ECHOLALIA- Issue 3

ECHOLALIA THE OFFICIAL UON MEDICAL SCHOOL MAGAZINE

Dealing with the ‘unintended consequences’ of women in medicine Is the glass ceiling justified?

Editorial

Having been on clinical placements for almost a year, it probably comes as no surprise to you that, unlike some of my female colleagues, not once have I been asked if I am training to be a nurse or a midwife.

Why, in this day and age, is medicine still seen as a men’s club in the eyes of many? And what do we have to do to change this warped view?

then Undersecretary for State for Health, Anna Soubry, a Nottinghamshire MP. We spoke to two female consultants working for NUH to get their opinion on the subject. However, I don’t want to tell you everything so turn to page 24 to find out more.

articles written by all of you, from a review of the 4th year musical to recipe ideas on a budget so there is something inside for everyone.

If there is something that you feel strongly about and want to share it with the rest of the medical school.

Email us at As we venture forward into 2014, echolaliasubmissions@gmail.com. with New Year resolutions already I must also quickly mention the broken, we can both look back to huge amount of effort my team put see what happened over the past into every issue of this magazine. I year but also look into the future to can never cease to be impressed see what 2014 will bring. For by the talent and enthusiasm some, the immediate future will shown by everyone. That said, we bring exams, and for those who are always on the look-out for have been working tirelessly over more editors and designers so let Our main feature this issue is the Christmas period, finals are us know if you are interested. about that age-old debate of just around the corner. sexism in medicine.

A topic This issue, like those before, is Ollie sparked by comments from the packed with the highest quality

s, marvel l a c i d Me -7. see p 6

Check out our lead feature on sexism in medicine (p24), fe aturing interviews w ith orthopaedic surg eon, Brigitte Scam mell, and paediatrician , Louise Wells.

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In This Issue Editor-in-Chief

Editors

Oliver Burbidge

David Thomas Alexander Fox

Deputy Editor-in-Chief

Lorna Neill

(Design Editor)

Louisa Hepworth

Mei-Ling Henry Design and Artwork Finance

Mei-Ling Henry

Anouska Lerner

Julian Bender

News Global News……………………………………………………………………… 4 Dua’s Layer—a new eye discovery………………………………… 6 Grow Your Own Brain in a Bottle……………………………………… 7 Climate Cha nge……………………………………………………………8

Societies MedSoc Committee 2013/14…………………………………………… 10 Do You Follow?………………………………………………………………10 Societies Round-Up……………………………………………………………12 Vital Signs—GP Soc Sign Language Course……………………13

Sports inFOCUS: Medics’ Cycling………………………………………………… 14 NUMSki Trip………………………………………………………………………15

Features Madiba; The Life of Nelson Mandela………………………………… 16 The Cocktail Party Archive…………………………………………………19 The Painful Truth Behind Anaesthesia…………………………………20 Welcome to Nottingwarts—the medics’ sorting hat……………… 21 What’s Playing At The Roxy?………………………………………… 22 Lead Feature: It’s a Man’s World…………………………………… 24 Mental Health in the Media……………………………………………… 28 Haemodialysis 101…………………………………………………………… 29 Child Protection……………………………………………………………… 30 A Cure for Blindness………………………………………………………… 31 A Right To Die………………………………………………………………… 32 Housemates From Hell…………………………………………………… 33 Angelina’s Choice…………………………………………………………… 34 Health Benefits of Olive Oil……………………………………… 35

Arts and Culture The Psychopath Test……………………………………………………… 36 X Box One Vs PS4…………………………………………………………… 37 Medical App-titude…………………………………………………………… 38 Films of the 2013………………………………………………………………40

An idiot’s guide to U+E results, p42.

Essential Lecture Handouts How to Interpret U+E results……………………………………………

Student Cook-Off…………………………………………………………

Case Study: Cyclist Down…………………………………………………

Case Study Answers………………………………………………………

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Echolalia—The Official UoN Medical School Magazine @echolalia_mag echolaliasubmissions@gmail.com echolaliamagazine@gmail.com echolaliadesign@gmail.com

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USA

News

Here’s a feel good story to restore your faith in humanity. When homeless man, Glen James, found a rucksack at a shopping mall in Boston he discovered it contained cash and travellers cheques adding up to a whopping £26,000.

Despite his desperate situation, Mr James flagged down police officers on patrol to hand in the rucksack, stating that he ‘would not have kept a single penny’. He was honoured at Boston police headquarters, where he was given a special citation and thanked for his honesty. Mr James also took the opportunity to publicly thank everyone who had ever given him spare change on the street.

Uruguay In a controversial but historic move, Uruguay has become the first country to legalise the growth, sale and consumption of marijuana. The government believes that this will help in the fight against drugs and the associated crimes implicated in their trade. Hordes of young people gathered outside Congress to await the results of the vote and many celebrated once the news was announced, partying outside with reggae music and sharing joints of marijuana with their friends.

Not all were so elated by this news, however. A conservative senator against this decision told the BBC that: ‘We used to be known for our excellent meat and football, now the world is watching us because of our marijuana’. And right he is, the world will indeed be watching to see how this plays out and we could be seeing a move towards legalisation in more countries in the coming years.

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GLOBA Mei-Ling Henry highlights some news stories from around the world over the last few months.

L NEWS Germany Index Subject 1 is the girl at the heart of a new study that could provide us with a solution for chronic pain sufferers. Index subject cannot feel pain and this has been attributed to a rare gene mutation. This mutation had not been found in any genome databases until recently when it threw up another interesting subject – a boy who has also not been able to feel pain since birth. These two children have frequent injuries, slow wound healing, severe digestive problems and suffer muscle weakness. Both share a mutation to SCN11A – a gene responsible for a particular type of sodium channel that is abundant in nociceptors. The mutation was replicated in lab mice to show that it was indeed this gene causing the inability to feel pain, with similar effects exhibited. So why is this useful to us? While there is no immediate solution for Index Subjects 1 and 2, their genome may provide us with key genetic targets as it seems so far that their painlessness stems from a single mutation. This is really quite an unusual event in genetics. This exciting discovery would allow a drug to be created, targeting the protein made by this gene; a prospect that will delight chronic pain sufferers everywhere.

Russia Students may be known for having long and heated discussions about culture and politics but few will top this pair of Russian men where a discussion about the philosopher Kant ended up with one being shot; no joke. The victim was shot with a rubber bullet and hospitalised although not seriously injured.

New Zealand Imagine coming home one day to find beer flowing from every tap. Sound like a dream? Well it became a reality for one man in NZ whose friends pulled off a real whopper of a prank when they replumbed his entire house with beer kegs. The group filmed the prank from start to finish with a video on youtube showing them stowing dozens of beer barrels under the house and connecting them to the mains so that their friend would find cold beer in every tap. The video also shows Russ, the victim of the jape, wandering round the house turning taps on in disbelief. What are friends for, eh?

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Nottingham discovery

News

Dua’s Layer Once again the University of Nottingham has proved itself to be at the forefront of ground-breaking medical science. Professor of Ophthalmology, Harminder Dua, and his team have discovered a new layer to the cornea of the human eye. This will mean ophthalmology textbooks will quite literally need to be rewritten.

The cornea is the transparent protective lens at the front of the eye which covers the iris, pupil and anterior chamber. Alongside the lens and anterior chamber, it is responsible for refracting light, and accounts for roughly two-thirds of the eye’s total optical power. In humans, the refractive power of the cornea is approximately 43 dioptres. Although the cornea is the main contributor to the eye’s focusing power, its focus is ‘fixed’.

The lens is then responsible for fine tuning this focus, depending upon the distance of the object.

made up of 5 layers: Corneal epithelium, Bowman’s layer, corneal stroma, Descemet’s membrane and the corneal endothelium. Dua’s layer is located between the corneal stroma and Descemet’s membrane, and measures just 15 micrometres thick. Despite its thinness, the layer is very strong and impervious to Alex Fox air.

Professor Dua and his team discovered the new layer by simulating human corneal transplants and grafts on eyes donated to medical science in Bristol and Manchester. Tiny air bubbles were injected into the cornea during this surgery, thus gently separating the different layers. Following this the separated layers underwent electron microscopy, allowing the identification of the fine layer.

"From a clinical perspective, there are many diseases that affect the It was previously thought to be back of the cornea, which clinicians

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across the world are already beginning to relate to the presence, absence or tear in this layer," the Professor said in a statement. He believes that a tear in the layer could be responsible for corneal hydrops.

This is a nasty complication resulting from keratoconus (a conical deformity of the cornea). Corneal hydrops occurs when one of the internal layers of the cornea splits and fluid from the eye enters the cornea.

This causes the cornea to swell and become cloudy and white, rendering the person blind.

Currently there is no treatment available; however, with knowledge of Dua’s layer, this could in the future no longer be the case. It is also believed the discovery could have an impact on advancing knowledge of other diseases of the cornea, such as Descematocele and pre-Descemet’s dystrophies.

University of Nottingham Professor of Ophthalmology— Harminder Dua .

Grow your own brain in a bottle

structure which allowed the cells to organise into separate regions and ultimately form complex structures.

They were then placed into a spinning bioreactor which gave the cells extra oxygen and other nutrients, thereby allowing them to grow larger - up to a certain point.

It’s like something from the future or a Dr Who episode. But actually its 2013, no one has encountered the Doctor and somewhere in Austria there are tiny brains made from stem cells growing in a laboratory.

Recently scientists from the Austrian Institute of Molecular Biotechnology have successfully grown ‘brains in a bottle’, in the hope of increasing understanding of neurological disorders. They proposed that these brain ‘organoids’ can be used to test new drugs and study the genetic causes of defects in brain development.

Ultimately, the goal is to be able to tackle complicated diseases such as schizophrenia and autism.

So far, the stem cell scientists have used the mini brains to investigate microcephaly - a developmental brain disorder which results in the brain being smaller than normal.

Using cells from a patient who already had microcephaly to create a mini brain, they found that

resulting organoid growth was stunted. They discovered that the cells had differentiated too early before they had a chance to grow large enough; thus leading to an overall smaller brain.

This particular experiment was set up to illustrate the potential use of the miniature brains and how they could be used to model development of the brain and therefore study the causes of defects in development. However, a lot remains to be done in order to improve them as the mini brains have many limitations. One unsurprisingly, is their size. They can only grow up to 4mm in diameter due to their lack of blood supply. Nutrients cannot penetrate the centre of the brain structure, consequently preventing further growth.

Although they contain regions present in the brain of a 9-10 week old embryo such as the dorsal cortex and choroid plexus, it was found that the ultimate structure was very different from a normal brain. Professor Jeurgen Knoblich from the Institute of Molecular Biotechnology likened it to having car parts in the wrong places; like having an engine on the roof - it is not functional but what you need is essentially there. He further stated that due to the complexities of an adult brain, it would be highly unlikely that a lab grown brain could ever replace that of a person.

However, a different expert has said that the discovery may result in the production of an animal like brain. Although simple, it could be attached to sense organs and so would then have the ability to learn. Now T H A T sounds like The mini brains were grown by something taking embryonic or adult stem from a sci-fi cells in order to produce thriller film! neuroectoderm. The young cells Ella were grown in a ‘matrix’ - a gel like

Quintela

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c News

limate Change The evidence of the argument

With the pressures on your time that a medical degree inflicts, the recent publication of a scientific report running at 2216 pages may not have been your top priority, but there is an argument it should have been. The report, by the UN’s climate panel (the Intergovernmental Panel on Climate Change), aims to provide a comprehensive review of the current evidence for climate change, and concludes that the existence of global warming is undeniable, and there is a 95% chance that human activity is the dominant driver for it.

The report’s facts are shocking: The 1980s was the warmest decade since 1850. That is, until the 1990s came along, which were then themselves beaten by the 00s. Taken as a whole, the 30 year period from 1983-2012 is likely the warmest for 1400 years.

This is not new information, but what is new is the confidence that well over half the temperature rise since 1950 can almost certainly be attributed solely to human activity.

Worryingly, it also established that sea levels are rising faster than predicted, with the panel doubling the previous upper estimates, to 1m by the end of the century.

Dr Pachauri, a scientist on the panel, is quoted as believing the report ‘will clearly convince the public’, although whether this will be the case remains to be seen. A poll by YouGov in March found that only 39% of the British public believed that human activity was making the planet warmer, and

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the UK’s environment secretary, Owen Paterson, is a known climatechange sceptic. Whether it changes opinion or not, this report should certainly be taken seriously by believers in the scientific process.

Evidence-based medicine relies on trust in good science, and while we are taught to critique papers and studies, this report is essentially a meta-analysis of hundreds of studies, reviewed by experts. We accept far poorer evidence than this to form guidelines on how to treat disease in the individual, yet despite 97% of climate-change scientists agreeing that global warming exists and that we are the cause, we are reluctant to do the same to form similar strategies to treat the planet.

Even if the report does successfully alter public opinion, it seems unlikely large-scale action will result. Longterm measures for tackling climate

change are fairly incompatible with government administrations that, in a democracy, are likely to last 15 years at most, and indeed the UK government has recently scrapped its 2030 target for decarbonisation.

Science thrives on disagreement and a consensus does not necessarily make a theory right. It may well be that in time the evidence shows a different picture, but the IPCC’s report analyses the data we currently have, and at this point in time it seems fairly conclusive. There is also an argument that the potential severity of man-made global warming is such that, even if we are not certain, we should assume it is occurring, and take steps to stop it. After all, if a patient might have sepsis you don’t wait to get the cultures back before you start antibiotics.

Sam Quarton

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MedSoc committee 2013/2014 Clockwise from top left: John Wardlaw (President) Beth Portman (Publicity) Christine Lam (Societies) Gemma Dracup (Welfare) Hannah Carden (Logistics) Kyle Fleischer (Social) Izzy Straw (Social) Sophie Blackburn (Gen Sec)

Societies

Elsie Cotterell (Sports) David Lee (Treasurer) Emma Lucas (VP)

The new committee took over in September and we have all thoroughly thrown themselves into our hard-won roles. We’re all excited to represent you guys and are looking forward to what the next year brings. We hope to see lots of you apply for positions on next years committee when we hold our annual elections at Easter. MedSoc love!

Jamie van Oppen, Mei Henry and James Lainchbury

Do you follow?

I’ll start this column with a confession; I have, on at least two occasions, boasted about something cool I’ve been allowed to do on the wards, or a clinical encounter that I’ve absolutely nailed. It always seems fairly innocuous beforehand, but a few minutes later the realisation that nobody cares what kind of tubes I have inserted where will hit like a freight train, and I will feel frightfully embarrassed about potentially coming off all superior.

However, there is a breed of medical student that seems to have managed to suppress this natural shame reflex; they are the gunners and they think they’re better than you.

are the rest of us. Even if you hide it well behind a veneer of being a bloody layabout, nobody made it into medical school, let alone out of pre-clinical, without some form of motivation. The motivation of a gunner, though, seems to be so fragile that it can only be sustained through continued public airing.

“You mean you don’t know all of the systemic manifestations of IBD?” they will crow as their unsolicited pop-quiz elicits naught but blank stares. On the wards they will turn up first thing in the morning and clerk every single patient who isn’t currently intubated or in an induced coma, because the thought of their peers benefitting from a patient encounter instead of them fills a But how do you define a gunner?

That’s the million dollar question. gunner with a deep sense of Yes, they are very driven, but so existential dread. It’s true - if you

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Part 3 - Gunners.

publicly best a gunner (especially in front of a consultant from the specialty they’re gunning for) you will see their eyes glaze over as they plot your untimely demise, lest your interference today prevents them from getting into core surgical training.

Ultimately though, gunners deserve your pity because they are psychologically broken in the same manner as Apprentice contestants.

Their deep insecurity and resultant narcissism has convinced them that everyone is as awful as they are and that medical school is exactly like the world of Mad Max; a zero-sum game where there is a set amount of medicine, and every piece they allow somebody else to take is a step backwards.

Do you follow?

Doodle page for lectures

Noughts + cros

ses

Societies

Societies round up GP Soc

Marrow

GP Soc has taken huge steps this year in increasing its profile, with Sign Language for Medics being a resounding success, attracting huge numbers, being even better this year with new content and videos. 1st & 2nd year OSCE practice sessions, external speakers and therapeutics sessions lie ahead for a great GP Soc year.

What a year! Marrow recruited 250 students to the Bone Marrow Register, raised more than £3000 for Anthony Nolan, AND we won Volunteering Project of the Year! Now we’re bigger and better! With Save-A-Life Sessions, fundraisers and socials there’s something for everyone. Come to our introduction evening and see!

Musical Medics Once again Musical Medics shall be adding to the cultural flair of the medical school with our orchestra, jazz band, small groups and choir. Our last concert programme included: Disney, Hans Zimmer, Grieg, Piazzolla, John Williams, Ben E King and more.

Teddy Bear Hospital TBH visits schools and Rainbow groups in Nottingham. Children bring their poorly teddies and ‘Teddy Doctors’ (us!) make them better! We help to decrease anxiety about visiting the doctor and teach children important health issues. In March we held a cake sale in the Medical School and made £50.

WAMS

HoMed

WAMS helps and encourages lowincome Nottinghamshire students to study medicine. We offer events and visits throughout the year, including our recent 2-week work-experience programme. If you want to get involved with WAMS, look out for our emails in September; or email us at: wams@nottingham.ac.uk.

Committed to helping the homeless people of Nottingham, we have become known to the local community as not only a society doing weekly soup-runs, but also a non-judgmental listening ear. This term we are looking for donations and volunteers to continue making a difference in the lives’ of those less fortunate.

Juniors 2012-2013, what a great year for Juniors! Our Annual Careers Fayre highlighted exactly what paediatrics is all about. The months leading up to 4th year paediatric exams were busy with revision lectures and OSLER practice.

Keep your eyes open for new projects including Play Team and Paediatrics Abroad coming in 2013-2014!

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SCRUBS We started 2013 with our ever popular Surgical Careers Fayre and CP1 revision series. This year SCRUBS introduced laparoscopic skills sessions. Looking ahead to October, we’ll host our Trauma Conference; a great opportunity for students to implement advanced life-support skills with wet-lab advanced suture teaching under professional tuition.

Wilderness Medicine Society We has been somewhat quieter this year. However, an enthusiastic core membership and some cracking talks have ensured that the spirit and enthusiasm are still there. With more speakers and conference trips in the pipeline, we're looking forward to welcoming new members with a Wilderness Scenarios challenge in the Peak District.

Vital signs You are driving down the A52 towards Derby. Suddenly, out of nowhere, a lorry spins out of control directly into your lane. You slam on the brakes. And before you know it you are strapped to a hard, uncomfortable board so that you can’t move your head. Dozens of strangers bustle around you.

Someone is putting something sharp into your arm. You don’t know where you are or what is happening. You are completely out of control and it is terrifying.

Someone peers above your head and starts to explain what is happening.

ambulance and not being able to Have you ever realised that for the phone 999. deaf community, English isn’t their Approximately 1 in 7 people in the first language? BSL has different UK, have significant hearing grammatical rules to English. Just someone a patient difficulty - that’s 9 million people! A giving huge proportion of these people information leaflet, in their second report feeling isolated from their language, just isn’t a good enough environment and public places and way to overcome communication importantly, this isolation extends barriers. to health and environments.

social

care Do you want to get involved?

Nottingham GP Society are offering In 2009 a GP Patient Survey found a FREE 9 week course to cover that deaf people experience basic British Sign Language with a enormous health inequalities, with particular emphasis on medical 20% of deaf people registered as language and terminology! The ‘sick or disabled’ compared to just course was an enormous success 6% of the overall population. The last year, and this year promises to The problem is, you are deaf. report revealed that a proportion of be even better! It is open to all students including This is an extreme example, but it the deaf population wanted to see healthcare medics, nurses and midwives. illustrates how a situation that their doctor but were not able to, would be difficult for you or I, can due to physical limitation and Learn a new skill for life, improve be phenomenally difficult for greater distrust or dislike of your non-verbal communication someone with a hearing doctors. skills, be that person that can step impairment. These scenarios are Following this research, up and communicate when an occurring daily in both primary and recommendations were promoted interpreter hasn’t been booked in secondary healthcare settings in by the GP access programme. clinic (this does happen!). the UK, ranging from clinic Notably, that healthcare staff Look out for the information e-mails appointments where an interpreter should receive Deaf Awareness, from GP society for more details, or hasn’t been booked, to needing an BSL training or wider disability e-mail training. At Nottingham GP Society, Sarah we think this recommendation is vitally important, and that the (mzysw2@nottingham.ac.uk). opportunity to learn some basic British Sign Language (BSL) should be viewed as an exciting chance to access a world that would otherwise be isolated from healthcare services.

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In focus: medic’s cycling A closer look at what the society offers

Sports

Cycling in Britain has really taken off since the Olympics. Cyclists such as Sir Bradley Wiggins, Sir Chris Hoy and Mark Cavendish are now household names. Thousands of people are picking up the sport every day and more people are racing than ever before.

Medics cycling is a small but active club that caters for anyone who is interested in picking up the sport. We cater to all levels of ability, from seasoned racers to those who have just bought bikes and are interested in seeing what all the fuss is about.

There are rides all week and we work with the University team (NUBike) to provide rides and events throughout the year.

Nottingham is also a great area for cycling with some fantastic scenery.

The hills of the peak district are only a

short distance away and the countryside surrounding the city makes for great fast rides during the summer.

While the club is mainly for road riders, you don’t need to have the latest and greatest carbon frame. Anything with two wheels is good enough as long as you’re willing to give it a go. We do recommend however that as most of our riding is on the roads that you have a set of thin tires equipped, it will help you out in the long run! There are also plenty of local mountain bike routes with a strong University team.

Nottingham’s 2013 Varsity-Winning Team

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If Medics cycling interests you, then contact us. There will be rides going out throughout the year, so there’s plenty of pedalling to be had .

Alex Thomas

NUMski

What can be disclosed about last year’s Ski trip I miss snow. Remember the NUsnow trips? No? Well I went and I don’t even remember them all that well, but I do remember that they were incredible. If you’ve never been on the slopes then your bucket-list is one tick short. And now you’re in the Clinical Phase and you have weird holiday dates and you can’t go. It’s not fair and the world is rubbish. You’re stuck, right? WRONG.

The trip was like fresher’s week with snow. You can bring whoever (medics, non-medics, friends from home), and for the trip NUMski joins with a long list of ski societies from other Medical and Dental schools who share our annoyingly restrictive timetable and so feel our pain (Leicester, Newcastle, UEA, Peninsula, Cardiff, Bristol, Liverpool etc). We were a massive glorious Medic-shaped blob of awesome, and surprisingly there was barely any med-chat because of ‘the rules’, of which I’m not allowed to disclose.

Last year I went on the NUMski trip to Les Deux Alpes and it was the best holiday I’ve had. I really mean that. It was cheap and I spent New Year’s Eve in the gorgeous and ruckus French Alps with my mates. Where were you? What happens on the slopes stays on Yeah. I win. the slopes, but I think I can say this much:

1 – There’s plenty of Medics vs Dentists rivalry (always fun because we always win).

2 – The beginner skiers and boarders picked it up ridiculously quickly.

3 - The resort was perfect. The beginners, pros and park bums all felt at home plus our hostel couldn’t have been closer to the main ski lifts and nightlife.

4 – I intend to go again. I advise keeping your eyes on the NUMski Facebook page for dates of this winter’s trip on the NUMski Facebook page.

NUMski

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Features

madiba

Nelson Mandela is a man who needs no introduction. December 2013 marked a significant moment, in not only the history of South Africa but of the entire world, with the death of this famous statesman after a significant period of ill-health. His funeral was held on 15 December in his ancestral home of Qunu following a week of international commemorations.

Although Mandela retired from public life in 2004; his memory in South Africa will remain for years to come.

His death was announced by South African President Jacob Zuma, declaring that the nation had lost ‘it’s greatest son’.

Following the announcement, both the public and international statesmen spoke words of condolence to his family and reflected on his life. The American President said, ‘he no longer belongs to us—he belongs to the ages’.

democratically elected President of South Africa, and the symbol of the end of apartheid and the struggle against white minority rule. During his 27 years in prison, Mandela became famous across the world. South Africa’s ban on his image and his words only added to his fame and appeal. What really made Mandela so exceptional was his innate ability to forgive.

Despite decades of persecution from the white minority government, he only strived for equality and never to pursue revenge.

The Truth and Reconciliation Commission that he set up with Archbishop Desmond Tutu sought to understand what had happened and allow people to seek forgiveness rather than extract revenge. It was a model which was widely admired and tried in Northern Ireland and other troubled areas.

The question now is how will When Mandela was elected as Mandela’s legacy continue after his president in 1994, he became the first death? Reports from South Africa show that the two major political parties have already begun arguing over which has the most legitimate right to use Mandela’s quotes and ideas.

radical citizens who believe Mandela was too forgiving to the minority white population unleashing a wave of violence, it is hard to comprehend that this 95 year old man had the power to singlehandedly keep peace. I believe the concern comes from the realisation that his death will promote a period of national reflection and an analysis of the current state of the country. There remains an uneven distribution of wealth; there is anger at injustice and repeated accusations of corruption against the government. Unemployment also stands somewhere between 25 and 40%. This nation still has many challenges.

“A great light has gone out in the world.”

- Rt Hon David Cameron MP

Hopefully this will be a time for South Africa to reflect and then look to the future and continue to strive for a “Rainbow Nation” of peace and equality, and therefore ensure the legacy of one of the greatest Many are concerned about South statesmen of all time.

Africa’s future now that Mandela has passed away. Despite concerns Tembe Carveth-Johnson expressed in the media that it will be a catalyst for racial war, with more

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Nottingham Medico-Chirurgical Society The Nottingham MedChi Society is the second oldest medical society in the country and continues to be one of the most active. Each year we organise a series of lectures to which medical students are welcome. A buffet is available before the meetings at a special student concessionary rate of ÂŁ2.50 per head. Supper is available from 6pm onwards and the lectures commence at 7pm. All meetings this year will be held in the Lecture Theatre at the Postgraduate Education Centre at the City Hospital, Nottingham.

We look forward to seeing you!

Wednesday 19 February 2014 Mood Disorder: Medical management in the Modern Age (Bart Meeting) Prof Richard Morriss, Chair of Psychiatry, University of Nottingham

Wednesday 12 March 2014 Advances In Treatment Of Aortic Disease (Tony Mitchell Memorial Lecture) Mr Donald Adam, Consultant Surgeon, Birmingham Heartlands Hospital

Wednesday 16 April 2014 Fraudulent Physicians of the Renaissance Dr. Alexander Marr, Lecturer in the History of Art 1400-1700 at the University of Cambridge

Wednesday 14 May 2014 Human Rights - Law v Medicine?

(Joint Meeting with the Nottingham Law Society and the Notts Medico Legal Society) Prof Rob McCorquodale, Director of the British Institute of International and Comparative Law, London. Former Head of the School of Law, University of Nottingham

Features

The cocktail

Once again the MedSoc Celebrity Cocktail party exceeded all expectations with wilder and more inventive costumes than ever.

Costumes ranged from Pokemon and Angry Birds, to religious leaders and world dictators. Super Mario got jiggy on the dance floor with the Pink Power Ranger; Gandalf and Obi-Wan Kenobi downed a Jaeger Bomb or two at the bar, and Rafiki got on down to some dub and step, while in the corner Where’s Wally got a bit of action from an Avatar Navi.

Never again in your life will you experience such an array of costumes and resulting hilarity. It is for this reason that the event has become a staple of the Nottingham Med School calendar, and quite rightly so. For the purpose of this article I tasked myself with exploring the origins of this legendary event, yet I am sad to report that I was unsuccessful. All I can gather is that once a year for as long as anyone can remember (well, as long as the F2 doctors remember) a suspect ‘cocktail’ has been dished out, and many an escapade has ensued. However, if anyone out there can shed some light on the subject we would love to hear from you.

Cocktail Party Top Tip 1 Planning.

This varies greatly by year. 1st years can generally get away with having a five minute discussion the night before. However, for the 4th and 5th years this is the time to shine. House meetings should be planned.

And, if you’re really on the ball, construction will begin at the start of next year, meaning your lounge will appear as if the Art Attack studio has exploded over it (scarily that reference may go over some of the 1st years’ heads).

Cocktail Party Top Tip 5 Put some clothes (read: cardboard) on.

Don’t be the medic we all hate who uses the event to dress as slutty as possible.

Weirdly, this mainly applies to the guys.

Taking your top off and throwing some glitter on yourself does not make you Edward Cullen. It makes you an idiot.

Cocktail Party Top Tip 6 Amazed by this years costumes?

Maybe you need to start thinking about planning for next year. Here are my top tips:

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Face paint doesn’t stay on faces.

That’s right. If you become acquainted with someone who’s bright blue, people will know about it.

party archive Cocktail Party Top Tip 2

CARDBOARD. CARDBOARD. CARDBOARD. Seek it high and low. Supermarkets and storage companies such as ‘The Big Yellow Storage Company’ are your best bet. It’s an essential. ‘But I don’t need cardboard’ I hear you cry. Well, you’re wrong. It isn’t a true Cocktail Party outfit if it doesn’t involve some sort of intricate cardboard creation.

Cocktail Party Top Tip 3 Arrive early.

Pre-drinks should commence at around 7pm for arrival at 9pm. That way you can saunter up to Ocean happy in the knowledge that you will soon be suckling on the sweet nectar that is the free ‘cocktail’.

Cocktail Party Top Tip 4 Make friends with a barman.

Following the previous tip you should already have arrived early - good work. Next, you want to carefully strike up a humorous conversation with whichever barkeep is within your local vicinity.

This will lay the groundwork for later when the bar is packed and you can coolly strut over and order a cocktail with ease. And, by strut, I mean stumble. And, by coolly, I mean appearing like a slightly worse for wear Paul Gascoigne.

Finally...

ENJOY YOURSELF! Let loose, get to know your year, get to know other years, and get to know everyone (although not too well if you catch my drift).

Alex Fox

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Features

The painful truth behind anaesthesia My name is William Morton and I am the inventor of anaesthesia. Before me, surgery was painful, but faster.

Liston, a prominent surgeon of my time, was famously quick. He amputated legs in less than 2 and a half minutes. Alas, in his haste he often took other body parts, and is credited with the only operation in history with 300% mortality.

Our story starts in 1844: my dentistry tutor, Horace Wells, and I attended a travelling circus promising gas that, when inhaled, would ‘bring out the leading trait’ of a person: singing, laughter, anger, and so on. One volunteer launched himself around the room and injured his legs; before passing out. When he awoke, he was surprised to see blood – he felt no pain. Curious, Wells and I returned to our dental office with the gas, and a friend of mine extracted our tutor’s tooth. As before, it was painless.

He summoned the courage to publicly display the finding, at Massachusetts General Hospital, Boston. Dr Warren performed the procedure. The patient made small noises during the operation, interpreted as pain, and Wells was mocked as a fraud (despite the patient’s report of painlessness).

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He fell into illness, and our academic vascular tumour was removed, with relationship deteriorated. little pain. The next day, another tumour was removed, again with no Meanwhile, I had been training in pain. All in attendance were forced to medical chemistry under Charles believe in this ‘insensibility during Jackson. I told him of the nitrous surgical operations’ that I had oxide and during another tooth developed. With a tear in his eye, extraction, asked if stronger agents Warren turned to his stunned may exist. Jackson remarked that audience and announced, ‘ether’ could work. Our patient, Eben “Gentlemen, this is no humbug.”

Frost, confirmed his hypothesis.

To my detriment, I could not mask the Seeking to redeem Wells’ name and ether forever, and surgeons around promote mine with this ‘ether’, I the world employed my methods. I requested another audience with Dr etherised thousands of soldiers in the Warren in Boston. He accepted, for American civil war, but received no the final time. The potential revenue living recognition or compensation for of this discovery did not elude me, my endeavours.

I petitioned and I had to find a way to disguise the congress, even meeting the easily recognisable scent of ether. president, to no avail.

Adding harmless, odorous chemicals to the mixture, I rushed to patent my Despite our previous camaraderie, ‘Letheon’ – named for the river of the Wells, Jackson and I fell into bitter Greek underworld – those who drink terms, each of us clambering to claim from it have their memories erased. the title of inventor. Scorned, and heavily in debt, I died aged 48 in New October 16th, 1846 arrived: the day of York City. Wells became heavily my life-changing surgical attendance, addicted to chloroform, and whilst but I was running late. To further incarcerated, took his own life. disguise my concoction, that morning Jackson outlived us both, dying years I’d developed a primitive inhaler. This later in an asylum. promoted patient dignity, comparatively superior to smothering Tim Mercer with a handkerchief. Edward Abbott’s

Welcome to Nottingwarts The Gryffindor-medic is trying so hard to be a doctor that they seriously get on your nerves. Someone passes out at the Rose and Crown—and they’re ripping off their shirt shouting “STAND ASIDE! I’M A MED STUDENT!” and performing CPR until the ambulance arrives. You can’t really begrudge them for having spotted someone’s heart murmur in clinical skills, but they didn’t have to extoll their own virtue in a Facebook status. Well-rounded as they are, they naturally represent Nottingham in every medic sport.

So, you made it to medical school, no doubt thanks to the wizardry in your blood. Imagine you found yourself in the Potterverse (or Notterverse…?) where decisions about your medical future were made by a dirty, crumpled old hat.

Imagine such a hat had the power to sort you into a House which can define you as a future student. When it’s your turn to wear the hat, into which House do you hope to be allocated?

The Hufflepuff-medics are the true substance of the medical school - ever dependable, they want to be a GP, make cupcakes in their spare time, have an anatomy colouring book and draw nice diagrams. After an exam when you say to your friend “OMG there are so many people in our year that I’ve never spoken to in my life”, these are the people you’re referring to.

“You might belong in Gryffindor, Where dwell the brave of heart, Their daring, nerve and chivalry, “You might belong in Hufflepuff, Where they are just and loyal, Those patient Hufflepuffs are true And unafraid of toil;”

“For Ravenclaw, the cleverest, Would always be the best”.

You can find Slytherin-medics slyly offering demonstrators their help in the DR and asking obnoxious questions at the end of every lecture. They want to be a neurosurgeon and Daddy already secured their summer placement on the neurology ward. They are the despicable kind of person who overhears your answer to Dr. Merrick’s question in the tasking room, then repeats it louder in order to claim the credit for themselves.

Who are these people anyway, always “Or perhaps in Slytherin ranking within the top ten each year?

You'll make your real Chances are you’ve never seen the friends, Ravenclaw-medic—and not because Those cunning folks their face is always buried in a book. use any means They’re too good for the library, they don’t need the mock spotter and they laugh in the face of revision. They’re All of this aside, you may love to have playing video games while you trawl butour you’re never going to Whether you’reslides a newbie or read an old-hand in the medical school, magic take apowers look at little black book through the Scrubs and they regrow the bones of someone’s broken towhole find out how toin make most of Nottingham medical school life. the of Gray’s like, athe second arm overnight with a potion. If you really (aided by a photographic memory). wish you were a wizard instead of a They must have more magic than the medical student, joining Quidditch Socirest of us- how else could anyone have Written ety andatresearched by isMei-Ling Henry Fresher’s Fayre the closest 90% average for the year? you’re ever going to get.

Shannon Boardman

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

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What’s playin Features

Back in October the Fourth Year Medics produced their annual musical – and saw Guys and Dolls appear on the Nottingham stage. When we first came together back in July I had big dreams about what we could achieve with this year’s musical. The journey was by no stretch of the imagination straight forward or easy – from issues with finding a rehearsal space thanks to the works in the Medical School to only having two minutes of the Havana bar scene choreographed just a month before the show we came a long way.

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Managing to bring together students from the Australia and Norway, as well as both GEM and BMedSci students, the show really did involve everyone. The hard work of the crew and cast led to an amazing production which was well received by fellow students and members of the public

g at the roxy? alike – particularly following the final sell-out show.

As many of you will know, we used the show to raise money for Mind in memory of Philippa Kirkwood. In total, we raised £500

for this cause, so thank you to everyone who bought and ticket or donated money.

I’m already excited to see what next year’s Fourth Years can produce!

Rob Cullum Producer, Guys and Dolls Medics Musical 2013

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Features

IT’S A MAN’S WORLD

ECHOLALIA explores some of the issues and challenges faced by women in modern medicine

Female doctors - old news surely; women have been attending medical school since the 1800s?

Recent comments in parliament and the press would appear to show attitudes haven’t changed much since then.

In a recent debate in parliament, the Under-Secretary of State for Public Health, Anna Soubry and Tory MP Anne McIntosh spoke about the ‘unintended consequences’ of 70% of medical school intake being female, and how this puts a ‘tremendous burden’ on the NHS, due to women working part time due to family commitments.

These comments caused some outrage and sparked debate.

Echolalia decided to investigate this further and discover what Nottingham medical students think of these comments. Is there a view 24

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within medicine that female medical students are destined for part time work, and thus should not go into demanding careers? We went to find out.

commenting that it is a ‘joke’ if a female student picks orthopaedics, or a male student gynaecology.

One student told us that ‘the surgeons in Boston didn't look at when speaking; only Opinions were mixed. 95% of me addressing me when discussing respondents thought there should be flexibility for childcare. However, periods or pregnancy’.

40% thought this puts a strain on Women account for only 28% of the NHS. Many commented that it consultants, yet make up around should not be assumed the role of 70% of applicants to medical a primary caregiver is a female school. Many students felt that this one, and that ‘MPs should be is due to the lag between the time challenging assumptions and taken for these women to progress making it easier to share parental through training, however others responsibility rather than pandering thought that this reflects that to archaic sexist narrative’. ‘having children slows a career We asked about attitudes path for women’, and partly due to experienced in medical school, and women being ‘overlooked’. if students feel supported in following any career path.

Worryingly, nearly half of students who replied have experienced negative viewpoints; with many

However, on a more positive note, 70% of people felt they had experienced positive attitudes whilst in medical school, and 70% also though the NHS was an

organisation that is open to flexible working for women in senior positions. As to whether students have been put off a career path due to concerns about work/life balance; the responses were almost evenly spilt.

Our brief survey has demonstrated that while the majority have a positive experience, negative opinions towards women (and men) attaining both a successful career and personal life, such as the ones demonstrated in parliament, are still held. As the majority female future workforce reaches consultant level, it will be up to the NHS to adapt to accommodate them.

Lorna Neill

57% of you said that you had been put off a potential career pathway because of concerns about work-life balance.

What do you think?

26% of you have never found any doctors supportive of your career aspirations in relation to gender.

43% said this wouldn’t influence your decisions.

74% of you have found doctors very supportive of career choices, regardless of your gender.

47% of you have experienced gender discriminatory attitudes whilst on placement.

53% have never had a problem with this.

OPINION The first time you meet someone, often you get onto the subject of what are you studying. I have lost count of the number of times in response to ‘medicine’ I been asked, completely seriously, ‘Really! So what kind of nurse do you want to be?’.

I don’t. That is why I am at medical school, not nursing school.

Not once has this confusion happened to a male friend.

Coincidence? I think not. Once it’s accepted that miraculously, I am going to qualify as a doctor it is then deemed acceptable to ask ‘so, where do you want to be a GP?’ As if that is the only option.

us from ourselves. I certainly wouldn’t have got through CP1 without them. Nevertheless that is not what I am training to do and it infuriates me that the assumption is still made in 2013 that women can’t be doctors.

The idea female doctors put pressure on the NHS is ridiculous.

Why is it assumed I want to get married and have babies? And if I do, surely being a parent will only enhance my empathy skills and ability to relate to my patients.

excising difficult tumours easier. I can be an orthopod because I am strong enough for that too. It is 2013 and I can be whatever I damn well please with or without your patronising assumptions.

The reality is that 70% of medical students are now female, meaning soon 70% of doctors will be female, and so the profession has no choice but to change to accommodate us. Next time someone tries to put you down with a sexist comment, call them on it, because whether they like it or not, medicine isn’t a man’s world anymore. So embrace it, go out there and be brilliant.

It is 2013. I am a woman. I can be a nurse and help hundreds of people. I can be a GP and be a pillar of a community. I can also be We all know nurses run the wards a neurosurgeon and be amazing Anouska Lerner and, as students and juniors, save because my small hands make

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ECHOLALIA wanted to get some insight into what it is like as a woman in different specialties so we spoke to two very different but equally influential women working at the Queen’s Medical Centre in Nottingham.

Features

Real life perspective

How did you get into your specialty?

Prof. B Scammell: I knew at medical school I liked practical things and wanted to be a surgeon.

I loved how even at a really junior level you could make a difference just by pulling a leg straight or putting on a bit of plaster. I enjoyed the immediacy of trauma and immediate results and how rewarding that was. It’s quite holistic being an orthopaedic surgeon.

Dr. L Wells: It was always something I've wanted to do and I just never changed my mind, I always enjoyed working with children and I always enjoyed the diagnostic and investigative side of medicine, which is why I like acute paediatrics so much.

Professor Brigitte Scammell is a clinical academic, foot and ankle surgeon, Head of Trauma and Orthopaedics and Sports Medicine Department at the University of Nottingham, working with BMedSci and postgraduate students.

She has also been admissions Sub-Dean since 2010, with overall responsibility for all 3 medical courses, A100, A108 and the GEM course, A101. She is involved in liaising about the tricky things, fraud in applications, criminal records and disability.

Doctor

Louise

Wells

is a consultant paediatrician and heavily involved with medical education, having studied for a Masters in Medical Education during her registrar training.

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“Nottingham last year admitted 55% women, 45% men,” What do you think of recent comments about women in medicine by Anna Soubry MP? LW: Most certainly there is a high percentage of women in medicine, and that number is even higher in pediatrics. We have 30-40% of our staff working less than full time and even full time contracts have changed now, averaging 4 days a week. You often get more out of it, if you have two people contributing to one full time post they do more of the extras; organising rotas and teaching so you get two for the price of one in many ways.

BS: Nottingham last year admitted 55% women, 45% men, reflecting the numbers that applied, which implies our admission process is robust and doesn’t favour one gender.

“I don’t think I’ve encountered sexism at all…”

I think we need to turn it around on its head and say if there is perceived to be a problem then we need to make the working environment such that women continue to work.

Do you think you’ve been treated differently during your career because of your gender?

BS: I’ve been asked some odd things in interviews. I was asked once, ‘So if you got the job and the baby was crying, and they wanted you back at the hospital, what would you do?’ and I don’t think they would have asked that of the male candidates but at the time I was too

junior and too naive to say anything so replied ‘Well I’d do exactly what you would do, deal with the baby, hand over to my spouse and pick up the phone’.

I was also asked something outrageous, which I should have complained about though never did.

It was ‘What form of contraception do you use?’ to which I said ‘I refuse to answer that , it’s completely inappropriate’. And I didn’t get that job.

LW: I don’t think I’ve encountered sexism at all and that may have been because of the specialty I’m in. I suspect 40 years ago it would have made a massive difference but nowadays makes no difference at all. Because there are such a large number of women in medicine everyone is on a par. There is no doubt a difference between specialties. I have many friends who are surgeons and definitely struggled until recently to get that equality that we’ve had for many years in paediatrics but with more and more women going into surgery that equality is happening, just a bit slower than other specialties.

BS: Things change. We have more women doctors now. I think in my year there were 157 students and 28 women.

How do you think things have changed for women in medicine since you qualified?

LW: I think it’s far easier for people to juggle their work life commitments. In the 5-10 years before I qualified there were many women who trained in medicine and then left because it wasn’t compatible with having a family, I think that’s much less of an issue now, there is a much better work life balance. I think working less than full time is almost the norm now.

There are things that have changed which aren’t so good. There are fewer training opportunities; going

from 80 to 50 hour weeks its much harder to get that experience and continuity of care for patients.

BS: I think there is much better understanding of the need for part time working and getting doctors back to work after a period off. I also think WIST (Women in Surgical Training—a support programme run by the Royal College of Surgeons)

“Aim high and you will achieve far beyond your expectations.” and similar initiatives have helped not just women but men too because they may need part time work for family or health reasons. It has helped all of medicine not just women.

What are your predictions for the NHS now the workforce is changing to become majority female?

BS: We need to be more flexible and I think we need to have flexibility throughout our careers, not just as a junior. We need to have 24/7 cover 365 days a year including senior cover, not the reduced cover we have now. That would mean flexible work at the senior level. It just has to happen to continue improving healthcare and using resources effectively. Our contracts will change to reflect the working week differently; much less 9-5 working. All acute specialties are and will continue to change to shift work.

LW: Well the nurses seems to have managed it okay! I think it requires a change in thinking, which is already happening. I suspect the change in numbers won’t change dramatically from where it is now, if you look at the figures more recently medical schools are actively encouraging men to apply. I think that the way we work in the NHS in changing, there is a big drive for consultant delivered services as opposed to consultant led services and therefore I think it’s very likely we are going to be doing more and more shift patterns, more nights and weekends and fewer days overall.

How did you manage having a large family with your career?

LW: It’s not completely easy, it’s difficult, I was one of very few of my antenatal friends who went back to work full time after my eldest was born. I had 3 under 4 at one time, but actually it’s doable. You do need some support, if you don’t have active parents who can step in for emergency childcare then you need something else in place, it’s about fitting your childcare around the job that you do, If you can do that you can balance it very nicely.

What message would you like to convey to female medical students of today?

“Training is only 8 years out LW: When you look at your career choices, look beyond the training of a 40 year career… and look at what the consultants do decide if the consultants in because training is only 8 years out that specialty are what you of a 40 year career so look and decide if the consultants in that aspire to be” specialty are what you aspire to be.

BS: If you really, really want to do something just do it, just go for it.

Why do you think there has been an Aim high. Aim high and you will increase in the number of women in achieve far beyond your medicine? expectations. Aim high.

BS: I don’t know. I don’t think it happened overnight, I think the Interviews by Anouska Lerner. public are more accepting, it’s more Collated by Mei-Ling Henry. the norm.

Bored during summer The dreaded ‘you’re no longer a normal student’ two week summer holiday came and went in the blink of an eye, and I found myself back in Nottingham much sooner than I really wanted to be. We were all agreed that we needed to make the most of the time we did have free though so I got in touch with Brass Monkey about cocktail classes, they only charge for drinks and were happy to cater for however many wanted to come. So 22 of us headed to Brass Monkey not really sure what to expect, but knowing we would have a good time catching up either way! Glass of fizzy on arrival and then split into two teams for cocktail making. The first group stepped up to the mark while the rest of us had time to finish our drinks, clearly giving us the disadvantage when it came to a cocktail making competition! Mojitos were the drink on the agenda, everyone did pretty well, although one person did get the Dunce cap for worst cocktail.

Then four people chosen out of us all to battle it out for best cocktail, spurred on by everyone else enjoying a cocktail made by the barmen.

The winner got Polish Oreos, and I was fortunate enough to be the loser, having the pleasure of a shot of tequila followed by a shot of pickle juice (it’s much worse than you think it will be). Overall a really fun night enjoyed by all, a few hiccups when it came to payment, so I would recommend clarifying the price 100% first (we paid £16).

Definitely something a bit different to get a group of friends to go along to and have a great night!

Hannah Tobiss

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Mental Health in the Media

It’s a Mad World

Features

Thanks to documentaries, advertising and the help of outspoken celebrities, mental health is receiving increased media coverage. But while there is generally a greater understanding and awareness of mental health issues in the adult population, this does not extend to everyone.

Many psychiatric conditions do not begin in middle-age; 850,000 children and young people in the UK are diagnosed with a mental health problem, according to the charity YoungMinds. During my placement in an adult psychiatric unit, I spoke to several people about their childhood and youth. I found that many were too embarrassed to seek help, or were not treated appropriately by mental health services when they finally did. Young people developing self-awareness compare themselves to their friends and do not want to admit that they might be having problems.

BBC Three plans to challenge the stigma and the problems with youth mental health services in a real-life series called It’s a Mad World. The series began in July with Don’t Call Me Crazy, a three-part in-patient reality documentary, and continued with programmes such as Diaries of a Broken Mind, which showed 20 young people with a variety of mental health issues videoing their daily lives, and Rachel Bruno: My Dad and Me, in which the daughter of the famous boxer investigated the effect of growing up with a father suffering from bipolar disorder.

The series vary in both style and tone in an effort to provide both informative and entertaining programmes to BBC Three’s regular (often younger) viewers. Yet, this has lead to mixed reviews in the national press and from mental health charities. Reviews from the Telegraph and Guardian have commended the series’ ‘sensitivity’, whereas mental health charities such

as YoungMinds, MIND and Time To Change have questioned the morality behind some of the more ‘reality’ style shows. They raised concerns that videos of young people in psychiatric units being shown alongside clips of people huddled in corners and being restrained, appealed to the public’s ‘morbid curiosity’, without providing appropriate explanations.

The issues of removing stigma and promoting service use are difficult to address. Television and film can provide some realistic exposure, but often popular culture romanticises or demonises mental health, forsaking reality to gain large viewing figures and doing more harm than good.

Some question the ability of TV programmes to raise confidence in mental health services, when shows such as Failed by the NHS document cases where young people have been let down by A&E, GPs and other services, often with serious consequences.

One aspect of the series has, however, been universally praised - the portrayal of the young people themselves. Those featured were commended on their bravery and insight, providing a real-life context to the problems they were facing and challenging the stereotypes that lead to stigma.

Although suffering production and editing pressures, this series has shown how mental health problems are relatively common in young people, yet are rarely discussed. As healthcare students, we must make every effort to increase our awareness of those difficulties, both inside and outside of clinical practice.

Henry Robert Casserly BBC Three’s ‘Don’t Call me Crazy’ follows Beth, 17 (pictured middle, above) and other teenagers as the receive inpatient treatment for a variety of mental disorders.

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Haemodialysis 101 As the cylinder turned, the blood within would continually fall with gravity, causing movement through the machine. The dialysing area of their first artificial kidney was 17,000cm2, later improved to 23,000cm2. Kolff had certainly succeeded in his goal, surpassing the human kidney dialysing area of 20,000cm2.

Out with the old...

Despite the scientific community’s speculation, it wasn’t until during the Second World War that a working ‘artificial kidney’ was developed. The breakthrough was made Kolff, a Dutch clinician, who managed to revive a woman from a uremic coma in 1943.

In terms of health and safety, haemodialysis has never been better.

As we now know, endotoxins from bacteria are able to cross the membrane into the blood, having potentially devastating effects to an already vulnerable patient. As such, all solutions are now purified before use. Computerised systems allow the monitoring of blood temperature, pressure and content. Plus, the advent of the A-V fistula allows a safe and long-lasting access point to the 21st century dialysers have patient’s circulation, where clinicians improved; in efficiency, materials and would have previously struggled to safety: however the principles find a vein after multiple sessions. involved have changed little.

The future of dialysis lies in the Current dialysers not only allow the development of portable systems, transfer of urea and electrolytes shorter, more frequent dialysis between the blood and dialysate (the sessions and more freedom to the modern equivalent rinsing fluid) via patients overall. But the history of diffusion and osmosis, but also use haemodialysis is also a cautionary the process of ultrafiltration. A tale; are we missing anything as difference in pressure is established laughable as germs travelling through across the semi-permeable a semi permeable membrane, that membrane by direct volumetric medical students will cringe to read control of the blood entering the about in years to come? machine, creating a pressure gradient. In other words, by forcing Courtney O’Beirne

...and in with the new

The original device was a rotating drum dialysis machine with over 30 metres of tubing. Like modern physicians, Kolff knew that in order for this humble device to be successful he would have to generate sufficient filtration efficiency to rival blood through the machine we can that of the human kidney – no easy mimic the ultrafiltration occurring in feat! glomeruli of the kidney. This surge in He succeeded in this by rotating an efficiency means dialysis can now be aluminium cylinder containing a semi- completed in just four hours. permeable cellophane membrane, in Dialysates are now a complex the form of a helical tube, whilst cocktail of ions, including submerging it in rinsing fluid. The bicarbonate, potassium and calcium, rinsing liquid was largely composed tailored to optimum concentrations to of tap water warmed to body result in diffusion into or out of the temperature – Kolff believed that the blood. Semi-permeable membranes liquid need not be sterile as bacteria for the machines continue to be were unable to permeate the fashioned using regenerated membrane. NaCl and glucose solutes cellulose, but can now be adapted to were also added to the solution in specific molecular weights, increasing concentrations of 0.7% and 1.5% or decreasing diffusion rates of respectively. solutes as required.

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Child protection

Features

Don’t let it go unnoticed

His teachers accounted how, within months, he became ‘a bag of bones’ and how his own sibling had to provide him with food. 4 year old Daniel Pelka, one of the most recently headlined victims of child abuse, died alone in his dark room 1st March 2012. Although clearly abhorrent, the MP for his area worryingly likened this ordeal to the case of Baby Peter in 2007. Indeed, one common thread seems to exist; the insufficiencies of the systems there to prevent such atrocities.

Despite more people becoming cognisant of the signs and reporting abuse more efficiently, at the time of Daniel’s death there were 42,850 children identified as being at evident risk of abuse in England alone. The NSPCC estimates that 8 times such

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figures of abuse are being perpetrated unnoticed.

Despite these numbers, no public whistleblowing laws exist, reporting is left to the subjective morality of the population. The responsibilities for medical staff are, however, more defined.

Unfortunately, the Quality Care Commission in 2009 highlighted the shortcomings of current care trusts’ safeguarding; concluding most should ‘urgently review their safeguarding arrangements’.

be conscientiously examined as well.

We should also observe the general attitude of their carers, and encompass concerns expressed by all people affiliated with the child.

Importantly, it encourages us to clarify to young patients how judiciously possible accounts of child abuse would be received, to reduce any taciturnity concerning their abuse.

Throughout, it emphasises how a tentative balance between confidentiality and protection needs to be sought out. On the first hand, one does not want to aggrieve the child’s family, but on the substantially more important second hand; preservation of the child’s health is the paramount enterprise. The Children’s Act 1989 also encourages people assuming care of children to affirm the child’s comprehension and appreciate their viewpoint.

Above all, personal reluctance must be usurped when evidence of abuse arises and we should always consult with medical seniority in these situations.

“We are all responsible for his death,” said David Cameron concerning the conclusion of Daniel’s case. More than most, medical staff need to have the propensity to question children’s safety. Developments such as the £8.6 million scheme to cross reference incidences of children coming to A & E with a national database could supply more efficacious means to identify possible wrongdoing in future. For now though, medical students should be taught the crucial differences between everyday maladies of childhood and the signposts associated with abuse, and with vigilance we can do our part in preventing child abuse.

The GMC, along with most PCTs, have however, composed comprehensive frameworks for the instruction of medical professionals. ‘0 -18: guidance for all doctors’ by the GMC, demarcates the considerations concerning possible child abuse. It highlights how medical staff, and by juxtaposition medical students, should have the necessary training in recognition and handling of abuse.

Firstly, multiple injuries or repeated afflictions to children should always be sourced from both patient and carers, and any discrepancies identified diligently. Not only that, but the child’s overall disposition and health ought to Oliver Smith

A Cure for Blindness Two steps forward and one step back

Degenerative retinal conditions are one of the leading causes of irreversible blindness in the developed world. These conditions will inevitably afflict increasing numbers of the ageing population over the next several decades causing a frustrating process of slow deterioration as the ability to read, drive or even recognise a face is gradually lost. Tragically these degenerative visual conditions will rob many sufferers of the potential enjoyment to be had from the increased life span that the majority of us can now expect. Whilst the idea of a cure for blindness still seems an almost biblical proposition, a new study published this July in the journal Nature Biotechnology suggests that retinal replacement therapy could be only five years away from clinical trials.

The field of regenerative medicine promises us a bright future and this latest leap forward like so many others is buoyed rather unsurprisingly by stem cells.

The idea of using stem cells for generating new photoreceptors to treat retinal degeneration is nothing new and has been an area of considerable interest over the course of the last decade. Previously however, the use of stem cells in retinal replacement has been hampered by considerable technical problems. Embryonic stem cells transplanted into the adult retina demonstrate only a very limited capacity for differentiation into the required photoreceptor cell types.

Therefore potential donor cells had to be harvested at a much later precursor stage, which unfortunately severely reduced the likelihood of successful transplantation.

This latest study carried out by the team at University College London and led by Professor Robin Ali, utilised a ground breaking technique developed in 2011 by a team at the Riken centre for developmental Biology in Kobe, Japan. This technique allowed the production of 3D cellular structures which mimicked the normal

development of the embryonic retinal tissues of mice. This generated correctly differentiated populations of retinal photoreceptors at an appropriate stage of development, which subsequently had a much greater chance of successful integration with existing retinal tissues in the adult mouse.

Unfortunately generating the cells themselves is only part of the problem, you also then have to get them to connect with the existing retinal synaptic circuitry. This next problem has proven to be a further challenge as this latest study demonstrates. The transplantation of approximately 200,000 stem cell derived photoreceptor precursors in to the adult mouse retina resulted in only 0.3% achieving successful retinal integration. Earlier work carried out by the same team at University College London indicated that reliable electrical responses in the retina required the restored function of at least 150,000 photoreceptor cells.

Improving the number of photoreceptor precursors capable of successful retinal integration is undeniably a hugely complex problem.

The development of the techniques that will allow the manipulation of the numerous growth factors necessary for normal photoreceptor development will require considerable improvements in our understanding of the molecular biology of eye development. In reality whilst human trials maybe only a few years away, it seems unlikely that we can expect degenerative retinal conditions to achieve the same readily treatable status as cataracts any time soon.

Alex Granger

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A right to die

Features

On the 31 July 2013, the Court of Appeal upheld a ruling by the High Court that only Parliament, not individual judges, should be able to decide whether the law on assisted dying should be changed.

The decision was made as part of a series of high profile cases that has kept the subject of assisted dying squarely in the public domain. These include the cases of Tony Nicklinson, who was paralysed from the neck down after a stroke in 2005 and fought a long High Court battle to try to win the right to end his own life, and Paul Lamb, a 58 year old man similarly paralysed after an accident in 1990.

After losing his case in 2012, Nicklinson refused food and treatment for pneumonia and died a week later aged 58. His widow, Jane Nicklinson continued his case with Paul Lamb, winning a battle to appeal the original ruling in the High Court.

But their appeal was rejected, and the Court of Appeal judgement confirms a long held view that it remains the responsibility of Parliament, not judges, to determine the ‘conscience of the nation’ on the issue of assisted dying. But what is the conscience of the nation, and should a particular group's opinions be taken especially into account if new legislation were to be created?

Recent studies have shown that prevailing public opinion is supportive of assisted dying in cases of terminal illness and severe suffering, or loss of independence. A review by Hendry et al. in August 2013 showed that whilst patients and members of the public acknowledged that the fear of suffering and pain could be a motivating factor in the desire for assisted dying, and that good palliative care with adequate pain relief could alleviate that suffering, factors such as loss of physical function and inability to perform activities of daily living constituted acceptable reasons not to go on with life. In addition, many patients expressed a desire for the right to choose, and for autonomy regarding the manner of death.

Tony Nicklinson (above) and Paul Lamb (below) , both contested their right to die.

McCormack et al in 2011 found that most doctors opposed the introduction of legislation to allow AVE or PAS. Despite these objections, there does appear to be growing support amongst patients and the public for the provision of some form of legal protection, or at the least clarification of existing guidelines, for those people who intend to assist terminally ill patients to die, be they close family or a healthcare practitioner. Exactly what form any sort of legal protection will take, and how long it will take to be agreed upon and implemented, remains to be seen.

However, most UK doctors remain opposed to the idea of assisted dying either in the form of physician assisted suicide (PAS), where a patient is provided with the means to end their life by self administration, or active, voluntary euthanasia (AVE), where a patient’s life is ended by a doctor at that patient’s voluntary and competent Michael Hutchinson request.

A review by

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Housemates from Hell

How to avoid being that person With the start of every new university year it’s all excitement and fanfare-.

Last year’s forgotten woes, the enchantment of Freshers’ week and the end of summer magically masks all previous stresses as everyone settles in for another year.

However, snack thievery and midmorning wake-up calls will all make a comeback, and despite our best efforts no amount of preparation can ease the surprises of living together with new housemates at university.

Let’s take a look at how it all started…

It’s during first year that the pressure of having housemates begins. Within 3 months of being at university colleagues are already on the hunt for next year’s accommodation. There’s an ever-present fear that the ‘best’ accommodation will slip away, and so a race to find the best house begins even before the Christmas holidays.

Snippets of “where are you living next year?” can be heard around campuseven small talk topics turn from your degree, to your address. Who you are living with is another real concern, and as it approaches exam season the pressure mounts. Though it is true Could man-flu be real? that, as the year goes on, the

availability of good housing decreases, Nottingham has plenty of decent housing. Everyone has different needs and priorities and adding pressure to the already present exam-stress is unnecessary.

On the other hand, housemates are one of the defining factors of accommodation as great ones can make even the shabbiest of places look classy. However, finding the right ones is no easy task. Everyone has different ways of finding their fellow house companions. Whether living with people from halls, degree courses or societies, the list is endless. Big groups of people split up and small groups have to find people to fill in the gaps, meaning that often the resulting group is an unexpected mix. However, with ever-shrinking student budgets and the presence of housemates allowing living costs to be split, taking the risk still seems like a welcome benefit. As of 2012 70% of students live on campus, yet house sharing is easily a cheaper and more studentfriendly option as on-campus accommodation alone costs £200-270 per week on average.

From anti-gravitating your room and hording all the dirty dishes to waking you up for an important seminar and supervising your revision, housemates are both frustrating and supportive. It’s rare to encounter people who have absolutely detested their house sharing experiences, although in the beginning there can be a bit of a scuffle. Sorting out household bills, rent, broadband and maybe even indulging in a TV license can all become a spark to ignite the hellish experience that housemates can provide. Stingy heating bills may be aggravating, but even having to use a blanket instead of the heater can be less troublesome than overly organized chore schedules pinned up on the fridge. House maintenance problems are unavoidable, and can often be blamed on different individual habits with pranks often being blamed on this too.

That being said, good housemates can become your closest friends. From ‘Pictionary’ to experimental cooking, there are many moments that can be cherished: The ‘Friends’ cliché of writing messages on the bathroom mirror are a reality for some, while others indulge in post-coursework deadline muffins. All in all, living in a shared house at university is an experience not to be missed.

Henna Shiwani

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Features

Angelina’s Choice Earlier this year Angelina Jolie, one of Hollywood’s leading ladies, shockingly revealed she’d undergone a drastic double mastectomy. The decision, Jolie insists, “was not easy” but it was the knowledge that she carried a mutation in the BRCA1 gene that catalysed her into action. Her doctors predicted that her risk of developing breast cancer was 87% and ovarian cancer, 50%. It has sparked furious debate about both the ethics of genetic testing and that of undergoing radical treatment for a disease that may not even develop.

For those of you that don’t know, BRCA1 and BRCA2 genes are involved in tumour suppression, stabilising cellular DNA and preventing uncontrollable cell growth. Mutations in both genes predispose the individual to breast and

ovarian cancers as well as cervical, uterine, pancreatic and colon cancers.

Men are also affected, with testicular and prostate cancers linked.

Normal lifetime risk of breast cancer is 12%; with one of the BRCA mutations this risk is increased five fold.

Similarly normal lifetime ovarian cancer risk is 1.4% but carriage of BRCA1 or BRCA2 magnifies this to between 15 and 40%. The chances of developing one of these cancers is highest in families with numerous breast cancer cases, having different members with breast and ovarian cancer, as well as more than one individual having two primary cancers. There is also a higher prevalence in central and eastern Europeans with Ashkenazi Jewish decent.

Although these mutations only represent a small percentage of breast cancer cases (estimated

between 5-10%) their presence has devastating effects across generations of families. Jolie laments “my mother fought cancer for almost a decade and died at 56”. This was not a fate she wanted for herself, “I decided to be proactive and minimise the risks as much as I could”. Jolie describes waking up after the surgery, as being “like a scene out of a science fiction film” but despite this, she was back to normal life days after.

Sadly, just weeks after Jolie finished the last stage of procedures, her aunt lost her battle with breast cancer. This reaffirmed her belief she had made the right the choice. She also insists that she does “not feel any less of a woman”; she is “empowered” and doesn’t consider her femininity in any shape or form to be affected.

Jolie implores any woman who has a strong family history of either breast or ovarian cancer to access all information and support available from healthcare professionals. In this way they can explore all their options and make informed decisions about preventive treatment, which can be anything from frequent screening to risk avoidance and chemoprevention.

Although Jolie’s treatment process took almost three months, she remains adamant it was a choice she was “very happy” she made. Her breast cancer risk has now dramatically fallen to 5%, less than half of most women’s lifetime risk.

She can now live safe in the knowledge that she has done everything in her power to stave off the disease that prematurely ended her mother and aunt’s lives.

Sophie Jackson

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Health Benefits of Olive Oil Is it the super-food that is portrayed in the media?

According to Google search there are 119 kilocalories in a tablespoon (14g) of olive oil. There are 14g of fat in a 14g tablespoon of olive oil. There are 1.9g of saturated fat and a second website suggests that there can be up to 1.6mg of vitamin E in olives, but it never quite states that this makes it into the olive oil itself. The point that I’m trying to make is that olive oil is essentially and completely ‘fat’.

There are a lot of stories in the media about the healthiness of a Mediterranean diet which is defined by webster as; “a diet… that consists mainly of cereals, grains, vegetables, beans, fruits, and nuts… moderate amounts of fish, cheese, olive oil, and wine and little red meat”.

Olive oil is listed there and in many other places if you search for the term Mediterranean diet. Olive oil is thus seen as

Mediterranean. However as one scientist at the healthy living expo 2007 put it “people seem to think…If I put olive oil on my burger then it’s Mediterranean, right?”’

In the hope that olive oil was the new scavenger of oxidants that crusade to cancerify our bodies, Dr. Robert Vogel and colleagues in the year 2000 published a paper on the effects of olive oil on what he called FMD (Flow mediated vasodilation) of the brachial artery before and after a meal with three different fats, olive oil with unprocessed brown bread, canola oil with unprocessed brown bread and salmon with crackers. They hypothesised that olive oil would have no effect or per chance that it would have a beneficial effect on the arteries of the ten volunteers. It turns out that olive performed the worst when compared with both canola oil and salmon, causing a 31% reduction in vasodilation in the brachial artery when compared with salmon, which had no effect on vasodilation 3 hours after a meal. This study was completed over 6 hours in the postprandial period where olive oil had its peak effect at

four hours. The implications on circulatory health seem to give a counter argument to the heart healthy badge that olive oil proudly wears.

The small sample size of this study obviously means that it is limited in its ability to apply to the general public, but it gives a good idea that there are always two sides to a coin.

In the medical community we use olive oil to loosen wax as a more natural safe way of cleaning out our ear canals. Other interesting research avenues include: Memory and cognition Alzheimer’s disease Reducing Coronary heart disease Hair Loss I suppose in terms of the food we eat, it might depend what we put our olive oil on that makes it healthy or ‘Mediterranean’.

Daniel O’Sullivan

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The psychopath test Arts and Culture

By Jon Ronson

Book Review The ‘Psychopath Test’ is a light hearted journalistic account following Jon Ronson’s exploration into the world of psychopathy. Guided by an influential psychiatrist, Ronson jet-sets the globe challenging himself to identify psychopathic tendencies in people from tell-tale signs and clues. On Ronson’s travels interviewing prolific psychopaths, heartless business moguls and industry advancing psychiatrists, questions are raised as to where the line can be drawn between a personality disorder and a quirky personality.

The ‘Psychopath Test’ entertains and informs, drawing in the reader with fascinating insight of life through the mind of a psychopath.

David Thomas

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Xbox ONE vs PS4 In the gaming world there is no bigger event than the release of a major games console, let alone the release of the 2 largest companies’ flagship models. Announced in February and May of last year respectively, the PS4 and Xbox ONE are were released this Christmas and were expected to sell out, following the success of their predecessors the PS3 and Xbox 360.

systems except the price tag, placing the Xbox ONE at £80 dearer. Given the Xbox ONE’s controversial DRM policy restricting customers from trading in and buying used games, it has some ground to cover to reclaim some of its Japanese rival’s popularity. With specifications close enough to practically mean little by way of comparing the two, the exclusive games offered will ultimately Like all students on a tight budget, if determine the success of either you’re going to be able to afford either, console, as well as gamers favourite its only going to be the one, so which current-generation consoles. one do you invest your sacred student loan in?

Among Xbox ONE’s arsenal is the mighty ‘Titanfall’, a man vs. machine As visible in the accompanying table, epic brought to you by the creators of there is little to differentiate the 2

Call of Duty: Modern Duty 4, promising breath-taking action sequences.

Combatting ‘Titanfall’ is the PS4’s ‘The Order: 1886’, an adventure venturing back in time to an alternate reality of Victorian London, in which historical figures aid your quest to conquer the supernatural enemies haunting the capital.

With plenty of other games confirmed to whet the pallet of gamers from all demographics, both consoles will deliver on the entertainment promised and are worth your money if you can spare a few hundred squid.

David Thomas

Cost

£349

£429

CPU

8-core x86-64 AMD

8-core custom AMD

Graphics

1.84 TFLOPS AMD Radeon

1.23 TFLOPS AMD Radeon

Memory

8GB GDDR5

8GB DDR3

Hard Drive

500 GB HDD (upgradeable)

500 GB HDD (non-removeable)

Hardware included

Dualshock 4 controller + Headset

Xbox ONE controller + Kinect

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Arts and Culture

MEdical

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App-titude

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Arts and Culture

Films of

Bored of Bopp? Feeling too old for Ocean? Put on a film this Friday night instead! To help you pick, here’s a rundown of the best – and the worst – films so far this year.

Django Unchained Quentin Tarantino’s spaghetti western follows Django, a freed slave who teams up with a bounty hunter to rescue his wife from an evil plantation owner. Django Unchained has everything you have come to expect from a Tarantino film- wonderfully written dialogue, gratuitous violence, a ridiculously high body count (64 apparently) and of course, Samuel L. Jackson being exactly what it says on his wallet. Plus, if you find Tarantino himself insufferable, you’ll enjoy the part with the dynamite.

WORTH STAYING IN FOR

Star Trek Into Darkness I’m not sure I need to say anything more than ‘Benedict Cumberbatch’ here, but I guess I will anyway. The second film in a reboot of the original series, this blockbuster sees the crew of the Enterprise on the hunt for a former Starfleet member out to destroy his old organisation. It is packed full of exhilarating action sequences and impressive CGI, plus the cast are more than capable of taking on the iconic roles of Kirk, Spock and co. Trekkies will either love it or hate it, but for the masses it is a thoroughly enjoyable adventure.

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2013 A Good Day to Die Hard As opposed to the Scary Movies the Die Hard films have, up until now, formed an entertaining and respectable franchise. In this fifth instalment John McClane (Willis) travels to Russia to help his son, who has been arrested on assassination charges.

As usual McClane’s trip does not run smoothly, and the reluctant hero finds himself up against the Russian underworld. Whilst this formula has worked so well up until now this time around the plot is bland, the dialogue is cringe worthy and the villains have nothing on Hans Gruber. If you are a diehard (sorry) fan of the previous films you might want to pretend this one never happened.

Ones to avoid Scary Movie 5 The latest (and hopefully last) instalment in this completely unnecessary franchise, Scary Movie 5 parodies a number of films which do not deserve to be associated with such a train wreck – including Paranormal Activity, Black Swan and Cabin in the Woods. A couple try to lift the curse on their house, Charlie Sheen and Lindsay Lohan try (and fail) to revive their careers and Snoop Dogg/Lion is there for some reason. It is very terrible.

After Earth One thousand years after Earth has been evacuated, Cypher and his son Kitai (played by Will Smith and his real-life son Jaden) crash land back on the now-quarantined planet.

With his father injured Kitai must travel alone to find their only hope of survival – a rescue beacon. It is an interesting premise, but the bad acting and monotonous script make for a tedious 100 minutes. There aren’t even any of director M. Night Shyamalan’s signature twists which, though usually ridiculous, might have at least spiced things up for a bit.

(Dis)honourable mentions: The Host, Movie 43, Texas Chainsaw 3D

Before Midnight Before Midnight is the third film in the Before trilogy, a series of indie romantic dramas starring Ethan Hawke and Julie Delpy. Eighteen years after their first fateful meeting, Jesse and Céline are now a couple and parents to twin girls, but love still isn’t easy for the pair. This film offers an intelligent and emotional insight into long-term relationships, after the initial excitement and passion has long since subsided. Set against a beautiful Greek backdrop, it is hard to imagine a more perfect – or more genuine – love story.

Honourable mentions: Stoker, The Bling Ring, Monsters University Katie Jeffs

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Essential Lecture Handouts

“What did you think of the U + E results?”

Unfathomable + Exasperating?

As a medical student in your clinical years and as a junior doctor you will probably see many patients undergoing a U+E (Urea and Electrolyte) investigation. This is the most commonly requested investigation in biochemistry.

would be that medications are common culprits for electrolyte disturbances. So always check which drugs a patient is taking!

If the thought of interpreting U+E test results leaves you looking like the picture above right then we Usually, the test involves the suggest this stepwise approach. measurement of plasma sodium, 1) Is one component more potassium, urea and creatinine. If significantly affected? OR there is one principle that you 2) Are multiple components should definitely bear in mind significantly affected? regarding U+E interpretation, it

What if one component is significantly affected?

Normal Ranges Sodium

135—145 mmol/l

Potassium

3.5—5.0 mmol/l

Urea

2.5—6.7 mmol/l

Creatinine

70-150 μmol/l

cause st isolated e g ig b is e h ia—T n, but it ernatraem ia is salt ingestio p y H Sodium (135-145 mmol/l) atraem of hypern rare. aemia in extremely f hypernatr cause o Hyponatraemia e s u a c on lso —Isolated low sodium is often The most comm tion, but this will a due to too muc ra d y h water rather h than too little general, is de sodium. Howev er drugs are urea. another very an increase in common cause.  Drugs – Drugs that cause an isolated decrease in sodium includ e TCA’s, SSRI’s, anticon Urea (2.5-6.7mmol/ vulsants and lit hium. Be aware that man y drugs affect d to potassium alongside sodium change compare e ut . ac an is e Check if ther  Dilutional –Ofte ual change. n due to SIAD lts or if it is a grad su re us io ev pr H secondary to ca the (often sodium levels, ncer) and fluid s ct fe af so al overload from conditions ea is As dehydration like severe hear ated raised ur ol is an t failure, cirrhosis, nephro of e tic syndrome. It biggest caus ad such could also be from water eased protein lo cr in an to e du intoxication (drin generally king too much water) something often as a GI bleed. seen in schizophrenic pa tients.

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Hyperkalaemia—The most common causes of isolated increase in potassium are artefactual in nature. However it is important to note, that acute hyperkalaemia is very dangerous and knowledge of its immediate management is essential.

Artefactual causes include: 

Haemolysis –often due to drawing blood through a small bore cannula or through particularly traumatic venepuncture



Other artefactual causes –samples not being used quickly enough or even stored in the fridge can lead to potassium leaking from the cells and a resultant hyperkalaemia. Also beware of EDTA contamination.

WHAT IF MULTIPLE COMPONENTS ARE INVOLVED? Given below are some of the usual presentations of some common /well known conditions (that examiners love). Remember though, that in these scenarios and often in exams, you only have one U+E reading but in real life you will have previous readings and the clinical context, to help in diagnosis.

Dehydration The most common cause of hypernatremia is loss of water due to dehydration. A rise in urea alongside sodium helps with the diagnosis.

Na ↑↑ K—Usually normal Urea ↑↑ Cr—Usually normal

Potassium (3.5-5.0mmol/l)

Hypokala isolated caus emia—The e of low pota ssium is drugs, then investigation s are looking at potassium lo ss from kidneys. 

Drugs- certa in drugs suc h as salbuta laxatives (c mol, hronic abus e ), insulin a nifedipine ca nd n cause hypo kalaemia.  Type 1 an d Type 2 Re acidosis - b oth can cause nal tubular hypokalaemia  GI losses .

- cause dir ect losses potassium w of hich subseq uently result in Drugs Affecting Potassium

Potassium sparing diuretics and ACEi are a big cause of hyperkalaemia but also can cause hyponatraemia (K↑ Na↓).

Thiazide and loop diuretics are major causes of hypokalaemia but again can also cause hyponatraemia (K↓ Na↑).

Kidney Disease (Acute/Chronic)

Urea and Cr stay the same in both cases.

Na—Usually normal but can be low in CKD.

Addison’s Disease

Conn’s syndrome is an aldosterone producing adenoma that leads to increased blood pressure due to sodium reabsorption back into the blood

Addison’s disease is a result of decreased production of aldosterone and cortisol by the adrenal glands.

Na ↑ (but can be normal)

K ↑

K↓

Urea ↑↑

Urea—Usually normal

Cr—Usually normal

Na ↓↓

Above: Skin turgor as in dehydration

K ↑↑

Conn’s Syndrome

Cr—Usually normal

commonest drugs. If not directed at the gut or

Urea ↑↑↑ Cr ↑↑↑ From U+E’s alone, it can be difficult to differentiate between these, but often CKD presents with anaemia as well as a smaller kidney size.

Serial readings of the eGFR and urea will give a timeframe and help distinguish between these.

Sushant Saluja, MedSoc teaching

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Essential Lecture Handouts

Student cook-off

We challenged two self-confessed foodies to go head to head and try to out-cook each other on a student budget.

The catch? Their recipe had to feature a seasonal ingredient; in this case, the humble butternut squash, a vegetable often seen languishing in the aisles of Sainsbury’s not knowing what do to with itself other than be roasted.

So here are the recipes put forwards by our culinary medics. Let us know which one you preferred.

Bon appetit!

George’s Squash Pasta This is one of my favorite pasta dishes and the ingredients are very autumnal and Tuscan. I think the squash and pumpkin family are my favourite vegetable. For this dish you want something sweet or not too stringy, such as a butternut squash. You can adapt this recipe however you like, cooking it quicker or missing out a few ingredients. I have included a few optional extras which will make this dish that bit more luxurious if you are cooking it for someone special.

Ingredients 75-100g spaghetti or linguine 1/2 small red onion A pinch of crumbled dried chili or chili flakes A pinch of fennel seeds A small handful of pancetta lardons, or a chopped rasher of smoked streaky bacon A small handful of peeled and chopped squash or pumpkin 25ml fresh cream - single, double or crème fraîche (whatever you have) A small handful of spinach or whatever greens you have Extra virgin olive oil Salt & pepper Optional Pine nuts Parmesan or other cheese Sage

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Slice the red onion with the grain so you end up with nice long slices of onion and slowly fry it in the olive oil on nearly the lowest heat. You want it to go really soft and sweet but not brown - this usually takes about 15 minutes. You can of course fry the onion quicker if you’re short on time, but the taste wont be as good.

Meanwhile chop your peeled squash into small 12cm chunks. Once the onion is nearly soft turn the heat up and add the fennel seeds, dried chilli and the pancetta and fry for 2 minutes. Now add the chopped squash and turn the heat back down again. Cover the pan and leave for 20 minutes stirring occasionally.

With 10 minutes to go, add your spaghetti to plenty of salted boiling water and cook according to the packet instructions. Once the squash is done, add the spinach and let it wilt for a minute before stirring in the cream. Then drain the pasta and stir into the sauce. Check the seasoning the bacon might mean you don’t need to add any salt, but black pepper is always nice.

For a real treat, sprinkle the dish with a few pine nuts and some grated parmesan. You could serve with some of pumpkins best friend - sage.

Just fry a few leaves in olive oil until crisp and serve on top.

Alison’s Butternut Squash Ravioli with Sage Butter Vegetarian but surprisingly alright?? Looks poncey but isn’t that hard if you don’t want to arse around making the fresh pasta. Enjoy.

Ingredients 250g butternut squash

£1.3

5

3tbsp olive oil 25g finely grated parmesan Freshly grated nutmeg to taste 250g fresh egg lasagne sheets (for fresh pasta 200g ‘00’ grade flour and 2 eggs) 70g salted butter Handful fresh sage leaves Salt Freshly ground black pepper Cut the butternut squash into rough chunks, drizzle with olive oil, season and bake in a 180 degree oven for 30 minutes or until tender.

Blend until a smooth puree in a food processor.

Leave the mixture to cool for 20 minutes and then add the cheese and nutmeg. Season to taste and then allow to completely cool.

Roll out your fresh pasta dough or alternatively place your pasta sheets on a lightly floured surface.

Place a heaped teaspoon of the filling onto the pasta making sure they are a reasonable distance apart.

Place another pasta sheet on top and carefully press the moistened pasta around the filling ensuring to remove all air.

For the sage butter fry the sage leaves in butter until they are crisp. Add olive oil if the butter is burning but a ‘nut brown’ colour is what you’re looking for.

To cook the ravioli place it in boiling salted water for 4-5mins.

Drizzle the butter over the top and add more cheese if you like Insert it into your face.

I’ve yet to meet a fellow foodie who knows the difference between a squash and a pumpkin. A butternut squash tastes similar to a crown prince pumpkin, but nothing like the more watery acorn squash. There is no logic to the nomenclature.

Many people think pumpkin is a bit of weird food, but they don’t realise it is the same vegetable as is in the butternut squash ravioli they bought from Tesco the day before! Squashes come into season in September and continue being harvested up until just before Christmas.

There are hundreds of different varieties most of which grow brilliantly in the British climate.

There is one exception, and that is the butternut squash which really needs to be grow somewhere a little bit warmer. I struggle to understand why this has become the most well known squash, yet is the only one we don’t grow in Britain. You will find numerous varieties in a good greengrocers or large supermarket, but perhaps the finest is the Crown Prince pumpkin.

A distinctive duck egg blue skin hides a sweet orange flesh, that is similar to a butternut squash but in most peoples opinion is better. Acorn squashes are smaller, about the size of your palm, and are a little but watery and a yellow colour. Their size and loose texture means they absorb flavours well and are an excellent choice for a stuffed squash. The Turks Turban squash has to be one of the prettiest and strangest looking vegetables you will see, however I can assure you the flesh is vile!

Squashes will keep in a dark cupboard for several months without going off or losing any quality. A cut open squash will also keep for over a week in the fridge if the cut face is covered with tin foil/cling film. That is why I suggest at the start of this autumn you do what I always do, and buy a ‘squash box’ from Riverford Organics (www.riverford.co.uk).

Although not online at the current time of writing, last year they offered a box containing several kilograms of different varieties of squash for £6-7 (free delivery). The squashes are homegrown and organic, and the box contains some advice on how to use each one. I found the box lasted me through till January, eating squash nearly once a week.

George Hulston

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Essential Lecture Handouts

Case Study: cyclist down You are a doctor working in A&E on a busy Friday afternoon. A 21 year old student is brought in by ambulance, together with his friend. The friend describes how they were cycling from the local university a few hours previously. The patient did not notice a large pothole in the road, and fell off his bike and onto the road, the left side of his head hitting the kerb. He initially complained of having a severe headache.

[Q1. What are the differential diagnoses for a malignant headache?]

However, this seemed to resolve after a minute and got back onto his bike and cycled home.

As he sat down at home, he became increasingly drowsy, and after 40 minutes he became fully unconscious. The patient has no [Q2. What would be your immediate management plan for this patient?]

On initial examination, the patient’s breathing is rapid and shallow, and it has become apparent that it is necessary to intubate him. His pulse is 55 beats per minute and his temperature is 36˚C. A CT scan of the head was ordered, and the patient is provisionally diagnosed as having a suspected intra-cranial haemorrhage.

The patient is given high-flow oxygen, and IV access is also gained. A 500ml bolus saline infusion is subsequently administered over 10 minutes. You decide to order the following blood tests: 

FBC.



U&E. [Q4. Explain why each of these actions have been taken.]

The CT scan results arrive after 25 minutes.

A section is shown below:

[Q3. Describe the different types of intra-cranial haemorrhages (ICH).]

[Q5. What does this section of the CT scan shows?]

[Q6. What would you do in the longterm management of this patient?]

Answers on page 47. Ajay Jumbu 46

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| 47 answers are more likely to occur in the elderly. Acute SDHs are generally caused by acceleration-deceleration injury [Q1] Malignant headaches (a severe, potentially disabling headache of clinical significance) generally have one of four Intra-cerebral haemorrhages tend to present similarly to SAHs, but symptoms are variable depending on the area causes: affected.

Malignancy Extradural haemorrhages (EDH) are usually caused by Haemorrhage damage to the middle meningeal artery. It tends to present Ischaemia as described in this case study: with a headache; but Infection crucially, this is followed by period of recovery which can last Malignancy can cause severe headache and should always from minutes to hours, where the headache appears to be a differential, particularly in younger children or patients resolve. This is also known as a lucid interval. Eventually, over 50 years old. However, malignancy is unlikely to result further symptoms do become apparent. Other symptoms in such an acute history. include seizures, symptoms of hemiparesis, and an It can often be challenging to distinguish between an ipsilateral dilated pupil (due to compression of CN III). ischaemic and haemorrhagic stroke, but the patient history [Q4] The way in which the scenario has progressed thus far and relevant risk factors can help point you to identify the suggests that this patient is in shock. It is necessary to likely cause. It is imperative that you ask for a CT scan prior administer both high-flow oxygen and IV saline in order to to treatment if there is even a slight suspicion of a maintain tissue perfusion. A bolus injection has been haemorrhagic stroke. Bear in mind that as this is a trauma administered as if the patient has concurrent heart failure, a case, there may also be a co-existing spinal injury; therefore full infusion could make the patient worse (although this is care should be taken when handling the patient. unlikely given the patient’s age). FBC has been ordered to Common infections include meningitis and encephalitis. check for anaemia, whilst U&E has been ordered to monitor Meningitis tends to be associated with the symptoms of renal function. Whilst these investigations are relatively meningism, and sometimes a purpuric rash; whilst useful basic tests, bear in mind that the priority is to obtain a encephalitis is associated with fever, drowsiness and more CT scan, and these investigations should only be carried out focal symptoms. CSF/blood samples, as well as a detailed whilst waiting for this scan. Cross matching is a useful test, history may be important in order to reach a diagnosis, particularly if the patient is in urgent need of blood. though a lumbar puncture may be contra-indicated in cases Remember that type-specific blood can usually be provided of high intra-cranial pressure. in 10-15 minutes; if there is an immediate need for blood, administer 2 litres of O –ve blood to allow for time for the cross-match results.

[Q2] As with all acute emergencies, it is imperative to use a DRS ABC approach. The important points regarding this [Q5] This CT scan shows a grey, convex, lentiform-shaped collection (of blood) in the temproparietal region, adjacent to particular case have been outlined below: the skull. Notice how the falx cerebri has been shifted to the right, indicating an early midline shift. This is typical of an EDH caused by damage to the middle meningeal artery.

Close monitoring of all vital signs.

Intubation and ventilation if necessary.

Monitor fluids and electrolytes, giving IV fluids if necessary.

Measurement of intra-cranial pressure, using osmotic diuretics such as IV mannitol as required.

Perform a full trauma assessment to check for other injuries.

Usually no other tests are required to make a diagnosis. It is important to note that lumbar puncture is contra-indicated in this setting (due to the risk of brainstem coning [herniation]).

More detailed information detailing the criteria for ordering a [Q3] There are four main types of ICH: here: found be can scan CT Subarachnoid haemorrhages (SAH) tend to result in heavy http://www.patient.co.uk/doctor/CT-Head-Scanningsymptoms Indications.htm This section may need to be removed if acute very therefore and bleeding, e.g.’thunderclap’ occipital pain, nausea and vomiting. SAHs there is not enough room. are more likely to be as a result of a berry aneurism, as [Q6] The condition is considered to be potentially opposed to trauma. salvageable if there is less than a 4 hour delay from the Subdural haemorrhages (SDH) usually have a more injury to neurosurgical intervention. Neurosurgery is often insidious onset, with progressive symptoms of headache, the treatment of choice and involves clot evacuation (making nausea, vomiting and other neurological symptoms. SDHs burr holes if necessary) and ligation of the bleeding vessel.

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