MIDLANDS MEDICINE NOV 2018 VOLUME 28 - ISSUE No 6
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Editor’s Notes
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Human Organ Trafficking
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Covenants in Healthcare
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WHR Rivers (1864-1922): Conquering the Inner Demons
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Portrayals of Dementia 2004 – 2018
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Medical Paradoxes
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More Medical Ceramics
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An Open Letter to the Family and Relatives of My Kidney Donor
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Award Winners
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News
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Asthma Quiz
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Wordplay 17
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Interesting Images
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Asthma Answers and Explanations
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 IMAGES Front cover: One of many community gatherings held across the Midlands to mark the centenary of the end of the First World War on Sunday 11th November 2018. Back cover: the same location (Kidsgrove memorial gardens) when the communal ceremonies were done: time and space for quiet personal reflection. Photographs by The Editor.
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Midlands Medicine
MIDLANDS MEDICINE
CONTENTS
EDITOR Dr D de Takats
EDITORIAL
ASSISTANT EDITOR Mr C Bolger
Human Organ Trafficking Dominic de Takats
EDITORIAL BOARD Mr D Gough Dr I Smith Mr D Griffiths Helen Inwood Clive Gibson Tracy Hall Professor Divya Chari EDITORIAL ASSISTANT Spencer Smith THE NORTH STAFFORDSHIRE MEDICAL INSTITUTE President: Mr B Carnes Chairman: John Muir Honorary Secretary: Mr J Kocierz Honorary Treasurer: Mr M Barnish Please forward any contributions for consideration by the Midlands Medicine Editorial Board to the Editor c/o Spencer Smith, Editorial assistant.
Editor’s notes
Covenants in Healthcare Paul Laszlo ORIGINALS WHR Rivers (1864-1922): Conquering The Inner Demons Jennifer Hands Portrayals of Dementia 2004 – 2018 Hawys Mererid Evans Medical Paradoxes David Manson & Sriram Rajagopalan More Medical Ceramics Anthea Bond REPORTAGE An Open Letter to the Family and Relatives of My Kidney Donor Richard Chapman Award Winners
By email: spencer@nsconferencecentre.co.uk
News
Or by post: North Staffs Medical Institute, Hartshill Road, Hartshill, Stoke-on-Trent ST4 7NY
ENDPIECES
Views expressed in articles and papers are those of the author(s) and do not necessarily reflect the views of the Midlands Medicine Journal or the NSMI, nor imply any agreement with, nor condonement of, those views. All material herein copyright reserved, Midlands Medicine ©2018. Volume 28, No 6, Nov 2018
Asthma Quiz Corinne Salt & Oluseyi Ogunmek Wordplay 17 Dominic de Takats Interesting Images Asthma Answers and Explanations 215
EDITORS NOTES This issue is, in case you haven’t noticed, a little later in the year than usual. There are a number of reasons for this. The one is sluggishness on my own part and another is that I have contrived to get this issue out after the centenary of the end of World War One. This is a moment, like all moments, that will never pass our way again. But this one is of particular significance. The First World War was the advent of modern warfare, at least mechanised warfare, and of total war with military might splayed across land, sea and air with industrial and economic back-up. It was also an absolute beast of a war, a quagmire, bogged down in attrition. We also encountered sheer stupidity as the 19th Century infantry charges ran before the 20th Century machine gun. As this has passed into history, with no eyewitnesses left, it is only our conscious acts of remembrance that can help us to say, and try to mean, “Never again”. Sadly, in political terms, the First World War failed to resolve underlying disputes and the memories couldn’t prevent the Second World War from following on. Now we must have cumulative memories and stack up the arguments against war as a means of politics and understand that the prevention of wars lies so much earlier on, in not travelling the roads that lead there. At the time, loyal, patriotic decent ordinary folk risked, and many thousands gave up, their lives. We should remember them and pay them our respects, this November in particular. They shall not grow old as we that are left grow old: Age shall not weary them, nor the years condemn. At the going down of the sun and in the morning, We will remember them. Reduce, re-use, recycle. If repeats are good enough for the BBC then perhaps I can justify the practice too. In recognition of the need to do something special to mark the centenary of the end of the First World War, I have brought back a couple of articles from seven years ago. The first, by Paul Laszlo, is perhaps only a partial reference to those times, but does touch on the military covenant as we see it today, and argues, perhaps, that NHS workers are somehow too on a battlefront and in some small way perhaps it would be good if the NHS took care of its own. Very much more directly related to WW1 is the story of WHR Rivers and the work around the concept of Shell-Shock, what it might mean and what could be done to help. If you missed this last time around, don’t miss it again. Last chance! 216
One of the important tasks of an Editor is balance. I may have forsaken that a little and sprinkled quite a lot of Renal Medicine into this issue. This starts with an account and a collation of thoughts and tangents around human organ trafficking. This is an issue of very real concern and it is very current, but its roots go way back. If you have any interest at all, please read the editorial. There is also an open letter from a cadaveric kidney transplant recipient. Reading these two items together might be quite interesting, bringing different perspectives together, hopefully in a complementary way. Finally there is some news about a dialysis anniversary in the News section. Medical Students have done us proud I this issue. Jennifer Hands, now long since graduated, was a medical student when she wrote of WHR Rivers, but two current medical students have contributed substantial original articles. Hawys Evans has written about the media portrayal of dementia. That is a very difficult subject to tackle but rather important, and David Manson has tackled paradoxes in medicine, all sorts of paradoxes, wherever he has been able to find them. This is a very interesting approach to quirky medical knowledge and should make for some fun reading. On the cultural side, Anthea Bond tells us a little more about medical ceramics and retrospectively introduces us to Philip Hardacre (but you’ll need to dig out a back issue to fully appreciate that). The NSMI is continually active in its core business: supporting medical research projects by giving targeted funding, and encouraging the development of clinical exellence; please read what we’ve been up to in the Award Winners’ section. Once again I am indebted to the staff at Furlong Medical Centre for providing a quiz. This one is themed on asthma and COPD and is very technical and tricky, not one for guessing at. Finally, let me appeal to you for your contributions. Putting an issue like this together is hard work which would be easier if there was more material to collate. If you have a topic you have been thinking of writing about, put it off no longer: get writing. In the mean time: Happy reading! Midlands Medicine
HUMAN ORGAN TRAFFICKING Dominic de Takats Consultant Nephrologist, Organ Donation Committee Chair, UHNM INTRODUCTION The first human kidney transplant that is generally recognised to have been successful was one that required no immunosuppression because it took place between identical twins with Ronald donating to Richard Herrick.1,2 This was in 1954 at the Peter Bent Brigham Hospital in Boston, USA, led by surgeon Joseph Murray who later received the Nobel prize. So, though living kidney donation is seen as something modern and on the up, actually it was the foundation of all modern successful solid organ transplantation. Once immunosuppression was available, however, the much commoner source of organs was from deceased owners; most people do not have a healthy identical twin handy when they need an organ transplant. But the genie was out of the bottle and human organ transplantation is now both routine and commonplace from deceased and from living donors. Wherever there is a technology that can achieve a desired outcome, a choice exists as to how to apply that technology. The World Wide Web is a fantastic instrument for sharing information that is news, inspirational, supportive, entertaining or educative. But it can also be used to facilitate bullying, grooming, exploitation and, particularly on the Dark Web, criminal activity. Email is a great communication tool spanning from private, delicate exchanges to mass urgent communication, but its volume is a curse and it has brought to us the previously non-existent issues of spam, phishing, and malware viruses. Medicine is not immune from this sort of corruption: We have legitimate good clinical uses for nitrous oxide and opioids, but they can be misused recreationally. (Occasionally the traffic goes the other way as we are now seeing with cannabinoids.) It does seem that it is only human always to find a more selfish and less moral way to use any means to an end.
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Physical life is difficult for some and morality is a quagmire for others. Moral precepts can and do get battered when put up against desperation. Antiabortionist parents might not prevent their young teenage daughter from having a termination, as heartbroken and defeated as they might feel; When serious ill health affects individuals with means to access additional or alternative healthcare, sometimes positions change, or perhaps true self-centredness is revealed: an NHS doctor with socialist leanings might spend his savings on unproven nth line chemotherapy privately, ditching his general principles when he has become the particular case in question. Human organ and tissue transplantation is a wonderful thing. It often transforms lives for the better and sometimes it saves lives. But commodification of human organs and tissue is a delicate matter to be handled with great care. In the right setting, such as paired exchange kidney transplantation as practised in the UK, a regulated, arbitrated and moderated exchange makes victims of no-one and is a positive construct driven by a coalition of the desiring, the able and the responsible. However, in other settings, the buying, selling and the trading of organs is exploitative, a power-broking game in which the powerful desperate exploit the poor desperate and the middle merchants exploit them both. In such a situation, neither the suppliers (they are not donors because they are selling, not giving) nor the recipients are treated with respect nor dignity nor with due care and attention. Both are used by the fixers merely as a means to personal gain. Consequently the risks are higher and the outcomes are poorer. For these several and distinct reasons UK Blood and Transplant are very much against commercial organ transplants and is signed up to the principles in the 2008 Declaration of Istanbul which has been updated
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in 2018.3 These ten laudable principles* though widely supported by authorities internationally are practically opposed by organ traffickers who range from chancers and small criminal gangs to more professionally based groups to organised crime outfits. It has been estimated that up to 5% of all transplant activity is illegally commercial and kidneys are the most commonly traded organs.4 This reflects the large numbers of people for whom a kidney transplant represents a considerable benefit. (There tend to be more of them than those waiting for a liver or a heart transplant because dialysis can keep kidney failure patients alive over long periods of time in a way that simply is not the case for liver or heart failure patients, despite technologies that have tried to emulate the success of dialysis in these other contexts, e.g. MARS5 and Jarvik6.)
HUMAN ORGAN TRAFFICKING What human organ trafficking comprises is officially defined in the documentation around the declaration of Istanbul, but here follows a description of a range of activities which fall within the scope of the definition: 1. Recipients in need of a kidney travel to a (usually poorer) country to purchase a kidney from a local citizen (‘transplant tourism’). 2. A poorer individual travelling to another country with the explicit purpose of donating an organ. 3. Kidnapping and forcible removal of an organ for transplantation. 4. Consentless removal of organs from dead people. 5. Execution of prisoners in a manner designed to make organs available for transplantation. 6. Murder with the object of organ harvesting. All of the above have definitely happened and some probably quite recently. The first point is seen occasionally when some West Midlands residents travel to India or Pakistan. Point 2 is covered in ‘IT WAS EVER THUS’ below. Points 3 and 6 are the subject of many stories posted on the web. Point 4 was the subject of a classic suspense thriller film, Coma (1978), and they must have gotten the idea from somewhere. Point 5 has been practised in China at times. 218
MORAL DIMENSIONS Many of the activities described are clearly illegal. Forcible organ removal, theft from cadavers, kidnapping extortion, blackmail and deception are activities that do not need a moral case built against them; the arguments are self evident. But opposition to organ trafficking is more than these obvious cases, it is also a moral principled opposition to those cases where consenting adults, one who needs an organ (for simplicity consider a kidney) and one who needs money and feels they are prepared to give up an organ in exchange for that money. The objections are twofold, firstly there is a principled objection to the commodification of human entity (and the same objections hold where we are considering the sale of blood or eggs or sperm, and similar arguments prevail around sex trading and pornography) and the second is the view is that these exchanges are necessarily exploitative and reflect in personal circumstances inequities and injustices which are seen on societal and trans-national scales. The arguments are about unfairness on both sides: Firstly, that the seller of an organ doesn’t really have a free choice; no one who didn’t feel compelled by their circumstances would sell an organ for money - contrast this with altruistic living kidney donation as currently practised in the UK; Secondly, it is unfair that someone with sufficient wealth should be able to procure themselves a kidney whilst others of lesser means wait in a queue. Incidentally, in terms of the distribution of the money involved, there can be enormous inequity of distribution with a recipient paying up to £200,000, medical and surgical staff, the brokers and the hosting hospital getting paid in the tens of thousands each and the seller lucky to be paid a few thousand pounds.
PRACTICAL CONSIDERATIONS As if to back up the undoubted self-righteousness of those who believe in intrinsic worth and the dehumanising and degrading effects of commodification, markets in human substances tend to generate ‘the wrong kind of donor’ compared with altruistic donors. For example, there are those who have fathered too many progeny as excessive sperm donors and blood products from the US have left the UK with a scandal in terms of infecting haemophiliacs with HCV. Midlands Medicine
IT WAS EVER THUS You might think that, with the first real effort to document the problem of organ trafficking being in 20074 and the first coordinated response to it being in 20083, this is a 21st Century problem. But at least some of the Human Organ Transplants Act (2009) and its successor Human Tissue Act (2004) is a direct response to an organ trafficking scandal in London in the 1980s: A Transplant surgeon was barred from undertaking any private kidney transplants for a three year period having been found guilty of serious professional misconduct after removing kidneys sold for transplantation from four Turkish villagers between June and November 1988 at the Wellington Humana Hospital in St John’s Wood in North London.7 The recipients were, reportedly, wealthy Arabs. The technical expertise was British, based in London. This was not the sort of expertise the GMC wanted UK medicine to be known for. Alternative instances of treating humans, or parts thereof, as medical commodities can be traced back at least a little further to a time when, in the early 19th Century, the falling number of executions in Britain led to a shortage of cadavers for dissection. As in any market, shortages drove up prices. Enter the very embodiment of enterprise in the form of Messrs Burke and Hare.8 Grave-robbing had become a widespread nefarious activity with Burke and Hare possibly participants, but it was messy, and the graves got watched over when fresh and it became difficult to come by fresh corpses by that means. So, ever resourceful, they set about avoiding grave-robbing by procuring fresh dead bodies directly, by means of murder. They chose for their victims the gullible, the vulnerable, the disabled and prostitutes drawing a very clear distinction for these ladies between choosing to ‘sell their bodies’ alive and being killed for their bodies. Incidentally, it was the prostitutes and the disabled man who partly did for Burke and Hare because the disabled man was a recognised character locally and for some reason or other the prostitutes were familiar to the medical students.
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Between 1827–8 Burke and Hare, with their partners as accomplices, went on a killing spree, selling the bodies to the local anatomy school for cash. Eventually getting careless, they were discovered and came to trial in 1829. William Burke was hanged for his crimes in 1829 whilst William Hare was released, and fled. Burke’s skeleton is kept in the Anatomical Museum at the University of Edinburgh, an ironically fitting end to his contribution to medical science. One thing that drove the market in illicitly obtained cadavers was a law which permitted only the dissection of executed criminals and did not allow dissection of donated bodies. In response to the behaviours of Burke, Hare and the London Burkers (body snatchers), the Anatomy Act (1832) was passed allowing the use of donated bodies for dissection. This altered the market entirely and essentially ended the problem.
CONLUDING THOUGHTS Though I have sought to inform rather than preach, I do have a view and it is only fair to be open about that, so here goes: To preserve the moral integrity of organ and tissue transplantation, it is both correct to attempt to maximise the provision of organs and tissues obtained from dead donors, which may be and argument for England moving over to a presumed consent model in the future, and the donation journeys of living donors need to continue to be closely supervised and supported within the existing frameworks, and, in the future, there is not a great deal of scope for loosening such controls unless we decide as a society that we wish to move into a moral landscape very different from the one we now inhabit. The declaration of Istanbul, as updated this year, crystallises the very best thought on these issues. We should support the declaration, steer patients to the better, fairer path and oppose exploitation of the vulnerable at every opportunity.
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REFERENCES
FURTHER INFORMATION
1. PEOPLE AND DISCOVERIES www.pbs.org/wgbh/aso/databank/entries/dm54ki/ html
United Network for Organ Sharing at: unos.org/ transplantation/history
2. World’s first organ donor dies aged 79 [in 2010] Ronald Lee Herrick donated kidney to his dying twin brother in pioneering 1954 operation www.theguardian.com/society/2010/dec/30/firstorgan-donor-dies-79 3. The declaration of Istanbul on organ trafficking and transplant tourism www.declarationofistanbul.org/images/Policy_ Documents/2018_Ed_Do/2018_Edition_of_the_ Declaration_of_Istanbul_Final.pdf See also: www.declarationofistanbul.org 4. Shimazono Y (2007) The state of the international organ trade: a provisional picture based on integration of available information Bulletin of the World Health Organization Vol 85 pp955-62 5. Saliba F The Molecular Adsorbent Recirculating System (MARS®) in the intensive care unit: a rescue therapy for patients with hepatic failure Critical Care (2006) Vol 10 p118 doi.org/10.1186/cc4825 6. www.jarvikheart.com Editor’s note: Other artificial hearts are available. For some of the background briefly refer to the book review of The Nuts And Bolts Of Life by Paul Heiney in the last issue of Midlands Medicine, a biography of Willem Kolff, the father of synthetic organ replacement therapies 7. Tannenbaum J “Tiger Country” Kidneys for Sale in London in the 1980s Configurations (2014) Volume 22 pp337-60 doi: 10.1353/con.2014.0024 8. The Story of Burke and Hare www.historic-uk.com/HistoryUK/HistoryofScotland/ Burke-Hare-infamous-murderers-graverobbers/
*The declaration of Istanbul on organ trafficking and transplant tourism 1. Governments should develop and implement ethically and clinically sound programs for the prevention and treatment of organ failure, consistent with meeting the overall healthcare needs of their populations. 2. . The optimal care of organ donors and transplant recipients should be a primary goal of transplant policies and programs. 3. Trafficking in human organs and trafficking in persons for the purpose of organ removal should be prohibited and criminalized. 4. Organ donation should be a financially neutral act. 5. Each country or jurisdiction should develop and implement legislation and regulations to govern the recovery of organs from deceased and living donors and the practice of transplantation, consistent with international standards. 6. Designated authorities in each jurisdiction should oversee and be accountable for organ donation, allocation and transplantation practices to ensure standardization, traceability, transparency, quality, safety, fairness and public trust. 7. All residents of a country should have equitable access to donation and transplant services and to organs procured from deceased donors. 8. Organs for transplantation should be equitably allocated within countries or jurisdictions, in conformity with objective, non-discriminatory, externally justified and transparent rules, guided by clinical criteria and ethical norms. 9. Health professionals and healthcare institutions should assist in preventing and addressing organ trafficking, trafficking in persons for the purpose of organ removal, and transplant tourism. 10. Governments and health professionals should implement strategies to discourage and prevent the residents of their country from engaging in transplant tourism.
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11. Countries should strive to achieve self-sufficiency in organ donation and transplantation.
COVENANTS IN HEALTHCARE Paul Laszlo, Consultant Physician Editor’s note: This article was first published in Midlands Medicine seven years ago in October 2011, Vol 26 issue 4 and the date references are unaltered, so please adjust your mental clocks accordingly. AN ARMED FORCES’ COVENANT
When we see this laid out in terms of:
The word covenant can hold several meanings. Put in rude simplicity, a covenant is a contract, a binding agreement. In law, the terms follow through, but outside the straight legalistic context, less is more. A covenant is a contractual agreement strongly bound not by law but by such notions as honour and duty. The form of the contract may be little more than an understanding, generally known, capable of being articulated but rarely explicitly stated. To declare out loud that one intends to invoke the unstated understanding somehow robs it of its power, weakens the bonds. Of what am I writing? Well, the most overt manifestation recently considered by society at large has been the military covenant between the Armed Forces personnel and the British Government on behalf of the state and broader society. Interestingly, when put in its broadest and most general terms, it sounds a grand thing that there exists a covenant between the British state and its Armed Forces such that we understand that they operate entirely as an organ of a democratically accountable government, that they go where they’re sent, obeying orders so risking and losing limbs and lives in return we undertake not to actually disadvantage them in society, to honour and respect their risks and their sacrifices, and (this is very important) to continue caring for the injured and the widows in their damaged lives beyond the Forces. When this was just an understanding it lacked explicitness and it lacked force. If society could be trusted it needed not force; we’d have got on with it because we all understood that it ought to be so. But because we seem to have fallen short, because the required respect to make this work as an honourable covenant, an outworking of understood and accepted duty dose not seem to permeate as widely in society as once it did, we have decided to codify the military covenant in law. And so flows the necessary explicitness and nitty gritty of detail.
• Amputees should have access to good prosthetics even after they leave the Armed Forces • Seriously injured veterans and Armed Forces personnel to be automatically eligible for concessionary bus travel across England • Armed Forces personnel suffering genital injuries while on operations will get free access to three cycles of IVF treatment
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the military covenant gains bite but loses scale, its overarching moral authority. The real shame is on a society where doing good and helping others becomes a matter of rights enshrined in law rather than a matter of courtesy and duty, and honourableness between people.
ALONG PARALLEL LINES Perhaps, there is a sense in which something similar, might be either appropriate or inappropriate in healthcare: a healthcare covenant. In times past, if a doctor saw a colleague privately, fully intending and prepared to pay the appropriate fee, a consultation would commonly either be declared ‘On the House’ or the anticipated bill would never arrive. Or, in the case of surgery, the invoice might only cover costs incurred with the surgeon’s and or anaesthetist’s fee waived or reduced. Perhaps there was a tacit understanding that where, for example, a GP had undergone a hernia repair privately at little or no cost, the GP would, in turn, return the favour by way of steering private referrals in the Surgeon’s direction. This is not necessarily what I imagine as ideal for a modern healthcare covenant. (But there might be a certain honesty in the GP’s subsequent referrals: if he had received poor technical care then, free or not, the GP would be unlikely to recommend 221
the Surgeon to his or her patients whereas if s/he had received good technical care complimentarily then personal recommendations might reasonably be expected to follow.) We are not in times past. Indeed we are stuck in a process of modernisation and reform that seems to have been going on for at least a generation, and shows little sign of slowing just yet. Twenty years after the New Deal for Junior Doctors and just over 10 years on from The NHS [10 year] plan introduced by Alan Milburn in 2000, and as we currently enmesh ourselves in the Health and Social Care Bill 2011, it is clear that in many ways we cannot go back. However, just codifying everything doesn’t reliably make matters better. Do we really pay any attention anymore to all that nonsense with Charters that John Major was responsible for? But I do think that an honourable covenant among healthcare workers, along the lines I’ll outline in a while below, is something worth considering for the future.
PERSONAL REFLECTIONS Recently, I needed a few tests done. The NHS served me well to start with, at both ends, so to speak: I was able to work flexibly around my appointments and I was seen (by choice) at a hospital a little outside my own catchtment area pretty quickly and dealt with fairly efficiently. (I find that being on the other side of the professional-patient relationship desperately disconcerting, an experience I suspect might be true for many who find themselves in such a position.) People were straightforward and genial, although the more obvious politeness expected by my parents seems now to be a thing of the past. The follow-up appointment was fine, in a quiet cottage hospital slightly closer to home. (The only oddity being that the Consultant and I had trained together in the past leading to a consultation and a catching-up session in one.) But when it came to the CT scan needed for final checks and re-assurance, things did not go so well. Perhaps the GP was a little slow on the off. No matter. The real problem was that having received the request card in the department, there was going to be a waiting time of two or three months and then an appointment would be issued at relatively short notice, certainly too short to cancel clinics in any reasonable, civilised, or contractually 222
allowed, way. So I arranged to have the scan privately. The appointment was quick (once the GP’s referral had been secured) and could, no doubt, have been rearranged if inconvenient. It was impersonal. And once the scans and report were done, I arranged to pick up a CD of the doings at the weekend. Of course, the irony was that the Private Hospital couldn’t manage the whole body CT with contrast, and it was done in the local NHS hospital where I had been referred in any case, by NHS staff, but reported by the radiologist in his own time under contract to the private company through whom I had procured my CT scan. I don’t begrudge the fee: it was my choice and I’m lucky to be well enough paid by the NHS to be able to afford the fee to get a scan at my convenience so I don’t have to cancel clinic and don’t have to look after patients distracted by the thought all the while that I might just be worse off than they are, but don’t know it yet. However, I wonder if there might be a better way. And not so much for me; the NHS employs many more people on low wages for whom recourse to the private sector is not such a ready choice.
A HEALTHCARE COVENANT: A BETTER WAY When I do clinics, I’m usually made aware if the person is a member of the hospital staff or if they work in healthcare somewhere. Some of my chronic patients work directly on the corridors I roam, or in the wards I visit. If they have a clinic appointment we make arrangements, if they at all wish it. People are seen first thing in the afternoon clinic if they want to be seen in their lunch hour. They’re seen in the evening if they’re about to do a night shift, they’re seen outside the main clinic setting if they don’t want to chance waiting alongside their own patients, they’re called when their clinic slot’s coming up so they don’t have to wait around and can disrupt their work (for the NHS and for other patients) as little as possible. If they have a quick question, they’re seen at short notice, often informally. This, I would refer to as accommodation. We do it, too, for demanding patients and for those with particular needs, so this is not exclusively something accessible to fellow NHS workers, but the opportunity to either treat them just the same as everyone else, or to make accommodation, does arise more commonly Midlands Medicine
among fellow NHS workers. And maybe there is a little hope that such an accommodating attitude might be reciprocated and that when I become a healthcare consumer, rather than provider, my life will be made just a little easier by like-minded souls. No formal covenant exists that states that NHS healthcare workers should take special care of each other and I am far from advocating any such thing, but I do think we should choose to look out for each other, to make some special accommodation, where we can, and where there’s no material disadvantage to other patients. In doing this it is perhaps worth remembering this simple truth: if we take better care of each other, that enables us to deliver better care to all patients.
ADDRESS FOR CORRESPONDENCE Paul Laszlo, Consultant Physician C/o The Editor Midlands Medicine North Staffordshire Medical Institute Hartshill Road Hartshill Stoke -on-Trent ST4 7NY FURTHER INFORMATION www.britishlegion.org.uk
With proud thanksgiving, a mother for her children, England mourns for her dead across the sea, Flesh of her flesh they were, spirit of her spirit, Fallen in the cause of the free.� Laurence Binyon
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WHR RIVERS (1864-1922): CONQUERING THE INNER DEMONS Jennifer Hands, KUSoM graduate Editor’s note: This article was first published in Midlands Medicine seven years ago in October 2011, Vol 26 issue 4, when Jenny was a fourth year Medical Student at Keele University. It is republished in this issue to mark the centenary of the end of World War 1. Be mindful that internet sources were originally accessed in 2011 and some may not still work. (PTSD) is an uncommon but significant consequence of these events, affecting between 1.6% and 6% of military personnel over the last twenty years.2 Although PTSD did not appear in the International Classification of Diseases until 1992, soldiers in World War I were falling prey to an illness with very similar symptoms; symptoms which would likely have seen them diagnosed with PTSD today. World War I was the first industrial war where high explosive artillery was used on a large scale. For the soldiers on the ground, artillery warfare meant that death was a constant threat at any time, without warning, from a shell fired by an enemy many miles away. To witness such a death was gruesome, with body parts scattered over a wide area. The soldiers must have felt helpless knowing how totally vulnerable they were to artillery attack. These factors contributed to the emergence of a new illness: shell-shock.
Fig. 1 – Portrait of William Halse Rivers Rivers
INTRODUCTION ‘These are men whose minds the Dead have ravished.’ (Mental Cases, Wilfred Owen 19171) The bloody images in the media of the conflicts in Iraq and Afghanistan are a stark reminder of the traumatic events that members of the Armed Forces endure in the course of active duty. Post Traumatic Stress Disorder
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During the four years of intense fighting it is estimated that up to two million British military personnel were injured, of which 85,000 were classified as having shell-shock.3 The first recorded case of shell-shock was documented in 1915. Initially the term was used to define the illness caused by traumatic brain injury from the blast of high explosives. However the diagnosis of shell-shock was also applied to those individuals suffering from similar symptoms who had not been subject to a blast injury. The War Office dispatched a physician, Dr William Turner, to classify this new condition and compile a list of diagnostic symptoms:
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‘...a form of temporary ‘nervous breakdown’ scarcely justifying the name of neurasthenia, which would seem to be characteristic of the present war... ascribed to a sudden or alarming psychical cause such as witnessing a ghastly sight or a harassing experience... the patient becomes ‘nervy’, unduly emotional and shaky, and most typical of all his sleep is disturbed by bad dreams...of experiences through which he has passed. Even the waking hours may be distressful from acute recollections of these events.’ 4 Shell-shock was now officially recognised as an illness. The Army Council separated the diagnosis of shellshock into Shell-Shock (W) (for wounded), which was deemed to have been caused by enemy action – in other
Fig. 2 - The ‘thousand yard stare’ typical of shell-shocked patients
words a blast injury, and Shell-Shock (S) (for sickness), which was not deemed to have been caused as a direct result of enemy action. Shell-Shock (W) attracted a war pension and allowed the soldier to wear the honourable wound stripe, whereas Shell-Shock (S) did not allow the soldier either of these advantages.
In the early 20th Century psychiatric diagnosis was still somewhat crude; patients were either classified as sane or insane. Any individual, and crucially any soldier, could be fitted into one of three categories: well, wounded, or insane. Anyone classed as ‘insane’ could not be held legally responsible for their actions which meant they could not be accused of cowardice.5 But where did Shell-Shock (S)b fit in? Without a tangible medical explanation for its cause, public opinion on the whole was still that shell-shock was tantamount to cowardice. Indeed, there was still disagreement as to the credibility of shell-shock in the highest echelons of the Armed Forces. The Director of Medical Services in 1916 publicly declared that he ‘never had and never would recognise the existence of such a thing as shellshock’.6 By the end of the war the British Army had executed a tenth of the 3,080 soldiers awarded the death sentence for cowardice.7 However, the dilemma of the Army manning department was what to do with those men diagnosed with shell-shock. They had been classified as having a mental illness and were therefore deemed not be cowards, plus they were not fit to serve on the front line. With the ever increasing need to keep the Army fully manned it was essential that a cure was found for shell-shock. With the whole nation vehemently supporting the war effort, cowardice was seen as one of the worst possible crimes, but executing soldiers left gaps in the ranks which was contrary to the war effort. It may have been this need to keep the ranks filled which finally made the diagnosis of shell-shock more palatable to the general public. Their distaste was appeased by the admission that, although there was still something wrong with these soldiers, they could still be ‘fixed’ and returned to the front-line.
a
A phrase coined from the painting of the same name painted by Tom Lea in 1944.
b
For the purposes of this paper Shell-Shock (S) will be referred to simply as shell-shock.
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RIVERS’ BACKGROUND
THE AETIOLOGY OF SHELL-SHOCK
William Halse Rivers Riversc, an eminent 51-yearold anthropologist, neurologist, and an emerging psychologist, had just arrived home from a field-trip to Melanesia when a call went out in 1915 for doctors to join the Royal Army Medical Corps to help deal with the dilemma of shell-shock. Rivers had already resigned himself to the fact that he was too old to serve as a front line doctor, but he was intrigued by the idea of getting involved with what he termed ‘war neuroses’.8
During the early years of World War I the aetiology of shell-shock was still little understood. Once it had been established that not all cases were due to blast injury, a psychiatric origin was sought. Sigmund Freud applied his psychoanalytical theories based on repression and the unconscious to shell-shock but they were not well received by the medical profession due to the sexual contextf. Rivers’ extensive work in anthropology and neurology meant that he took a more holistic approach to the problem than those physicians who had only studied psychiatry. His studies of remote tribes had already led him to hypothesise about the links between human instinct and the unconscious. Rivers used the basis of Freud’s theories to produce his own theory for the aetiology of shell-shock. Rivers proposed that the war neuroses were ‘due to disturbance of an even more fundamental instinct – that of self-preservation.’13 Rivers evolved Freud’s theory of repression explaining that it is the active process of burying unpleasant memories from the immediate conscious that allows the individual to continue functioning during times of extreme pressure.14 This creates a conflict between ‘instinctive tendencies and the forces by which they are controlled’;15 usually the brain succeeds in actively repressing this primitive survival instinct. However in times of extreme stress or shock there is an overwhelming conflict between the self-preservation instinct and the controlling forces causing an imbalance in favour of the instinctive tendencies. Rivers claimed that the symptoms of shellshock manifested from the brains attempts to redress the imbalance. The nightmares and flashbacks were all part of the ongoing unconscious battle to restore the balance and the aggression, ‘thousand yard stare’ and tremors were due to the now uncontrolled selfpreservation instinct. Something now recognisable as the activation of the sympathetic nervous system.
Rivers was born into a family with an impressive military lineage including a great uncle who served on HMS Victory in the Battle of Trafalgar and was credited with shooting Admiral Nelson’s killer.9 It has been suggested by Pat Barkerd that when the young Rivers cried he was directed to a picture of his great uncle and told that he must never cry.10 His father was a speech therapist yet Rivers suffered enormously with a stammer as a child; he was bullied incessantly at school for this and consequently became something of a recluse. Furthermore, a serious case of typhoid fever in his last year at school meant that he had to drop out a year early and failed to secure a place at Cambridge University to read medicine.11 He no doubt felt that he was a failure to his father and perhaps this is what then turned him into such a determined character. Despite these early setbacks he went on to read medicine at St. Bart’s and graduated aged 22 years; at the time the youngest person ever to be awarded the Bachelor of Medicine degree. However he remained a very shy and private man, never marrying and rarely socialising with colleagues. He fought hard to keep his stammer a secret; which may have been what deterred him from seeking social company. Rivers’ work on war neuroses began in 1915 at Maghull military hospital in Lancashire where he treated psychiatric patients sent back to England. After one year he was transferred to take over as senior psychiatrist at Craighlockhart Hospital for Officers after the incumbent Commandant was sacked following a snap inspection of the hospital. The Commandant did not recognise shell-shock as an illness so it is hardly surprising that his ‘treatments’ were more like punishments – soldiers were kept in isolation apart from when they were drilled for hours a day. It was at Craighlockhart that Rivers came up with his aetiology theory for shell-shock and struggled with his own ‘Catch-22’ dilemma.c
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Understanding the mechanism of the illness gave psychiatrists an initial foundation on which to build their treatments. However the implications of Rivers’ theory on the aetiology of shell-shock were more farreaching. There was now a medical explanation for shell-shock which gave the illness credibility among the general public and helped to remove the implication of cowardice from the label. It took another four years before the Shell Shock Enquiry finally gave official credence to shell-shock and awarded war pensions to most sufferers.16 Sadly Rivers died a week after the Shell Shock Enquiry report was published, from a strangulated hernia, so was unable to further progress his work on shell-shock. Midlands Medicine
THE SEARCH FOR A CURE Great pressure was placed on the Royal Army Medical Corps (RAMC) to keep the ranks filled with fit men in order to sustain the war effort; there was no exception for psychiatric patients. In a bid to return shell-shocked patients to the front line many different treatments were tried. These ranged from electrotherapy, a treatment that consisted of shocking the patients at higher and higher levels whilst ordering them to be cured; to the rather novel abstinence therapy. This involved ‘finding out the likes and dislikes of each patient, and ordering them to abstain from the former and apply themselves diligently to the latter.’17 The most common form of treatment, and that promoted by the RAMC, was to use the method of forced repression in an effort to make patients forget whatever it was that was most distressing to them. However this only worked whilst the patient was engaged in the treatment. At night their defences were lowered and their demons would come back to haunt them. In the short term, this treatment may have enabled soldiers to return to the front-line symptom free, but current research into PTSD shows it
would likely only have been a temporary reprieve and their illness would probably have returned much worse. Rivers’ therapy took an alternative approach in developing his talking therapy. Patients were encouraged to talk about the event that was causing them most distress and Rivers attempted to divert their cognitive processes to make them see it in a different light. One case that Rivers describes in Repression and the War Experience14 illustrates how his therapy worked. A patient had been suffering from nightmares, headaches and tremors since almost being hit by a shell. He described how he went searching for his friend after the dust of the explosion had settled and found his mutilated body spread over a wide area. He was clearly dead. When discussing the event with Rivers, the officer described his feelings of utter helplessness and misery at the horror of what had happened. Rivers suggested to the officer that the horrific nature of his friend’s injuries meant that he had almost certainly died instantly and had in fact been spared any pain or awareness of what had happened. He encouraged the officer to think of this whenever he imagined the picture of his friend’s corpse in his head. From that point on the officer suffered no further nightmares. Rivers realised that although he could not change the situation that had happened, by altering the way the patient thought about the situation (cognition) he could change their associated feelings and actions (behaviour). This form of therapy is recognisable as being very similar to how modern Cognitive Behavioural Therapy (CBT) works (Figure 4). Nevertheless, although Rivers’ techniques were highly successful in treating shellshock during the war, further development of cognitive and behaviour therapies did not start for another fortyfive years.
Fig. 3 – A soldier undergoing electrotherapy in WWI
c
Despite extensive research by many historians, no explanation can be found for the use of‘Rivers’as both forename and surname.
d
Author of ‘Ghost Road’, a novel closely based on Rivers’ work.
e
A paradoxical situation with no way out – a phrase coined from Joseph Heller’s novel Catch-2212.
f
Freud believed that the hysterical symptoms of shell-shock were the manifestations of unconscious emotional conflicts caused by the Oedipus Complex, whereby all men have a repressed sexual desire for their mother.
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His most famous patient, Second-Lieutenant Siegfreid Sassoon described how he felt that Rivers ‘made me feel safe at once and seemed to know all about me’6. The childhood bullying he experienced may have enabled him to have more empathy with his patients; they too felt ostracised, and despised talking about their problems.
Situation
Thoughts
Physical Reactions
CATCH-22
Moods / Feelings
Behaviour
Fig. 4 - Cognitive Behavioural Therapy Model
Using his new psychotherapy Rivers achieved an almost 100% success rate curing patients of their symptoms within six months. Little data is held as to the long term outcomes of these patients, so whether it can also be claimed that they remained in long-term remission from their shell-shock remains unknown. Eventually other physicians at military hospitals adopted Rivers’ technique. Whilst great improvements were seen in an overwhelming majority of the patients, no other physician equalled Rivers’ impressive results. Despite his shy and private character, Rivers developed an intimate rapport with his patients and this was probably why he was able to have such an effect on his patients. His colleague, Frederic Bartlett, describes him: ‘...the other side of him was his sympathy. It was a sort of power of getting into another man’s life and treating it as if it were his own. And yet all the time he made you feel that your life was your own to guide, and above everything that you could if you cared make something important out of it.’ 11 228
As a doctor, Rivers wanted to do everything possible in order to free his patients of their unpleasant symptoms. However by doing so he thus made them fit for military service again so they were put back into the very same environment which had caused the problem in the first placeg. Rivers felt that he was in a Catch-22 situation: he either left his patients to suffer, or relieved them of their symptoms only to send them back to potentially develop shell-shock again. Rivers faced a conflict of interest between the Hippocratic Oath and his military orders. John Adair developed the ‘Circles of Needs’ (Figure 5) to demonstrate the conflicts faced in leadership, but they can be also used to illustrate the dilemma faced by Rivers. He was torn between the needs of the individual (cure of symptoms), the task needs (defence of the nation thus requiring manpower), and the team needs. The needs of the team were the maintenance of morale of the unit, achieved in this case by demonstrating that if anyone were to succumb to shell-shock they would receive the best possible care and hopefully be relieved of their symptoms.
Task Needs
Team Maintenance Needs
Individual Needs
Fig. 5 - Adair’s Circles of Needs
Midlands Medicine
RIVERS’ CHARACTER The huge scale of World War I and the large number of casualties precipitated the advances in the diagnosis and treatment of shell-shock. However Rivers’ achievements cannot just be attributed to the circumstances of the time. He was a man of purpose, and when he set his mind to something he didn’t stop until he achieved it. This determination was evident from an early age; not least in his academic achievements despite the setbacks he faced. Rivers came to psychiatry with a strong background in anthropology and neurology, and made sure he used this broad knowledge base to take a holistic approach to the problem at hand. Military physicians were renowned for their indifference to medical research – they were employed to ensure that casualties were ‘patched up’ and returned to the front line as soon as possible. Rivers was determined not to succumb to this stereotype and endeavoured to work as hard as he could in the patients’ best interests. He threw himself wholeheartedly into treating his patients at Craiglockhart. He made himself available to his patients twenty-four hours a day at a moment’s notice, coming to them at night if their nightmares returned. But Rivers was to pay the price for such dedication to his job. He too began to suffer from nightmares and tremors like his patients, and his stammer got much worse. Rivers himself was suffering from a form of shell-shock. After a short period of leave, he returned to work much rejuvenated. CONCLUSIONS Rivers’ papers on the aetiology of shell-shock went some way towards improving the public perception of the illness, and contributed significantly towards the decision made to award war pensions to sufferers of shell-shock. The psychotherapy he developed laid the foundations for modern Cognitive Behavioural Therapy to evolve nearly half a century later. Had he not died so suddenly, maybe his continued work would have enabled Cognitive Behavioural Therapy to develop sooner. There can be little doubt that Rivers’ work saved many men from the firing squad and perhaps also from a lifetime living with demons. But he was still aware that there was nonetheless much more to learn about shellVolume 28, No 6, Nov 2018
shock: ‘Psychiatry will emerge from the war in a state very different from that it occupied in 1914. Above all it will be surrounded by an atmosphere of hope and promise for the future treatment of the greatest of human ills.’ (Rivers 1919) ACKNOWLEDGEMENTS Thanks to Professor E Jones, Professor of the History of Medicine and Psychiatry at King’s Centre for Military Health Research. ADDRESS FOR CORRESPONDENCE Jenny Hands C/o The Editor Midlands Medicine North Staffordshire Medical Institute Hartshill Road Hartshill Stoke -on-Trent ST4 7NY REFERENCES 1. Owen W The Collected Poems of Wilfred Owen Edited by C. D. Lewis. London: Chatto & Windus; 1966 2. Sundin J et al. The impact of the conflicts of Iraq and Afghanistan: a UK perspective Int Rev Psychiatry (2011) Vol 23(2) pp153-9 3. Jones E, Palmer I and Wessely S War Pensions (1900-1945): Changing Models of Psychological Understanding Br J Psychiatry (2002) Vol 180 pp374-9 4. Turner WAS Remarks on cases of nervous and mental shock Br Med J (1915) May 15; 1(2837): 833-5 5. Trial of Lunatics Act 1883 (c.38,46&47) London: HMSO
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6. Sassoon S Sherston’s Progress London: Faber; 1936 7. Shephard B A War of Nerves: Soldiers and Psychiatrists, 1914-1994 London: Pimlico; 2002. 8. Kloocke R, Schmiedebach H and Priebe S Psychological injury in the two World Wars: changing concepts and terms in German psychiatry Hist Psychiatry 2005 Mar; 16 (61 Pt 1): 43-60 9. Ballantyne I and Eastland J HMS Victory (Warships of the Royal Navy) Stroud: Leo Cooper Ltd; 2005 10. Barker P The Ghost Road London: Penguin; 2008 11. Bartlett F. Obituary notice of WHR Rivers. The Eagle 62(269):156-160; 1922
PICTURE CREDITS Figure 1 STONEMAN, W (1917) William Halse Rivers Rivers. National Portrait Gallery Collection, NPG number x164465, London Figure 2 KIFF, J (1917) Combat Stress Reactions psychology.wikia.com/wiki/Shellshock Figure 3 BEHARY, J (2010) Use of Electrical Apparatus www.electrotherapymuseum.com/2008/NMH2/index. htm Figure 4 HOLMES, D (2010) Cognitive Behavioural Therapy www.watfordhypno.co.uk/blog/cognitive-behaviouraltherapy Figure 5 CANNELL, M (2006) Leadership: An Overview www.sterling-selection.com/eventsandarticlesleadership---an-overview-29.htm
12. Heller J Catch 22 London: Corgi; 1964 13. Head H. Obituary. W.H.R.Rivers, M.D., D.Sc., F.R.S. An Appreciation Br Med J 1922 June 17; 1 (3207) pp977–978 14 . Rivers W Repression and the War Experience Proc R Soc Med 1918; 11(Sect Psych) pp1–20 15. Rivers W Instinct and the Unconscious Cambridge: University Press; 1920 16. Richards A Report of the War Office Committee of Enquiry into “Shell-Shock” London: Imperial War Museum; 2004 17. Slobodin R W.H.R.Rivers Pioneer, Anthropologist, Psychiatrist of the Ghost Road Stroud: Sutton Publishing Ltd; 1997 230
Midlands Medicine
PORTRAYALS OF DEMENTIA 2004 – 2018 Hawys Mererid Evans, Medical Student, KUSoM ABSTRACT Public attention of dementia is increasing and as result increasing portrayals of dementia is seen in media and films. There has been a notable change in portrayals between 2004, when one of the first major blockbusters which discussed dementia came out and today in 2018. At the beginning, dementia was used as a plot device and portrayals were romanticised. Still Alice in 2012 lead the way for giving truthful and meaningful portrayals of dementia. At the same time public perception of dementia increased and films and media discussing dementia received a more positive reception. The number of media used to portray dementia has increased: from blogs to soap operas. Additionally, the target audience has grown wider, with some portrayals now targeted towards children. Celebrities talking about their own experiences has been pioneering in the change. INTRODUCTION “Dementia is a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not clouded. Impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation”.1 The above medical definition is objective and doesn’t describe what living with dementia feels like, but media portrayals provide scope for the exploration of the personal experience of dementia. The voices of those living with dementia are slowly being heard; several of those who live with dementia write about their experiences and use several different modalities including: blog entries, books, poems, documentaries.
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Wendy Mitchell is the author of the bestselling book Somebody I Used to Know, a book all about her and living with the diagnosis of early onset Alzheimer’s disease. She also writes an online blog about her illness. In one of her blog entries titled, what does dementia feel like? She answers: “Every day is different. Some days it feels like Alzheimer’s has never entered my life and parts of some days are like this too. On bad days, it’s like a fog descends on the brain and confusion reigns from the minute I wake up. On these days it feels like there’s so little in the brain left to help you get through the day.”2 Kate Swaffter who also has a blog about the experience of living with dementia, uses poetry as a way of expressing how dementia feels to her. “what the hell happened to my brain… It has been diagnosed with dementia when I was much too young a deadly terminal disease effecting my memory, thinking, perception, judgement, language and speech but worse than that, effecting my life, my friendships, my sense of self, my identity it has brought with it a bucket load of guilt truckloads of stigma and discrimination and isolation and loss of dreams, and grief and sadness, disbelief, lost employment”3 An estimated 850,000 people in the UK are living with dementia, affecting one in fourteen people over the age of sixty-five in the UK living with dementia. By 2020 this number is expected to rise to one million people. Of those born this year one in three will develop dementia. This highlights how dementia is an ever-growing public health matter, which affects almost everyone in some way be it as a relative or sufferer.4 This essay discusses whether the portrayal of dementia in film and media changed in the period from 2004 to 2018, exploring some of the reasons for this change and the potential consequences. To examine this, I 231
will be looking at films, blogs, soap operas, books and documentaries. The period begins in 2004, as The Notebook was one of the first major blockbuster to pioneer the use of dementia creatively in film. DEMENTIA AS A PLOT DEVICE At the beginning of this period 2004 to 2012 dementia was featured in films, however, was generally only seen on the side-lines and not the centre of the story. The Notebook premiered in 2004 and tells the love story of Allie and Duke and their love story.5 The film uses Allie’s dementia as a narrative: Duke reads Allie the story of how they fell in love. Her dementia is used as a plot device to tell this love story, not a story about living with dementia. Other than her memory loss the film doesn’t touch upon any other aspect of living with dementia. This is similarly seen in the film Away from Her (2006) although a film where dementia is key to the plot, the subject of dementia is heavily romanticised and doesn’t give a rounded portrayal of dementia.6 Dementia is then mentioned in the 2011 rom-com Friends with Benefits.7 Friends with Benefits isn’t a story about dementia, but like The Notebook is a film about falling in love. It doesn’t use dementia as a storytelling tool but uses it as a sub-plot (Dylan’s farther has worsening early-stages of dementia) with incredible sensitivity and truth, which especially resound in the last scene where Dylan comes to terms with his father’s diagnosis. However, in the same year we see The Iron Lady falling back into using dementia as a plot device, using Margaret Thatcher’s dementia to narrate her biography.8 Although a more honest portrayal of dementia is seen compared to Away from her, it still doesn’t tell the full tale of dementia. Dementia is clearly then being used as a plot aid rather than a story. In doing this dementia isn’t truthfully portrayed in films; it takes advantage of the drama and struggle that comes with dementia instead of telling the honest story of living with dementia. DEMENTIA AS A LEAD ROLE Things have changed in the recent years, with dementia more recently being told as its own story and no longer at the side-lines. Still Alice in 2015 told the story of Alice, who lives with dementia.9 The plot follows her progression through having disease and the challenges it caused. Taking a step further the ITV soap opera, Emmerdale aired a special episode in December 2016 232
where the audience saw the episode from the dementia sufferers, Ashley’s point of view.10 This shows how things have changed, no longer is dementia used as a storyteller it’s been shown as a story. Additionally, the way dementia as a condition is being portrayed is changing to the point of having a whole episode where the audience is put into a sufferer’s shoes. Public awareness and opinion about dementia has changed massively since 2004 and could be responsible for the change. The public now understand the severity of the disease and seek truth in its portrayal. In 2013 the Alzheimer’s Society launched Dementia Friends to increase public awareness. Dementia Friends encourages the awareness of dementia and a drive for the change in public perception by arranging group meetings and online training sessions. In 2017 they hit 2 million dementia friends which really shows how much public awareness has increased, and how much people want to learn about dementia.11 Public awareness could be derived from the portrayals seen in media and film, and the inspiration to gain knowledge about dementia could have been due to portrayals seen in films and media. On the contrary, it might have been an increase in the Government drive for dementia awareness and discussion could be what drove the change in public perception or even the change in the portrayal of dementia in film and media. All these factors are likely to have played a role in increasing the public discussion of dementia and thus increased the desirability to truthfully portray dementia in film and media. Personal experience might have also increased the desirability to portray dementia, as, the executive producer of Still Alice, Maria Shriver lived with her father who had Alzheimer’s disease.12 Although each patient is different, she would have known that the disease is difficult and would have wanted this to be shown truthfully. The prevalence of the disease is increasing due to an increasing aging population meaning more people are being personally affected by the disease. David Walliams said that he hoped that his work lead to “people might be more sympathetic to those with Alzheimer’s or similar conditions”, and this reason lead to him writing a children’s book about dementia.13 This really shows that not only is public interest in dementia increasing but so is the desire to write and create material which provides the opportunity to discuss dementia.
Midlands Medicine
TRUTHFUL PORTRAYAL “Good Luck,” she says as I leave her office. I won’t see her again, there’s no follow up after diagnosis. There’s nothing they can do.”- Wendy Mitchell. In an interview she discussed the effect of hearing the negativity of the words spoken by her consultant rather than delivering some hope: “Yes, the diagnosis is that of Early Onset Dementia. Think of it as the start of a different way of living; a way of adapting; of trying to outwit the challenges dementia will throw at you. There is still so much you CAN do, albeit differently and with support.”14 There’s a bad habit of painting dementia as a purely negative picture. It can’t be denied that a dementia diagnosis is devastating. However, people like Wendy Mitchell fight to prove that there is some element of hope associated with a diagnosis. Films in the period before Still Alice in 2014 were all guilty of painting a purely dark picture of the disease, like the consultant did to Wendy. Then Still Alice came, the film doesn’t romanticise dementia but tells the truth of someone living with dementia. It manages to give some hope, trying its best to show how a person living with dementia can still function and manage up to a certain point to outwit dementia. To reflect this the title of the film Still Alice could be seen in two ways. Still Alice in the sense “I am still Alice”, this portrays her determination at the start of the film to still be herself and to still carry on life as if nothing’s changed. The Christmas day scene where she insists no-one is to help her make dinner although she’s overwhelmed. However, it could be ‘Alice stood still in time’ and that the world around her is still moving but she’s stuck behind. Her stillness is shown to progress to the point where her movements and mind both slow down. However, in The Iron Lady it’s the blankness and emptiness of the person living with dementia we see from the outset, shuffling across laminate flooring in her slippers and dressing gown rather than going out and still living. David Walliams in his book Grandpa’s Great Escape which was then adapted into a film shown on the BBC in 2018, sends a positive message to children that having a relative with dementia can be fun and they shouldn’t be ignored and left behind. It’s hard to portray a disease that causes so much sadness as positive, but Still Alice defies this, for the first half of the film it shows someone who’s living with dementia not a dementia sufferer, a completely unique perspective to what The Iron Lady and The Notebook took. Volume 28, No 6, Nov 2018
There hasn’t been much change in this respect since Still Alice, except for in factual portrayals. Programmes like Panorama on the BBC allowing those living with dementia to tell their tale. In her book Wendy Mitchell offers a bit of hope, telling tales of her travelling across the country on her own even when dementia tries its best to stop her and explaining how she copes. To give a truthful portrayal of dementia the devastation must be demonstrated, a potential reasoning for why films and media discussing dementia don’t offer much hope, an example being Emmerdale which gave a very accurate and truthful representation of a dementia sufferer in their special episode but no hope. Still Alice might have had the ability to be different and offer a bit of hope because it doesn’t tell the story of the eighty year old woman who has dementia it tells the story of a fifty year old professor with early onset genetic Alzheimer’s disease which affects around four percent of people with Alzheimer’s disease, so she’s not your typical dementia suffer.15 PUBLIC RECEPTION When The Iron Lady came out in 2011, it caused several controversies. Margaret Thatcher was a controversial woman and the public have very strong opinions on her. This film clearly divided opinions on the topic of dementia; even two doctors had very different views. O’Neill in the British Medical Journal described the film as “one of the most sympathetic and insightful treatments of dementia”16, whereas in 2012 Pemberton in the Daily Telegraph described the film as “disgraceful”.17 Compared to the portrayals of dementia in film prior to The Iron Lady, where it is romanticised in films like The Notebook or Away from Her, The Iron Lady show’s dementia from the perspective of the sufferer. Andrew Chidgey, Director of Alzheimer’s Society applauded this: “We must bust this appalling idea that it is shameful in any way to portray people living with dementia. It isn’t. Also, just because someone now has a different life because of a serious medical condition does not change what they did or achieved. We need to see more portrayals of dementia in the media.”18 However, when a film where someone has a degenerative or chronic disease is released for example The Theory of Everything about the life of Stephen Hawking it’s 233
described as being “tasteful and affecting”19 rather than “disgraceful”. Why is dementia treated differently in its reception and portrayal to other conditions? The controversies caused by the portrayal in The Iron Lady and the need for reassurance from the Alzheimer’s Society leads to the argument that dementia isn’t an easy disease to broach audience’s with, especially with it affecting so many of the public in some way and it being such an emotive topic. So, the mentality that dementia isn’t what audiences want could be one reason to why it’s often the storyteller rather than the story being told. Still Alice in 2014 moved away from using dementia as a plot device and told the story of Alice who has dementia, and how having dementia affected her life and her family. It’s told from her perspective, but the audience is watching as an outsider on her situation. Wendy Mitchell applauded Still Alice for: “how real Alice’s decline is, how her story is portrayed with sensitivity, avoiding clichés. It is a powerful insight into dementia, the reality of the disease, the reality of the effects it has on the individual and those around them”.20 This shows how a fictional portrayal based on a character from a book can be real and that it’s not an impossible task to avoid romancing or to use dementia as a plot device, it can be an entertaining Oscar award winning film and still truthfully portray dementia. There doesn’t have to be a choice between entertainment and truth, it can go hand in hand as shown in Emmerdale which had 6.2 million people watching its special episode about the experience of dementia compared to its usual 5.3 million viewers.21 The reception a programme or film about dementia receives no longer causes a stir it’s applauded for raising the subject. Dementia provides a challenge for production teams and the opportunity to push creative boundaries. This was the case for the special Emmerdale episode; using techniques rarely seen before such as changing the cast and location for one episode and using sharp disorientating scene changes. The scope for pushing boundaries is another potential reason why dementia is seen much more. WIDENING THE PORTRAYAL Dementia is a subject that is now regularly seen on the screen: as a programme, documentary, news piece or film. Recently dementia featured on Netflix in the British Black Mirror series in the episode Playtest and 234
had its own storyline in a soap opera. Slowly but surely production teams aren’t avoiding discussing dementia. This could be directly from the success of other programmes or films such as Emmerdale which then leads to increase in demand from audiences leading to increasing portrayals. As mentioned earlier it is also likely that increasing public awareness also plays a role. It’s impossible to decipher which of these is the biggest driving force, it’s quite possible both the success of other films and media and public awareness leads to increase demand for these programmes. Dementia is becoming a more accepted discussion point in films and media. THE ROLE OF CELEBRITIES The rise of social media in the recent years have encouraged the discussion about dementia. Only recently, Dame Barbara Windsor’s husband spoke out about her dementia diagnosis which she received in 2014.22 The role of celebrities like Dame Barbara Windsor in raising awareness, bringing up the discussion and reducing the stigma is pivotal. Alzheimer’s Society have several ‘celebrity ambassadors’ which range from comedians to presenters each with their own personal experience of dementia.23 Celebrities talking about their experience provides awareness and acceptance. Dementia sufferers themselves becoming celebrities drives a change in the portrayal and demand. Wendy Mitchell is one of those living with dementia who took to social media to share her experience. Dementia sufferers provide the most honest and insightful portrayal of the disease, which then leads to increased awareness and demand from audiences. As well as, forcing production teams to provide honest and substantial portrayals rather than side-lined romanticised portrayals due to comparison to the genuine experience. It will be interesting to see how social media: twitter, blogs, Facebook play a role in the way dementia is portrayed. Not only do celebrities provide public awareness they’re also able to drive change. David Baddiel one of Alzheimer’s Society’s celebrity ambassadors was able to do this. In The Trouble with Dad (2017) on Channel 4 he pushed the boundaries with a documentary of his severely demented father particularly showing the effect of his dementia on their relationship. His father couldn’t provide informed consent to be filmed but was able to provide detailed insight into his own dementia journey. David himself said: “Maybe it’s not okay to put my dementia-suffering father on camera – but Midlands Medicine
the alternative is that nobody ever talks about this”.24 So where in the quest for a truthful, honest portrayal which raises awareness of dementia does the line to respect the dignity of those living with dementia need to be drawn? SUMMARY After examining media portrayals of dementia between 2004 and 2018, it can be concluded that overall the portrayal has changed. Portrayals seen are more truthful and central rather than romanticised and dementia is no longer used as plot device. The interest of the public has increased, and audiences have become more accepting. It is now less controversial to discuss dementia in film and media. The media in which portrayals are seen are wider, with the use of social media ever increasing. This change is likely to be due to numerous factors which all have interplayed together such as: increased public awareness of the condition, increased demand by audiences, desire by production teams to seek truth, success of films and TV programmes which portray dementia leading to more portrayals, and lastly the role of celebrities engaging in the discussion of dementia. Having a change in media portrayal of dementia has been vital in increasing public understanding of dementia. REFERENCES 1. WHO, 2015 The ICD-10 Classficiation of Mental and Behavioural Disorders 2. Mitchell W (2015) Which Me Am I Today? whichmeamitoday.wordpress.com/2015/03/18/whatdoes-dementia-feel-like/ [Accessed 26 06 2018] 3. Swaffter K (2013) kateswaffer.com/2013/04/27/saturdays-poem/) [Accessed 26 June 2018]. 4. Alzheimer's Research UK, 2015 Dementia Statistics www.dementiastatistics.org/statistics/numbers-ofpeople-in-the-uk/ [Accessed June 2018]
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5. IMDb (2004) The Notebook www.imdb.com/title/tt0332280/?ref_=tt_ch [Accessed 26 June 2018] 6. IMDb (2006) Away from her www.imdb com/title/tt0491747/?ref_=nv_sr_1 [Accessed 26 June 2018] 7. IMDb (2011) Friends With Benefits www.imdb com/title/tt1632708/ [Accessed 28 June 2018] 8. IMDb (2011) The Iron Lady www.imdb com/title/tt1007029/ [Accessed 26 June 2018] 9. IMDb (2014) Still Alice www.imdb com/title/tt3316960/?ref_=ttqt_qt_tt [Accessed 26 June 2018] 10. Alzheimer's Society (2017) In praise of Emmerdale’s ground-breaking Ashley Thomas dementia storyline www.alzheimers.org.uk/blog/praise-emmerdalesground-breaking-ashley-thomas-dementia-storyline [Accessed 26 June 2018] 11. Alzheimer's Society (2017) Alzheimer’s Society hits staggering two million Dementia Friends milestone www.alzheimers org uk/news/2018-04-10/alzheimerssociety-hits-staggering-two-million-dementia-friendsmilestone [Accessed 26 June 2018] 12. Hepburn K Still Alice The Gerontologist (2015) Vol 55 pp328-9 13. Chortle (2017) www.chortle.co.uk David Walliams on Grandpa's Great Escape 14. Mitchell W Delivering A Diagnosis of Dementia Psychology Today Blog post: (2018) www.psychologytoday.com/us/blog/which-me-am-itoday/201806/delivering-diagnosis-dementia 235
15. Alzheimer's Research UK, 2018 Alzheimer's Disease www.alzheimersresearchuk org/about-dementia/ types-of-dementia/alzheimers-disease/early-onsetalzheimers/ [Accessed 26 June 2018]
FILMS
16. O'Neill D How Dementia Tests Thatcher' Mettle BMJ (2012) Vol 344: e378 - doi.org//10.1136/bmj.e378
Friends With Benefits. 2011. [Film] Directed by Will Gluck. US: Caastle Rock Entertainment, Zucker Productions.
17. Pemberton M Why this despicable film makes uneasy voyeurs of us all The Daily Telegraph (2012)
Grandpa’s Great Escape. 2018. [Film] Directed by Elliot Hegarty. UK: King Bert Productions.
18. Chidgey A Maggie film divides opinion just like she did The Sun (2012)
Still Alice. 2014. [Film] Directed by Richard Glazter, West Westmoreland. United States: Killer Films.
19. Robey T The Theory of Everything: Review The Daily Telegraph (2015)
The Iron Lady. 2011. [Film] Directed by Phyllida Lloyd. United Kingdom, France: Pathe, Film4 Productions.
20. Mitchell W Somebody I Used To Know (2018) First Ed London: Bloomsbury
The Notebook. 2004. [Film] Directed by Nick Cassavetes. US: Avery Pix.
21. BBC, 2016 Emmerdale dementia episode praised by Alzheimer's Society www.bbc.co.uk/news/entertainment-arts-38389953 [Accessed 26 June 2018]
TV PROGRAMMES
22. Telegraph Authors Dame Barbara Windsor battling Alzheimer's, her husband reveals The Daily Telegraph (2018) 23. Alzheimer's Society 2018 Celebrity Ambassadors www.alzheimers.org.uk/about-us/our-people/ celebrity-support/celebrity-ambassadors [Accessed 26 June 2018]
Away From Her. 2006. [Film] Directed by Sarah Polley. Canada: Capri Releasing, Echo Lake Productions, Foundry Films, Hanway Films, The Film Farm.
Black Mirror. S2. E3. 2016. Netflix. 21 October Emmerdale. 2016. ITV. 20th of December, 19:00 Panorama: Living with Dementia. 2016. BBC One. 2nd of June, 20:00 The Trouble with Dad. 2017. Channel 4. 20 February, 21:00
24. Wollaston S The Trouble with Dad review – joking about his father’s ementia is a kind of therapy for David Baddiel The Guardian (2017)
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MEDICAL PARADOXES David Manson, Medical Student, KUSoM Sriram Rajagopalan, Consultant Vascular Surgeon, UHNM INTRODUCTION Paradoxes in medicine are widespread but usually associated with a rational explanation. This article comprises a non-exhaustive evaluation of various paradoxes found throughout clinical medicine. These self-contradictory examples span physiology, clinical examination, anatomy, epidemiology and pharmacology. However, there are various paradoxes which are still too poorly understood to fully evaluate in such an article. Similarly, there are many paradoxical effects observed in pharmacology which have been excluded due to their unspecified nature. These include the paradoxical hyperalgesia seen in some cases of opioid administration, arrhythmia induction caused by anti-dysrhythmics and the paradoxical Eagle-effect seen in in vitro antibiotic testing. A description of some clinically encountered paradoxes are listed below. RESPIRATORY Paradoxical Breathing During inspiration, the diaphragm contracts and moves inferiorly displacing the abdominal contents, while the ribcage is assisted by the intercostal muscles to move upwards and outwards. These synergistic movements allow for increased volume in the thoracic cavity, facilitating efficient inspiration. Thoraco-abdominal asynchrony (TAA), colloquially referred to as paradoxical breathing, occurs when the complimentary movements of the thoracic wall and abdomen are not synchronised.1 This lack of coordination, especially in the context of diaphragmatic impairment or paralysis, can be observed as unusual inward movements of the abdomen during inspiration. TAA is often a sign of primary or secondary respiratory pathology, and is typically associated with an increased work of breathing. In infants, there may be signs of paradoxical breathing, especially with chest contraction during inspiration, but this is less often linked to serious pathology than in adults.2 Common causes of TAA in adults include trauma, neurological pathology such as motor neuron disease (MND), electrolyte imbalance, muscular dystrophy such as in Duchenne’s (DMD), upper respiratory tract obstruction and lastly, chronic Volume 28, No 6, Nov 2018
respiratory conditions such as interstitial lung disease (ILD) and chronic obstructive respiratory disease (COPD).3 Flail chest (FC) is a common cause of traumainduced paradoxical breathing, and occurs when there are segmental fractures present in three consecutive ribs. This segment of the ribcage acts independently of the thoracic wall and opposes normal ventilatory mechanics, sinking into the chest during inspiration and expanding through expiration. This paradoxical movement can result in atelectasis, lobar collapse, acute shortness of breath and chest pain.4 Pulsus Paradoxus During inspiration, there is delayed blood flow through the pulmonary system, resulting in a slightly reduced end-diastolic volume within the left ventricle. Decreased intrathoracic pressure during inspiration is responsible for this reduction, as it promotes blood pooling in the pulmonary vasculature. There is a subsequent decrease in cardiac output from the left ventricle, which results in a fall in systolic blood pressure.5 Systolic blood pressure is known to fall slightly in inspiration, however, pulsus paradoxus is associated with abnormally large decreases in inspiratory systolic pressure. Pulsus paradoxus is defined clinically as a >10mmHg decrease in systolic blood pressure during the inspiratory phase of ventilation. The paradox in this instance is that during cardiovascular examination, a pulse can be detected in all heart auscultation areas during inspiration, which is not present on palpation of the radial pulse. This as a result of an exaggerated decrease in systolic blood pressure, resulting in an absent radial pulse during inspiration.6 Pulsus paradoxus is now considered an important aspect of every respiratory and cardiovascular examination, as it is commonly associated with pathology. Conditions which exaggerate the intrathoracic pressure changes that occur during inspiration, or which result in right ventricular distension, can cause pulsus paradoxus. Cardiac tamponade, restrictive cardiomyopathy (RCM) and constrictive pericarditis are common cardiac pathologies responsible for an exaggerated decrease in end-diastolic volume and subsequent pulsus paradoxus. Additionally, respiratory pathology including COPD and asthma can result in chronic vascular congestion in the pulmonary network, increasing susceptibility for swings in intrathoracic pressure.6, 7 237
Paradoxical Vocal Fold Paradoxical vocal cord motion (PVCM) or paradoxical vocal cord movement disorder (PVCMD) is a condition characterised by the inappropriate movement of the laryngeal vocal folds during ventilation. During normal inspiration, the vocal cords abduct under the action of the posterior cricoarytenoid muscles, thereby facilitating minimal airflow resistance. In expiration, this degree of abduction is relaxed, and the vocal fords return to baseline position.8 In PVCM, there is inappropriate adduction of the laryngeal vocal cords during inspiration, resulting in restricted airflow into the trachea. This presents as upper respiratory tract obstruction with inspiratory stridor. Due to the clinical similarity, patients with PVCM can often be misdiagnosed as suffering from asthma. The paradoxical movements of the vocal folds and laryngeal mistiming is an uncommon but important differential diagnosis in asthma and vocal cord paralysis/cancer9 The aetiology of PVCM has recently evolved to encompass not only psychological factors, but also laryngeal irritants causing secondary PVCM, such as reflux, allergic reaction, obstructive sleep apnoea and Sjogren’s syndrome.10, 11 ANATOMY Ulnar Paradox Hand function is mediated by intrinsic and extrinsic muscles. The intrinsic muscles, despite being small, collectively provide half of the strength used for grip and are crucial for intricate digital movement. Therefore, intrinsic muscle impairment can result in reduced grip power in addition to marked deformity.12 Such deformity is observed in ulnar nerve palsies, and interestingly, it is distal lesions which produce a more pronounced ‘ulnar claw’. It is uncommon for a distal lesion to result in a more symptomatic presentation. This paradox, however, can be explained by the innervation of specific muscles. A lower ulnar nerve palsy results in partial or full denervation of the 3rd and 4th lumbricals, which are supplied by the deep branch of the ulnar nerve.13 These lumbricals, which are intrinsic hand muscles, are responsible for flexion of the metacarpophalangeal (MCP) joints, and extension of the proximal (PIP) and distal interphalangeal joints (DIP) of the 4th and 5th digits. Following lower ulnar palsy and denervation of the deep ulnar nerve, these actions are weakened. Due to the unopposed action of extensor digitorum and extensor digiti minimi, there is MCP hyperextension. In addition, there is impaired extensor action at the DIP and PIP joints, resulting in flexion at both IP joints.13 This gives the appearance 238
of the ‘ulnar claw’ at the 4th and 5th digits. The ulnar paradox is observed following a more proximal lesion, caused by cubital tunnel syndrome or trauma, where there is reduced flexion at the IP joints; a less severe claw deformity. The flexor digitorum profundus (FDP) has dual innervation, supplied medially by the ulnar nerve and laterally by the medial nerve. It facilitates flexion at the IP joints, and is the only muscle which flexes the DIP joint. It can therefore provide important information on the nature of ulnar palsies. If the ulnar lesion is proximal, and the FDP is subsequently denervated, there will be reduced flexion of the IP joints, especially the DIP joint, and the claw-like appearance of the 4th and 5th digits will be less pronounced.14 CLINICAL PHYSIOLOGY Paradoxical Aciduria Gastric outlet obstruction (GOO) in adults is usually caused either by carcinoma or peptic ulcer. The patient often presents with profound non-bilious vomiting and subsequent electrolyte abnormalities. Gastric loss of hydrochloric acid results in hypochloraemic metabolic alkalosis.15 The alkalotic pH of the blood is detected by the kidneys and there is an initial compensatory excretion of alkaline urine. HCO3- is primarily excreted to correct alkalosis. Na+ and K+ are excreted alongside bicarbonate, which in turn leads to activation of the renin-aldosterone-angiotensin system (RAAS). In the absence of administered fluid the need to correct volume deficit supersedes that of pH maintenance, being of evolutionary greater importance. With RAAS activation, K+ is still excreted in the urine, but Na+ is resorbed leading to an increase in extracellular volume. Hypokalaemia drives H+ excretion with resultant aciduria.16, 17 This explains the origin of paradoxical aciduria in an alkalotic patient with GOO, where you might expect compensatory alkaluria, but through normal physiological sequelae, extra-cellular dehydration stimulates an aciduria which may compound the initial electrolyte abnormalities. EPIDEMIOLOGY Obesity Paradox The obesity paradox is well described and is demonstrated in a variety of epidemiological data. In the developed world, the incidence of obesity has reached epidemic proportions, with an associated increase in premature mortality. Obesity is typically measured using the body mass index (BMI), which positively correlates with comorbidities including insulin-independent diabetes mellitus, cardiovascular Midlands Medicine
disease (CVD), hyperlipidaemia and hypertension.18 The obesity paradox is related to unexpected survival rates in overweight and obese patients. There is a marked risk of congestive heart failure (CHF) in this subset of the population. However, in chronic and acute CHF, obese patients have a higher probability of survival than those with a normal BMI.19 This paradoxical finding has also been highlighted across other measures of body composition, including the waist-to-hip ratio (WHR), skinfold averages of percentage body fat and waist circumference.20 The flaw of this unexpected relationship is that most studies have not taken adiposity into account. Visceral adipose tissue is considered unhealthy, whereas functional adipose can be protective. CVD is associated with the class of adipose tissue rather than the standardised BMI measurement. It is suggested that the complex physiology of fat deposition explains the obesity paradox, which may, in truth, be simply explained by a lack of understanding.18 VASCULAR Paradoxical Embolism An embolus is arterial or venous in nature. Arterial emboli can become lodged at terminal vascular locations such as the brain and lower limb, resulting in ischaemic stroke and leg ischaemia respectively. Assuming there is no vascular malformation, venous emboli nearly always impact in the lungs, presenting as a pulmonary embolism. A paradoxical embolism is a pathological phenomenon whereby an emboli of venous origin terminates in the arterial circulation21 For a clinical diagnosis to be made, there are three requirements. There must be evidence of venous origin and arterial effect, in addition to an arterio-venous connection such as a cardiac defect or pulmonary fistula. Cardiac defects including patent foramen ovale (PFO), atrial septal defect (ASD) and ventricular septal defect (VSD) can facilitate a paradoxical embolus.22 However, these defects are all consistent with a leftto-right shunt of blood flow, making embolus transfer less likely. Shunt reversal, such as in Eisenmenger syndrome or with some Valsalva manoeuvres, can lead to brief or sustained right-to-left shunts and an increased propensity for paradoxical emboli. Pulmonary malformations are also a common source of these emboli, due to a permanent patent connection between pulmonary arteries and veins.23 In patients with increased risk of deep vein thrombosis (DVT) and known intracardiac defects, a diagnosis of paradoxical embolus should be entertained if they present with symptoms consistent with ischaemic stroke, ischaemic bowel, ischaemic leg or macroscopic haematuria. Volume 28, No 6, Nov 2018
PHARMACOLOGY Paradoxical Psoriasis Current understanding of the pathogenesis of psoriasis is limited, but there is a known association with cytokine imbalances. Anti-tumour necrosis factor alpha (TNFι) treatments, including infliximab, adalimumab and etanercept, are commonly used to manage autoimmune inflammatory diseases such as psoriasis. The paradox in this instance is that these antiTNF agents have the potential to induce a psoriasiform reaction, and even exacerbate current psoriasis.24 In recent years this has become an accepted drug-related side-effect. The incidence of psoriasiform reactions to anti-TNF treatment is 5 per 100 person-years.25 De novo psoriasis is more common, and is described more often in the available literature. This is most commonly associated with anti-TNF use in the treatment of another, usually unrelated, inflammatory condition such as inflammatory bowel disease (IBD). Aggravation of current psoriasis is less common, but can result in associated changes in the morphology of active psoriasiform lesions.24, 26 The cause of this paradoxical side-effect is poorly understood, but it is thought to be mediated by leukocyte imbalances. The pathogenesis has been substantially refined in recent years, and is now thought to involve the interplay between T-helper (Th) 1 cells, Th17 and Interleukin (IL) 17/23.27 Further research may clarify the paradoxical pathophysiological interaction between anti-TNF agents and the immune mediators responsible for psoriasis. Paradoxical Bronchospasm Beta-2 (β2) adrenergic agonists are a generally well-tolerated class of bronchodilators used in the management of asthma. Long-acting beta agonists (LABA) are used in the maintenance and prevention of asthma, whereas short-acting beta agonists (SABA) are given to relieve acute symptoms in exacerbated flareups. Beta agonists act to relax the surrounding smooth muscle in hyper-responsive airways, facilitating bronchial dilation and reduced airflow resistance. In recent decades, bronchodilators, principally beta agonists, have been linked to paradoxical bronchospasm in asthmatic patients. This unexpected effect has been observed following treatment with beta-agonists including salbutamol and salmeterol, muscarinic antagonists such as ipratropium, and even with inhaled steroid use.28, 29 It has been suggested that this phenomenon may be attributed to individual reactions to certain inhalants, especially those containing preservatives.30 More recently, the intricacies of betaagonist chemical formulae have been shown to dictate the likelihood of bronchoconstriction. Salbutamol, a 239
SABA, is a racemic compound consisting of both R- and S-stereo isomers. These enantiomers are considered to have differing effects, and it is the contractive action of the S-stereo isomer that may result in the paradoxical bronchospasm. Levalbuterol, a purely R-stereo isomer compound, is now thought to decrease the incidence of paradoxical bronchoconstriction compared with the racemic salbutamol.31, 32 Although beta-agonists are widely used , and are typically well-tolerated, clinicians should be vigilant with regard to their potential adverse effects. Medical paradoxes are so-called due to their unexpected and apparently contradictory nature, and as such carry added importance with regards to understanding physiological and clinical sequelae. With increasing evidence and understanding, it is likely that many current paradoxes will be fully explained. Conversely, due to increasing availability of epidemiological data and new pharmacological agents, previously unrecognised paradoxical findings or effects may emerge. ADRESS FOR CORRESPONDENCE Mr Sriram Rajagopalan, Consultant Vascular Surgeon, UHNM A Block, Vascular offices, Royal Stoke University Hospital STOKE-on-TRENT ST46QG Sriram.rajagopalan@uhnm.nhs.uk REFERENCES 1. Wijdicks E Neurogenic paradoxical breathing Journal of Neurology Neurosurgery & Psychiatry (2013) Vol 84 p1296 dx.doi.org/10.1136/jnnp-2013-305485 2. Hammer J and Newth C Assessment of thoraco-abdominal asynchrony Paediatric Respiratory Reviews (2009) Vol 10 pp75-80 3. Pereira M, Porras D, Lunardi A, da Silva C, Barbosa R et al Thoracoabdominal asynchrony: Two methods in healthy COPD and interstitial lung disease patients PLOS ONE (2017) Vol 12(8) pe0182417
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4. Naidoo K and Bates P Natural History of Flail Chest Injuries International Journal of Surgery (2017) Vol 47 pS84 5. Brzezinski W Walter H Hall W and Hurst J Clinical Methods: The History Physical and Laboratory Examinations Annals of Internal Medicine (1990) Vol 113 p563 6. Hamzaoui O Monnet X and Teboul J Pulsus paradoxus European Respiratory Journal (2012) Vol 42 pp16961705 7. Van Dam MN and Fitzgerald BM Pulsus Paradoxus [Updated 2018 Feb 7] In: StatPearls [Online] Treasure Island (FL): StatPearls Publishing; 2018 Jan. www. ncbinlmnihgov/books/NBK482292/?report=classic 8. Deckert J and Deckert L Vocal Cord Dysfunction Am Fam Physician (2010) Vol 81 (pp156-9) 9. Franca M Differential diagnosis in paradoxical vocal fold movement (PVFM): An interdisciplinary task International Journal of Pediatric Otorhinolaryngology (2014) Vol 78 pp2169-73 10. Forrest L, Husein T and Husein O Paradoxical vocal cord motion: classification and treatment Laryngoscope (2012) vol 122 pp844-53 11. Matrka L Paradoxic Vocal Fold Movement Disorder Otolaryngologic Clinics of North America (2014) Vol 47 pp135-46 12. Dell P and Sforzo C Ulnar Intrinsic Anatomy and Dysfunction Journal of Hand Therapy (2005) Vol 18 pp198-207 13. TeachMeAnatomy (2018) The Ulnar Nerve teachmeanatomyinfo/upper-limb/nerves/the-ulnarnerve/ 14. Draeger R and Stern P The Inverted Pyramid Sign and Other Eponymous Signs of Ulnar Nerve Palsy The Journal of Hand Surgery (2014) Midlands Medicine
Vol 39 pp2517-20 15. Kaye P Acquired pyloric stenosis resulting in hypokalaemic hyperchloraemic normal anion gap metabolic acidosis Persistent vomiting in an adult: cause and effect BMJ Case Reports (2018) ppbcr-2017-222800 16. Ahmad J Thomson S Taylor M and Scoffield J A reminder of the classical biochemical sequelae of adult gastric outlet obstruction Case Reports (2011) (Jan 29 1) ppbcr0520102978-bcr0520102978 17. Bajpai M Singh A Panda S Chand K and Rafey A Hypertrophic pyloric stenosis in an older child: a rare presentation with successful standard surgical management Case Reports (2013) (nov20 1) ppbcr2013201834-bcr2013201834 18. Goyal A Nimmakayala K and Zonszein J Is There a Paradox in Obesity? Cardiology in Review (2014) Vol 22 pp163-70 19. Gupta P Fonarow G and Horwich T Obesity and the Obesity Paradox in Heart Failure Canadian Journal of Cardiology (2015) Vol 31 pp195-202 20. Clark A, Fonarow G and Horwich T Obesity and the Obesity Paradox in Heart Failure Progress in Cardiovascular Diseases (2014) Vol 56 pp409-14 21. Stefanov S Smolianinov K Matiugin M Frants M Mizin A Papinen A Nikitin D and Dobrovolsky A [Paradoxical embolism: clinical situation and approaches to treatment] (2015) Angiol Sosud Khir 21(1) pp192-7 22. Hakman EN and Cowling KM Embolism Paradoxical [Updated 2017 Dec 8] In: StatPearls [Online] Treasure Island (FL): StatPearls Publishing; 2018 Jan www.ncbinlmnihgov/books/NBK470196/ 23 . Windecker S, Stortecky S and Meier B Paradoxical Embolism Journal of the American College of Cardiology (2018) Vol 64 pp403-15
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24. Navarro R and Daudén E Clinical Management of Paradoxical Psoriasiform Reactions During TNF-α Therapy Actas Dermo-Sifiliográficas (English Edition) (2014) Vol 105 pp752-761 25. Pugliese D, Guidi L, Ferraro P, Marzo M, Felice C et al Paradoxical psoriasis in a large cohort of patients with inflammatory bowel disease receiving treatment with anti-TNF alpha: 5-year follow-up study Alimentary Pharmacology & Therapeutics (2015) Vol 42(7) pp880-8 26. Wendling D and Prati C Paradoxical effects of anti-TNF-α agents in inflammatory diseases Expert Review of Clinical Immunology (2013) Vol 10 pp159-69 27. Ogawa E Sato Y Minagawa A and Okuyama R Pathogenesis of psoriasis and development of treatment The Journal of Dermatology (2017) Vol 45 pp264-72 28. Hodder R, Pavia D, Dewberry H, Alexander K, Iacono P et al Low incidence of paradoxical bronchoconstriction in asthma and COPD patients during chronic use of Respimat® soft mist™ inhaler Respiratory Medicine (2005) Vol 99 pp1087-95 29. Eckert B Armstrong JG Mitchell CA Paradoxical bronchoconstriction in patients with stable asthma Med J Aust (1993) Vol 159 p566 30. Snell NJC Adverse reactions to inhaled drugs Respir Med (1990) Vol 84 pp345–8 31. D’Alonzo GE Jr Levalbuterol in the treatment of patients with asthma and chronic obstructive lung disease J Am Osteopath Assoc (2004) Vol 104 pp288-93 www.jaoaorg/cgi/content/full/104/7/288 32. Broski S and Amundson D Paradoxical Response to Levalbuterol The Journal of the American Osteopathic Association (2008) Vol 108 pp211-3
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MORE MEDICAL CERAMICS Anthea Bond, retired Consultant Orthodontist The picture to the left is one I was able to take in the Potteries Museum. An albarello is a jar with a distinctive shape, made of tin glazed earthenware and used for dry medicines. It originated in the Near East in about 800 A.D., then spread through the Islamic countries of North Africa to Islamic Spain. The style was copied in Italy in the Renaissance. This example with painted decoration and inscribed “Coloquintida”, dried apple, was made in Deruta, Italy, c 1620. The Potteries Museum in Hanley has a huge collection of ceramics, the largest collection of British ceramics in the world, and a smaller selection of ceramics from abroad. The last journal showed an Italian medicine jug made of tin glazed earthenware in the early 1700s. A year ago, the front cover of Midlands Medicine (October 2017, Volume 28, Issue 4) showed a typical example of the work of local ceramicist Philip Hardaker. He creates small items for the home as well as wall hangings which include shards and pieces of ceramic he has made with embossed words and patterns. These can be seen in public places eg pedestrian underpasses in Newcastle.”
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AN OPEN LETTER TO THE FAMILY AND RELATIVES OF MY KIDNEY DONOR Richard Chapman, Kidney Transplant Recipient in 2018 I am writing this to you all, for two reasons. The first to give my thanks and the second to tell you a little about myself and the impact this gift has had on my life. To say ‘Thank You’ seems so inadequate especially as the gift is so enormous. Not only am I so very grateful for the kidney, I am also very proud of my donor and the family that made this gift possible and I hope that you will also feel the massive impact and benefit that has impacted on my life. THANK YOU. I will try to give you a broad brush stroke, of who I am and the impact, that will not only affect me, but all of my family and my close friends.
I go to the hospital and get ready for transplantation. It is very difficult to express the feeling of excitement mixed with trepidation as you make the journey into hospital. Thinking ‘this one is mine!’ My time has at last arrived. Initially all went well and I was back home after only a few days. Since than, I have had a few complications as is to be expected with this type of surgery and the Doctors and staff supporting me have got to grips with my medication and at last it is all looking good. Not being on dialysis is a real bonus. Having a new kidney is totally life changing. When you are in a regular routine that dialysis requires, you naturally change your concept of what you can expect from your life and adjust accordingly. The benefit of a new kidney is mind blowing!
I am a retired former professional business man working at director level in sales. I have 4 children and 8 grandchildren ranging from just born to 21 years old, some in USA and in Europe. I retired early about the same time as I was diagnosed with kidney failure. It took 12 years of slow decline to get to the Dialysis stage and I embarked on the treatment of 4 hours a day for 3 days a week just over 3 years ago. I am one of the fortunate patients, as I have remained quite fit and healthy and physically strong. I took the opportunity to train with my wife supporting me, to go on the home dialysis treatment program and had all the equipment installed in my home and we became most proficient in the dialysis process. This alone was life changing as we had gained total flexibility to undergo treatment to suit our daily plans remove the travel to hospital and the waiting for treatment.
I still have some months of tests and balancing medication ahead, but I can now start to plan for my new life that will almost certainly revolve around all my family and my friends. The doors that have been closed, will have to be re-opened and will be the platform for my new life.
I have been on the kidney transplant list for over 3 years and I have been called in on 5 occasions as a back-up, No.2.
I hope that you can appreciate the impact that this has to me and my family and how much I appreciate the generosity of my donor and all the family that supported this and this background information helps you all a little, in what must have been a very sad time for you all. From a most grateful kidney recipient. 243
On the evening of Sunday 27th May, I had the phone call to say that they had a good kidney match and could Volume 28, No 6, Nov 2018
I also want to contribute to help all kidney patients and carers, supported by all my family. We have held two charity events in the last two years, to raise funds for National Kidney Federation (NKF), and two local hospital kidney wards. My son in law ran the London and Liverpool marathons this year for NKF and we have another event organised for November. I feel privileged that I am able to actively participate in these events and to help gain publicity to constantly raise the awareness of kidney disease and the benefits of transplantation.
AWARD WINNERS On the evening of November 8th 2018 in a ceremony held at the North Staffordshire Medical Institute, the following medical research projects were awarded grants by the institute in accordance with its charitable objective “to promote and advance the study and general knowledge of science and medicine and all matters relating to the progress and development of all branches of medicine and surgery…”
Dr. V. George, Dr. D. Tonge and Prof. N. Forsyth
Dr. A. Sharples, Dr. M. Kitchen, Mr. I. Dos Remedios and Mr. D. Turner
Modulating disease severity in arrhythmogenic right Ventricular Cardiomyopathy using optogenetics in human induced pluripotent stem cells
Genome-Wide Epigenetics of Skeletal Muscle Wasting in Elderly Patients
Awarded: £20,000.00
Awarded: £19,985.00
Dr. A. Richardson Development of an assay for branched chain keto-acid dehydrogenase kinase Awarded: £18,450.00
The Medical Institute also supports the development of clinical excellence in by awarding prizes to medical students…
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The Keele University Medical Student best overall performance in Year 4 OSCE (2017–18)
The Keele University Medical Student best overall performance in Year 2 (2017–18)
Ahmed Al-Hayalee
Samuel Tushingham
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NEWS NSMI NEWS “We also made a lot of changes to the structure of our grants, making them pump-priming for new researchers.” Appointed vice chairman of the Royal College of Gynaecologists (RCOG) in 2004, Prof. O’Brien stepped back from the Institute to concentrate on the role and his own research. He found himself taking the reins again in 2015, admitting: “It seemed like a good idea at the time.”
After his second three years as chairman, Professor Shaughn O’Brien is leaving the North Staffordshire Medical Institute. The obstetrician and gynaecologist takes a moment to reflect on his time at the helm. “It’s a lovely building for meeting and conferences,” he says. “It’s a good focus for research, a good focus for postgraduate education, it’s a good focus for the community and it’s a good focus for people putting on meetings an conferences of a high standard.” During two separate tenures as chairman, Prof. O’Brien has seen the Institute through some challenging times. His first, from 2002 to 2005, included the biggest shakeup in the charity’s history when the hospital trust’s Clinical Education Centre, part of Keele University’s Medical School, was built at the University Hospital of the North Midlands. The Institute, which had been the area’s main teaching centre for postgraduate medicine, was suddenly left with less purpose and little funding. “The medical library was moved and all the funding went with it,” says Prof. O’Brien. “In the process of that we had to really set up the Institute as a conference centre. One of the key things we achieved was to make sure we took ownership of the land rather than leasing it from the NHS – and more importantly for conferences, the whole of the parking facilities. Volume 28, No 6, Nov 2018
The chairman went on to face another period of change with his trademark creativity and vision. His legacy at the Institute includes their support for the annual Firelighter Awards, organised by Keele University’s Dr Adam Farmer, which give NHS staff the chance to pitch for medical research grants in a Dragon’s Den-style competition. He also arranged Institute funding for the ASPIRE programme at Keele University, designed to help medical students engage with academic research. The scheme is led by Professor Divya Chari and Dr Samantha Hider. Prof. O’Brien is now behind plans to re-brand the Institute as part of a major refurbishment project. The facility will even be given a new name – as yet being kept under wraps. He says: “We’ve had a significant donation to allow us to redevelop the Institute as North Staffordshire’s highprofile, named conference centre. It should highlight our ability to hold conferences which are not only medical, while retaining the loyalty we’ve built up with our existing customers.” While he hopes to remain involved with the building work, the father-of-two already knows how he will fill his semi-retirement. It will begin with his valedictory meeting at the RCOG in September. 245
As well as his continuing research and private practice, he plans to devote the extra hours to his artistic side. He says: “I’ve already begun to go to sculpture school in London, I’ve got some pieces in the Medical Art Society’s Annual Exhibition at the Royal Society of Medicine in July. I also want to get back to playing the clarinet and saxophone some more.” Prof. O’Brien has been replaced as chairman by Mr John Muir, the UK’s longest-serving NHS consultant. Back in 2016 a special presentation was made to UHNM’s veteran Orthodontic Consultant, Mr John Muir, (seen, centre, in the picture above) who had completed 45 years at the Trust. Mr Muir was joined by a number of colleagues for the presentation, which was conducted by fellow surgeon Mr Robert CourteneyHarris and Chairman, John MacDonald. Mr Robert Courteney-Harris, commented on this incredible achievement and the impact John has made at UHNM: ‘’John’s achievement of completing 45 years at the Trust, displays not only his commitment to the profession and UHNM, but also his desire to provide world-class Orthodontic care to the people of Staffordshire. John has helped keep the department thriving and has been an inspiration to many aspiring 246
Orthodontists. The department is in a very healthy state currently, and because of the work from John and his team, the future is also looking very positive.” Mr John Muir commented: ‘’I have wholeheartedly enjoyed these past 45 years here at UHNM, so much so that the milestone crept up on me somewhat! I’m proud to have been a part of the Orthodontic department’s continued development over the past 45 years, and we’re now recognised as one of the leading departments in the country.” Mr Muir was the first Orthodontic Consultant when he arrived at the Trust in 1971, and in that period, he has witnessed the various changes that UHNM has undergone. Mr John Scholey, Consultant Orthodontist lead Clinician, and a long-term colleagues of John’s, said: "John has been a rock in this department, and his reputation nationally was a big reason in my decision to join UHNM. I’ve learned a huge amount from John in our time working together, and he’s helped develop UHNM’s Orthodontic department in to one of the best in the country, with our work also now being recognised internationally." Midlands Medicine
Ms Karen Juggings, also commented on John’s achievement: “His clinical excellence has benefited generations of North Staffordshire residents. The service has developed under him from a single clinician to an entire multi-disciplinary team. His influence goes far beyond the county lines. He was elected as President of the British Orthodontic Society in 2015 when London hosted the World Orthodontic Conference. He is regarded locally and nationally as a living legend in orthodontics!”
STOP PRESS: DIALYSIS UNIT’S 50TH ANNIVERSARY CELEBRATIONS About the time you first read this, it will be true to say: The Department of Renal Medicine has just celebrated the 50th anniversary of hospital haemodialysis in Stoke-on-Trent. The very first unit, formally opened on 6th December 1968 by the President of the Renal Association, professor MD Milne, was a modest affair on the Royal Infirmary site. It had just a few dialysis machines in fairly cramped conditions. Much of that setup today would be described as Heath Robinson. It was supported by a coalition of enthusiastic doctors, nurses and technicians, finding their way in an enterprise supported by donations and public subscriptions rather than direct NHS support. One key source of moral and fundraising support at the time was the relatively young and energetic North Staffordshire Medical Institute and we, the Department of Renal Medicine, remain profoundly grateful for that help at our outset as a dialysis provider.
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Over time the clinical need to support patients with dialysis vastly outgrew that initial provision but the make do provision continued, and for many years a much larger haemodialysis facility (ward 31 then, was provided out of huts placed on the edge of the car park on the northern periphery of the Royal Infirmary site. Later, early this Century, this was further extended with the addition of Ward 34, a conversion of the former social club building. When the new hospital was built, once again, haemodialysis provision was late to the party with the Renal Ward and dialysis unit being the very last clinical facilities to move down to the main site. This time things were different, however. Having secured independent funding, it was possible to build a bespoke integrated Haemodialysis unit and ward. Opened formally on 30th November 2012 by Dr Gavin Russell, a state-ofthe-art Haemodialysis unit and ward are at the heart of the Department of Renal Medicine which also includes The Kidney Unit outpatient suite and offices for the many support functions, particularly Home Therapies and Transplant Services. Our current Haemodialysis unit has a potential to dialyse up to 50 patients at any one time (or a patient total approaching 300 if fully staffed) and includes an area to train patients for home haemodialysis. It has the latest machines and monitoring facilities and offers online haemodialfiltration. In short, it is a vast leap from its humble beginnings, now fully integrated into the NHS provision and it is a facility for local people of which we can all be rightly proud.
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ASTHMA QUIZ Corinne Salt, Practice Nurse with a Special Interest in Asthma and Oluseyi Ogunmekan, General Practitioner, Furlong Medical Centre, Stoke-on-Trent 1. Which of the following inhalers is/are licensed for use as maintenance and reliever therapy in asthma? a) Symbicort 400/6 c) DuoResp Spiromax 320/9 e) none of the above
b) Fostair 200/6 d) all of the above
7. Which of the following inhalers is/are not recommended for use in children aged under 12 years old? a) Flutiform b) Relvar Ellipta c) Fostair d) DuoResp SpiroMax e) All of the above
2. Which of the following inhalers is/are not compatible with for use with a spacer device?
8. Trimbow is compatible and licensed for use with a volumatic.
a) Breath actuated dry powder b) Soft mist inhaler c) both of the above d) neither of the above
a) True
3. Which of the following antimuscarinic inhalers is /are NOT licensed for use in asthma? a) Braltus d) all of the above
b) Incruse Ellipta e) Spiriva Respimat
c) Eklira
4. Which of the following bronchodilators is/are NOT recommended for twice daily use to target end of day symptoms in COPD? a) Braltus c) Both a and b
b) Incruse Ellipta d) Eklira Genuair
5. Which inhaled corticosteroid is particularly shown to be associated with a higher risk of pneumonia? a) Fluticasone
b) Budesonide
c) Beclometasone
6. Which of the following measurment tools is/are recommended for use by GOLD in the assessment of patients with COPD a) MRC scale c) Spirometric clssifiction scale e) All of the above 248
b) CATS score d) exacerbations
b) False?
9. Which of the following is/are not licensed for the treatment of asthma? b) Seretide Accuhaler 500 BD d) All of the above
a) Salmeterol c) Spiriva Handihaler
10. Which of the following is/licensed for use in asthma but not COPD? a) Flutiform c) Both a and b
b) Fostair 200/6 d) Revlar Ellipta 184/22
11. When treating an exacerbation of asthma using a short acting beta agonsit,the maximum number of puffs per cycle is 10 whether child or adult: a) True
b) False?
12. Fractional concentration of exhaled nitric oxide (FENO) levels may be elevated in which of the following? a) eczema c) eosinophilic bronchitis e) all of the above
b) allergic rhinitis d) asthma
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WORDPLAY 17 Dominic de Takats, Consultant Nephrologist EASILY CONFUSED
Glossary:
Sir Gawain and the Green Knight (misheard as the Green Giant, clearly in some subconscious reference to the Jolly Green Giant, which makes just about as much sense, but is incorrect, itself a reference to a mythical character involved in advertising the canned produce of the Minnesota Valley Canning Company, founded in 1903; and then there’s that whole seam, that rich vein of misheard lyrics to be considered, and, with discretion, left to one side for now, but misheard dictation is a tangent worth a thought; perhaps you have some amusing examples you’d care to send in) was written down in the late 14th Century. It is a mythical tale of the knights of the round table written in complex verse, according to those with prodigious prosodic skill, in middle English, which would pass for nonsense now, such is the twisted and lengthy path travelled by the English language in 700 years. To understand the tail in modern terms it needs translation into today’s English as has been done by Simon Armitage.3
AMRA CiC COC CoF COO CoW Cow CsoW CSW
Not to be confused with Jaberwocky, said to be a nonsense poem, but it is a narrative poem containing neologisms that are not so much nonsensical as guttural, intuitive, raw and primitive in a conceit to affect a middle English of yore and to reprise in brief the loft grandeur of Gawain. There are true nonsense poems and there are those which by Jove appear to content no sense but which joke some truth in their awkward belching flow. Sometimes it’s difficult to discern true nonsense from the superficially nonsensical satirical pastiche. The CoW can be the CiC. Should we kick the cow the cow may cough. If the cows do well the farmer is pleased. Double the CoW and get a CoF. If the CsoW do well the COO will coo. If the COO is an independent advisor, he may be a COC. Cocks will crow, and pigeons coo. If the COC gets the CsoW to jump over the moon, and serve the organization well, he’ll be over the moon too, Cock-a-hoop COO coos. Hoorah for the AMRA! Volume 28, No 6, Nov 2018
Acute Medical Receiving Area Consultant in Charge Chief Operating Consultant Consultant of the Fortnight Chief Operating Officer Consultant of the Week Mammalian quadruped that eats grass and is farmed for milk or beef, depending on the breed. Consultants of the Week Community Support Worker
There may be nonsense poems but there is also poetic nonsense: When Wordsworth wrote “wandered lonely as a cloud” what was he thinking of? But Don’t hold your breath waiting for your blue sky to be encroached by a reclusive individual cloud. Solitary clouds are rare; single clouds quite singular. Obviously cumulus, stratus and nimbus were discounted and discarded for the poetic purpose. What is a rosy-fingered dawn? Apparently it is an epithet of the type commonly used by Homer and a contrivance to aid meter and cadence of dactylic hexameter and more about sounding good than being accurate. (Suitable link to the next section…) CONTRIVED ACRONYMS AND WORD PLAYS Somewhere in my hoarder’s lair there is a misplaced little handbook from the early noughties (not to be confused with naughties, which were probably more fun, but that’s one for you to work through on your own) which was a slim tome, but nevertheless an actual book, in alphabetical order, composed entirely, dictionary-like, of clinical trial acronyms. Some of these are awfully contrived, forced and cheated. You just hope that as much effort goes into the power calculations as goes into the sexy acronym contriving. (I am developing a something of an admiration for the more Ronseal trial names, those that basically state what the trial is about without bothering to squeeze it into an acronym, e.g. EMPA-REG: an FDA regulatory trial 249
regarding cardiovascular safety for empagliflozin. You can see how it goes in the meeting. Here is our drug, empagliflozin, and we’ve got a number of clinical trials we’ve got to do with it in different areas, this one’s the empagliflozin trial done purely for regulatory purposes, EMPA-REG for short: “That’ll do for a name, no more energy wasted on coming up with a sexy acronym. Let’s split the time saved between triple checking the power calculations and the expected recruitment rates and the pub, in that order!”) These days a slim pocket book is very unlikely to cover the matter: a multi-volume set of books is more suited (yes, okay, or an online database).
Cardiovascular Outcome Results (And leave stuff out if it doesn’t fit your preconceptions?) JUPITER Justification for the Use of statins in primary Prevention: An Intervention Trial Evaluating Rosuvastatin (Pure backronym.)
Some of those who did spend time working on their acronyms produced the following:
It’s not just clinical trials where this sort of approach has caught on, initiatives, programmes and scoring systems also take part. Some of these are just lazy backronyms, but occasionally other stuff creeps in such as subliminal messaging, relevance and double entendre. A few examples:
ACCORD Action to Control Cardiovascular Risk in Diabetes
ASH Action on Smoking and Health
(Two front-ended action words giving dynamism, a clear definition of the territory studied and a feel-good, genuine, within-the-rules acronym [almost, but cheeky with the ‘o’]: Full marks for effort.)
(Reminds you of fouler aspects of smoking, and how you’ll end up too soon if you do, as well as being a straight acronym.) MADE Multi-Agency Discharge Event
ADVANCE Action in Diabetes and Vascular Disease: Controlled Evaluation (Where did they get the N from?) BASE Biomarkers of Acute Stroke Etiology (Theft! BASE jumping, jumping off a solid base at significant height as opposed to out of an aircraft, already stands for Building, Antenna, Span [Bridge] or Earth [cliff].) DECLARE Dapagliflozin Effect on CardiovascuLAR Events (See what they did there? Stayed with the order, but played with the conventions of initialism and of only using one or two letters; utter mavericks!) EXAMINE EXmination of CArdiovascular OutcoMes: AlogliptIN versus Standard of CarE (What rules? Make it up as you go along.) LEADER Liraglutide Effect and Action in Diabetes: Evaluation of 250
(A match made in the boardroom.) MUST Malnutrition Universal Screening Tool (Backronym designed to unsubtly convey just how important it is to pay attention to nutrition in patients.) PICARD Programme to Improve Care in Acute Renal Disease (Backronym by a Treckie) PLACE Patient-Led Assessment of the Care Environment (Patient-centred, backronym)
politically
correct,
dynamic
SNOT-22 score Sino-Nasal Outcome Test (A 22-item item questionnaire for assessing symptom severity in chronic rhino-sinusitis, this handy backronym acts as its own mnemonic.)
Midlands Medicine
Mnemonics, reminders of memory aids, often take the form of an acronym. If effective, or just by happenstance, they can become widely used. For example, the SSKIN Care Bundle was developed by US health services initially and propagated as an effective tool in altering the way nursing care is actually delivered. It has been taken up by NHS Scotland and various regions of England. Like SNOT, directly it references its own subject, making that element important enough that it’s something of a contortion to make the points fit the initial letters. But it’s caught on and it seems to work: S Surface (Mattress, covering, support type and materials) S
Skin inspection (Look for blanching, reddening, any changes)
K
Keep your patients moving (#End PJ Paralysis)
I
Incontinence or moisture: keep patients clean and dry
N
Nutrition and hydration need to be adequately maintained
FAST HUG FIDDLE is supposed to give those structured ward rounds in Critical Care the structure that underpinned their approach. FAST HUG is agreed, but there are competing versions of how that should be followed. One is FAST HUGS IN BED, the other is: F Feeding and nutritional support A Appropriate analgesia S Sedation T Thromboprophylaxis H U G
Head elevation (aiming for 30°) Ulcer prophylaxis (peptic ulcer) Glucose control
F I D D L E
Fluid balance Infection control (host defence) Drug chart review, dosage adjustment Dialysis or CRRT (Continuous renal replacement therapy) Lines and cannulae (inspect, secure, remove, change) Electrolytes and other blood results
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TACKLING BAFFLING INHERENT AMBIGUITY Is a ‘Volunteer Co-ordinator’ a volunteer who coordinates things or someone in a formal position whose job it is to co-ordinate volunteers? TRUS stands for ‘Transrectal ultrasound guided prostate biopsy’ but if we hyphenate thus: Trans-rectal ultrasound-guided prostate biopsy, does it read any more easily? Is the meaning clearer? Double-blind placebo-controlled trial. Better understood than Double Blind-placebo controlled trial? Trial? Trail of discovery?
PUNS FOR FUN Ophthalmologists never lose sight of their objectives; they stay focussed on their task. Pathologists take things lying down. ADDRESS FOR CORRESPONDENCE Dr D de Takats Consultant Nephrologist The Kidney Unit Royal Stoke University Hospital Newcastle Road Stoke-on-Trent ST4 6QG
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INTERESTING IMAGES
This middle aged woman with fever and weight loss was found to have hazy mid-zone shadowing on a chest radiograph but the cavitating nature of the lesion is much more readily appreciated on this cross sectional CT image. Picture used with her permission.
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This ECG shows life-threatening hyperkalaemia with a near sinusoidal wave form:
The same patient after effective dialysis:
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ASTHMA QUIZ: ANSWERS AND EXPLANATIONS 1. (e) None of the above. Symbicort 100/6, Symbicort 200/6, Fostair 100/6 and DuoResp 160/4.5 are the doses that are licensed for both maintenance and reliever therapy in asthma. DuoResp 320/9 can be used for both asthma and COPD. This strength must be used for maintenance only (in asthma).
8. b) False
9. d) All of the above. Salmeterol is licensed for use in asthma ONLY for those already on inhaled corticosteroids
2. c) Both a and b
10. e) All of the above. Fostair 100/6 may be used in asthma or COPD. Fostair 200/6 is licensed for use in asthma but not COPD.
3. d) All of the above
Both strengths of Revlar Ellipta are licensed for asthma, but only the lower strength (92/22) is licensed for use in COPD.
4. c) Both a and b
11. a) True.
5. a)
For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes, according to response. For a child, give 1 puff every 30-60 seconds. Each puff should be given one at a time and inhaled with five tidal breaths. Repeating every 10-20 minutes according to response.
6. e) All of the above 12. e) All of the above 7. e) All of the above
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www.nsconferencecentre.co.uk
Operating within the North Staffordshire Medical Institute research charity, the North Staffordshire Conference Centre is the perfect solution to make your meeting, conference or event a success. With two tiered lecture theatres, six seminar rooms, state of the art audiovisual equipment and an on-site catering team, the NSCC can accommodate your needs. Book with us and help to fund vital medical research.
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