Sphygmo 08/09 | Issue 2 | January by Media MMSA

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PHYGMO 2008 - 09

issue 2

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EDITORIAL

On Christmas Sp irit and Other A lcoholic Drinks For some people, Christmas is the festivity marking and honouring the birth of Jesus Christ. It is a time where believers rejoice over the fulfilled prophecy of a much awaited Saviour as promised in Isaiah 9: 6, together with so many other Biblical passages starting from Genesis 3: 15. For others, Christmas is merely an exuberant display of human ingenuity, capitalist productivity, and the enjoyment of life. Then you get the cynical few who see Christmas as being that weird time of the year where families gather around plastic trees, eat sweets out of old socks and indulge on goodies leftover by Santa during the ―night before Christmas‖ rounds. Yet, whatever our beliefs or walks of life, be it Christmas or Hanukkah, the majority of us do find a reason to celebrate the season. And most of our holiday spirit would, perhaps inevitably, contain a rather hefty dose of alcohol. After all, alcohol is quite a good social lubricant for the many social gatherings that come along with Christmas time. It‘s not the purpose of this editorial to drearily preach to you on alcohol being a dependence forming drug that comes with immediate and late consequences like: upper GI problems, cirrhosis, neurological problems and, possibly, even Wernicke-Korsakoff‘s syndrome. However, Christmas is also that time of year when drinking and driving does deserve special attention. It is well known that driving under the influence of alcohol increases the risk of road traffic accidents, with 16,005 people being killed in the US in alcoholrelated road traffic accidents back in 2006. According to an article written by Manuel Mangani (Service Manager, Alcohol Services, Sedqa), there was a time when car accidents would have claimed the lives of at least one person, (often more) every year at Christmas-time.

Admittedly, this mainly occurred before the introduction of the breathalyzer-test in 1998. Yet, the possibility of alcohol-related accident fatalities still remains. And the more you don‘t keep those units in check, the higher the chances of it happening to you. In fact, all this editorial wants to drive home is this… Whatever you do, please don‘t be part of these statistics. Abstaining from alcohol will most definitely help. But I know most of you are cringing at the thought of abstaining from the merriment that comes with having a drink or two. So, here‘s something from my forensic medicine notes that may prove useful: ―The law regarding drinking and driving sets the limit of alcohol as follows:  35μg of alcohol /100ml of breath  80mg of alcohol /100ml of blood  107mg of alcohol /100ml of urine The police can stop a driver on suspicion of driving or attempting to drive under the influence of alcohol - no spot checks - and carry out a breath test on the roadside.‖ But don‘t worry… No spot checks!

Marquita __________________________________________________ 1 ―For

to us a child is born, to us a son is given, and the government will be on his shoulders. And he will be called Wonderful Counsellor, Mighty God, Everlasting Father, Prince of Peace.‖ (Isaiah 9: 6) 2 ―And I will put enmity between you and the woman, and between your offspring and hers; he will crush your head, and you will strike his heel.‖ (Genesis 3: 15) 3 Drinking to your Health at Christmas http:// www.sedqa.gov.mt/pdf/information/alcohol_xmas07.pdf

The Sphygmo Team Media Officer: Claire Vella Editor: Marquita Camilleri Article Co-ordinator: Stephanie Azzopardi Layout and Design: Anne Marie Bonnici Mallia Thank you to all those who have contributed to this edition of Sphygmo

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MMSA DIARIES As you might have heard (!), MMSA took Valletta by storm during the first ever HealthFest, a celebration of health in City Gate with participation of most of our subcommittees. Be sure to check out our report somewhere on Sphygmo! However, besides all that, this has been a busy month indeed – and here‘s what we were doing! SCOPH SCOPH descended on University on the 9th and 10th December to hold one of the most successful blood drives ever. A successful TBH took place on the 2 nd December at Siġġiewi primary school. There was also the annual SCOPH lottery with proceeds going to buying Christmas presents for paediatric patients at MDH. Next up – SCOPH decides what to do with the cigarettes collected at the HealthFest, and the result is sure to be entertaining! SCOME SCOME has launched its anonymous Suggestion Box, accessible on the MMSA website! If you feel that there is room for change anywhere in the course, do drop SCOME a line – you never know what we may achieve! A meeting with Prof. Gary Hunter was also held, with the intent of discussing possible changes in Physiology and Biochemistry teaching and exams. SCOME also collaborated with the Malta Emergency Nurses‘ Association to enable medical student attendance at the Trauma Training Camp from the 17th–19th December. Look out for updates on the all-important Careers‘ Convention, which will be held in February 2009! Media Media is working very hard on this Spring‘s Murmur, and you can see for yourself the fruit of the Sphygmo team‘s labour!

SCORA The SCORA-angels can now rest easy after a fantastic World AIDS Week! The Candle Vigil and Piazza Café‘ drew large crowds, and the outreaches at Valletta, Sliema and Gzira helped raise awareness about STIs and their devastating effects. The week culminated with the Unplugged and Exposed concert in the KSU Common Room on the 7th December – a showcase of music and drama with a meaningful message. Well done SCORA! SCORP Human Rights week has come and gone! This year marked the return of the Ethics seminars held on the 10th December for preclinical students, which were received very well. Guest speakers included Dr. Pierre Schembri Wismayer, Dr. Isabel Stabile, Dr. Pierre Mallia, Father Emanuel Agius, and Dr. Chris Rizzo. There was also a 3-day Peace Test project held at St. Aloysius‘ College and a talk on the 11th December by representatives from Doctors Without Borders. As always, the week was a resounding success! A party was also held for immigrants at Lyster Barracks on the 21st December, which had an extremely good turnout – many remarked that it was an eye-opening experience! Leisure First up was a paintball match organized on the 7th December, which drew a strong first-year response and has sparked fierce rivalries for years to come! Leisure‘s football tournament was also a great success, with the 5th year team ―XXXX‖ coming out victorious – well done! Next up was the Consultants‘ party (be sure to check out our Wall of Shame for this, folks – no-one is spared!), where pastizzi were eaten, wine was drunk, and much merriment was to be had. Christmas celebrations then took on a slightly rowdier note with the Gangsta Santa party on the 21st December. We even have eyewitness reports of Aunty ELSA knocking back vodka skittles shots and dancing on the bar! This display was immediately followed by an after-party at Qube – because just one party is never enough! Exchanges Applications for exchanges in Summer 2009 are officially over. Congratulations to all those selected!

PEARLS OF WISDOM Some advice from Mr. Karl German: “AFTER PENILE BIOPSY, THE PENIS IS TAPERED FOR BETTER AERODYNAMICS AND BETTER PENETRATION.”

Dear Boozu,

Dear Boozu, I met this most wonderful guy at the beginning of my first year. I call him Rosario, and we’ve had some fine times. I’ve spent hours in his company, and I feel that I’ve got to know him to his very bones. Thanks to him, studying anatomy has been easier. His sense of humour is also very similar to mine, and we’ve played countless pranks on my family and friends. He’s not that good-looking perhaps, but he’s been a good friend. But now the time is coming when we must part forever…this summer we will have to say goodbye… How can I get over this heartbreak? How will I face seeing his empty cardboard box on the top of my wardrobe? How can I bear this parting, even if I’m broke and badly need my deposit back? Yours sadly, Jolly Rogers and her pal, Rosario DeBone —————————————————————————————————————————————————————-

Ahhh!… The heart wants…. (Whatever the heart wants!) Break ups are never easy, or fun for that matter, but I‘m afraid you are going to have to toughen up and keep on strutting. The easiest thing to help you move on is to distract your self with something else. And next year you will have ample distractions. These include the sick lot (pun intended) across the road at MDH. You will find that patients will also interact, and not just lump themselves in a box on your wardrobe like Mr. DeBone! (Editor‘s note: Although, may I remind you that ―too much‖ interaction with a patient is unethical. Gray‘s Anatomy scenarios are not very well tolerated in hospital even though we might be in desperate need of drama and gossip.) This time I will even go as far as suggest you get a living mate… Male or female… I‘m not one to discriminate. The time to be attached to inanimate objects such as books and bones is over. In other words… GROW UP! Life is about moving on and not fixating on a silly set of bones no matter how useful they were for your learning. So, here is the proposed plan of action… 1. Pack up bones. 2. Get deposit. 3. Don‘t tell mom or dad about deposit. Go to the nearest bar in your nicest frock (even if you are a guy) and get trollied until you eventually meet your next companion. (God help him!) Keep well!

Boozu More “Dear Boozu” on the next page!! -->

PEARLS OF WISDOM Dr. Farrugia: What not to do when taking a 24 hour urine collection to calculate your GFR… “THE WRONG THING THEY [PATIENTS] DO IS THAT THEY PEE IN THE TOILET.” “THE OTHER THING THEY DO WRONGLY IS THIS – BUT PLEASE DON'T LAUGH AT THIS – WHEN THEY GO AND DO NUMBER TWO THEY END UP DOING NUMBER ONE TOO WITHOUT COLLECTING IT.”

Dear Boozu, Dear Boozu,

I am a very frustrated medical student in my 4 th year of studies, living in a caravan with my bummer parents and three good-for-nothing siblings. As you can imagine, trying to study for exams has always been a big problem. Yet, somehow, someway, I always managed to cope through my University years, mostly by finding refuge in libraries . Currently, I'm studying round the clock at the Health Sciences Library at Mater Dei Hospital. It's a nice place, despite being rather small for it to be shared between both medical and IHC students. But, what's really bugging me is that loads of people come in and they cannot do anything without making a racket. And it is so distracting! They're usually IHC people either working on some group work or simply bored working on their dissertation. To be honest, I don't mind them being there. But they're far too noisy and they're driving me up the wall!!! And the librarians aren't doing anything to improve the situation. Going to the University library is an option, but it's not as resourceful for the average clinical student such as myself. Oh Boozu! How am I going to shut up these IHC students without killing someone?!

Sincerely, Frustrated Nerdy ————————————————————————————————————————————————————————————————————————————————————————--

Dear Frustrated Nerdy, First of all, kudos for the caravan… Cool stuff! Maybe you should invite me over one day. I‘ll fit in just fine with your bummer family. Anyways… moving on! The age old rivalry between medical and nursing students… you just have to love it! Whoever thought of having one library really had conflict on their mind, but that‘s beside the point. What you need to do is stand your ground. It‘s bad enough you cant study at home (illegal parking site) but don‘t let them boss you around. These are a few suggestions which you may find helpful: 1. 2. 3.

If they can make noise, so can you. It sounds babyish… and it is, but it will show whoever these bright sparks are, that making noise in a library is annoying. Hopefully they will get the message. Leave kind little notes on the desks next to you, or next to them, asking them (politely if you wish) to shut up, or else face nasty stuff done to their cars Personal favourite) go a few weeks without showering, that way, no one (and believe me on this one) will want to stay next to you. That way you can work in peace and quiet. An alternative is to chug down as many cans of baked beans as possible (I think you know where I‘m going with this) and let them rip right next to them. No one likes being around some one who is farting (ask my friends).

Get an iPod, play some relaxing music, and this will drown out all the silly chatter of the ―busy‖ IHC students I hope this has been useful, and don‘t be too nasty, otherwise you are going to be paged non stop every night duty you have!

Keep well,

Boozu PEARLS OF WISDOM Pawlu Coccus on common sense: “IT’S NOT THAT I AM MORE INTELLIGENT THAN OTHER PEOPLE, IT’S BECAUSE I WAS TOUCHED BY THE HOLY SPIRIT!”

MYALGIC ENCEPHALOMYELITIS…BUT WHAT IS IT? By Sylvana Vella For this past year I have taken it onto myself to raise awareness and educate all members of the community, especially doctors and nurses, about the little known medical condition Myalgic Encephalomyelitis (ME) defined by the World Health Organisation as a neurological illness (code WHO-ICD-10-G93.3). At present, there is no medical diagnostic test for ME and this is particularly unhelpful since rest is so critical in the early phase of the illness. Doctors usually come to the diagnosis after a laborious process of elimination to rules out any other condition. This means patints have to take a substantial number of blood tests and any other tests the doctor deems necessary. ME is a multi-system illness, having various symptoms. Unnatural and inexplicable fatigue and severe malaise that‘s not relieved by rest are common ailments of an ME sufferer. However there is an accompanying list that is unique to every individual sufferer. To add to the complexity, an ME sufferer‘s symptoms might change or fluctuate during the course of their illness and not all people with ME suffer from all the symptoms. Some of the symptoms experienced by many severe ME sufferers may include:                 

Muscle, nerve and joint pain and/or stiffness Disturbed sleep/ insomnia Glandular swellings Migraines Poor temperature control Poor circulation Low-grade fever Increased sensitivity to bright light, noise and odours Increased sensitivity to medication Intolerance to certain foods Indigestion and nausea Diarrhoea/constipation Brain fog Loss of short-term memory and concentration Blurred vision and dizziness Light-headedness and difficulties with balance Moodiness or depression [brought on by the condition‘s difficult recovery]

There are different stages of ME, ranging from slight to very severe. Some ME sufferers are mildly affected and manage to juggle work and rest. But people with severe ME can be bedridden and need 24hour care. Since ME is an erratic and fluctuating condition of highs and lows, improvements and relapses, sufferers often get a taste of the various degrees of severity. Indeed, an ME sufferer's condition can vary from one day to another, or even hour by hour.

Up till now, there is no cure – and until the exact causes of ME are found, a cure is unlikely to be found. However, symptomatic relief may be possible to some extent. Treatments aimed at various symptoms can help some people, though not everybody, and it is often a question of trial and error to find the optimum regimen for each individual. The recent case of Sophia Mirza, who died from ME, shows the urgency of funding research into treatments and in finding a cure. Many do improve but not equivalent to full pre-illness levels. It has presently been estimated that between 6 and 12% ME sufferers in the UK regain full health within two years, but around 60% never regain their previous level of health, with up to 20% becoming permanently disabled. Those sufferers who are diagnosed early and given appropriate advice on managing the illness have the best prognosis. The reason I have taken a personal interest to address this topic is because I myself have been a severe sufferer of ME for the past four years. I had previously been a promising athlete, competing and winning in international meetings and would never have thought that in the future I would have to use a stair lift to climb a flight of stairs or that on most days I would struggle to go to sixth form due to the pain, brain fog and complete and utter exhaustion (not to mention the other accompanying myriad of symptoms). All these symptoms make school and social life difficult, which is hard to accept at any stage, let alone during the teenage years. Therefore, I know through experience that certain hardships endured during sufferers‘ daily lives can be avoided if the general public and the medical community had a better understanding of this illness. I believe that the awareness campaign is the key to overcome certain obstacles we face everyday due to encountering people with little or no knowledge of ME. This is especially the case when the people in question form part of the medical community whom we rely on for assistance, care and most importantly the ability to diagnose this condition as quickly as possible. My goal is that, as a result of this campaign, ME sufferers can enjoy better understanding about their condition from the people around them. Although this acceptance and sympathy may not be a cure, it will certainly be a great boost to be finally understood. For a better understanding of the condition visit www.mesufferersmalta.org which is the website of the only ME support group in Malta.

Aunty ELSA on MMSA at Christmas Time The rising charges of water and electricity have been the subject of much heated debate over the past good number of weeks. But, apparently, this didn‘t seem to have taxed us enough to drown the whole nation‘s Christmas spirit this year! I bet there are enough lights to get even Meredith Wilson singing from his grave ―It‘s beginning to look a lot like Christmas, Ev‘ry where you go!‖ The street lights and all the decorations… they‘re all making it hard for me to forget how society is obnoxiously obligating everyone to display their joy and exuberance during this stupid holiday season! In case you‘re a retard and did not get the hint let me spell it out for you… I hate Christmas! Christmas is the best thing I passionately love to hate! No, actually it‘s the second best thing… The real, best thing to do in life is getting a kick out of doctors and medical students! And they sometimes also get a kick out of me too. Though, I have to admit… It seems to be that Christmas is the only time when people actually make an effort to be human beings… To prioritize family, friends and the fun bits of life, like giving gifts and sharing food. Christmas is a time for people to hug, be fuzzy and be all warm towards each other. And considering how much it‘s costing us to heat up our homes these days, I‘m expecting more hugging and kissing (and maybe sex) this time round. In the meantime, I‘ll just stick to my ways of cutting down on those soaring electricity bills… By being very grouchy and naughty instead of being very nice! Who knows! Maybe this year, Santa will do me a big favour and surprise me with a bit of coal in my stocking! Yes I‘m a Scrooge… And the current credit crunch certainly is not helping. But I doubt I stand alone in this one. I noticed people were more frenzied than usual, running around trying to get the best deals this year. I mean, let‘s face it! The real joy in giving is getting it on sale! Though, there are other ways of reducing those dreaded visits to the ATM and avoid going ―over board‖ whilst buying cheap junk to your relatives. Today, there are the One4All gift vouchers from the Gift Voucher Shop Ltd. There‘s nothing like a gift card to say, ―This is how much I‘ve been willing to spend on you this year!‖ That‘s how I got my Christmas shopping done early. And they saved me from having to listen to cheesy, modernized Christmas carols that always want make me gag, like ―Christmas time… mistletoe and wine‖. These carols really need an update! Firstly, just drinking wine on Christmas is for amateurs, especially for the current cohort of doctors-to-be. Secondly, (horny) couples don‘t wait for mistletoes these days to exchange saliva and go all the way to suck down at each other‘s throats. At this rate I‘m surprised I haven‘t seen any Christmas deals for condoms. I can picture an ad just now… ―Play with your partner safely for less and give him/her the ultimate Christmas experience.‖ But then again why am I so surprised! SCORA are still on about introducing that condom machine at University! They‘ve been at it for years now! Most probably, my nephew would graduate… Do the foundation program… Pass the foundation program and become a BST (Bull S**t Trainee) in Malta… Get fed up of Malta… Fight with Dr. Martin Balzan to find his fortune in the UK… Become a consultant in the UK… Buries his beloved Aunty ELSA who would have got him out of so many malpractice law suits… And SCORA would still be fighting to install that blessed condom machine at the University!!!

All MMSA seems to know how to pull off is a party! And this season was yet another opportunity for them to show off doing what they do best! Then you get SCOPH sometimes struggling to do a decent thing or two occasionally. SCOPH has once again infiltrated the children‘s wards on Christmas Eve! I can only genuinely say that my heart really goes out to those poor kids who must have been waiting for this moment since last year‘s Boxing Day. And what do they get? A fake Father Christmas handing out easily breakable, good-for-nothing junk from the 2€ Shop, which is still affectionately known as Tal-Lira! And then again… Why go see the sick children only on Christmas day?! What about Carnival? Or Halloween?! Halloween is becoming rather fashionable lately. I‘m sure the kids would love a visit from SCOPH during Halloween and help them go trick or treating round the wards. The kids would love it… Bullying the nurses a bit and telling them that if they don‘t get their sweeties then their shift would be totally done for! I think that would be a real lot more fun for both the children and even the doctors… seeing nurses at the mercy of minors. There are doctors that take pleasure in seeing nurses get harassed and treated like housemaids, slaves, underlings or anything other than the educated, professional people that they really are. So, really… SCOPH should consider this idea for next year. And then there‘s the SCORP party. The fact that MMSA organizes parties for the refugees is a potential Xarabank program for when Peppi runs out of ideas. Aren‘t there the Jesuits taking care of these people‘s human rights? And MKSU? Why can‘t SCORP see that there are other vulnerable groups whose rights are not being that well respected? Like the elderly for example! Everyone forgets the elderly, even at Christmas time! You know, we old edentulous hags with boobs hanging down to our knees, locked up in homes, hospitals and other sick buildings have rights to… Including the ―right to be free from abuse, neglect, and exploitation‖. We might not have a big problem with abuse and exploitation. But we do have a problem with neglect! And as Mother Theresa rightly puts it, ―being unwanted is the worst disease that any human being can experience.‖ Loneliness is not a condition you will find in many psychiatric classifications. Yet, it is the root of much psychopathology. And, without shame, MMSA doesn‘t really do much. The only old hags MMSA reaches out to are the consultants and registrars with a cheap Christmas party on the last day of the semester!!!! In fact, that is where my nephew went… sucking up to a few big heads since he knows he‘ll never get far with hard work and well earned merit alone. In the meantime, I‘ll just try and enjoy the holidays alone like every other blooming year… with my hot cider, hot chocolate and hot flushes!

HEALTHFEST 2008

AND

Complied by Claudine Micallef

The 8th of December is the locally celebrated feast of the Immaculate Conception and many Maltese families traditionally flock to Valletta for Christmas shopping. This year, MMSA took this opportunity to create a health awareness day by organising HealthFest 2008 in Freedom Square Valletta. Numerous activities were organised by the various Standing Committees of MMSA with the aim of creating awareness of important health issues and offering advice to the general public. Another major event on the MMSA calendar is World Aids Day (WAD), commemorated on the 1st of December, and this year SCORA was very busy organising a week packed with sexual health related activities. Here are some reports from members of the various Standing Committees of MMSA who organised and participated in these events. Both events were surely a successful collective effort. Well done to all! SCOPH Activities Anti-Smoking Activity by Sandra Zammit The anti-smoking stand was set up just outside City Gate, complete with anti-smoking awareness leaflets and a box wrapped up in Christmassy wrapping paper for smokers to throw away their cigarettes in exchange for apples and mouse pads. People soon started flocking to Valletta and surrounded by medical students, trying to convince them to give up two cigarettes for an apple (a healthier option by far) or even better, to exchange five cigarettes for a mouse pad. Many of the smokers that stopped by decided to renounce two of their precious cigarettes (with, admittedly, a lot of cajoling from our end!) and at the end of the day some hundred cigarettes were collected! An astounding large number of people decided, on the spur of the moment, to apply for the ‗Quit Smoking‘ program offered by the Health Department. This was undoubtedly one of the best Christmas presents they could give themselves, both from an economical and from a health point of view. Duħħanu was a favourite with children, who gaped, pointed, and a couple of the braver ones, even decided to kick him! Overall, the anti-smoking campaign was a great success and was well received by the general public.

WAD

Teddy Bear Hospital by Alexia Farrugia This was a huge success!! We had children from the ages of around 2 to 10 playing with teddy bears and pretending to cure them... I have to say some of them were quite cute wearing huge lab coats and playing with toy stethoscopes! Some of the older children also participated in a survey on whether they knew what a tendon hammer was used for and some of them gave quite inventive answers. Of course, the red balloons were what attracted the kids initially but most of them were quite interested in playing doctor too! _______________________ Eating Disorders by Alexia Farrugia This actually went a lot better than expected! Most people thought we were giving nutritional advice and had no idea what eating disorders actually were, so I believe the aims of the outreach were satisfied. The people most interested were mainly parents of teenagers or soon-to-beteenagers, but we even had a few schoolteachers asking questions and requesting further information. _______________________ BMI and Blood Pressure stand by Sandra Zammit and Jacob Vella. Over 50 people visited the stand. Most people seem to perceive BP monitoring as being more indicative of their health status since their family doctor never measured their BMIs. Two thirds of the individuals who were found to be hypertensive, were not aware of this and were thus on no treatment. These were advised to consult their GP. We had very positive feedback regarding this activity, and many appreciated the fact that we were doing this on a voluntary basis. Some people already knew about this event through the newspaper announcement. A particularly funny incident was when an elderly man insisted on checking if the weight scales were calibrated i.e. if the reading of one corresponded to another, and after weighing himself on both he showed us that they were not… Continues on the next page…...

PEARLS OF WISDOM A lesson from Prof. Albert Fenech: “THE HEART IS THE FIRST ORGAN YOU CAN FEEL WORKING IN THE FEMALE. IN MALES, IT’S THE SECOND.”

HealthFest 2008 and WAD cont.. Media/SCOME Surveys on Health Care Management and Smoking by Marquita Camilleri The Media standing committee, with the help of Martina Falzon (current NOME), decided to move away from MMSA‘s stand and conduct two very short surveys. Through one of the short validated surveys, we hit the streets of Valletta and asked Joe Public what they thought of the present management of the local Health Care system and what issues are currently of pressing importance. There was also another questionnaire on smoking, which was, however, only filled in by smokers. This included CAGE questions which tried to assess a smoker‘s possible desire to quit the habit. Most of the questionnaires have been filled in, with more than 100 people being surveyed at the MMSA Healthfest. The results of both studies are now being compiled to be issued in next year‘s edition of Murmur. SCORP Leaflets on Patient Rights & Duties and the A&E by Beatrice Farrugia For Healthfest 2008, SCORP members prepared two leaflets, one listing Patient Rights and Duties and the other giving an explanation of the triage system at Mater Dei Hospital‘s Accident & Emergency Department (A&E). These were handed out by students and discussed with passers-by during an outreach activity. Many of the people approached were not aware of some of their rights and responsibilities as patients or had misconceptions about the system at the A&E and as such, I believe that an information campaign about these two issues was a worthwhile initiative.

SCORA World Aids Week Activities by Marina Sciberras Monday, the 1st of December, marked World Aids Day, and initiated a week-long series of activities organized by SCORA to commemorate World Aids Week 2008. The week kicked off with an outreach on Monday morning at Junior College, where the students were briefed about sexual health, including things like the ABCD policy, condoms, STIs and the GU clinic. In the evening, a Candle Vigil was held wherein a sizable group of medical students braved the cold weather and walked from Sliema to Baystreet to show solidarity with HIV/AIDS victims. Tuesday saw a group of SCORAngles talking to shoppers in Sliema. We were met with stares, funny looks, interest and even the occasional appreciation. Upon asking the Christmas shoppers whether they were aware of the fact that Monday was World Aids Day, the absolute majority said they did not. It was also clear that many did not know about the services offered by the GU clinic, as well as many basic things involving their sexual health. Wednesday's activity was Piazza Cafe at the quadrangle, wherein unsuspecting students were lured by the smell and sight of delicious cakes, and given information on sexual health and related leaflets. The event was a particular success, and it was concluded that the amount of cake is directly proportional to people being interested in what you have to say. Another outreach to the general public was held on Thursday evening, this time in Valletta, while Friday's outreach was directed towards prostitutes working in Gzira. The hectic week culminated with the well-attended Exposed and Unplugged concert which consisted of a series of thought-provoking monologues, bands and recitals as well as some short talks.

PEARLS OF WISDOM Dr. Farrugia on his ever ringing mobile phone… “PLEASE EXCUSE ME ABOUT MY MOBILE ALWAYS RINGING. BUT I NEVER SWITCH IT OFF. I ONCE SWITCHED IT OFF AND PEOPLE DIED!”

HUMAN RIGHTS WEEK Human Rights Week activities for SCORP kicked off with Healthfest on Monday 8th December. For SCORP, however, this was only the first of a series of activities marking the 60th anniversary of the United Nation‘s infamous Declaration of Human Rights and the related Human Rights Week. On Human Right‘s Day, Wednesday 10 th December, two well-attended ethics seminars were held at the KSU common room. A number of difficult clinical cases were discussed with several guest speakers giving their contribution, namely: Dr. Pierre Mallia, Dr. Pierre Schembri Wismayer, Dr. Isabel Stabile, Rev.Fr. Emmanuel Agius, Dr. Chris Rizzo and Dr. Miriam Giordano. What gave this seminar that extra edge was the fact that all attendees were given the opportunity to voice their opinion on the ethical situation, and even ask questions to the guest speakers, who then responded based on their knowledge and life experience. The seminar provided plenty of food for thought and intelligent discussions ensued in both sessions.

Another SCORPian activity held in this week, specifically from Wednesday to Friday, was the Peacetest survey, which was this time conducted to the 6 th formers at St. Aloysius College. The Peacetest is an international survey in which students fill out an anonymous questionnaire about their attitudes towards violence, war, conflict resolution, human rights and ethnic differences. Volunteers went to different classes and spent a session with the students. After conducting the survey, the volunteers spent around half an hour talking to the students about discrimination based on gender, age, race, sexual orientation, and mental abilities. This activity brought to an end Human Rights Week. Special thanks go to Daniel Azzopardi and all other members involved for working hard to raise awareness about such an important issue, and for all the activities organised for this week. Keep up the great work SCORP!

For Thursday, SCORP invited two members from Médecins Sans Frontières (Doctors without Borders) to talk to medical students about MSF‘s work, with a particular emphasis on their project in Malta, wherein they give medical aid to asylum seekers reaching our shores. Questions that arose at the end of the session indicated that a good number of students are seriously interested in dedicating some of their time to the organisation, and SCORP shall be working on finding ways in which students may give their contribution to the Malta project.

PEARLS OF WISDOM What a 1st year medical student wrote whilst (faithfully) note-taking at Mr. A. Casha’s lecture on The Thoracic Inlet: “YOU WOULDN'T SURVIVE A DECAPITATION!”

This is All Greek to Me!

Christian Camilleri

Here is the promised Part 2 of Christianâ&#x20AC;&#x2122;s glossary of medical jargon which you should find useful. Part 1 can be found in the November issue of Sphygmo. Assisted Aggressive Euthanasia Treatment for loathsome patients, often in the form of APTFRAN (Apply Pillow To Face, Repeat As Necessary) Blattarian Factor [From Latin blatta(cockroach)] Refers to the hardiness of the scum of society. Often calculated as: Number of tattoos x Number of missing teeth + Recorded overdose cases - Contribution to society The higher the value, the higher the survival rate for any given medical intervention. eg Patient with high blattarian factor requested morphine. Administered DW instead. Unfortunately survived his horrendoplasty. BTSOOM Beats The S**t Out Of Me C2H5OH Ethanol. Alcohol. eg. "Patient admitted with C2H5OH overdose". See Hepatology Round DW Distilled Water. A misnomer for saline. A placebo. Donorcycle Two-wheeled vehicle designed to maim and kill users, rendering them suitable for organ harvesting. Fecal Encephalopathy: [From Latin faeces (s**t) + Greek encephalopathy (of brain) + Greek pathos(disease).] Having s**t for brains. eg. Patient presented with Eiffel Syndrome, showing major sign of fecal encephalopathy. Hepatology Round Booze party in the staff room. Hi 5 HIV positive (V being the Roman numeral for the number 5)

Horrendoplasty [From Latin Horrendus (Terrible) & Greek Plastein (To shape)] A God-Awful Surgical Operation. eg Radical bowel resection on a patient with a BMI of over 45 IQ/K+Equivalence: When the Intelligence Quotient of a patient is equal to his serum potassium levels. See fecal encephalopathy Imaginoscopy Radiological technique used by Medical students to find a lesion the clinician is showing you which you cannot see. LOL Before the age of Internet, used to mean "Little Old Lady" eg. LOL/FD/GB (Little Old Lady, Fall Down, Go Boom). NAD Nicotinamide Adenine Dinucleotide, a coenzyme OR No Abnormalities Detected (referring to a radiological report) OR Not Apparently Done (also referring to a radiological report) Psychologist Lesion Lesion on an X-ray so obvious that a psychologist would spot it. Rothman's sign Sore voice, shortness of breath and tobacco staining of fingers. SBI Something Bad Inside. Usually less serious than SVBI. Unlicensed Pharmaceutical Provider Drug Dealer. See blattarian factor.

Pre-clinical Corner

C R O S S W O R D P U Z Z L E Answers on page 17

CLINICAL CORNER Clinical Case 1

A 6P CASE By Andrew Camilleri GS is an 81-year-old old gentleman and known case of hypertension, chronic renal failure, hypercholesterolemia and atrial fibrillation (occurring as part of tachy-brady syndrome for which a pacemaker had been inserted 3 years previously), mild dementia and a past history of thromboembolism to the left popliteal artery. He is a nonsmoker and rarely drinks alcohol. He presented to A&E with a 2 hour history of right upper limb pain that was of sudden onset and was associated with parasthaesia, slight shortness of breath and copious vomiting. He had decreased sensation and increased capillary refill time of the right upper limb. GS had a history of hiatus hernia with Helicobacter pylori infection. Five days before he presented to A&E, he suffered an episode of vomiting with coffee ground staining. An oesophagastroduodenoscopy showed oesophagitis and duodenitis and warfarin therapy was withdrawn. On presentation, he was on regular doses of amlodipine (Istin®) 5mg/d, doxazosin (Cardura®) 1mg/d, simvastatin 40mg/d, lorazepam (Ativan®) 1mg bd and omeprazole 20mg bd. He was also on a course of clarithromycin and methronidazole (Flagyl®) to treat the H. pylori infection. He has no known drug allergies. On routine examination at A&E, his HR was 65bpm regular, BP 131/66, Temp. 97.5oF (axillary) and he had a RR of 15/min. He had a GCS of 15 and was oriented to time, place and person. Heart sounds were normal and chest was clear. He had absent radial, ulnar and brachial pulses of the right upper limb; the right forearm and hand were perishingly cold and white, with markedly reduced muscle power. Abdominal examination demonstrated a soft, non-tender abdomen. Lower limbs showed slight pitting oedema. CBC, U+E, RBG, creatinine, INR and APTT were requested. HGT was 13.8mmol/dl. SpO2 on O2 was 100%. 4 units of packed cells were crossmatched. An ECG and CXR (AP-sitting) were taken as part of the routine battery of tests.

A provisional diagnosis of arterial thromboembolism of the right upper limb was made. The consultant on call was informed. GS was given morphine 3mg i.v, metaclopramide (Maxolon®) 10mg i.v., a heparin bolus of 5000u i.v. and a heparin infusion of 5000u 6-hourly. The consultant on call examined the upper limbs, confirming the diagnosis of thromboembolism of the brachial artery of the right upper limb. A consent form for any possible surgical intervention was obtained. The patient was rushed to theatre, and an emergency embolectomy of the right brachial artery was performed under local anaesthetic (1% lignocaine infiltration) and sedative. Blood loss was minimal and no transfusion was required. Postoperatively, GS was given heparin 1000u i.v. hourly. An APTT was taken 2 hours post-op with a target APTT ratio of 1.5-2.0. Glucose was checked regularly, as were pulses and any signs of compartment syndrome. Regular medication (as above) was continued. The patient was encouraged to take a light diet and plenty of fluids. Two days postoperatively, the right upper limb was still warm and pulses were all palpable. Heparin was stopped and enoxaparin (Clexane®) started. APTT and INR were taken again. GS was prescribed Warfarin with a target INR of 2.5-3.0. The patient was discharged, and was given an SOP appointment in 6 weeks. ___________________________________________________

Questions 1. Why did a thromboembolism develop? 2. What are the six cardinal features of acute limb ischaemia?

3. Why was the procedure performed under local anesthetic?

4. How was the emergency embolectomy preformed?

Answers on page 18

CLINICAL CORNER Clinical Case 2

A DOSE

NEUROLOGY…

By Christine Azzopardi A 46 year old teacher calls her family doctor as she was feeling increasingly unwell. Two days previously she noted weakness in her arms and legs which was getting progressively worse. She also complained of blurred vision and headaches. That morning she developed parasthesia in her hands and feet to the extent that she was unable to hold a cup of tea. Her speech was becoming slurred and her gait unsteady. She has no past medical history of note except that she recently suffered from an upper respiratory tract infection for which she took Actifed and Paracetamol. She was on the oral contraceptive pill up to 1 month ago.

On examination: General Observations: Lady looking comfortable but tired. Oriented to time, person and place

Tone: Normal in both upper and lower limbs Power: Normal (5/5 in both upper and lower limbs) Reflexes: all absent, plantars down-going Sensation: intact in both upper and lower limbs, proprioception intact Other signs:

    

Ataxic gait present Dysdiadokinesis Past pointing Ophthalmoplegia in all directions No pyramidal drift ________________________________________________ __ Questions

Pulse: Rate: 100 Rhythm: regular Blood Pressure: 130/60 Respiratory Rate: 15

1. What is the most likely diagnosis? 2. What action should the family doctor take? Why? 3. Which are the more important investigations necessary? 4. What treatment does this patient require?

Neurological examination: Inspection: weakness, unsteady, uncoordinated gait

Answers on page 18

PEARLS OF WISDOM Pawlu Coccus on drug interactions: “YOUR COMPANION SHOULD NOT BE A BOYFRIEND OR A GIRLFRIEND… YOUR COMPANION SHOULD BE BNF APPENDIX ONE!!!”

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Physiology

ANSWERS Crossword Answers:

Across: 7 Fabella, 9 Spleen, 10 Rectus Abdominis, 12 Diaphragm, 14 Trigeminal, 17 Subclavian, 18 Right Down: 1 Duodenal, 2 Scalp, 3 Posterolateral, 4, Hypertrophy 5 Veins, 6 Situs Inversus, 8 Eosinophils, 11 Carina, 13 Meckel, 15 Liver, 16 Vagus Some Anatomy Notes of Interest A barium meal passes into the first part of the duodenum and forms a triangular homogenous shadow, the duodenal cap, which has its base toward the pylorus. The spleen is: 1 inch thick, 3 inches wide, 5 inches long, weighs 7oz (200g), lies between the 9th and 11th ribs.

 Meckel‘s cave is found in the brain whilst Meckel‘s diverticulum is found in the gut. 

The trigeminal ganglion occupies a cavity called Meckel's cave (trigeminal cave, cavum trigeminale) in the dura mater covering the trigeminal impression near the apex of the petrous part of the temporal bone. It is bounded by the dura overlying four structures: (1) The cerebellar tentorium (tentorium cerebelli) superolaterally (2) The lateral wall of the cavernous sinus superomedially (3) The clivus medially (4) The posterior petrous face inferolaterally. It houses the trigeminal ganglion (also known as the gasserian ganglion. It is named for Johann Friedrich Meckel, the Elder.



Meckel‘s diverticulum is an ileal diverticulum which exists in 3% of adults and represents the remnant of the proximal part of the intestino-vitelline duct. Diverticular inflammation may mimic acute appendicitis. Since Meckel‘s diverticulum and the appendix are both derived from midgut structures, pain from either structure is referred to the periumbilical region.

 The circumflex artery arises from the left coronary artery and curves left in the atrioventricular groove, continuing round the left cardiac border into the posterior part of the groove and ending left of the crux in most hearts. It gives off branches to supply the left ventricle, with atrial branches also supplying the left atrium.

 Layers of the scalp are as follows: Skin, Connective tissue, Aponeurosis, Loose areolar tissue and Pericranium. The scalp has a profuse blood supply and even a small laceration may cause severe blood loss since the arterial walls are attached to fibrous septa in the subcutaneous tissue and are unable to contract or retract to allow haemostasis.

 The scaphoid bone (hand navicular) of the wrist is found on the thumb side of the hand, within the anatomical snuffbox. The etymology derives from the Greek skaphe which means ―a boat‖, and the Greek eidos which means ―form‖.

ANSWERS cont A 6 P Case 1.

Why did a thromboembolism develop? The patient had been diagnosed with AF some years previously, for which he had been prescribed warfarin as an anticoagulant. AF is known to cause formation of thrombi on the atrial walls. Withdrawal of warfarin due to upper GI bleeding resulted in formation of a thrombus in the left atrium, which shot off emboli to the right upper limb. These impacted in the brachial artery with resultant acute limb ischaemia.

What are the six cardinal features of acute limb ischaemia? Pain, Pallor, Pulselessnes, Perishing Coldness, Paraesthaesia and Paralysis. All these features were demonstrated in the patient.

Why was the procedure performed under local anesthetic? A local anaesthetic was used in order to decrease the time period of limb ischaemia. A general anaesthetic would prolong limb ischaemia unnecessarily.

How was the emergency embolectomy preformed? The RUL was prepared and draped; i.v. augmentin was given prophylactically. 1% lignocaine infiltration was given as a local anaesthetic. A transverse cubital fossa incision was made, and the brachial artery was identified. Sloops were then passed around the artery proximally and distally. A transverse arteriotomy of the brachial artery was performed, and a size 3 Fogarty Balloon Catheter was passed into the artery proximally and distally to remove the embolus. The artery was then irrigated with heparinised solution and on-table angiography was performed. This demonstrated patent arteries extending to the hand. The arteriotomy was closed using interrupted 6/0 prolene sutures. Inflow and backflow were then checked. 2/0 vicryl sutures were used subcutaneously and 3/0 prolene interrupted sutures were used to close the skin.

___________________________________________________________________________________________________________

A Dose of Neurology… 1.

What is the most likely diagnosis? Guillain-Barré Syndrome, Miller- Fisher variant The Guillain- Barré Syndrome is an example of a post-infectious immune disease. It has been linked to Campylobacter jejuni and viruses such as cytomegalovirus, EBV. It involves a multifocal demyelination of the peripheral nerves in close association with macrophages. Miller-Fisher syndrome is a rare variant that typically presents with the classic triad of ataxia, areflexia, and ophthalmoplegia. Acute onset of external ophthalmoplegia is a cardinal feature. The ataxia tends to be out of proportion to the degree of sensory loss. Patients may also have mild limb weakness, ptosis, facial palsy, or bulbar palsy.What action should the family doctor take? Why?

Which are the more important investigations necessary? Diagnosis is mainly established on clinical grounds. Useful tests include:  Nerve conduction studies ~ these show slowing of conduction in the common demyelinating forms, however EMG may not be diagnostic  Lumbar Puncture ~ may show an acellular fluid with elevated protein.  Anti-ganglioside antibodies, particularly to GQ1b ~ will be positive in 90% of cases

What treatment does this patient require? Intravenous immunoglobulin shortens the time of recovery and physiotherapy helps rehabilitation. Early recognition of respiratory failure is vital. This would require intensive care with respiratory support. DVT prophylaxis with subcutaneous heparin in these patients is routine.

PEARLS OF WISDOM Dr. B. Debono when without a projector… “IT SEEMS WE DO NOT HAVE A PROJECTOR, SO I GUESS I MUST ATTEMPT TO EXPLAIN THE CARDIAC CYCLE THROUGH THE MEDIUM OF DANCE...”

MORE NEXT TIME!

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