand. As out a recent blog post entitled “Are we supporting or such, we have seen a 60% increase in junior doctor sacrificing NHS Staff?”, by Michael West.1 10

Midlands Medicine

With this context, comes a junior doctor contract that doesn’t solve these problems, but exacerbates them. My big three problems with this contract, which I firmly believe threatens the very future of the NHS, are as follows:

as such, “lacks teeth and would not command the confidence of junior doctors”. This means that the new contract potentially will not protect doctors from working excessive hours, which again may impact on patient safety.

(1) Jeremy Hunt doesn’t actually understand what we currently do in the NHS. Junior Doctors already provide 7-day service… providing care in emergencies as well as in a lot of “routine” situations during the weekend. We welcome expansion of services at the weekend … you’ll find it hard to find anybody in the health service that doesn’t. But the problem with the new contract is that it’s cost neutral, reduces the working hours of doctors from 91 hours/week to 72 hours/week and, yet, aims to increase the presence of doctors at the weekend. The mathematics simply doesn’t add up. How can you effectively make a static (and potentially, shrinking) population of doctors, who are having their maximum contracted hours reduced, provide an increasing presence in hospitals seven days a week? The only solution, in reality, is to spread junior doctor presence in hospitals more thinly across the entire week. Therefore, even if you believe the evidence did point to increased mortality at the weekend (which when you look at the original research, this case cannot be made) and this was due to an association between reduced staffing levels and mortality at the weekend (which the current body of literature cannot substantiate), the newly proposed contract would simply create a new problem – insufficient staffing seven days a week, rather than fix the problem of weekend staffing levels. This simply would be unsafe for patients. To truly deliver seven day care in the form the government have suggested, we need to listen to Prof Jane Dacre, the President of the Royal College of Physicians, who estimates that we need 40% more doctors than we have currently, and to deliver this, the NHS would need an extra £8 billion of funding. This is a far cry from the cost neutral contract that is currently on the table.

(3) The change to the pay structure in the new contract, particularly the way in which pay progression as seniority increases has changed, has been criticised by multiple bodies. It is seen, potentially, as discriminatory against women, single parents, carers, any who wish to work part time and academic trainees. Indeed, the government’s own equality impact assessment confirmed that women, single parents, carers and those working part time would be adversely affected by the contract, and instead of suggesting solutions, stated “any indirect adverse effect which may occur is a proportionate means of achieving a legitimate aim”. As such, women, who reflect 60% of the junior doctor population, doctors who are struggling with full time commitments for whatever reason (whether that be childcare, long term sickness etc), and academics … who drive creativity, ingenuity and research to find the latest solutions to complex diseases and processes within healthcare, will be adversely affected and will lose out financially. This is simply wrong. Therefore, in summary, the new contract has the potential to spread the workforce more thinly, reduces safeguards which protect doctors from being overworked and will be disincentivise doctors from pursuing research, going part time, remove the potential for flexibility when looking after loved ones and will penalise heavily those doctors who, through no fault of their own, are on long term sick leave. This, on top of the existing pressures and stresses within the NHS, means that this new contract threatens to impact junior doctor recruitment, training and retention for a generation, and risks exacerbating an already existential crisis in staff retention, wider NHS funding and staff morale. My message to the secretary of state, and the message of the wider BMA is simple - please remove the threat of imposition and return to the negotiating table. This may be a difficult conversation for both parties, but it’s a conversation that must happen if we, as a profession, and you, as a government, are to reconcile and work together for the survival of the NHS, and ultimately, for the safety of our patients.

(2) The removal of vital safeguards for junior doctors, particularly regarding the regulation of maximum working hours, is of major concern. The old contract financially penalised trusts when junior doctors worked excessive hours or hours beyond their contractual agreement. This had a number of problems, but, in effect, was a firm commitment to safeguarding terms and conditions. Although initially removed in the new contract, both sides agreed, following renegotiation, to an independent guardian REFERENCES … who would be appointed to enforce safe working conditions for doctors. It is clear, however, that the 1 http://www.kingsfund.org.uk/blog/2015/10/ role of the guardian is subject to interpretation, and are-we-supporting-or-sacrificing-nhs-staff Volume 28, No 1, May 2016

MOTHERS AND DAUGHTERS: EXPLORING KNOWLEDGE ABOUT, AND ATTITUDES TOWARDS, CERVICAL SCREENING AND HPV VACCINATION Susan M Sherman, Emee Estacio and Emma Nailer, all Keele University; Claire Cohen, Jo’s Cervical Cancer Trust; Jennifer Taylor, Keele University; and Charles W E Redman, UHNM This article gives the background to a research project supported by the North Staffordshire Medical Institute. INTRODUCTION There are over three thousand new cases of cervical cancer in the UK every year. An estimated 99.7% of cases of cervical cancer are caused by the human papillomavirus (HPV)1. HPV is a sexually transmitted virus which most sexually active adults will come into contact with. In the majority of cases our immune systems do a good job of tackling the virus. In those cases where the immune system does not protect a woman from the virus, this can lead to pre-cancerous changes on the cervix.

a quadrivalent vaccine, Gardasil®, which additionally provides protection against HPV strains 6 and 11 which are responsible for most cases of genital warts. Since countries have introduced these vaccines, the incidence of genital warts has plummeted and the prevalence of HPV strains 16 and 18 in young women has decreased along with high grade pre-cancerous lesions associated with these HPV types.4 It therefore follows that the incidence of cervical cancer will also drop slowly but steadily as those vaccinated accumulate and increase in proportion to the unvaccinated (cervical cancer can take years to develop). However, the current vaccine will not eliminate all cases of cervical cancer and it is important that young women who have been vaccinated still attend for screening when invited.

BACKGROUND

Recent research suggests that knowledge about HPV The NHS cervical screening programme (CSP) was amongst young women who have been vaccinated is introduced in the UK in 1988. Women aged 25-49 not as high as it might be. In one study a worrying are invited to attend screening (the smear test) every 32% responded that the vaccination would prevent all 5 3 years while women aged 50-64 are invited every cases of cervical cancer. This suggests that a valuable 5 years. Since the NHSCSP was introduced, the opportunity to educate young women about HPV is number of women dying from cervical cancer has being missed. dropped significantly with an estimated 800 lives RESEARCH RATIONALE saved every year in women under 55 years.2 However, the screening programme is only effective if it is The rationale for the current research is to explore used. The number of women who attend screening is whether there is a way to simultaneously tackle the two problems outlined above: the drop in screening dropping year-on-year across all age groups.3 attendance and the lack of understanding many young women display about a vaccination they have had. Can A further weapon against cervical cancer is the HPV we educate young women and nudge their mothers to vaccination introduced in the UK for girls aged attend their own cervical screening appointments? 12-13 years in 2008. The first vaccine, Cervarix® provided protection against two strains of HPV The research, which is currently underway, has two (strains 16 and 18) which are responsible for 70% of phases. The first phase involves surveying the mothers cases of cervical cancer. However the UK now uses of school girls across North Staffordshire, to determine 12

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existing levels of awareness of HPV and cervical 3. Cervical Screening Programme, England, Statistics for 2014-15. Health and Social cancer and attitudes towards both cervical screening Care Information Centre http://www.hscic. and the HPV vaccination. In phase two, focus groups gov.uk/catalogue/PUB18932/nhs-cervicalwill be conducted with the mothers to evaluate and stat-eng-2014-15-rep.pdf develop appropriate materials to increase knowledge about cervical screening and HPV vaccination and to promote maternal screening attendance. The study, 4. Herrero R, González P and Markowitz LE Present status of human papillomavirus vaccine which has the backing of Jo’s Cervical Cancer Trust, development and implementation will act as a pilot study for a longer term project to The Lancet Oncology (2015) explore the impact on knowledge and screening Vol 16 ppe206-16 uptake of reaching out to mothers and daughters. The research hopes to lead to increased uptake of cervical screening invitations which in turn will 5. hopefully lead to a reduction in new and more severe cases of cervical cancer. REFERENCES

Sherman SM, Nailer E, Minshall C, Coombes R, Cooper J and Redman CWE Awareness and knowledge of HPV and cervical cancer in female students: a survey (with a cautionary note) Journal of Obstetrics and Gynaecology (2016) Vol 36 pp76-80

1. Jo’s Cervical Cancer Trust About Cervical Cancer http://www.jostrust. ADDRESS FOR CORRESPONDENCE org.uk/about-cervical-cancer Dr Sue Sherman, 2. Quinn M, Babb P, J ones A and Allen E School of Psychology Effect of screening on incidence and mortality Keele University from cancer of the cervix in England: evaluation Keele ST5 5BG based on routinely collected statistics s.m.sherman@keele.ac.uk BMJ (1999) Vol 318 pp904-8

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MAJOR BLEEDING COMPLICATIONS FOLLOWING ACUTE MYOCARDIAL INFARCTION: SITE, FREQUENCY AND IMPACT Mamas A Mamas, Keele Cardiovascular Research Group; Kelvin Jordan, Institute of Primary Care and Health Sciences; and Umesh Kadam, Health Services Research Unit, Institute of Science and Technology in Medicine, University of Keele This article gives the background to a research project supported by the North Staffordshire Medical Institute.

coronary artery. PCI involves the passage of a catheter from a peripheral artery (radial or femoral artery) into the coronary arteries, under x-ray guidance, to enable visualisation of, and to define the site and INTRODUCTION nature of, any critical coronary stenoses or occlusions Cardiovascular disease (CVD) is the commonest cause that have contributed to the development of the AMI. of mortality in the United Kingdom (UK) accounting Once identified, treatment of the coronary stenosis or for over 160,000 deaths a year with coronary artery occlusion during the PCI procedure involves passage disease accounting for over 74,000 of these deaths. and deployment of a metal stent, maintaining the Over 175,000 patients in the NHS are admitted with patency of the coronary artery and reducing the risk a heart attack (acute myocardial infarction: AMI) of re-infarction. Over 90,000 such PCI procedures are annually. undertaken in the UK annually both in the elective and AMI setting. AMI represents a broad spectrum of clinical presentations sharing a common pathophysiological In contrast, STEMI is a medical emergency where substrate, in which rupture of a coronary artery thrombus has completely occluded the coronary atherosclerotic plaque results in the formation of artery resulting in necrosis of the myocardium. The intra-coronary thrombus and a consequent reduction main priority for the treatment of STEMI is urgent in blood flow to the myocardium. If left untreated the prognosis is poor. The initial management of restoration of coronary blood to reduce infarct size AMI is to pharmacologically inhibit the thrombotic and mortality. PCI treatment is the current gold processes that occur. Patients are initially treated with standard reperfusion therapy of STEMI and forms the dual anti-platelet therapy (both aspirin and a P2Y12 cornerstone of treatment for high-risk UA/NSTEMI receptor antagonist such as clopidogrel, ticagralor with 75% of such patients undergoing PCI during their or prasugrel) to inhibit platelet aggregation, with the hospital admission. Over 90,000 such PCI procedures potential use of more potent anti-platelet medications are undertaken in the UK annually. such as glycoprotein IIb/IIIa inhibitors as well as anticoagulant drugs to inhibit thrombin generation and/or POTNENTIAL PROBLEMS activity, thereby reducing thrombus-related ischaemic events. The subsequent management depends on the Central to the management of AMI is pharmacological type of AMI that the patient has presented with, such inhibition of thrombus formation and propagation, as unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI) or ST-segment using multiple anti-platelet agents and anticoagulants to prevent recurrent ischaemic events and thrombotic elevation myocardial infarction (STEMI). complications as outlined. The management of AMI is therefore a delicate balance between inhibiting DIFFERENT TREATMENT FOR TYPES OF AMI such thrombotic processes and the occurrence of The management of UA/NSTEMI involves risk major bleeding complications, and this balance varies stratification to guide the use of more invasive between individual patients, dependent on factors management strategies such as percutaneous coronary such as their age, gender and co-morbid burden. intervention (PCI) to treat the occluded or narrowed 14

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Whilst changes in pharmacological regimes have decreased the risk of ischaemic complications over time in AMI, this has been paralleled by an increase in major bleeding complications with two recent large randomised controlled trials (RCTs) APPRAISE-2 and TRACER stopped prematurely due to increases in major bleeding complications in the treatment arm.1, 2 The incidence of major bleeding in AMI has been reported between 1.5 and 37 % in contemporary cohorts of patients in the clinical trial setting3-6 depending on both the definition of major bleeding used and the clinical cohort studied. Major bleeding is not benign; it is independently associated with a six-fold increased risk of 30-day mortality6, 7 and developing a bleed following a PCI has a similar impact on mortality as an AMI would. Even minor bleeding events independently increase 30-day mortality by 60% 7 with over 10% of all of all in-hospital mortalities after PCI in the United States national CathPCI Registry related to bleeding complications.8 The majority of data around major bleeding complications in AMI are derived from RCTs, where elderly multi-morbid patients encountered in â&#x20AC;&#x153;real worldâ&#x20AC;? clinical practice are often excluded. Such patients are at greatest risk from sustaining major bleeding complications9 hence the applicability of such RCT data in informing about major bleeding complications in multi-morbid real world patients is uncertain. Furthermore, many of these RCTs are undertaken in North America, where management of AMI and PCI strategies and techniques are often very different to those practised within the UK and Europe particularly around access site and pharmacological practice in patients treated with PCI which are amongst the most important predictors of major bleeding complications, hence their applicability to UK populations is also unclear.10-12

been validated in UK populations. Finally, all of the existing risk scores rely on biochemical data such as renal function, anaemia, white blood cell count etc, and this information is often not available in the highest risk patients who present as emergency cases, and the PCI cannot be reasonably deferred until such information becomes available. Therefore, ironically and unhelpfully, assessment of risk cannot be easily undertaken in patients at highest risk of bleeding complications. Assessment of bleeding risk nevertheless is important, for example, a recent randomised trial has shown that, in patients judged at high risk of bleeding complications, changing the types of stents used in PCI can result in improved patient outcomes.15 Furthermore, our previous work has shown that patients at highest risk of bleeding complications assessed using a bleeding risk score gain most benefit by optimal arterial access site choice, but are least likely to receive optimal access site practice.12 Assessment of bleeding risk may influence the choice of pharmacology that will be used in AMI or PCI, with those patients deemed to be at low risk of sustaining bleeding complications often receiving the most potent anti-thrombotic regimes whilst those at higher risk of bleeding events may receive regimes that are less potent anti-thrombotics, but are less likely to promote bleeding. FINDING OUT FOR THE UK

To date there has not been a UK national analysis, of temporal trends, predictors and clinical outcomes of major bleeding complications in patients with AMI. Furthermore, whilst data around incidence, type, predictors and associated outcomes of inhospital major bleeding complications occurring in AMI in patients cohorts derived from RCTs are well described,6,8 little data post discharge to the primary care setting data is available, with data limited to patients in RCTs who have remained under longer term follow up. For example, in the APPRAISE-2 trial, >60% of major bleeding events occurred 30 WAYS FORWARD days after AMI presentation.3 To date, a systematic Attempts have been made to develop bleeding risk analysis of major bleeding events post AMI has not scores to identify patients at high risk of bleeding been studied in the UK primary care setting. There is complications, either in the AMI or PCI setting, an urgent need for greater understanding of bleeding 10,13,14 however, all of these scores have been derived complications following AMI nationally in real world from patients in North America and they have never populations of patients encountered in the NHS, Volume 28, No 1, May 2016

particularly given that major bleeding is amongst the most important complications that occur post AMI. There is also an important need to develop risk scores applicable to the UK population enabling clinicians to identify patients at high-risk from major bleeding complications in the primary and secondary care setting that will allow targeted bleeding avoidance treatment strategies in patients identified as high bleeding risk. Such risk scores can only be developed once bleeding complications are captured. The award of the North Staffordshire Medical Institute grant will support a program of work that aims to use routinely collected national data to study bleeding complications post PCI and AMI nationally through analysis of national audit data derived from the Myocardial Ischemia National Audit Project (MINAP) registry and the British Cardiovascular Interventional Society (BCIS). MINAP collects data on all patients admitted to every NHS hospital trust in England and Wales with a confirmed diagnosis of AMI and contains anonymised data derived from 750,000 patients (as of December 2013). For patients who undergo PCI following admission with AMI, The British Cardiovascular interventional Society (BCIS) dataset collects information on clinical, procedural, and clinical outcomes from every PCI undertaken in England and Wales since 2006 with data derived from over 650,000 patients (as of December 2013). It is a mandatory requirement that every hospital admission with AMI in England and Wales is entered into the MINAP registry and every patient that who undergoes PCI is entered into the BCIS registry. This work will aim to describe national changes in hospital major bleeding complications occurring in patients treated following an AMI in the United Kingdom over time and determine whether there are differences in different parts of the country and define whether changes in patient characteristics, pharmacology or interventional treatment strategies have contributed to these changes over time, or to geographic differences at one time. We will compare the clinical and procedural characteristics, treatment strategies, co-morbidity burden and clinical outcomes of patients admitted with AMI who sustain a major bleeding complication compared with those patients 16

that do not, and describe whether the impact of bleeding complications is similar across all patient subgroups. Finally, we will study the incidence of bleeding complications post discharge into primary care analysing data from established primary care datasets derived from primary care patient populations from North Staffordshire and Salford. The Consultations in Primary Care Archive (CiPCA)16,17 is an electronic health record database containing anonymised highquality data from 13 general practices in Staffordshire Moorlands, Stoke-on-Trent, and Newcastle-underLyme. The Salford Integrated Record (SIR) system integrates health record data from 53 primary care practices throughout the city of Salford and secondary care (The Royal Salford NHS Foundation Trust) forming an anonymised research data repository. These local primary care datasets provide a unique opportunity to study major bleeding complications from a local perspective to gain insight into the incidence and importance of such complications. CONLUSION Cardiovascular disease is the commonest cause of mortality in the UK with over 175,000 patients a year admitted with an AMI every year to the NHS. Treatment of AMI includes pharmacological strategies that inhibit the formation of thrombus and PCI to treat any coronary narrowings or occlusions that may have contributed to the AMI. Major bleeding complications are amongst the most important complications encountered in the treatment of AMI and are independently associated with a three-fold increase in mortality. Despite the importance of such bleeding complications, there are no national data to identify the magnitude of the problem in the UK, whether it is different in different parts of the country or any means of predicting in which patients such complications are most likely to occur. Support from the NSMI will enable a better understanding of major bleeding complications from a national perspective and provide a means for identifying high-risk patients to help guide safer interventional and pharmacological strategies. Midlands Medicine

REFERENCES 1. 2. 3.

Alexander JH, Lopes RD, James S, Kilaru R, He Y et al, Apixaban with antiplatelet therapy after acute coronary syndrome N Engl J Med (2011) Vol 365 pp699-708

Mamas MA, Fath-Ordoubadi F, Danzi GB, Spaepen E, Kwok CS et al Prevalence and Impact of Co-morbidity Burden as Defined by the Charlson Co-morbidity Index on 30-Day and 1- and 5-Year Outcomes After Coronary Stent Implantation (from the Nobori-2 Study) Am J Cardiol 2015

Tricoci P, Huang Z, Held C, Moliterno DJ, 10. Armstrong PWet al Thrombin-receptor antagonist vorapaxar in acute coronary syndromes N Engl J Med (2012) Vol 366 pp20-33

Mehran R, Pocock S, Nikolsky E, Dangas GD, Clayton T et al Impact of bleeding on mortality after percutaneous coronary intervention results from a patient-level pooled analysis of the Khan R, Lopes RD, Neely ML, Stevens SR, REPLACE-2 (randomized evaluation of Harrington RA et al PCI linking angiomax to reduced clinical Characterising and predicting bleeding in highevents), ACUITY (acute catheterization and risk patients with an acute coronary syndrome urgent intervention triage strategy), and Heart (2015) Vol 101 pp1475-84 HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute Xian Y, Wang TY, McCoy LA, Effron MB, myocardial infarction) trials Henry TD et al JACC Cardiovasc Interv (2011) Vol 4 pp654 The Association of Discharge Aspirin Dose With Outcomes After Acute Myocardial Infarction: 64 Insights From the TRANSLATE-ACS Study 11. Mehta SK, Frutkin AD, Lindsey JB, House JA, Circulation (2015) Vol 132 pp174-81 Spertus JA et al Vavalle JP, Clare R, Chiswell K, Rao SV, Bleeding in patients undergoing percutaneous Petersen JL et al coronary intervention: the development of Prognostic significance of bleeding location a clinical risk algorithm from the National and severity among patients with acute Cardiovascular Data Registry C i r c coronary syndromes Cardiovasc Interv (2009) Vol 2 pp222-9 JACC Cardiovasc Interv (2013) Vol pp709-17 12. Manoukian SV, Feit F, Mehran R, Voeltz MD, Ebrahimi R et al Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY Trial J Am Coll Cardiol (2007) Vol 49 pp1362-8 Rao SV, O'Grady K, Pieper KS, Granger CB, Newby LK et al 13. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes Am J Cardiol (2005) Vol 96 pp1200-6 Chhatriwalla AK, Amin AP, Kennedy KF, House JA, Cohen DJ et al National Cardiovascular Data R. Association between bleeding events and in-hospital mortality after percutaneous coronary intervention JAMA (2013) Vol 309 pp1022-9

Volume 28, No 1, May 2016

Mamas MA, Anderson SG, Carr M, Ratib K, Buchan I et al British Cardiovascular Intervention Study, the National Institute for Cardiovascular Outcomes Registry: Baseline bleeding risk and arterial access site practice in relation to procedural outcomes after percutaneous coronary intervention J Am Coll Cardiol (2014) Vol 64 pp554-64 Rao SV, McCoy LA, Spertus JA, Krone RJ, Singh M et al An updated bleeding model to predict the risk of post-procedure bleeding among patients undergoing percutaneous coronary intervention: a report using an expanded bleeding definition from the National Cardiovascular Data Registry Cath PCI Registry JACC Cardiovasc Interv (2013) Vol 6 pp897904 17

14.

Subherwal S, Bach RG, Chen AY, Gage BF, 17. Rao SV et al Baseline risk of major bleeding in non-STsegment-elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) Bleeding Score Circulation (2009) Vol 119 pp1873-82

15.

Urban P, Meredith IT, Abizaid A, Pocock SJ, Carrie D et al Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk N Engl J Med (2015) Vol 373 pp2038-47

16.

Porcheret M, Hughes R, Evans D, Jordan K, Whitehurst T et al North Staffordshire General Practice Research Network. Data quality of general practice electronic health records: the impact of a program of assessments, feedback, and training J Am Med Inform Assoc (2004) Vol 11 pp7886

ADDRESS FOR CORRESPONDENCE

Mamas A. Mamas Professor of Cardiology Keele Cardiovascular Research Group Institute for Science and Technology in Medicine Keele University Jordan K, Clarke AM, Symmons DP, Fleming Guy Hilton Research Centre D, Porcheret M, Kadam UT and Croft P Stoke-on-Trent Measuring disease prevalence: a comparison ST4 7QB of musculoskeletal disease using four general mamasmamas1@yahoo.co.uk practice consultation databases m.mamas@keele.ac.uk Br J Gen Pract (2007) Vol 57 pp7-14

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TISSUE ENGINEERING APPROACHES TO TREAT EMPHYSEMA

Tina P Dale, The Institute for Science and Technology in Medicine, Keele University, Guy Hilton Research Centre; Wa’el Osman RSUH, UHNM; Monica A Spiteri, Professor in Respiratory Medicine, Keele University and Consultant in Respiratory Medicine at UHNM; Mohammed F Haris Consultant in Respiratory Medicine at UHNM; Alicia J El Haj, Ying Yang and Nicholas R Forsyth all of The Institute for Science and Technology in Medicine, Keele University, Guy Hilton Research Centre This article gives the background to a research edge, proof-of-principle model to support the onproject supported by the North Staffordshire Medical going development of a regenerative device for lung Institute. reconstruction for the treatment of chronic lung disorders. INTRODUCTION BACKGROUND As the third biggest global killer Chronic Obstructive Pulmonary Disease (COPD) remains an incurable Chronic obstructive pulmonary disease (COPD) and progressive disease. COPD is characterised was the third leading cause of death globally in 2012 by persistent airflow limitation that is usually according to World Health Organisation data.2 There progressive and associated with an enhanced chronic are two principal phenotypes of COPD: chronic inflammatory response in the airways and the lung to bronchitis and emphysema, where either or both may noxious particles or gases.1 Affected individuals suffer be present, and it is characterised by the presence increasing breathlessness, chest tightness, wheeze, of irreversible, or only partly reversible, airflow and reduced exercise tolerance until day-to-day obstruction (in contrast to asthma where airway tasks become impossible, with the disease eventually obstruction is fully reversible).3 Current treatment leading to respiratory failure. Current interventions strategies exist to largely manage the symptoms of include lifestyle changes, bronchodilators, steroids, COPD, whilst the underlying pathological changes oxygen therapy, and surgical interventions with a view remain irreversible. The incurable and chronic nature to treat the symptoms but not the underlying disease. of COPD has resulted in an estimated 65 million people Emphysema, a subtype of COPD, is characterised by living with moderate to severe disease. Despite often the destruction of lung parenchymal tissue, greatly going undiagnosed and untreated4 it nevertheless reducing the surface area available for gas exchange represents a significant healthcare burden being the and airflow obstruction and also affects the mechanics second most common cause of emergency hospital of breathing. admission and with an annual associated global healthcare cost of £1.3 trillion.5 The current lack of a curative therapy means that there is an urgent, unmet need for novel therapeutics COPD is caused principally by smoking, although designed to either halt, or reverse COPD progression. environmental/occupational exposures and genetic We intend to characterise the mechanical properties predisposition via α1-antitrypsin deficiency are of lung tissue from patients with and without a history also causative factors.6 The disease results in a of emphysema and using this information develop a progressive loss of lung function, leading eventually biomaterial substrate with properties matched to to respiratory failure. The loss of lung function is healthy lung. Simultaneously we will isolate and associated with repetitive cycles of inflammation and characterise the cells from the lung tissue with a parenchymal scarring leading to the breakdown of particular focus on the differences in the proportion the delicate alveolar parenchymal structures and lung of distal airway stem cells (DASC) present in the remodelling with accumulation of fibrinous tissue healthy and diseased tissue, to ascertain a potential this is termed emphysema.7 The loss of the alveolarrole for these cells in the disease pathology. Finally the capillary functioning units greatly reduces the surface biomaterials and cell-based aspects will be combined area available for effective gas exchange. A key feature and the resulting tissue engineered lung equivalents of COPD progression due to emphysema is the (TELEs) assessed for biological integration in ex vivo development of trapped air within areas of damaged lung tissue cultures. This will establish a cutting- lung tissue. Emphysematous tissue has reduced Volume 28, No 1, May 2016

elastic recoil properties; as a result of this, during exhalation the small airways collapse leading to air trapping and lung hyperinflation thereby affecting the normal breathing mechanics. Macroscopically the lungs become stiffer and unable to support the patient through the physiological inhalation/exhalation breathing cycles.8 Patients become progressively more symptomatic with increased breathlessness, reduced exercise tolerance and poor quality of life. The pharmacological treatment options for emphysema are limited; current therapy with bronchodilators, steroids, and when necessary antibiotics, aims to improve airflow limitation, reduce airway inflammation and reduce exacerbations, but does nothing to reverse lung damage.6 Lung transplantation is a possible option9 but due to the scarcity of suitable donor lungs for transplant and the frequent incidence of co-morbidities associated with COPD10 it would only ever serve a minority of patients. Alternatively it is possible to relieve symptoms by the surgical removal of the most damaged regions of the lungs enabling improved function in less damaged regions. This can be achieved via lung volume reduction surgery (LVRS); however, this is associated with significant morbidity in the form of air leaks, and again would only be available to selected patients.11,12 To achieve similar results to LVRS with an improved safety profile, non-invasive endoscopic treatments have recently been introduced. Mechanical one-way valves or coils can be placed in the airways to reduce air trapping, airway collapse and hyperinflation and thereby improve elastic recoil and lung function13,14 without the need for surgical tissue resection. In a similar vein, trials are underway exploring the role of biological lung volume reduction strategies, whereby biological implants, for example fibrin/thrombin or autologous blood, are injected into the worst affected airways, initially to block or fill damaged airways with subsequent re-modelling leading to the formation of scar tissue.15 This tissue then contracts causing the collapse of the selected regions and thus reduces the lung volume leading to improvements in breathing.16â&#x20AC;&#x201C;18 These interventions, however, do not improve survival and there is therefore an urgent, unmet need for novel therapeutics designed to either halt, or reverse COPD progression. The recent introduction of these minimally invasive techniques 20

that are well tolerated by patients, and the use of biological materials in emphysema therapies raise the prospect of using biological therapies to regenerate damaged lung tissue, thereby treating the underlying causes of emphysema. We have previously determined that collagen/elastin hydrogel-based scaffolds can achieve mechanical values consistent with those of the alveolar wall when seeded with lung fibroblasts.19 The resultant construct acted as a simple model, or a tissue engineered lung equivalent (TELE). This raises the intriguing question of whether TELEs could be used to restore mechanical integrity of the emphysematous lung via air pocket displacement, local integration and ultimately by regeneration of local lung architecture. Coupled to the work described above a recent observation went some way to detailing the mechanism behind the previously misunderstood, but physiologically critical, capacity for lung tissue to regenerate following on from acute diseases such as pneumonia or acute respiratory distress syndrome. The key appears to lie with a population of distal airway stem cells (DASCs) that co-express Trp63 (p63) and keratin 5 (Krt5).20 These DASCp63/Krt5 cells appear to migrate to sites of injury in the lung where they have demonstrated differentiation capacity including lineages such as type I and II pneumocytes and bronchiolar secretory cells. It is crucial, both to our understanding of chronic lung disorders, and in the design of future cell-based therapies, to determine whether these cells remain present and dormant in diseased lung tissue, or are lost through as yet unknown mechanisms. TISSUE ENGINEERING APPROACHES TO TREAT EMPHYSEMA To expand our understanding of these areas and to pave the way for future therapies using TELEs, we will undertake a research project positioned at the interface of specialist respiratory medicine and regenerative medicine. Teams from the University Hospitals of North Midlands NHS Trust, Royal Stoke University Hospital and Keele Universityâ&#x20AC;&#x2122;s Guy Hilton Research Centre will work in collaboration, with the intent of ultimately developing a regenerative device as a new therapeutic solution to chronic emphysema. The project will have a number of objectives, with each aimed at the production of more physiologically Midlands Medicine

representative TELEs and will involve:

4. 1) Defining the physiologic and pathologic properties of lung tissues 2) Design and optimisation of the scaffold materials for TELEs

Bednarek M, Maciejewski J, Wozniak M, Kuca P and Zielinski J# Prevalence, severity and underdiagnosis of COPD in the primary care setting Thorax (2008) Vol 63 pp402-7

3) Establishing cell sources for TELEs

Lomborg B Global Problems, Smart Solutions: Costs and Benefits (Cambridge University Press, 2013)

4) Combining scaffold materials and cells to fabricate functional and representative TELEs

5) Introduction of the TELEs into an ex vivo lung tissue model

6. Celli, B R, MacNee W, Agusti A, Anzueto A, Berg B et a This programme will establish a proof-of-principle Standards for the diagnosis and treatment model that can be used for in vitro investigation of lung of patients with COPD: a summary of the ATS diseases and potential therapies, whilst concurrently ERS position paper being supportive of the on-going development of European Respiratory Journal (2004) Vol 23 a tissue engineered regenerative device for lung pp932-46 DOI: 10.1183/09031936.04.00014304 reconstruction to be used for the treatment of chronic lung disorders including COPD, and more specifically, emphysema. 7. Sharafkhaneh A, Hanania N A and KimV Pathogenesis of Emphysema CONLUSION Proc Am Thorac Soc (2008) Vol 5 pp475–477 In summary, we propose novel approaches for the development of tissue engineering-based models for Ito S, Ingenito EP, Brewer KK, Black LD, the investigation of potential treatments and actual 8. Parameswaran H et al insertable treatments for the repair of emphysema Mechanics, nonlinearity, and failure strength of damaged lungs. This promises to open new avenues lung tissue in a mouse model of emphysema: in lung therapeutics and to serve as flagship science possible role of collagen remodelling for North Staffordshire and UK-based research in an J Appl Physiol Bethesda Md 1985 (2005) Vol 98, 503-11 international arena. 9. Aziz F, Penupolu S, Xu X and He J Lung transplant in end-staged chronic obstructive pulmonary disease (COPD) Global Strategy for Diagnosis, Management patients: a concise review and Prevention of COPD, Global Initiative J Thorac Dis (2010) Vol 2 pp111-6 for Chronic Obstructive Lung Disease (GOLD) 2016 http://wwwgoldcopdorg/ 10. Dal Negro R W, Bonadiman L and Turco P Prevalence of different comorbidities in COPD patients by gender and GOLD stage WHO | The top 10 causes of death WHO Multidiscip Respir Med (2015) Vol 10 p24 wwwwhointmediacentrefactsheets/fs310en/ doi:10.1186/s40248-015-0023-2. eCollection 2015

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3. Lange P, Halpin D M, O’Donnell D E and MacNee W Diagnosis, assessment, and phenotyping of COPD: beyond FEV1 Int J Chron Obstruct Pulmon Dis 11, 3–12 (2016) Volume 28, No 1, May 2016

11. Marchetti N, and Criner GJ Surgical Approaches to Treating Emphysema: Lung Volume Reduction Surgery, Bullectomy, and Lung Transplantation Semin Respir Crit Care Med (2015) Vol 36 pp592-608 21

12.

Ginsburg M, Thomashow B, Bulman W, Jellen P, Whippo B and Sonett Surgical risk, functional outcomes, and late survival after lung volume reduction surgery (LVRS): Report of one hundred consecutive surgical cases Eur Respir J (2015) Vol 46, PA1832

13. Insertion of endobronchial valves for lung volume reduction in emphysema | Guidance and guidelines https://wwwniceorguk/guidance/ipg465

17. Criner GJ, Pinto-Plata V, Strange C, Dransfield M, Gotfried M et al Biologic Lung Volume Reduction in Advanced Upper Lobe Emphysema Am J Respir Crit Care Med (2009) Vol 179 pp791-98

18.

Refaely Y, Dransfield M, Kramer MR, Gotfried M, Leeds W et alq Biologic lung volume reduction therapy for advanced homogeneous emphysema Eur Respir J (2010)Vol 36 pp20-7

14. Insertion of endobronchial nitinol coils to improve lung function in emphysema | 1-Recommendations | Guidance and guidelines https://wwwniceorguk/guidance/IPG517/ chapter/1-recommendations

19. Dunphy S E, Bratt J A J, Akram K M, Forsyth N R and El Haj A J Hydrogels for lung tissue engineering: Biomechanical properties of thin collagen elastin constructs J Mech Behav Biomed Mater (2014) Vol 38 pp251â&#x20AC;&#x201C;259

15.

20.

Ernst A and Anantham D Bronchoscopic Lung Volume Reduction, Bronchoscopic Lung Volume Reduction Volume 2011, Article ID 610802, 6 pages doi:10.1155/2011/610802

Zuo W, Zhang T, Zheng'An Wu D, Guan SP, Liew A-A et al p63(+)Krt5(+) distal airway stem cells are essential for lung regeneration Nature (2015) Vol 517 pp616-20

ADDRESS FOR CORRESPONDENCE 16

Reilly J, Washko G, Pinto-Plata V, Velez E, Kenney L et al Biological Lung Volume Reduction: A New Bronchoscopic Therapy for Advanced Emphysema Chest (2007) Vol 131 pp1108-13

Nick Forsyth Institute for Science and Technology in Medicine Keele University Guy Hilton Research Centre Stoke-on-Trent ST4 7QB

Midlands Medicine

AN ACCOUCHEUR’S FINANCIAL STRIFE IN THE 19TH CENTURY Vera Cartlin, Local Resident

Postal history is a hobby that can take a number of forms. One is to study the postal service and its workings: to look at the flow of mail, tariffs, post marks and so forth. Another approach is to look at the mail going to and from a place over a particular period of time and to make inferences from the mail about the society of that place in economic, social and political terms. That can be done at a grand scale, almost epidemiological, if you will, or one can look closely at a particular letter and use this as a way into aspects of life at a particular place and time. So it is that I introduce this letter to you. Now the reading of manuscript of this type can be difficult, so a transcription of the letter in question follows: Remark, My client is a Surgeon and accoucheur, regularly admitted at Surgeons’ Hall in London, owing much more than £300, who has supplied his own patients with medicines in the regular course of practice; but has never been admitted a licentiate of the apothecaries company at apothecary’s [sic] Hall in London or elsewhere, nor dealt in drugs as an apothecary. Will he not, therefore, not be considered a trader and be able to avail himself, legitimately, of the 5th & 6th Vict: Cap: 116? It is important that this he duly considered before commencing. Pray, therefore, give me your opinion with the things now sent for, immediately. His Books will, of course, shew [sic] that he has supplied medicines to his own patients; but in the schedule I could insert the ^respective debts due to him as being “for my professional aid”, or in some other way so as to leave out, there, the mention of “medicines”.

That’s how it ends. There’s no signature and no mention of the address at which it was written. On the front (and on the front cover of this issue of the journal) you’ll see this appears to be a letter from an insolvency practitioner to a firm of solicitors at Birmingham New Street asking advice on a particular point of law which applies to the taxation of medicines depending who supplied them to whom and in what capacity. The post mark seen palely on the front is ‘LEICESTER’ and the date is 25th July 1843. An accoucher was a male birth attendant, either a male midwife* or, more likely as we would consider him today, an obstetrician.1 Our man was a surgeonaccoucheur but there were also accoucheurs with more physicianly leanings in the neonatology and paediatrics directions such as Michael Underwood who, in 1784, aged about 46 years, was the first physician-accoucheur to be appointed to the Royal College of Physicians in London. In that same year he published a textbook which did much to establish paediatrics as an emerging discipline in its own right.2 Volume 28, No 1, May 2016

This ‘surgeon’ is in trouble because the technical 5th & 6th Vict: Cap: 116 appears to refer to the Insolvent Debtors Act 1842. There is a specific distinction made in the Act whereby ordinary persons could receive some financial protection for any amount but those considered traders were not protected if sums owed were over £300. The question is whether or not he should be considered an ordinary citizen or a ‘trader’ within the meaning of the Act. If he is a trader, he can apply for bankruptcy rather than insolvency. The following information is offered by the National Archives: “Insolvent debtors and bankrupts are different. Bankrupts were supposed to be traders, making their living by buying and selling. Many were not though and described themselves fictitiously … [in order] to qualify for bankruptcy. (Bankruptcy was later extended to include most skilled craftsmen.) Insolvent debtors were individuals unable to pay their debts … they could be kept indefinitely in a debtors’ prison if their creditors so wished.”3 Traders owing more than £300 could not gain protection but they 23

could be made bankrupt instead of insolvent. In the case of bankruptcy, creditors would have a claim to any assets left, and the court would order how these were to be distributed but the bankrupted surgeonaccoucheur, though perhaps destitute, would not find himself in debtors’ prison. In England, imprisonment for debt only ended in 1869. In 1843 this future humane turn is an unknowable irrelevance for our surgeon-accoucheur; so then this desperate plea for helpful advice from his insolvency practitioner: for him it was a matter of liberty or prison. But the Insolvent Debtors Act (1842) was rather soon itself in some difficulty with an amendment Bill before the House of Commons as early as 1844.4

accoucheur who supplies medicines to his patients but is no apothecary. He does this to make money, keeps accounts but somehow or other he spends more than he earns and is in such financial embarrassment that debtors’ prison is a very real possibility. He is in out of his depth and seeks legal advice from a local man who, in turn, runs his thoughts by a larger legal practice based in central Birmingham. Sadly, we cannot know the outcome, and that is one of the less satisfying aspects of this type of postal historical research, but it has taken us down some interesting avenues.

REFERENCES

It is clear that the evolution towards the licensed and registered medical profession of England today, which 1 took a great leap forward in the 16th Century when Henry VIII granted a charter to the Royal College of physicians in 1518 and the Company of Barber Surgeons in 1540, was only part done by the mid-19th Century. It was the Medical Act of 1858 that laid down the more familiar foundations of “The Qualifications of Practitioners of Medicine and Surgery”. 2 An apothecary might reasonably be considered a ‘drug dealer’ had that term not already been laden with a particular and derogatory sense, but that is what they were; people who knew about medicines (or herbs or cures or drugs, and their constituents) a combination of what to use them for and how to use them, and where to source them; and also traded in them and dispensed them. The term apothecary is from the Greek apotheca, which is a storehouse, as they were characterised in the minds of the public more by the sourcing and storage of all the medicines (row upon row of shelves with jars containing all sorts of pills and powders and potions; barrels, sacks and boxes etc) than by the acts of preparation and dispensing. The correct modern term is pharmacist with the colloquial usage ‘chemist’ still very much in use. In the modern era there is a reasonably clear distinction, and separation, between those who prescribe and those who dispense but our surgeon-accoucheur melds these faculties in a way that is usually avoided in England today. Whilst the physicians and surgeons gained their royal professional recognition from Henry VIII in the 16th Century, it took some little while longer for the apothecaries to be similarly acknowledged: The Worshipful Society of Apothecaries was incorporated by royal charter in 1617 under the auspices of James I of England.

Duncan, JM† ON A DIGITAL IMPRESSION PRODUCED BY THE ACCOUCHER IN THE CRANIUM OF A FOETUSDURING BIRTH: ITS HISTORY AND RESULTS BMJ 1(873) Oct p456

Dunn, P M Michael Underwood, MD (1737–1820): physician-accoucheur of London Arch Dis Child Fetal Neonatal Ed. (2006) Vol 91 ppF150–F152 doi: 10.1136/adc.2005.074526

3 http://www.nationalarchives.gov.uk/helpw it h - y ou r- re s e a rc h / re s e a rc h - g u i d e s / bankrupts-insolvent-debtors/

4 Hansard: HL Deb 25 July 1844 vol 76 cc1387- 411

*‘mid-husband’ would be a misunderstanding as the wife referred to in the term is the one giving birth, the term being an Old English one meaning ‘withwife’, (‘mid’ being of the same root as the German ‘mit’). Accoucheur is from the French verb accoucher, meaning: to put to bed. We know a male is meant since accoucheuse is the feminine alternative.

Physician to the Royal Maternity Hospital and What can we reasonably infer from this single sheet of Lecturer in Midwifery in the School of Medicine, 19th Century paper? Our gentleman is a surgeon and Edinburgh 24

†

Midlands Medicine

AWARD WINNERS

As part of the 50th anniversary celebrations the North Staffordshire Medical Institute did as it is supposed to do: it gave away large sums of money in support of medical research led locally. These were two very important grants, mainly in that they will, due to their size, considerably assist the advancement of significant research. But they are further important in that the excellence, innovation and scope of the research is such as to likely raise the profile of this area and local medical research institutes, and Keele University, both nationally and internationally. Furthermore, being in a position to make grants of this size, thanks to generous benefactors, confirms the NSMI as a key player in medical research in North Staffordshire and much wider afield and confirms our continuing relevance and justifies our raison d’être. The three award winning teams have each given an account of their research projects in this issue of Midlands Medicine. Each is a very different area of endeavour, each one very worthwhile with genuine potential to change many lives. Please do read them. 50TH ANNIVERSARY RESEARCH AWARDS 2015 Major bleeding complications following acute myocardial infarction: site, frequency and impact; insight from a national and primary care perspective Prof. Mamas Mamas, Prof. Umesh Kadam, Prof. Kelvin Jordon, Dr. Matthew Sperrin, Dr. Evangelos Kontopantelis, Prof. Ian Buchan

Awarded: £249,983.01 A tissue engineering approach to improve lung function and clinical outcome in patients with emphysema Dr. Nicholas Forsyth, Prof. Monica Spiteri, Dr. Mohammed Haris, Prof. Alicia El Haj Dr. Ying Yang Awarded: £249,659.00 The awarding of large grants did not dint our ability to make our usual awards, as you can see: RESEARCH AWARDS 2014 Mothers and Daughters: Exploring knowledge about and attitudes towards cervical screening and HPV vaccination Dr. Susan Sherman Awarded: £8,511.00 ********************* The Keele University Medical Student best overall performance in Year 2 – 2014/15 Sara Day The Keele University Medical Student best overall performance in Year 4 OSCE – 2014/15 Michael Eastwood Our congratulations to the pair of them once again.

Volume 28, No 1, May 2016

A VIEW FROM THE WARDS DURING THE JUNIOR DOCTORS’ STRIKE Paul Laszlo, Consultant Physician

The much anticipated junior doctors’ strikes have come and, for the moment, gone. Who knows where we will find ourselves next. But for the record it might be of interest to lay down in the record how it was on the wards on the strike days that have recently passed by. As I’ve said, things were much anticipated. And, therefore, much prepared for. We were fortunate in the first walk-outs to have some cover due to the consolation that emergency cover would remain, and the very generous interpretation that emerged of what constituted such emergency cover. In the end we settled for weekend cover. I suppose in other settings we’d call that having a skeleton staff. And one may further suppose that the staffing in the first strikes matched weekend cover was rather ironic given what the dispute is said to centre upon, but there we are. But weekend cover is not emergency cover, it is reduced and thin, however more work is done, far more, than rushing from one medical crisis to another. Indeed, medical crises are occasional distractions and interruptions: usual weekend working is a steady plod of a ward round methodically going over the patients to make sure that existing management plans are being carried out appropriately and are modified in the light of changes in clinical condition where appropriate. The problem of the weekend is, of course, stasis: one can endeavour to keep patients safe, and to actively treat the acutely sick ones, but those who need investigations and procedures only available Monday-to-Friday lie in something of a limbo. And on a normal weekend the rest of the staffing matches with the notable exception of the nursing contingent who have to staff to an adequate level day and night, public holiday or normal working day, term time or school holiday, weekday or weekend, whilst others (pharmacists, radiographers, lab technicians, physiotherapists, occupational therapists and so on)

also have a different weekend working pattern. So the strange thing in the earlier strikes was that doctors were working as if they were on the weekend holding pattern whilst all around them were carrying on as usual. So how did we fare? (Consultants match or outnumber juniors in most departments.) During the strikes where emergency cover was provided we had one doctor for the ward. We allocated roles for about half the Consultant body in the department to take pressure off the ward, or to contribute directly to aspects of ward care. At the heart of it the Consultant in charge of the ward and the one junior doctor made a tight team and did the ward round. Other stuff happened too: medical students acted up into Foundation posts, juniors broke the strike for locum pay. In essence, it worked and patients were served relatively well. In the all-out strikes, all programmed activities were put to one side (clinics, committee meetings, MDT meetings, procedure lists etc) and all the Consultants were available to take pressure off the wards and/or to help on the wards. For many it was a day spent answering emails but ready to jump to it should the call come through. Publicity had urged people to stay away from A&E and a good number heeded the plea so that A&E attendances were actually reduced by 20% on those strike days. Again, in essence, it worked and patients were served well. At least those in hospital were, but thousands of operations, procedures, investigations and clinic appointments were cancelled and most are going to have to be caught up on, as well as all those missed meetings (well, perhaps not all) and at least there’ll be fewer emails than there might have been.

Midlands Medicine

QUIZ NIGHT

Oluseyi Ogunmekan, General Practitioner, Furlong Medical Centre, Stoke-on-Trent INTRODUCTION

This is a version of a quiz we do in our practice as fun way of undertaking the serious business of keeping up-to-date. 1.

Which of the following is associated with Haglund’s deformity?

(a) Pump bump (b) Tennis elbow (c) Housemaid’s knee (d) Genu valgus (e) Bunions

Charles Bonnet syndrome only occurs in people who are mentally ill:

True or False?

What is the range of points on Borg’s scale?

(a) 1-10 (b) 6-20 (c) 0-100 (d) 15-93 (e) 10-1000

Which of the following is not licensed for use with dapaglifozin?

(a) Metformin (b) Insulin (c) Pioglitazone (d) Gliclazide (e) Linagliptin

Ottawa ankle rules are a set of guidelines for clinicians to help decide if a patient with foot or ankle pain should be offered x-rays to diagnose a possible fracture:

True or False?

Which of the following is true of latent autoimmune diabetes mellitus (LADA)? (a) C-peptide is high (b) Patients are overweight (c) positive GAD antibodies (d) All should be started on insulin at diagnosis (e) patients are young

Volume 28, No 1, May 2016

The empty beer can test is used to diagnose a tear of which of the following muscles? (a) Gastrocnemius (b) Quadriceps (c) Supraspinatus (d) Orbicularis (e) Biceps

In which condition is faecal calprotectin normal? (a) (b) (c) (d) (e)

Crohn’s disease Ulcerative colitis Irritable bowel syndrome Infectious colitis Ischaemic colitis

FODMAP diet has been suggested for use in which one of the following conditions? (a) Irritable bowel syndrome (b) Type 1 diabetes mellitus (c) Chronic kidney disease (d) Epilepsy (e) Eczema

10.

Which of the following is not a component of Wolfram (DIDMOAD) syndrome? (a) Dementia (b) Diabetes mellitus (c) Deafness (d) Diabetes insipidus (e) Optic atrophy

11.

According to the BNF what is the minimum 8 hourly dose of amoxicillin for a child aged 6 years? (a) 62.5mg (b) 125mg (c) 250mg (d) 375mg (e) 500mg

12.

The dose of nitrofurantoin prescribed is dependent on the eGFR:

True or False? 27

WORDPLAY 14

Dominic de Takats, Consultant Nephrologist

THE CODES WITHIN DRUG NAMES Time was when drug names were simple and readily remembered, particularly when there were so few of them. It was often easy to learn by rote and to distinguish chemical classes of drugs by their endings. Often roots were obvious, or at least easily absorbed (e.g. digoxin, frusemide, later: atenolol and propranolol, later still: cimetidine) but more recently, perhaps particularly with the advent of biologicals, things have become a little more involved. In the examples just given, –olol clearly signifies a betablocker, but –ine is not specific to H2 antagonists and can just as easily be found on the end of unrelated drugs such as quinine or atropine. I guess the most widely understood ending remains –cillin thanks to Alexander Fleming’s discovery. As the list of licensed medications expanded and the needs for both consistency and a shortcut to appreciation of what a drug may be about became more evident, efforts to give more away by squeezing more information within the generic name have moved on. Though sometimes the naming will tell you what a drug is, its broad type, and sometimes more directly what it does. For example, drugs ending with –mab (acronym for monoclonal antibody) let you know how the drug was made but that can leave you rather clueless as to what the drug is used for. On the other hand, the ending –statin tells you pretty much what the drug does because of the essentially limited role of HMG-CoA reductase inhibitors. Similar comments might be made about –pril and –sartan. To pile more meaning onto existing endings, letters can be added to the front of the ending. Above I stated that –ine is not particularly the province of H2 antagonists, but stick a ‘d’ in front and you start to get somewhere (ranitidine, famotidine, nizatidine). Similarly, to get more information about the monoclonal antibodies –mab can be prefixed by additional letters such that, for example, –ximab (e.g. rituximab) may indicate a chimeric antibody whilst –zumab indicates a humanised antibody giving birth to the coinage natalizumab which is a monoclonal antibody against the cell adhesion molecule alfa 4 integrin and is used in Crohn’s disease and multiple sclerosis. 28

Drugs ending –tinib are tyrosine kinase inhibitors (e.g. sunitinib, used in renal cell carcinoma; trametinib for unresectable or metastatic melanoma with a BRAF V600 mutation, authorised either as monotherapy or combined with dabrafenib). Drugs ending in –zomib are proteozome inhibitors (e.g. bortezomib, ixazomib, both used in multiple myeloma). That last one reminds me of a wise general physician who regarded any drug names containing x or z with great suspicion and suggested that if any odd symptoms occurred in a patient on such medication then an adverse event to the drug was to be top of the differential diagnosis. Drugs ending –cept are native or modified receptor molecules and preceding letters are added to identify the ligand (e.g. etanercept for tumour necrosis factor) but if the molecules are small and more the ligand than the receptor itself, you can take the p away, so –cet is a small molecule that binds with a receptor (e.g. cinacalcet binds with the calcium receptor on parathyroid cells). The inventors of this nomenclature live not without wit. The inclusion of an acronym or other clue to form or function is seldom resisted, but the –xaban is perhaps neat all the same (these drugs ban the effects of factor Xa, e.g. apixaban). And in all the above, note that we’ve been dealing only in the generic (non-proprietary) names all, quite correctly, in all lower case, the initial capital being reserved for brand (trade) names. PIGS MAY ROLL Every now and then seriously put important messages mire themselves with such pomposity of tone that they might, in some quarters, achieve less gravitas than intended. It may be wrong for me to think this, but the following is a possible example: “The topic of unauthorised use of cages has been flagged at a number of the Trust Health & Safety committee meetings, and is also repeatedly flagged at Trust “Clinical Equipment Standardisation and Product Implementation Group” (CESPIG) group to ensure holistic awareness of what could be a major issue in regard to the distribution of goods.” I know it’s simply ignorance on my part but ‘holistic awareness’ loses me. Midlands Medicine

IT’S A LETTERS GAME

IT’S A NUMBERS GAME

You’ve heard of e-books no doubt, but some examples of constrained writing would present you with e-less books. Constrained writing is writing in which some arbitrary rule has been applied, just for the joy of the challenge of staying within the lines. A fifty thousand one hundred and ten word novel, Gadsby, written in English in 1939 by Ernest Vincent Wright, fully avoided use of the letter e, the commonest letter in English, usually. The feat was repeated in 2002 by Andy Went in his not-so-novel novel Lost and Found, leaving the e in his name as the only one used. (I suppose that since it’s on the cover and not within the text, that’s alright.) The advertisement proclaims the absence of sex, violence and crime in the book. This form of constrained writing is called lipogrammatic, and the exclusion of e is clearly the biggest challenge in English. Lost and Found turns out to be one of the commonest book titles going, used at least ten times over, however it would have fared badly as a phrase in James Thurber’s 1957 fairy tale The Wonderful O within the covers of which no o is used.

The following observations may be made: The word binary is trisyllabic, the word trisyllabic is tetrasyllabic, the word tetrasyllabic is pentasyllabic. The word pentasyllabic is pentasyllabic but hexasyllabic, septasyllabic, octasyllabic and nonasyllabic are also pentasyllabic, which means that in this series pentasyllabic is the only term which displays congruence of meaning and form. It lives out what it expresses. Were it a character displaying such self consistency we’d say it had integrity, which in mathematical terms means a whole number, nothing left over, no remainder, no fractions, nothing fraying at the edges.

It is on the cards to write text in which all words have just one part, where not one of them spans two or more parts. And it can all make good sense and not seem forced; it can be read quite well. Give it some time and you will see that there are ways round some of the hard bits where you think you might not be able to say just what you want. To make my point, I could go on and on, but that would be to write for the sake of it. But the truth is that at this point my job is done!

Wholeness is bisyllabic, unity is trisyllabic and integrity is tetrasyllabic. Undividedness is the best synonym for integrity that is pentasyllabic, but it’s so clunky

ADDRESS FOR CORRESPONDENCE Dr D de Takats Consultant Nephrologist The Kidney Unit Royal Stoke University Hospital Newcastle Road Stoke-on-Trent ST4 6QG

FURTHER INFORMATION

The constraint employed above is that of using only druginfo.nlm.nih.gov/drugportal/jsp/drugportal/ DrugNameGenericStems.jsp monosyllabic words.

Volume 28, No 1, May 2016

INTERESTING IMAGES

This young lady on peritoneal dialysis presented with severe shoulder tip pain occurring over a period of days and slowly worsening. The plain AXR shows the PD tube coiled perfectly in the pelvis, some degree of faecal loading and an interesting stippled pattern from a dressing on the abdominal wall, but gives no explanation for the pain. The plain erect CXR, however, shows air under both diaphragms: There had been a recent interposition of additional tubing for attachment to the automated PD machine but without programming additional priming fluid, so each night since the change in practice about 50 mL of air had been pumped in, causing the pain. Once diagnosed, the problem resolved rapidly on programming for additional priming fluid to take account of the additional tube volume. Radiographs used with patientâ&#x20AC;&#x2122;s permission. 30

Midlands Medicine

QUIZ ANSWERS AND EXPLANATIONS 1.

a) ‘Pump bump’.

c) Irritable bowel syndrome.

Haglund’s deformity is a bony enlargement on the back of the heel that often leads to bursitis. It is sometimes called “pump bump” because the rigid backs of pumpstyle shoes can create pressure that aggravates the enlargement when walking. People can inherit a foot structure that makes them prone to developing the condition

Elevated faecal calprotectin indicates the migration

2. False.

positive).

Charles Bonnet syndrome is the experience of complex visual hallucinations in a person with partial or severe blindness. It predominantly affects people with visual impairments due to old age, diabetes or other damage to the eyes or optic pathways.

may have a beneficial effect on sufferers of irritable

b) 6-20.

Borg’s scale measures perceived exertion. It is used in clinical diagnosis of breathlessness and dyspnoea. The range of 6-20 covers a subjective experience of not much exertion at all to overwhelming exertion. 4.

c) Pioglitazone.

5) True. Similar guidelines have been developed for injuries apart from ankle and foot injuries. For example, there are Ottawa knee rules. 6)

c) positive GAD antibodies.

C-peptide measures residual beta cell function and persons with LADA have low levels. GAD antibodies are commonly found in Type 1 diabetes mellitus. LADA is not associated with obesity as Type 2 diabetes mellitus is. Insulin need not be introduced at first diagnosis. Patients are clearly older than the usual age of presentation for Type 1 diabetes mellitus. 7)

c) Supraspinatus.

A positive test indicates rotator cuff tear, specifically, supraspinatus muscle. A positive Hawkins-Kennedy test suggests damage to the tendon of the supraspinatus muscle. Volume 28, No 1, May 2016

of neutrophils to the intestinal mucosa during intestinal inflammation from a variety of causes; IBS is not an inflammatory condition. Use of proton pump inhibitors (e.g. omeprazole) is associated with significantly elevated calprotectin levels. (False

a) Irritable bowel syndrome.

FODMAP stands for Fermentable Oligo~, Di~ and Mono-saccharides and Polyols. There is some evidence that restriction of FODMAPs from the diet bowel syndrome and other functional gastrointestinal disorders. 10) a) Dementia. DIDMOAD stands for diabetes insipidus, diabetes mellitus, optic atrophy and deafness.

The first

symptom is typically diabetes mellitus, usually Type 1.

Life expectancy of people suffering from this

syndrome is about 30 years. 11)

d) 500mg.

The 8 hourly dose of amoxicillin between 1 month and 1 year is 125mg, rising to 250mg for children aged between 1 and 5 years. Between 5 and 12 years the dose is 500mg (same as for adults). 12) True. Nitrofurantoin should be avoided if the eGFR is less than 45mls/minute/1.73m² due to potential ineffectiveness as antibacterial efficacy depends on renal secretion of the drug into the urinary tract.

INDEX TO VOLUME 27

As it happened TITLE

AUTHORS

ISSUE

PAGE(S)

Secundum clamo! Francis Report 2013: A Charter for Candour

de Takats, D

1 (April 13)

6-8

Moving Onwards: The Musculoskeletal Interface Service: Its development and Future

Stevenson, K Menen, A

1 (April 13)

9-12

Clinical Education: Lessons for Practice

Gibson, C

1 (April 13)

13-14

Teaching Undergraduates in the Clinical Setting

Gibson, C

1 (April 13)

15-17

An Approach to Investigating the Cervical Screening History Review Meeting

Sherman, S Nailer, E

1 (April 13)

18-20

The Adult Attitude to Grief Scale â&#x20AC;&#x201C; a Measure for Identifying Vulnerability in Bereavement

Machin, L Sim, J Bartlam, B

1 (April 13)

21-6

Getting to Know Tracy Hall

Hall, T

1 (April 13)

27-8

Elective Tale from Nepal

Storrow, J

1 (April 13)

29-32

My Journey to a Kidney Transplant and Beyond

Mitchell, K

1 (April 13)

33-5

The 43rd Wade Lecture: An Evening with Lee Pearson

Smith, S

1 (April 13)

36-7

Junior Doctor Diaries

Mason, R

1 (April 13)

40-41

Book Review: Falling & Laughing, The Restoration of Edwyn Collins by Grace Maxwell

Alcock, H

1 (April 13)

42-3

Tentative Wordplay

de Takats, D

1 (April 13)

44-6

Ensuring Best Care of Dying Patients after the Demise of the Liverpool Care Pathway

Kelt, S

2 (Oct 13)

58-9

A Place for non-Medical prescribers

Hall, T

2 (Oct 13)

60-61

Commentary on Diverse Matters

de Takats, D

2 (Oct 13)

62-3

A Journey Into Interstitial Lung Disease

Hall, T

2 (Oct 13)

65-7

The Assessment of Medical Professionalism Post The Francis Report:Do It Well, Do It Often And Do It Repeatedly

Gibson, S

2 (Oct 13)

69-72

Change, the Built Environment and Healthcare

Whitehurst, J

2 (Oct 13)

73-80

Type 2 Diabetes Mellitus in Children

Hurst, J

2 (Oct 13)

81-5

Contemplating a Career in Emergency Medicine

Iqbal, N

2 (Oct 13)

86-8

The Pathway to Quality Neurology: Introducing the Staffordshire Neurological Alliance

Searle, S

2 (Oct 13)

89-92

Junior Doctor Diaries

Hegarty, G Mason, R

2 (Oct 13)

95-6

Book Review: The Blood of the Lamb by Peter De Vries

Laszlo, P

2 (Oct 13)

Book Review: Experiment Eleven by Peter Pringle

Alcock, H

2 (Oct 13)

98-9

Wordplay: once upon a hendecagon

de Takats, D

2 (Oct 13)

100-2

Duty of Candour

de Takats, D

3 (April 14)

110-11

Academic Psychiatry at Keele University:Lessons From the Past (1986-2002) and the Immediacy of the Future

Cox, J

3 (April 14)

112-13

Defining the Role of the Pancreatic Beta-Cell in the Development of Cystic Fibrosis-Related Diabetes Mellitus

Harper, A Robinson, J Yates, R Kelly, C

3 (April 14)

114-18

Interstitial Lung Disease 2

Hall, T

3 (April 14)

119-23

A Case of Acute Kidney Injury following Near Drowning

Menon, M Cullis, B Bingham, C

3 (April 14)

124-6

Midlands Medicine

TITLE

AUTHORS

ISSUE

PAGE(S)

Historical Notes: The Life and Legacy of Lady Rosemary Ednam

Cartlin, V

3 (April 14)

127-9

Developing the Keele Medical Research Pathway: Challenges For a Young Medical School

Chari, D Hider, S

3 (April 14)

130-2

Getting to Know: Alison Morris

Moris, A

3 (April 14)

133-4

Fracture Liaison Service & Osteoporosis Risk Assessment: an Award-Winning Model

Twemlow, A

3 (April 14)

135-7

Junior Doctor Diaries

Hegarty, G Mason, R

3 (April 14)

138-9

Medical School Taster at Keele University

Suzannah

3 (April 14)

140

Book Review: The Ghost Map by Steven Johnson

Alcock, H

3 (April 14)

141-2

Lexicon: Forty Years On (A-M)

de Takats, D

3 (April 14)

143-4

Crisis? What Crisis?

Laszlo, P

4 (Oct 14)

152-3

An Imperfect Squall

Thornflesh, I

4 (Oct 14)

1554-5

Selecting Students for Medical School

Gibson, C

4 (Oct 14)

156

An Intercalated Degree: A Chance to Grow

Vivekanantham, A 4 (Oct 14)

157-8

Becoming a Different sort of Doctor - The Consequences of Dipping into Medical Academia

Spooner, S

4 (Oct 14)

159-62

Clinical Education Series: Mentoring, Appraisal & Support

Gibson, C

4 (Oct 14)

163-6

Interstitial Lung Disease 3

Hall, T

4 (Oct 14)

167-70

Junior Doctor Diaries

Mason, R

4 (Oct 14)

176

Quiz Nite

Ogunmekan, O

4 (Oct 14)

177

Lexicon: Forty Years On (N-Z)

de Takats, D

4 (Oct 14)

178-9

Academic Medical Careers:An Insider’s Perspective on Getting Involved

Tabinor, M

5 (April 15)

186-8

Q & A on Non-Medical Prescribing

Hall, T

5 (April 15)

189-90

Fifty Years On

de Takats, D

5 (April 15)

191-2

Helping Clinicians to Provide Evidence Based Care for Patients with Back Pain: A Journey from Research to Implementation

Stevenson, K Duffy, H

5 (April 15)

193-4

Hip Fracture Care at UHNM: Progressive Evolution

Ctraig, P Browne, M Roberts PJ

5 (April 15)

195-8

Investigation of the Effect of TGF-β, its Inhibitor and Shear Stress in a 3D Conjunctiva Model

Ipek, T Yang, Y Nguyen, DQ

5 (April 15)

199-201

Assessing what Bioimpedance Can Tell us About Patients with End-Stage Disease Kidney Disease

Tabinor, M Dudson, M Davies SJ

5 (April 15)

202-6

Fifty Five Days in 2012

Bolger, C

5 (April 15)

210-12

Quiz Night

Ogunmekan, O

5 (April 15)

213

Word Play Dozen Off

de Takats, D

5 (April 15)

214-6

Professionalism: We Are What We Teach!

Gay, S

6 (Oct 15)

225-6

The Debate that will not Die

Laszlo, P

6 (Oct 15)

227-9

Nursing and Midwifery Revalidation

Inwood, H

6 (Oct 15)

230-31

HG Wells in Stoke-on-Trent

Cartlin, V

6 (Oct 15)

232-4

The New World of Academic Publishing: What ‘Open Access’ Means for Researchers

Ormerod, M James, E Smith, M

6 (Oct 15)

235-8

Interstitial Lung Disease 4

Hall, T

6 (Oct 15)

231-41

Volume 28, No 1, May 2016

TITLE

AUTHORS

ISSUE

PAGE(S)

Quiz Night

Ogunmekan, O

6 (Oct 15)

245-6

Wordplay 13: No Fear!

de Takats, D

6 (Oct 15)

248-50

Book Review: Being Mortal by Atul Gawande

Alcock, H

6 (Oct 15)

251

Book Review: Elizabeth is Missing by Emma Healy

Alcock, H

6 (Oct 15)

252

Ordered by first author TITLE

AUTHORS

ISSUE

PAGE(S)

Book Review: Being Mortal by Atul Gawande

Alcock, H

6 (Oct 15)

251

Book Review: Elizabeth is Missing by Emma Healy

Alcock, H

6 (Oct 15)

252

Book Review: Experiment Eleven by Peter Pringle

Alcock, H

2 (Oct 13)

98-9

Book Review: Falling & Laughing, The Restoration of Edwyn Collins by Grace Maxwell

Alcock, H

1 (April 13)

42-3

Book Review: The Ghost Map by Steven Johnson

Alcock, H

3 (April 14)

141-2

Fifty Five Days in 2012

Bolger, C

5 (April 15)

210-12

HG Wells in Stoke-on-Trent

Cartlin, V

6 (Oct 15)

232-4

Historical Notes: The Life and Legacy of Lady Rosemary Ednam

Cartlin, V

3 (April 14)

127-9

Developing the Keele Medical Research Pathway: Challenges For a Young Medical School

Chari, D Hider, S

3 (April 14)

130-2

Academic Psychiatry at Keele University:Lessons From the Past (1986-2002) and the Immediacy of the Future

Cox, J

3 (April 14)

112-13

Hip Fracture Care at UHNM: Progressive Evolution

Ctraig, P Browne, M Roberts PJ

5 (April 15)

195-8

Commentary on Diverse Matters

de Takats, D

2 (Oct 13)

62-3

Duty of Candour

de Takats, D

3 (April 14)

110-11

Fifty Years On

de Takats, D

5 (April 15)

191-2

Lexicon: Forty Years On (A-M)

de Takats, D

3 (April 14)

143-4

Lexicon: Forty Years On (N-Z)

de Takats, D

4 (Oct 14)

178-9

Secundum clamo! Francis Report 2013: A Charter for Candour

de Takats, D

1 (April 13)

6-8

Tentative Wordplay

de Takats, D

1 (April 13)

44-6

Word Play Dozen Off

de Takats, D

5 (April 15)

214-6

Wordplay 13: No Fear!

de Takats, D

6 (Oct 15)

248-50

Wordplay: once upon a hendecagon

de Takats, D

2 (Oct 13)

100-2

Professionalism: We Are What We Teach!

Gay, S

6 (Oct 15)

225-6

Clinical Education Series: Mentoring, Appraisal & Support

Gibson, C

4 (Oct 14)

163-6

Clinical Education: Lessons for Practice

Gibson, C

1 (April 13)

13-14

Selecting Students for Medical School

Gibson, C

4 (Oct 14)

156

Teaching Undergraduates in the Clinical Setting

Gibson, C

1 (April 13)

15-17

The Assessment of Medical Professionalism Post The Francis Report:Do It Well, Do It Often And Do It Repeatedly

Gibson, C

2 (Oct 13)

69-72

A Journey Into Interstitial Lung Disease

Hall, T

2 (Oct 13)

65-7

A Place for non-Medical prescribers

Hall, T

2 (Oct 13)

60-61

Getting to Know Tracy Hall

Hall, T

1 (April 13)

27-8

Midlands Medicine

TITLE

AUTHORS

ISSUE

PAGE(S)

Interstitial Lung Disease 2

Hall, T

3 (April 14)

119-23

Interstitial Lung Disease 3

Hall, T

4 (Oct 14)

167-70

Interstitial Lung Disease 4

Hall, T

6 (Oct 15)

231-41

Q & A on Non-Medical Prescribing

Hall, T

5 (April 15)

189-90

Defining the Role of the Pancreatic Beta-Cell in the Development of Cystic Fibrosis-Related Diabetes Mellitus

Harper, A Robinson, J Yates, R Kelly, C

3 (April 14)

114-18

Junior Doctor Diaries

Hegarty, G Mason, R

2 (Oct 13)

95-6

Junior Doctor Diaries

Hegarty, G Mason, R

3 (April 14)

138-9

Type 2 Diabetes Mellitus in Children

Hurst, J

2 (Oct 13)

81-5

Nursing and Midwifery Revalidation

Inwood, H

6 (Oct 15)

230-31

Investigation of the Effect of TGF-β, its Inhibitor and Shear Stress in a 3D Conjunctiva Model

Ipek, T Yang, Y Nguyen, DQ

5 (April 15)

199-201

Contemplating a Career in Emergency Medicine

Iqbal, N

2 (Oct 13)

86-8

Ensuring Best Care of Dying Patients after the Demise of the Liverpool Care Pathway

Kelt, S

2 (Oct 13)

58-9

Book Review: The Blood of the Lamb by Peter De Vries

Laszlo, P

2 (Oct 13)

Crisis? What Crisis?

Laszlo, P

4 (Oct 14)

152-3

The Debate that will not Die

Laszlo, P

6 (Oct 15)

227-9

The Adult Attitude to Grief Scale – a Measure for Identifying Vulnerability in Bereavement

Machin, L Sim, J Bartlam, B

1 (April 13)

21-6

Junior Doctor Diaries

Mason, R

1 (April 13)

40-41

Junior Doctor Diaries

Mason, R

4 (Oct 14)

176

A Case of Acute Kidney Injury following Near Drowning

Menon, M Cullis, B Bingham, C

3 (April 14)

124-6

My Journey to a Kidney Transplant and Beyond

Mitchell, K

1 (April 13)

33-5

Getting to Know: Alison Morris

Moris, A

3 (April 14)

133-4

Quiz Night

Ogunmekan, O

5 (April 15)

213

Quiz Night

Ogunmekan, O

6 (Oct 15)

245-6

Quiz Nite

Ogunmekan, O

4 (Oct 14)

177

The New World of Academic Publishing: What ‘Open Access’ Means for Researchers

Ormerod, M James, E Smith, M

6 (Oct 15)

235-8

The Pathway to Quality Neurology: Introducing the Staffordshire Neurological Alliance

Searle, S

2 (Oct 13)

89-92

An Approach to Investigating the Cervical Screening History Review Meeting

Sherman, S Nailer, E

1 (April 13)

18-20

The 43rd Wade Lecture: An Evening with Lee Pearson

Smith, S

1 (April 13)

36-7

Becoming a Different sort of Doctor - The Consequences of Dipping into Medical Academia

Spooner, S

4 (Oct 14)

159-62

Helping Clinicians to Provide Evidence Based Care for Patients with Back Pain: A Journey from Research to Implementation

Stevenson, K Duffy, H

5 (April 15)

193-4

Moving Onwards: The Musculoskeletal Interface Service: Its development and Future

Stevenson, K Duffy, H

1 (April 13)

9-12

Elective Tale from Nepal

Storrow, J

1 (April 13)

29-32

Volume 28, No 1, May 2016

TITLE

AUTHORS

ISSUE

PAGE(S)

Medical School Taster at Keele University

Suzannah

3 (April 14)

140

Academic Medical Careers:An Insider’s Perspective on Getting Involved

Tabinor, M

5 (April 15)

186-8

Assessing what Bioimpedance Can Tell us About Patients with End-Stage Disease Kidney Disease

Tabinor, M Dudson, M Davies SJ

5 (April 15)

202-6

An Imperfect Squall

Thornflesh, I

4 (Oct 14)

1554-5

Fracture Liaison Service & Osteoporosis Risk Assessment: an Award-Winning Model

Twemlow, A

3 (April 14)

135-7

An Intercalated Degree: A Chance to Grow

Vivekanantham, A 4 (Oct 14)

157-8

Change, the Built Environment and Healthcare

Whitehurst, J

73-80

2 (Oct 13)

Ordered by title TITLE

AUTHORS

ISSUE

PAGE(S)

A Case of Acute Kidney Injury following Near Drowning

Menon, M Cullis, B Bingham, C

3 (April 14)

124-6

A Journey Into Interstitial Lung Disease

Hall, T

2 (Oct 13)

65-7

A Place for non-Medical prescribers

Hall, T

2 (Oct 13)

60-61

Academic Medical Careers:An Insider’s Perspective on Getting Involved

Tabinor, M

5 (April 15)

186-8

Academic Psychiatry at Keele University:Lessons From the Past (1986-2002) and the Immediacy of the Future

Cox, J

3 (April 14)

112-13

An Approach to Investigating the Cervical Screening History Review Meeting

Sherman, S Nailer, E

1 (April 13)

18-20

An Imperfect Squall

Thornflesh, I

4 (Oct 14)

1554-5

An Intercalated Degree: A Chance to Grow

Vivekanantham, A 4 (Oct 14)

157-8

Assessing what Bioimpedance Can Tell us About Patients with End-Stage Disease Kidney Disease

Tabinor, M Dudson, M Davies SJ

5 (April 15)

202-6

Becoming a Different sort of Doctor - The Consequences of Dipping into Medical Academia

Spooner, S

4 (Oct 14)

159-62

Book Review: Being Mortal by Atul Gawande

Alcock, H

6 (Oct 15)

251

Book Review: Elizabeth is Missing by Emma Healy

Alcock, H

6 (Oct 15)

252

Book Review: Experiment Eleven by Peter Pringle

Alcock, H

2 (Oct 13)

98-9

Book Review: Falling & Laughing, The Restoration of Edwyn Collins by Grace Maxwell

Alcock, H

1 (April 13)

42-3

Book Review: The Blood of the Lamb by Peter De Vries

Laszlo, P

2 (Oct 13)

Book Review: The Ghost Map by Steven Johnson

Alcock, H

3 (April 14)

141-2

Change, the Built Environment and Healthcare

Whitehurst, J

2 (Oct 13)

73-80

Clinical Education Series: Mentoring, Appraisal & Support

Gibson, C

4 (Oct 14)

163-6

Clinical Education: Lessons for Practice

Gibson, C

1 (April 13)

13-14

Commentary on Diverse Matters

de Takats, D

2 (Oct 13)

62-3

Contemplating a Career in Emergency Medicine

Iqbal, N

2 (Oct 13)

86-8

Crisis? What Crisis?

Laszlo, P

4 (Oct 14)

152-3

Defining the Role of the Pancreatic Beta-Cell in the Development of Cystic Fibrosis-Related Diabetes Mellitus

Harper, A Robinson, J Yates, R Kelly, C

3 (April 14)

114-18

Developing the Keele Medical Research Pathway: Challenges For a Young Medical School

Chari, D Hider, S

3 (April 14)

130-2

Midlands Medicine

TITLE

AUTHORS

ISSUE

PAGE(S)

Duty of Candour

de Takats, D

3 (April 14)

110-11

Elective Tale from Nepal

Storrow, J

2 (Oct 13)

29-32

Ensuring Best Care of Dying Patients after the Demise of the Liverpool Care Pathway

Kelt, S

2 (Oct 13)

58-9

Fifty Five Days in 2012

Bolger, C

5 (April 15)

210-12

Fifty Years On

de Takats, D

5 (April 15)

191-2

Fracture Liaison Service & Osteoporosis Risk Assessment: an Award-Winning Model

Twemlow, A

3 (April 14)

135-7

Getting to Know Tracy Hall

Hall, T

1 (April 13)

27-8

Getting to Know: Alison Morris

Moris, A

3 (April 14)

133-4

Helping Clinicians to Provide Evidence Based Care for Patients with Back Pain: A Journey from Research to Implementation

Stevenson, K Duffy, H

5 (April 15)

193-4

HG Wells in Stoke-on-Trent

Cartlin, V

6 (Oct 15)

232-4

Hip Fracture Care at UHNM: Progressive Evolution

Ctraig, P Browne, M Roberts PJ

5 (April 15)

195-8

Historical Notes: The Life and Legacy of Lady Rosemary Ednam

Cartlin, V

3 (April 14)

127-9

Interstitial Lung Disease 2

Hall, T

3 (April 14)

119-23

Interstitial Lung Disease 3

Hall, T

4 (Oct 14)

167-70

Interstitial Lung Disease 4

Hall, T

6 (Oct 15)

231-41

Investigation of the Effect of TGF-Î˛, its Inhibitor and Shear Stress in a 3D Conjunctiva Model

Ipek, T Yang, Y Nguyen, DQ

5 (April 15)

199-201

Junior Doctor Diaries

Hegarty, G Mason, R

2 (Oct 13)

95-6

Junior Doctor Diaries

Hegarty, G Mason, R

3 (April 14)

138-9

Junior Doctor Diaries

Mason, R

1 (April 13)

40-41

Junior Doctor Diaries

Mason, R

4 (Oct 14)

176

Lexicon: Forty Years On (A-M)

de Takats, D

3 (April 14)

143-4

Lexicon: Forty Years On (N-Z)

de Takats, D

4 (Oct 14)

178-9

Medical School Taster at Keele University

Suzannah

3 (April 14)

140

Moving Onwards: The Musculoskeletal Interface Service: Its development and Future

Stevenson, K Menen, A

3 (April 14)

9-12

My Journey to a Kidney Transplant and Beyond

Mitchell, K

1 (April 13)

33-5

Nursing and Midwifery Revalidation

Inwood, H

6 (Oct 15)

230-31

Professionalism: We Are What We Teach!

Gay, S

6 (Oct 15)

225-6

Q & A on Non-Medical Prescribing

Hall, T

5 (April 15)

189-90

Quiz Night

Ogunmekan, O

5 (April 15)

213

Quiz Night

Ogunmekan, O

6 (Oct 15)

245-6

Quiz Nite

Ogunmekan, O

4 (Oct 14)

177

Secundum clamo! Francis Report 2013: A Charter for Candour

de Takats, D

1 (April 13)

6-8

Selecting Students for Medical School

Gibson, C

4 (Oct 14)

156

Teaching Undergraduates in the Clinical Setting

Gibson, C

1 (April 13)

15-17

Tentative Wordplay

de Takats, D

1 (April 13)

44-6

Volume 28, No 1, May 2016

TITLE

AUTHORS

ISSUE

PAGE(S)

The 43rd Wade Lecture: An Evening with Lee Pearson

Smith, S

1 (April 13)

36-7

The Adult Attitude to Grief Scale – a Measure for Identifying Vulnerability in Bereavement

Machin, L Sim, J Bartlam, B

1 (April 13)

21-6

The Assessment of Medical Professionalism Post The Francis Report:Do It Well, Do It Often And Do It Repeatedly

Gibson, S

2 (Oct 13)

69-72

The Debate that will not Die

Laszlo, P

6 (Oct 15)

227-9

The New World of Academic Publishing: What ‘Open Access’ Means for Researchers

Ormerod, M James, E Smith, M

6 (Oct 15)

235-8

The Pathway to Quality Neurology: Introducing the Staffordshire Neurological Alliance

Searle, S

2 (Oct 13)

89-92

Type 2 Diabetes Mellitus in Children

Hurst, J

2 (Oct 13)

81-5

Word Play Dozen Off

de Takats, D

5 (April 15)

214-6

Wordplay 13: No Fear!

de Takats, D

6 (Oct 15)

248-50

Wordplay: once upon a hendecagon

de Takats, D

2 (Oct 13)

100-2

Another example of Leicester-related postal history. This is the front part of an item of mail cut out by a 19th Century autograph collector. It was sent from London to Leicester in 1836 by the MP Mark Philip[p]s, MP for Manchester. Free post for MPs had its origins in the 17th Century. Covers were franked ‘FREE’ and had to be signed by the person bearing the privilege to so send. Four classes of folk were entitled to do this: MPs, sitting Lords, sitting bishops and certain civil servants. Mark Philips (1800-1873) was on of two MPs for Manchester in the modern era following the Representation of the Peaple Act 1832, commonly referred to as the Great Reform Act. First elected in 1832, he was then the MP for fifteen years. After retirement, he died in Ingon, near Stratford-upon-Avon, Warwickshire, where there is a memorial plaque in his honour on the Welcombe Bank Obelisk, which is now situated in Welcombe Hills Country Park.

Midlands Medicine

Volume 28, No 1, May 2016