Midlands Medicine Oct 2015

MIDLANDS MEDICINE OCTOBER 2015 VOLUME 27 - ISSUE NO 6

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EDITOR’S NOTES

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PROFESSIONALISM: WE ARE WHAT WE TEACH!

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THE DEBATE THAT WILL NOT DIE

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NURSING AND MIDWIFERY REVALIDATION

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HG WELLS IN STOKE-ON-TRENT

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THE NEW WORLD OF ACADEMIC PUBLISHING: WHAT OPEN ACCESS MEANS FOR RESEARCHERS

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INTERSTITIAL LUNG DISEASE 4

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NSMI NEWS

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UHNM NEWS

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QUIZ NIGHT

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WORDPLAY 13: NO FEAR!

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BOOK REVIEW: BEING MORTAL BY ATUL GAWANDE

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BOOK REVIEW: ELIZABETH IS MISSING BY EMMA HEALY

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INTERESTING IMAGES

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QUIZ ANSWERS AND EXPLANATIONS

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

COVER IMAGE

An imagined scene from HG Wells’ War of the Worlds by artist Paul Mudie (paul.mudie@blueyonder.co.uk), reproduced by kind permission. Paul has previously received recognition for work on medical topics. The image links with Vera Cartlin’s piece on HG Wells in Stoke-on-Trent.

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MIDLANDS MEDICINE

CONTENTS

Dr D de Takats

Editor’s notes

ASSISTANT EDITOR

Professionalism: We Are What We Teach!

Simon Gay

The Debate that will not Die Paul Laszlo

EDITOR

Mr C Bolger

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

EDITORIAL ASSISTANT Spencer Smith

THE NORTH STAFFORDSHIRE MEDICAL INSTITUTE President: Mr B Carnes Chairman: Mr D Gough Honorary Secretary: Mr J Kocierz Honorary Treasurer: Mr M Barnish

EDITORIAL

ORIGINALS

Nursing and Midwifery Revalidation Helen Inwood

HG Wells in Stoke-on-Trent Vera Cartlin

Interstitial Lung Disease 4 Tracy Hall

The New World of Academic Publishing: What ‘Open Access’ Means for Researchers Mark Ormerod, Ellie James & Mark Smith

REPORTAGE

NSMI News

UHNM News

ENDPIECES Please forward any contributions for consideration by the Midlands Medicine Editorial Board to the Editor c/o Spencer Smith, Editorial assistant.

By email: spencer@nsconferencecentre.co.uk Or by post: North Staffs Medical Institute, Hartshill Road, Hartshill, Stoke-on-Trent ST4 7NY Views expressed are solely those of the author(s) and do not reflect the views of the Midlands Medical Journal.

All material herein copyright reserved, Midlands Medicine ©2015.

Volume 27, No 6, October 2015

Quiz Night Oluseyi Ogunmekan

Wordplay 13: No Fear!

Dominic de Takats

Book Review: Being Mortal by Atul Gawande Helen Alcock

Book Review: Elizabeth is Missing by Emma Healy Helen Alcock

Interesting Images

Quiz Answers and Explanations

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EDITOR'S NOTES Sincere thanks to all those who have made contributions to this issue. Without your submissions there would be no editing to do and no journal. As is the customary structure for these notes, I’ll now preview what we have on offer for your reading pleasure.

Mark Ormerod and colleagues take us in an entirely new direction. This piece is entirely unrelated to the subject matter of all the other articles in the journal but is relevant to the journal in a much more fundamental way than any of the others because it deals with the philosophy of publication and access to Simon Gay opens proceedings in this issue with published material in the research sector. I am really a slightly disturbing piece. You may superficially pleased to publish this article in this journal as it is think that clinical professionalism (and I choose this keenly relevant to many of the medical researchers at broader term than medical professionalism because Keele University that the NSMI supports and it brings I see no reason why his conclusions do not apply us into the game. It is also the piece which has given across the various healthcare professions) might be a me most cause to stop and think, to examine our own rather dry subject, but his conclusion that the future future in an ‘Open Access’ publication culture. of our professions will be to some extent determined as much by the personal examples we set daily as by Thanks go once again to Tracy Hall as she rounds lectures and the curriculum certainly left me feeling a heavy burden of responsibility. The argument is off her series of papers on interstitial lung disease. essentially that, in matters professional, the courtesy, She explores care at the end of patients’ lives and the care and compassion we exhibit in practice, witnessed necessary future direction of study in the care of ILD by impressionable young charges probably does more patients facing their end. to shape their clinical behaviours of than preachy education campaigns.1 The middle section is full of news, a lot of it quite recent, to keep you up-to-date with happenings in and These notions of professionalism might be tested around the institute. In amongst the usual endpieces harder in few other places than in the assisted dying I will draw your attention to Helen Alcock’s two book debate. Paul Laszlo’s piece lays out some of the context and some of the arguments and seems to leave us with reviews. These are short carefully crafted pieces which the question “What’s all this got to do with doctors?” are not, on this occasion, about books that might be Intrigued? You’ll just have to read it to find out what rather interesting to read, but about books that might be a really deep reading experience. he’s on about.

Those of you who are doctors and are scrabbling about in order to compile your evidence into your portfolio to present at annual appraisal so appraisals can be collated by your Responsible Officer to make a recommendation to the GMC about revalidation may feel hard done by and picked upon. Perhaps that we’ve been picked out for special scrutiny. But are we such admirable leaders that where we go other health professionals will surely follow? Well the government certainly thinks so. To cheer up nurses and midwives they’ve been asked to join the appraisal party. Helen Inwood unpacks the dress code.

And if the articles feel at any moment like too much to get stuck into, why not test yourself with a quiz question or two, or just look at the images?

At the end it seems fair to observe that death hovered quietly over this issue of the journal. Assisted dying is covered in an editorial piece, care of the dying in ILD is explored by Tracy Hall and Atul Gawande’s book is all about dying. Interestingly the concept of assisted dying doesn’t even linger out of sight in the latter pieces. That’s worth a third thought.

A warm welcome back to Vera Cartlin who is either telling you a few things about HG wells that you knew REFERENCES anyway, or telling you one or two interesting things you really didn’t appreciate before. And she provides an excuse to use that splendid illustration on the front 1 www.england.nhs.uk/wp-content/uploads/ 2012/12/6c-a5-leaflet.pdf cover too.

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PROFESSIONALISM: WE ARE WHAT WE TEACH!

Simon Gay, Director of Curriculum, Keele University School of Medicine Until recent times, most newly qualified doctors would have quite reasonably thought that the professional concepts, attitudes and behaviours they embodied at graduation would see them through the rest of their careers without any suggestion of the need for change. However, inimical matters such as poor outcomes in paediatric surgery at The Bristol Royal Infirmary1, the crimes of Harold Shipman2 and, nearer to home, the findings of the Francis report3 have forced a change in that thinking. We must now all accept that we can no longer follow our careers with the concepts of professionalism that we started out with. If we fail to adapt, we risk the profession’s social contract with society becoming null and void.

Add in the meteoric rise in importance of the internet, the rapidly growing popularity of various forms of social media and the cumulative granularity of formal guidance on professional standards published by the General Medical Council (GMC) and one starts to appreciate the magnitude of the challenge facing young clinicians as they develop their own personal constructs of professionalism within their practice of medicine.

Yet this continuing development of professionalism, the ultimate CPD one might say, can be difficult enough for experienced clinicians to accomplish over many years. How much more difficult is it therefore for medical students to grasp a rudimentary construct of professionalism soon after admission to medical school and then to take that rudimentary construct and further develop it over the five years of an undergraduate medical course?

It is 10 years since Hilton and Slotnick proposed that achievement of professionalism is encapsulated in the Greek word phronesis or practical wisdom and that the developmental time leading up to this is a period of “proto-professionalism�.4 These concepts are simultaneously both simple and profound and it is appropriate to reinforce their relevance for medical students and the wider profession because several consequences arise if you consider the model valid.

Firstly, the rapid changes previously described combine with the concept of proto-professionalism to dictate that we must teach professionalism we cannot On a more encouraging note, despite pernicious wait for it simply to develop in different individuals events such as those described above, doctors have at different speeds. so far consistently topped the frequent lists of most respected professionals in UK society. How then Secondly, the teaching of professionalism emphasises do we ensure the continued positive perception of the need for assessment tools and other mechanisms our profession in the eyes of the public in the face by which to assess it. Clearly such tools are still far of accelerating change and increasing regulation? from ideal but the use and credibility afforded to And what can we, as individuals, contribute to this multi-source feedback and situational judgment tests undertaking? would be good examples of the direction and distance travelled so far.

Well, we can start by changing our concept of professionalism. Clinicians across the full breadth Thirdly, proto-professionalism requires us to consider of medical practice must consider their individual the standards of behaviour that are appropriate to professionalism as being in need of continuing students at different stages of their undergraduate development, challenge and review in much the same life. Few people would believe that a first year student way as they would consider that their core clinical should be judged by the same professional standards knowledge or procedural skills ought to be updated so that they continue to perform their clinical duties as a final year student, but what about a second year in a competent, safe and effective manner. Such student and a third-year student? Or a third year and a an approach is relevant to us all and appraisal and fourth year? How do you differentiate between them? revalidation, whilst a relatively blunt instrument, will Where do the watershed boundaries in professional continue to require us to provide some evidence that standards lie in the undergraduate continuum and does that also translate between different medical such a developmental process is taking place.

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school curricula? These are easier questions to ask than to answer but medical schools’ health and conduct systems for medical students across the country wrestle with these issues on a regular basis ably supported by GMC and Medical Schools Council guidance on medical student professional values and fitness to practise.5 Though even this document is currently under review in order for it to remain relevant and be more closely aligned with the latest version of Good Medical Practice.6 The publication of a new version is expected in 2016.

Finally, if proto-professionals are learning to be fully fledged professionals in their own right what inputs are informing their development? As an educationalist I would really like to believe that formal instruction through lectures, tutorials and the written word led the way. However, the reality is that day-to-day contact with clinicians presents the largest stimulus. The role modelling offered by respected clinicians is truly powerful in its effect on medical students, and that places an important and fundamental responsibility on the shoulders of each individual.

Our clinical environment is ever changing and as the demands of the clinical environment continue to rise it can be difficult to project a positive image to less experienced colleagues but this is precisely the time when that image matters most and “role modelling consciousness”7 is an important part of the armoury of the modern clinician. Further, we know that wherever the clinical teacher can articulate to the medical students the particular aspect of professionalism being role-modelled in a given situation the student perception of the teacher is itself further elevated.8 That is not to say that we can or must be the epitome of perfection in all aspects of clinical practice at every moment of every day but we do have a professional responsibility to ensure that the net effect of our influence on the educational process is positive.9 So I will conclude by issuing a challenge to all clinicians. Please reflect on how the role model you project during your next clinical encounter might be perceived by any learners nearby. Is your net effect on the educational process positive? For when it comes to professionalism, a lot of the time we are what we teach!

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ADDRESS FOR CORRESPONDENCE s.gay@keele.ac.uk REFERENCES 1

Department of Health (2001) Learning from Bristol: The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1982-1995

2

Smith J The Shipman Inquiry First Report. Death disguised (2002)

3

Francis R Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Department of Health (2013)

4 Hilton SR and Slotnick HB Proto-

professionalism: how professionalisation

occurs across the continuum of medical education Med Educ (2005) Vol 39 pp58-65 5

General Medical Council and Medical Schools Council (2009) Medical Students: professional values and fitness to practise

6

General Medical Council (2013) Good Medical Practice

7

Wright SM and Carrese JA Excellence in role modelling: insight and perspectives from the pros Canadian Medical Association Journal (2002) Vol 167 pp638-43

8

Balmer D, Serwint JR, Ruzek SB, Ludwig S and Gairdine AP Learning behind-the-scenes: Perceptions and observations of role modelling in paediatric residents’ continuity experience Ambul Pediatr (2007) Vol 7 pp176-81

9 Creuss SR, Creuss RL and Steinert Y Role

modelling – making the most of a powerful

teaching strategy BMJ (2008) Vol 336 pp718-21 Midlands Medicine

THE DEBATE THAT WILL NOT DIE Paul Laszlo, Consultant Physician

This is about assisted dying which has gained a formal meaning as a term, not helping someone to die, which may or may not be a bit dodgy. Assisted dying has become a technical term distinct from a simple interpretation of the words in English because of attempts to legalise it. (And I am concerning myself here not just with English, but also with England as laws do vary across the UK.) Put complexly, assisted dying is the medicalised facilitation of the bringing forward of a death which appears to be inevitable in a foreseeable timeframe, generally six months. Put more simply, it is about using medical supervision and means to bring lives to an end in the context of terminal disease. (But in making that simplification I’ve already strayed from the territory over which debate has usually been conducted which generally avoids those questions which may be asked around the administering a lethal dose of opioids to an already unconscious patient in the final hours or days of life.) In practice recent legal discussion of assisted dying has been more about the role of a doctor giving a prescription for an intentionally lethal cocktail of drugs that a patient can get fulfilled and then self administer at will, Dignitas-at-home, if you will.

There are awkward distinctions to be made between the term assisted dying as debated in parliament and other terms describing entities on the same spectrum.

So far as is possible in territory such as this I am putting moral questions to one side ― they entail a whole other discussion. One starts with the questions of suicide, self wrought death or assisted suicide and of euthanasia, intentional killing of someone for a perceived (medical) benefit to them. Both assisted suicide and euthanasia may be covered by the term ‘mercy killing’. The definition of euthanasia is messy as it concerns both commission (active euthanasia), as is most usually understood by the term, and omission, most usually practised, probably (also called ‘passive euthanasia’, covering withholding or withdrawing life-maintaining treatment, even though withdrawing treatment is, arguably active).

Euthanasia is potentially carried out with the knowledge, connivance or at the direction of the person dying, in which case it is very close to assisted suicide, but it can also be done without the knowledge or agreement of the person killed, such as if they were unconscious, delirious or suffering advanced dementia. Under current law in England that is tantamount to murder.

(Nowadays, as these arguments have become more complex and much hangs on precise use of terms: Volume 27, No 6, October 2015

‘non-voluntary euthanasia’ is used to refer to killing a person in a well meaning way without their sentient participation, ‘involuntary euthanasia’ would cover the circumstance in which there was, or previously had been, some explicit statement of a wish not to be killed whilst ‘voluntary euthanasia’ covers the situation where someone asks to be killed.)

Suicide is taking one’s own life, often by desperate and/or depressed people. Sometimes people who commit suicide are neither desperate nor depressed; they may reach a rational considered determination that it is their best course of action under a particular set of circumstances. Assisted suicide is where the determination to end the life comes from the person concerned but they can’t physically manage to carry out the act themselves. Assistance can range from merely supplying drugs for a person to take themselves, through helping them to take drugs by mouth that they cannot manage to take themselves (to lift the cup to their lips, to pass them the pills one by one), to rigging up and connecting contraptions to deliver fatal treatment, perhaps by injection or infusion or inhalation. Where assisted suicide is not in the context of depression or a rational philosophical response to apparent pointlessness of life, but in the context of disease and suffering, most particularly towards an anticipated end-of-life, the term assisted dying is used, and in this setting it is argued that “An assisted dying law would not result in more people dying, but fewer people suffering”.1 The main argument in favour of an Assisted Dying Bill is that suicide is open to those who are physically able but there are those whose disease enfeebles them just as they are beginning to suffer most, and so are most likely to wish to use death as an unarguably effective release from their suffering*. And here things continue to be unfair since those with financial means and family support can go over to Switzerland and avail themselves of Dignitas’ services. For those without that option the difficult choice lies between committing suicide earlier, whilst they can still manage that unassisted, or hanging on for longer and risking suffering pain and loss of dignity at the end of life. That people should be put in such a position is held to be inherently unfair, utterly unjust.

A related argument is covered in the title of the play Whose life is it anyway?2 Which is that people are individual and have autonomy in their important 227

decisions in their lives, by right, where they do not directly harm others, and that there is no counterright of the state or society to prevent a rational suicide: indeed, where a paralysed man makes an election for rational suicide the state ought to assist him.

Both these positions have their merits. Where you stand will depend on what you believe. The arguments have been rehearsed in England on two occasions in recent years. Firstly there was Lore Joffe’s bill in 2006 which got stuck in the Lords where it was delayed, indefinitely, only to be supplanted by a more recently defeated Bill introduced by Lord Falconer of Another argument is that we live in a representative Thoroton in 2013 “A Bill To enable competent adults democracy and that the majority of society support who are terminally ill to be provided at their request with specified assistance to end their own life; and legalisation of assisted dying. for connected purposes.” This was defeated in the There is an umbrella organisation for the opposite Commons in September 2015. camp campaigning against the legalisation of assisted Focussing down to the type of assisted dying, dying, assisted suicide and euthanasia, voluntary or essentially assisted suicide in those facing death, otherwise.3 Their essential arguments are that people that has been contemplated of late in our houses of who are elderly, frail and diseased might be pressured, parliament I would like to state one fear and ask one actually or in their own perception, by their families question. into pursuing assisted dying if it were an option available to them; that there is a spectrum and that My fear: proponents will keep bringing this back repeatedly until the law changes not because the however carefully a law is crafted to mean nothing arguments have been won but because MPs get tired more than assisted dying, it will lead to sequentially of rehearsing them and just yield through weariness. to assisted suicide, to voluntary euthanasia and to This is a similar fear to the idea of a neverendum in euthanasia. This argument caries some merit if one Scotland where the nationalists, instead of seeing looks at the developments in Belgium. The law allowing the independence referendum of 2014 as a oncevoluntary euthanasia for those in severe physical pain in-a-lifetime event, might decide to keep testing which could not be treated was first passed in 2002. the waters each few years until a majority in favour In 2012 a patient requested euthanasia for depression of independence is achieved. Of course, after that and her wish was granted and set a precedent. In there would be no going back, no vote to re-join with 2014 the lower age limit came down to 12 years. (It England at a later date. Such a change would not be would be churlish to avoid saying that many who fear a reversible experiment, just an experiment. But, this ‘slippery slope’ as a real phenomenon are also that fear is hopefully groundless and the situation is probably more like the votes on bringing back capital minded to place weight on the sanctity of life from a punishment. The idea often carries popular support faith perspective and that any euthanasia is anathema but MPs have consistently taken a view against its to them.) return in 1974, 1979, 1983, 1988 and 1994. In 2013 a Bill was introduced but failed to progress.

Additional arguments are that compassionate palliative care will not be supported as much when My question: If there is a genuine need for society there is the swifter and altogether neater option of to provide a means for those who wish to end their procuring a timely death and that this whole approach lives but who are physically unable to do so, or prefer degrades and devalues the esteem in which life is to die in a certain, humane and reliable way by their held. (There is an onwards argument from some with own hand, or with the assistance of others, why is this disabilities that there is a spectrum of thinking, which an appropriate role for a medical practitioner? Why runs from pre-natal termination to assisted dying and does a doctor have to do the deed of prescribing or euthanasia, which regards severe physical and mental even administering the lethal cocktail? handicap as something to be got rid of from society, With ever more types of prescribers working under along the lines of eugenics.) There’s also the argument specific training and licence conditions perhaps that many people who choose to try to die in these there is a place for licensing some special appropriate circumstances, and can’t manage it, often retreat from individuals for the very particular task of helping a pressing wish to die, at least for a time, but if assisted those who wish to die at a time of their choosing. dying had been successfully applied they’d have had (This technical bureaucratic constraint is something we do well in England: We can be very fussy, no such second chance. It’s just too final too early. detailed, specific. We are in the case of bats: “You’re 228

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breaking the law if you … possess, sell, control or transport live or dead bats, or parts of them” without an appropriate licence.4 There are four levels of licensing for researching bats, and separate licences for handling live bats and dead bats. To apply for the latter you must first become a member of the Guild of Taxidermists then register with the government department called Natural England and give an undertaking that you will only keep dead bats, or parts thereof, for scientific or educational purposes.

We also have licensing systems for interactions with badgers, hazel dormice, shrews, crayfish and many others. A country capable of this detail covering our dealings with nature and the environment could craft legal structures, having the effect of safeguards, in which assisted dying practitioners could be supported to do the things society asks of them in the way society feels reassured about.) The medical input in these situations, if required at all, could be limited to one, all or none of the following: oversight, supervision, arms length signing off of due process, necessary medical input in terms of sensible clinical review and relevant technical informing.

of assisted dying practitioners is worth a thought. For my part, I’d be relieved to keep doctors out of it as far as possible as it seems an anti-Hippocratic Rubicon to cross to make doctors instruments of death rather than companions on the journey.

So if this debate won’t die, let us not be guilty of repeating ‘the same thing over and over again and expecting different results’5 let us move the arguments on. Society sees a need for better, clearer and, in its terms, more compassionate law around the supervision of death. In terminal care in the medical setting, that obviously lies in the hands of healthcare professionals and there’s certainly room for discussion, learning and improvement but for assisted dying in the terms considered in recent parliamentary debates, we need to look at the arguments afresh if the debate is ever going to move on. We can’t just import a law from an American state such as Oregon or California, or from a European neighbour such as Belgium. This is England where an English solution is needed. If we are ever going to allow legal assisted dying the notion

REFERENCES

*Mainly the diseases concerned in high profile cases have been neurodegenerative in nature such as motor neurone disease or multiple sclerosis, but any chronic progressive physical illness which involves pain, and/ or breathlessness, and/or loss of control can make people consider ending their lives early. Cancer would, one might at first think, naturally come into this fold but it does seem to run differently with a much more natural medical involvement. This is probably due to an often quick transition from active treatment and hope to palliative care which is then enfolding and expert; the trajectory is different from neurodegenerative disease.

1 Dignityindying.org.uk 2

Clarke B Whose life is it anyway? (1972) First a television play, then a stage play (1978) and finally a film (1981)

3 Carenotkilling.org.uk 4 www.gov.uk/government/collections/bat- licences 5

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Volume 27, No 6, October 2015

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NURSING AND MIDWIFERY REVALIDATION

Helen Inwood, Deputy Chief Nurse, UHNM INTRODUCTION

The Nursing and Midwifery Council (NMC) is the largest healthcare regulator in the world with more than 680,000 nurses and midwives on its register. It is responsible for setting standards for nurse and midwifery education, professional conduct and performance as well as investigating allegations of misconduct within the UK, thereby promoting patient and public protection. Revalidation for nurses and midwives with the NMC is a compulsory regulatory process and since the publication of the Francis Report it has become a Department of Health priority. The aim of revalidation is to increase public and patient confidence that nursing and midwifery professionals are up-to-date with their practice.

In March 2015, the NMC introduced a revised code of professional standards of practice and behaviour for nurses and midwives (NMC 2015a).3 It has four overarching sections, which require registrants to: prioritise people, practise effectively, preserve safety, and promote professionalism and trust. The code plays a pivotal roles in the revalidation process, by acting as a framework to which registrants link their updating activities.

All registrants are required to maintain a professional portfolio which contains the following components:

Evidence of 450 hours worked in the preceding three years: a registrant is required to provide evidence of 450 hours worked for each part of the professional register listed. This means for example, a registrant who holds a dual registration, as a nurse and as a Nurses and midwives are required to be on the Nursing midwife, will have to demonstrate 450 hours worked and Midwifery professional register to practise within in respect of each part of the register over the three the United Kingdom. When the PREP (Professional years period to maintain their registration on both Registration Preparation and Practice) regulation was parts of the professional register. The NMC requires introduced by the NMC in 1995 all registrants were the date, the name and type of organisation where the required to maintain a portfolio containing evidence hours are worked, a brief description of the activities of 450 practice hours, 35 hours of continuous undertaken and the scope of practice in relation to professional development and reflection of practice patient care. within a three year period. However at this time there was no robust mechanism to check the compliance Evidence of 35 hours of continuing professional with this process and although the NMC did call for development: There is flexibility on how this can be some registrants to produce their portfolios it was not evidenced, but only a maximum of 15 hours of this development can be through the numerous e-learning a sustainable process. packages now available to healthcare professionals.

In 2011 the NMC introduced a system whereby The remaining 20 hours will be through participatory nurses and midwives were required to provide a self- learning, that is with others. There has been debate declaration of fitness to practise triennially in addition whether mandatory training can contribute to this to an annual fee to maintain their registration.1 The development, and this is dependent upon whether registrant’s renewal date corresponds to the month the training is a nurse related activity. Annual fire and year in which they were first admitted onto training would not be considered appropriate whereas the NMC register. Revalidation, which comes into medicine management would. There are multiple effect from April 2016, supersedes this by replacing learning opportunities that occur regularly in practice, the self-declaration component with a third party e.g. learning a new skill or technique, attending MDT declaration that each registrant meets the NMC’s meetings to facilitate a plan for a patient with complex minimum requirement. The NMC guidance asserts needs and questions and answers raised during that revalidation is a professional development handover or patient review. There is no protected activity and not a disciplinary procedure, although it time to enable staff to undertake this professional is a mandatory regulatory requirement (NMC 2015).2 development 230

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Feedback on practice. The portfolio needs to contain five examples of feedback on practice. Feedback is considered as anything that provides the individual registrant with greater insight into the effects of their practice and can be from a variety of sources such as, patients, relatives, staff, complainants, audits and inspection reports.

assessing of the validity of the information. If the content is deemed satisfactory the Confirmer will sign a declaration to that effect, but this is not or be confused with confirmation on whether or not a person is fit to be on the professional register.

Professional development discussion. Once the registrant has met and recorded the episodes of professional development, practice-related feedback and written reflections required for revalidation they will need to have a professional development discussion with a third party who is also on the professional register. This discussion will allow individuals to verbalise how their learning relates to the code and how it has affected their practice and delivery of patient care.

The revised process for revalidation aims to provide more assurance to patients and the public that the standards of professional practice are being maintained and up-dated and are in line with the government’s expectations and policy.

To renew their professional registration, the nurse or midwife will complete a form, verified by the confirmer Written Reflection. There is no formulated approach and submit this to the NMC for consideration. The to this but the content of the five written reflective NMC will ask a random selection of registrants on pieces must contain the type and context of learning an annual basis to submit more evidence from their undertaken or feedback received, how learning and portfolio electronically as part of an auditing process feedback has affected practice and how it relates to and final details of this process are awaited. any of the four revised aspects of the professional code CONCLUSION of conduct.

REFERENCES

1 Confirmation.

A registrant’s confirmer would ordinarily be his or her line manager, regardless 2 of whether they are on a professional register.

Confirmation is the process of verifying that the 3 information in an individual registrant’s portfolio

meets the minimum NMC requirements, not the

Volume 27, No 6, October 2015

NMC (2011) The Prep Handbook. Nursing and Midwifery Council. London NMC (2015) Revalidation. www.nmc.org.uk NMC (2015a) The Code: Professional Standards of Practice and Behaviour for nurses and Midwives

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HG WELLS IN STOKE-on-TRENT Vera Cartlin, Resident That is a poor title because in 1888 when HG Wells spent time locally at 18 Victoria Street, Basford, literally just round the corner from the Hartshill road on which the NSMI presides, Stoke-on-Trent did not yet exist. But it might have done as 1888 was the year in which the move was first proposed as an amendment to the Local Government Bill of that year.

The ‘six towns’ of Stoke, were actually a constellation comprised of the Municipal boroughs of Stoke, Longton and Burslem, the County borough of Hanley and the Urban districts of Tunstall and Fenton. These

were federated in 1910. This grouping gained city status in 1925, though it had to do this by direct appeal to King George V as technically it was not entitled to the categorisation as it had fewer than the 300,000 inhabitants, the threshold then normally required. It might well have fulfilled the quota if it had managed to amalgamate with the borough of Newcastle-underLyme, but there was stiff opposition to the proposal from the latter’s residents, and so it has remained at each subsequent attempt to date.

Wells was born in Bromley, Kent in 1866. Before coming to Basford had had a difficult upbringing mainly engendered by the need to support himself as he went along even from quite a young age. The more difficult times saw him as a draper’s apprentice and the better times as a teacher-pupil, one who is taught and pays their own fees by teaching younger pupils.

He moved between the two as circumstances dictated or allowed. Eventually he went to study sciences in London at South Kensington at the Normal School of Science. After finishing there in 1887 he turned up in Basford where he lodged with friends at number 18. (This is marked today by a small plaque to the left of the front door.) The following year was spent

between there and the Leopard Hotel in Burslem.

How he spent that year is not well attested but it is likely that he pedalled himself as a tutor and started to write stories, though these were only published later.

Albeit but a short period of his life was spent in these parts, like many of his experiences, it is reflected in some of his stories.

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HG Wells is well known for a few particular works but wrote continually through his life, publishing over a hundred books, mainly stories, and many articles, plenty of which were campaigning in nature. Those better known books include The War of the Worlds, The Time Machine, The Island of Dr Moreau and The Invisible Man. Not so well known is that, at about the Midlands Medicine

same time as he was working on the war of the worlds, and at the same time as The Time Machine came out (1895) Wells published a short story The Cone in which Stoke towns feature; he clearly drew on his time here. Its climax is set in a foundry (based on an iron works at Etruria) where a middle class educated man of poetry meets a macabre end just beyond the hands of his cuckoldee, a man of iron. On the way they walk along some railway tracks. The description of the journey gives us a contemporary, if rather literary, somewhat gothic, description of what life was like in the area in the late 19th Century. The story is out of copyright now so I may quote liberally to make this point: “A blue haze, half dust, half mist, touched the long valley with mystery. Beyond were Hanley and Etruria, grey and dark masses, outlined thinly by the rare golden dots of the street lamps, and here and there a gaslit window, or the yellow glare of some late-working factory or crowded public-house. Out of the masses, clear and slender against the evening sky, rose a multitude of tall chimneys, many of them reeking, a few smokeless during a season of "play."

Here and there a pallid patch and ghostly stunted beehive shapes showed the position of a pot-bank, or a wheel, black and sharp against the hot lower sky, marked some colliery where they raise the iridescent coal of the place. Nearer at hand was the broad stretch of railway, and half invisible trains shunted - a steady puffing and rumbling, with every run a ringing concussion and a rhythmic series of impacts, and a passage of intermittent puffs of white steam across the further view. And to the left, between the railway and the dark mass of the low hill beyond, dominating the whole view, colossal, inky-black, and crowned with smoke and fitful flames, stood the great cylinders of the Jeddah Company Blast Furnaces, the central edifices of the big ironworks of which Horrocks was the manager. They stood heavy and threatening, full of an incessant turmoil of flames and seething molten iron, and about the feet of them rattled the rolling-mills, and the steam hammer beat heavily and splashed the white iron sparks hither and thither.

Even as they looked, a truckful of fuel was shot into one of the giants, and the red flames gleamed out, and a confusion of smoke and black dust came boiling upwards towards the sky.”

mill sprang upon them suddenly, loud, near, and distinct…the hot water that cooled the tuyeres came into it [the canal], some fifty yards up - a tumultuous, almost boiling affluent, and the steam rose up from the water in silent white wisps … then [the white hot iron went] through the rolling-mills, where amidst an incessant din the deliberate steam-hammer beat the juice out of the succulent iron, and black, halfnaked Titans rushed the plastic bars, like hot sealingwax, between the wheels [of the rolling mill] … the tumbled fire writhing in the pit of the blast-furnace. It left one eye blinded for a while. Then, with green and blue patches dancing across the dark, they went to the lift by which the trucks of ore and fuel and lime were raised to the top of the big cylinder.” The glow over the potteries seen of an evening is thought to have inspired the vision of an earth attacked by incendiary aliens in The War of the Worlds.

At one point in The Cone Horrocks and Raut cross a railway line which must be, according to its natural location, the loop line between Etruria and Hanley which was used to deliver ore and coal to the foundries.

The description is a little poetic: “the further view of Etruria and Hanley had dropped out of sight with their descent. Before them, by the stile rose a noticeboard, bearing still dimly visible, the words, Beware of the Trains, half hidden by splashes of coaly mud.

‘Fine effects,’ said Horrocks, waving his arm. ‘Here comes a train. The puffs of smoke, the orange glare, the round eye of light in front of it, the melodious rattle…’ ”

Bradshaw’s Handbook of 1861 gives us a different perspective on the area: His entry for Etruria refers to the presence of Josiah Wedgwood’s mansion and the potteries but also refers to the almost overwhelming presence of the iron works of the Duchy of Lancaster threatening to destroy the natural beauty of the place. Of Burslem, Bradshaw notes a population of 15, 954, its status as a telegraph station, that the hotel is called the Leopard, that market days are Mondays Wells must have spent a fair amount of time in and and Saturdays and that fairs occur at various times around iron works as he fully appreciated the process: including Midsummer day and Whit Sunday which “As they came out of the labyrinth of clinker-heaps is the only place in England where a fair is held on a and mounds of coal and ore, the noises of the rolling- Sunday. The bankers at Burslem were Alcock & Co. Volume 27, No 6, October 2015

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Victoria Street, Basford Away from his literary pioneering in science fiction and all his other artistic achievements, Mr Wells was something of a ladies’ man. Considering the mores of the day he is lucky that he was met with appreciation for his writing and not condemnation for his philandering!

One possible lesser known fact that earns HG Wells a place in a medical journal is that he was co-founder with his own physician, Dr RD Lawrence, a fellow diabetic, of the Diabetic Association in 1934 (renamed the British Diabetic Association in 1954 and further re-named Diabetes UK in 2000). In typical style for a man of letters, he did this by writing a letter, published in The Times on 15th February, inviting diabetics of sufficient means to pay a subscription to join with

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him in creating an association open to all diabetics “for mutual aid and assistance, and to promote the study, the diffusion of knowledge, and the proper treatment of diabetes in this country”.

And the answer to the question that’s been plaguing some of you since the start: Herbert George.

ACKNOWLEDGEMENTS The information presented here was sourced from a wide variety of sites on the internet, including Diabetes UK, and from a reprint of Bradshaw’s 1861 Handbook. The picture of HG Wells is from a public domain source and the other pictures are my own.

Midlands Medicine

THE NEW WORLD OF ACADEMIC PUBLISHING: WHAT ‘OPEN ACCESS’ MEANS FOR RESEARCHERS Mark Ormerod, Deputy Vice-Chancellor & Provost, Professor of Clean Technology & Inorganic Materials Chemistry, Keele University; Ellie James, Head of Research Support Services, Directorate of Engagement & Partnerships, Keele University; Mark Smith, Research Manager, Institute for Science & Technology in Medicine, Keele University internet has enabled a broader readership, bringing research to the attention of practitioners, policy ‘Open access’ means unrestricted, online access to the makers, industry, journalists and the general public which in the past would have been read only by a published findings of research. handful of other scholars.

As a result of national reviews, government statements and pressure from research funders to ensure research As colleagues will be aware, the Open Access agenda results are Open Access. Researchers are being continues to change rapidly following national encouraged to ‘Act on Acceptance.’ From 1 April 2016: reviews, various government statements, changing policies from research funding organisations and the Research papers must be deposited in an publication of HEFCE’s policy (Higher Education 'open' repository (such as Keele University's Funding Council for England) on Open Access for own repository) within three months of the next Research Excellence Framework (REF).

Publications submitted to the next REF must be acceptance (not at time of publication) freely available via Open Access, whilst some research funders including Research Councils UK and many Papers may be embargoed for 12 months if charities are also increasingly requiring publications

required by the publisher. from research they have funded to be freely available via ‘gold’ Open Access.

Papers which do not comply will not count for the next Research Excellence Framework (“REF2020”).

This paper is intended to give colleagues in Keele and its partner NHS organisations an update on open There are two routes to achieve Open Access – access and recent policy, and various developments we ‘gold’ and ‘green’. The 'green' Open Access route is have now put in place, including our new institutional acceptable, avoiding the high costs of using a full Research Repository linked to our Publications Open Access ‘pay to publish’ journal. Advice and Database, to ensure we have systems in place to help is available from the Keele University Open fully support the Open Access agenda and research Access team http://www.keele.ac.uk/researchsupport/ generally, and in doing so raise the visibility, profile openaccessandrepository/ and awareness of research undertaken at Keele, as well as ensure full compliance with HEFCE and research NEW OPEN ACCESS REQUIREMENTS FOR funders’ policies.

RESEARCH – CREATION OF A RESEARCH REPOSITORY AND DATABASE In the interests of sharing the results of our research with the widest audience, ensuring accountability for Academic publication is changing. In response to the our use of taxpayers and donors funding, and driving explosion of research publications in the last 20 years, work in the UK forward for maximum benefit to and the vast number of academic journals which have patients, we are sure colleagues find the developments sprung up, various attempts have been made to bring positive and this paper helps to broaden understanding significant research results to a wider audience. The of the Open Access objectives.

SUMMARY

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which is available on Keele’s webpages dedicated to supporting all members of the University meet the new requirements, at: http://www.keele.ac.uk/ HEFCE has published its new Open Access policy researchsupport/openaccessandrepository/. Keele’s for the next REF but the exact details of the next REF developed its Open Access policy rapidly to address will not be known until 2017, however, it is assumed the needs it raises; it is very similar to those of the it will assess publications up to 2019 and is known majority of research-intensive universities, including, unofficially in the university sector as “REF2020”. for example that adopted by Cambridge.

HEFCE, Open Access policy applies to all Journal articles and Conference proceedings which are Keele has a well established Publications Database accepted for publication after 1st April 2016. It states which records almost all its published outputs, that ‘to be eligible for the next REF, author’s final peer- links these to its webpages and generates valuable reviewed manuscripts must have been deposited in an information about the University’s research activity. institutional or subject-based repository on acceptance Over the past year considerable work has been undertaken to ensure Keele has a fully-functioning, for publication’1 fit-for-purpose, modern Research Repository that Researchers have a maximum period of 3 months fully meets all external requirements, including after the date of acceptance to deposit the paper in those of HEFCE and research funders. Keele’s new a repository. Some publishers will have an embargo research repository is hosted by EPrints, one of the period typically 12 months which will restrict the two market leaders across the sector, and can be found visibility of the full text but not the ‘metadata’ e.g. at: http://eprints.keele.ac.uk/. Keele has invested in a basic details of author(s), date, title, journal, volume. dedicated Research Support Librarian expert, Scott In the medical and physical sciences, the REF main McGowan (s.mcgowan@keele.ac.uk) to support the panels A and B have decided that the maximum development of Open Access through the Repository. embargo period should also be 12 months; longer is The investment Keele has made in its Research being allowed in the social sciences and humanities.

Repository and Open Access Policy give benefits to all HEFCE has a very useful section about Open Access members if the University including research students on its webpages at: http://www.hefce.ac.uk/rsrch/ and current honorary title holders at Keele (e.g. oa/ which provide an overview, a list of frequently Honorary Professor, Honorary Clinical Lecturer) who asked questions by the research community and have a Keele HR record. It is therefore of particular administrators, and updates on current projects, e.g. benefit to research-active members of our local and one on research monographs in the humanities and regional partners in the NHS. social sciences.

WHAT ARE THE BENEFITS OF GREEN OPEN HEFCE has undertaken an analysis of all the outputs ACCESS? submitted to the 2014 REF and concluded that 95% of all outputs could have been compliant with its new The benefits of green Open Access through an policy if appropriate institutional or subject-based effective institutional Research Repository linked repositories were in place. However it has since made to the Publications Database are potentially very some modifications to its policy and timescales as a significant, increasing the visibility, profile and awareness of research undertaken at Keele University, result of pressure from researchers and institutions.2 hence increasing the University’s research and wider institutional reputation internationally. All members KEELE’S APPROACH TO OPEN ACCESS of Keele staff have a Staff Profile Page on the Keele Keele, and the university sector as a whole, website, and this includes many holders of Keele strongly supports the ‘green’ open access route, honorary titles as well (for an example for one of the whereby researchers deposit their publications in authors see http://www.keele.ac.uk/chemistry/staff/ an institutionally hosted repository (or subject- mormerod/). As a result of green Open Access all based repository like “arXiv” - http://arxiv.org/). research publications will be fully and freely accessible This is reflected in Keele’s new Open Access policy, to anyone from a researcher’s Keele webpage. On the NEW OPEN ACCESS REQUIREMENTS FOR PAPERS SUBMITTED TO THE NEXT REF

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Staff Profile 'Publications' tab, next to the paper will be a 'full text' link which takes anyone with internet access straight to the full text of the paper in the repository. The publications will also be freely and fully accessible to anyone, including all search engines such as Google, on the web via the Repository: http:// eprints.keele.ac.uk/ In addition to increasing the profile and awareness of research undertaken at Keele, having all publications freely and easily accessible to anyone with internet access, and being picked up by search engines, will potentially significantly increase the future citation of papers, which is clearly an important metric in its own right, particularly in some research areas. It will bring other research benefits too , including potentially increased conference and lecture invites, invited paper requests, more collaborative and partnership opportunities with academic and non-academic organisations, as well as increasing opportunities for non-academic impact of some publications.

The vast majority of publishers also allow researchers to use the green Open Access route, but sometimes this can involve an embargo period whereby the full text is not visible for a period of 12-24 months. Note that the publication must still be uploaded to the Keele Research Repository but will be hidden from view until the embargo period has passed. Up to that time only the metadata will be visible, and at the end of the embargo it will automatically become fully visible to anyone.

Keele University currently receives limited funding to support Article Processing Charges (APCs) for the gold route relating to publications from:

• Research Council UK funded research some research • Charities (most notably in Keele’s context, Wellcome Trust, Arthritis Research UK and Breast Cancer Campaign), through the new Charity WHAT DO RESEARCHERS NEED TO DO? Open Access Found (COAF), one of only 9 nonRussell Group institutions to be in receipt of this As soon as a researcher has a paper accepted for funding. publication, he or she needs to record this in Symplectic, the Keele Publications Database, see The Research Council UK (RCUK) funding is very https://publications.keele.ac.uk/ . This is not onerous, limited (amounting to only around 15 publications per as a minimum only the paper title and acceptance date annum) and will only fund around 10% of publications are required. Further information on the Database can based directly on research funded by RCUK grants be found at: http://www.keele.ac.uk/researchsupport/ on an annual basis. RCUK is currently reviewing its publicationsdatabase. policy on Open Access, in light of the clear steer from HEFCE towards advocating green Open Access. The Further information about Keele’s Research RCUK funding is overseen at an institutional level and Repository, including a ‘how to deposit’ video, can requests to have high impact papers resulting from be found on the webpage http://www.keele.ac.uk/ RCUK funded research considered should be made to researchsupport/openaccessandrepository/ under Scott McGowan (s.mcgowan@keele.ac.uk). The policy ‘What do I need to do?’ around the charity Open Access fund is different and based on a ‘first-come, first-served’ model, so requests DO RESEARCHERS HAVE TO PAY A FEE? to have papers resulting from charity funded research, for COAF-participating charities, considered should There is no fee associated with the green Open Access be made through Keele’s Research Institute Managers route, and it ensures full compliance with the HEFCE Mark Smith (m.e.smith@keele.ac.uk) and Claire policy and policies of the majority of research funders. Ashmore (c.ashmore@keele.ac.uk).

The European Commission has pursued the goal of Some research funders provide funding for the Open Access research publications since 2008 and gold Open Access or ‘pay-to-publish’ route, where a in 2012 decided it had to find a mechanism through payment (Article Processing Charge or APC), typically which publications could be made Open Access around £2,000 per paper, is made to the publisher to after a research grant had finished.3 The European make the publication accessible for people who do not Commission launched a pilot project to fund Open have access to the journal through an institutional or Access publications for finalized projects it supported under Framework Programme 7 (FP7), from which personal subscription.

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Keele and local partner NHS organisations held several awards, plus awards by the European Research Council. The FP7 post-grant pilot is being developed in the context of the OpenAIRE2020 project, and is aligned with the Open Access infrastructure and support network provided by OpenAIRE. This gold Open Access Pilot provides an additional instrument to make FP7 project research results Open Access.

It does not affect authors' freedom to choose which way their project publications should be made Open Access. The European Commission’s pilot will be reviewed in early 2016; at the moment it will cover OA APCs for FP7 projects up to two years after they end. A maximum of three publications per FP7 project will be funded. Funded publications must be peer-reviewed and be made available under a CC-BY licence where possible, and must also be deposited into an OpenAIRE-compliant repository such as Keele’s. Further information about Open Access in Horizon 2020 is available at: https://www.openaire. eu/h2020openaccess/

NOTE The content of this paper was correct at mid-September 2015 and based on the information available at that time. Open Access is a rapidly evolving area and colleagues are advised to address any questions to Scott McGowan or Hannah Reidy in Keele’s Directorate of Engagement & Partnerships, (email: h.reidy@keele. ac.uk, tel: 01782 733588).

ADDRESS FOR CORRESPONDENCE Mark Smith Research Institute Manager Guy Hilton Research Centre Thornburrow Drive Hartshill Stoke-on-Trent ST4 7QB

Full details of publisher’s policies are automatically m.e.smith@keele.ac.uk pulled through to Symplectic and summarised under ‘deposit advice’, so authors can check them before they upload their file, or seek advice from the Keele REFERENCES Open Access team. Alternatively publishers’ policies 1 HEFCE 2014/07 “Policy for Open Access in the on Open Access can be searched here: http://www. post-2014 Research Excellence Framework: sherpa.ac.uk/romeo/ . Details of research funders’ Updated July 2015 (http://www.hefce.ac.uk/ policies can be found here: http://www.sherpa.ac.uk/ pubs/year/2014/201407/ juliet/.

2 Researchers are permitted to use their own funds to pay APCs for papers they have published if they wish to do so, but Keele’s Open Access policy, in line with the rest of the sector, is to promote the green Open Access route. There are increasing audit requirements for compliance with Open Access policies so researchers are asked to inform their Research Institute if they do elect for the gold route and make an APC payment from their own funds, so that a central register can be 3 maintained.

WHAT HAPPENS IF A PAPER DOES NOT MEET THE HEFCE OPEN ACCESS REQUIREMENTS? It cannot be submitted to the next REF as it would be unclassified. Exceptions will be very rare, e.g. an individual was not employed by a UK university at time of submission for publication, if the paper is published via the gold Open Access route and any instances will require a written supporting case.

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HEFCE CL 20/2015 “Open access in the next Research Excellence Framework: policy adjustments and qualifications” – a CHEFCE Circular letter from David Sweeney to Vice Chancellors dated 24 July 2015 http://www.hefce.ac.uk/media/HEFCE,2014/ C ontent/Pubs/2015/CL,202015/Pr intfriendly%20version.pdf EC SWD(2012) 221/2final “Commission recommendation on access to and preservation of scientific information” dated 17 July 2012 http://ec.europa.eu/research/ science-society/document_library/pdf_06/ recommendation-access-and-preservationscientific-information_en.pdf

Midlands Medicine

INTERSTITIAL LUNG DISEASE 4 Tracy Hall, formerly Community Matron

not realistically deny patients the use of an opioid just because the evidence base specifically for ILD The fourth and last article in this series will round is lacking as there is an evidence base for other lung up the discussion of the current state of knowledge diseases which are in some ways comparable; although of treatment for people with Interstitial Lung Disease this approach may be flawed it is unavoidable to note (ILD) and explore what needs to be done next to that anecdotally and observationally opioids are advance our knowledge and care in this field. effective for both dyspnoea and anxiety.

INTRODUCTION

DILEMMAS WHEN APPROACHING THE END IN ILD When reviewing the evidence base for use of pharmacotherapy for the symptomatic relief of breathlessness it is important to consider the quality of the evidence, the validity and the generalisability of the population studied. However within the context of palliative care it is difficult to conduct studies due to the population having multi-factorial contributions to their disease processes. Studies specifically reviewing people with severe disease and palliative care may not be easy to interpret because serial reviews don’t happen as patients die, leading to fewer data points and fewer data for statistical analysis. Therefore within palliative medicine a resort to the best evidence concept is required.1 There is a deficit in the knowledge base around the most effective drug therapy treatment regimen for people with ILD generally due to the small number of trials to date. The current evidence base pertains to the diagnosis and initial management rather than treatment strategies for people with more compelling advanced symptoms of dyspnoea and compounding anxiety. Yet if we are to offer evidence-based medicine this must be addressed via a multi-centre trial which includes people with moderate to severe disease. It will not surprise you to hear that practical difficulties arise due to the poor prognosis associated with this disease.

Moreover it is ethically difficult to conduct trials in people who require effective dyspnoea management, as up till now there are no good alternative treatments available that might manage symptoms of dyspnoea effectively when compared with opioids. But if the trials don’t happen we are forced to continue with the ethical dilemma of continuing the current practice of using an approach that doesn’t have the usual formal evidence base. As practitioners we could Volume 27, No 6, October 2015

People are living longer with long-term conditions.

Changing demographics means there are increasingly older people with multiple co-morbidities. This can lead to fragmented end-of-life care in people with advanced disease, especially when the disease trajectory is variable, resulting in patients being more likely to die in hospital due to exacerbation and crisis management. It is difficult to manage palliative care needs for people with multiple pathology. The use of a supportive care plan using a holistic approach to all the patient’s needs together with advanced care planning can facilitate a plan which takes into account a patient’s wishes.2 The goal of palliative care is to provide the best quality of life for the patient by effective symptom management via pharmacological and non-pharmacological approaches.3 For patients with severe disease, with restricted mobility, who are breathless at rest, and are distressed by the degree of breathlessness then pharmacological treatment is necessary. If anxiety is compounding the situation then the compassionate approach is to introduce medication, justified by whatever evidencebase there is for the particular set of circumstances and evaluating the benefits for each individual patient. There remains the clinical difficulty regarding identification of the appropriate time to initiate treatment when patients experience a variable disease trajectory which means that patients may be stable for some time, a rapid decline can occur and death maybe acute or sub-acute. Palliative and respiratory medicine have to learn from each other so as to increase the evidence base to facilitate improved care for patients at the end-of-their life.

It is imperative to offer good end-of-life and palliative care for patients with ILD. Unfortunately there is limited literature available regarding quality of life and palliative care for patients with advanced restrictive 239

lung disease.4 The traditional approach applied in However, until this is available then the designated cancer of first curative treatment tried, and palliative clinician responsible for the care must holistically assess each individual patient’s needs, ensuring they care when that fails, is not applicable in ILD.5 are appropriately met. Effective communication To improve upon the provision of palliative and between all parties including the clinician, patient, terminal care for people with advanced respiratory carers and families and the involvement of the multidisease requires respiratory clinicians to receive disciplinary teams across the primary-secondary training in and to be competent in the delivery of care interface will help address and palliate often palliative care, with the recognition of the practitioners’ distressing symptoms for the persons concerned. own limitations so seeking the advice and support from palliative care specialists as appropriate.6 ADDRESS FOR CORRESPONDENCE We must improve access to end-of-life care within primary care, to facilitate this there is also the need Tracy Hall to improve training of physicians and health care Non-Medical Prescribing Lead Staffordshire & Stokeprofessionals so we improve communication with on-Trent NHS Partnership Trust patients and families, at all stages of the disease trajectory.7,8 Due to the poor prognosis associated Medicines Management Department with the majority of ILD with a significant number Edric House of people expected to die within three to five years, Wolseley Court then it could be suggested that upon receiving the Towers Plaza diagnosis that the patient is then entered onto the Wheelhouse Road Gold-Standards Framework (GSF) within primary Rugeley care.9 Therefore the patient will receive regular review Staffs and input from a named designated health care WS15 1UW professional, so that early identification of problems are addressed and palliative care is co-ordinated. This would mean that symptom control of problems such REFERENCES as dyspnoea is dealt with in a timely manner thereby improving upon patient care.

1 Currow DC Pharmacological approaches to However the practicality of this within primary care, breathlessness In Booth S, Dudgeon D (Eds) whereby some GPs can struggle with the concept Dyspnoea in advanced disease. A guide to of using the GSF for patients with a poor prognosis clinical management Oxford University Press such as carcinoma, could be questionable. The (2007) ability to deliver the best care requires all parties to Skilbeck JK and Payne S End of life care: a communicate effectively and to pre-empt situations, 2 discursive analysis of specialist palliative care such as prescribing the end-of-life drug pack to be nursing Journal of Advanced Nursing (2005) kept at home, so when the patient deteriorates the Vol 51 pp325-34 medication to alleviate their symptoms and to help ensure comfort and dignity is available without having 3 Varkey B Palliative Care for End-Stage Lung to obtain and cash prescriptions in. The difficulties Disease Patients Clinical Pulmonary Medicine arise when the GP who has medical responsibility (2003) Vol 10 pp269-77 for the patient, has not been able to actively engage Gilbert CR and Smith CM Advanced with the patient for whatever reason, making effective 4 parenchymal lung disease: quality of symptom management and the delivery of good end-

life and palliative care Mount Sinai Journal of-life and palliative care difficult.

of Medicine (2009) Vol 76 pp63-70 CONCLUSION 5 Spruit MA, Janssen DJA, Franssen FME and An ideal clinical development would be that further Wouters EFM Rehabilitation and palliative care in lung fibrosis Respirology (2009) Vol 14 well conducted research would produce the robust evidence base needed to enhance the care provision. pp781-7 240

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6 Lanken PN, Terry PB, DeLisser HM, Fahy

BF, Hansen-Flaschen J et al An Official

American Thoracic Society Clinical Policy

Statement: Palliative Care for Patients with

Respiratory Diseases and Critical Illnesses

Am J Respir Crit Care Med (2008) Vol 177 pp912-27 7

Davies E and Higginson IJ (Eds) Better Palliative Care for Older People Copenhagen, World Health Organisation Europe (2004)

8

Hughes RG, Hilton LK, Maglione M, Rhodes SL, Rolon C et al Evidence for Improving Palliative Care at the End of Life: A systematic review Annals of Internal Medicine (2008) Vol 148 pp147-59

9

Duck A Principles to effectively manage people with interstitial lung disease in the community Nursing Times (2009)Vol 105 pp29-30

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NSMI News The key piece of news is that during the course of the year the North Staffordshire Medical Institute has been celebrating its 50th anniversary.

On Thursday 30th April there was a dinner held at Keele Hall with guest after dinner speaker Jeremy Wade, grandson of Colonel Sir George Wade. Jeremy is a significant character in his own right and a polished raconteur, but I would hazard a guess that he’d have been not quite a match for his grandfather.

Over the summer a formal open events took place and there has been an exhibition delving into some of the history behind and associated with the Medical Institute at Hartshill.

Last month the 46th Annual Wade Lecture was presented by Mr Adrian Levine on the topic of: Journeys - The History of Cardiac Surgery in Stoke (and the rest of the world). Adrian covered three journeys. He educated us all about the general history of cardiac surgery from the early days of valvuloplasty through an atrial appendage of a still-beating heart through to heart transplants. The boom times of coronary bypass surgery rested away with the advent of percutaneous angioplasty by physicians. The absolute change in possibilities brought about by the advent of cardio-pulmonary bypass technology, and the subsequent return to operating on beating hearts and more recently the advent of laparoscopic techniques. He explained the part that cardio-thoracic surgery in Stoke had contributed to ideas and techniques adopted far and wide (perhaps rather more than you might have thought) and in the Q&A afterwards he learnt a thing or two himself from audience members with good memories explaining just what pioneering surgery had been going on quietly in Stoke many years ago.

Adrian also included his own story, from his first inkling of perhaps reading medicine, through early house jobs and then a career as a registrar. Obviously something of a perverse character, psychopathic surgeons that would have put off most physicians and many surgeons from working anywhere near them seemed to have an inexplicable allure for Levine. He survived, then flourished. He came to join a modestly staffed department and now leads in a major cardiothoracic unit. Inspiring stuff. But one of the nuggets is that fundamentally he enjoys what he does: mending people’s heart disease surgically. The enthusiasm has not been extinguished and there seemed more than enough left to inspire others: I think Adrian should be let loose on prospective medical students.

A very significant way to mark this special year took place on 15th October when, due to great benefaction by supporters of the institute, some particularly large grants by our standards were awarded as follows: £249,983.01 to Professors Mamas Mamas, Umesh Kadam, Kelvin Jordon & Ian Buchan and Drs Matthew Sperrin & Evangelos Kontopantelis to study: Major bleeding complications following acute myocardial infarction, site, frequency and impact; insight from a national and primary care perspective £249,659.00 to Nicholas Forsyth, Professors Monica Spiteri & Alicia El Haj and Drs Mohammed Haris & Ying Yang to study: A tissue engineering approach to improve lung function and clinical outcome in patients with emphysema

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UHNM News Change, development, progress and striving for excellence whilst battling a difficult financial situation and a heavy demand through the various acute portals are the characteristics of the University Hospitals of North Midlands: County Hospital in Stafford and Royal Stoke University Hospital in Stoke-on-Trent. Now that Royal tag is more than a tenuous connexion to the past. Read on ‌ THINGS TO COME The Royal Stoke Multiple Sclerosis (MS) Centre is a new concept for MS care in the region and is development is now underway. It will provide rapid access to diagnosis, enhancing and increasing our neurology services at a time when the demand for MS care is rising year on year.

The model: A designated MS Centre of Excellence with attached community-based MS satellite clinics (Hub & Spoke model) Rapid access to the service through an MS nurse on-call (9am-5pm) to reduce A&E attendance, hospital admission and length of stay.

Rapid access to diagnosis, through fast-tracked diagnostics and a one-stop diagnostic clinic Rapid access to specialised treatments Technology Enabled Care Services Coordination of patients’ long term needs with other health care providers.

Expansion of the service into Cheshire, Derbyshire, Burton, and South East Staffordshire.

THINGS ALREADY DONE Paediatric oncology clinicians at University Hospitals of North Midlands have been given royal approval after meeting Prince Harry at the prestigious WellChild awards in London recently. The team won a WellChild award for their work treating seriously ill children and were nominated by two families whose children had been treated at Royal Stoke University Hospital. They were picked out for the award from hundreds of nominations in the category of Best Medical Team.

The awards are run by WellChild, a national charity for seriously ill children and celebrate the courage of children coping with serious illnesses or complex conditions. They also honour the dedication of professionals who go the extra mile to help sick children and their families.

The seven-strong team is made up of three Children's Oncology Specialist Support Nurses, Kelly Walters, Penny Holt and Rebecca Boden, a Children's Oncology Clinical Nurse Specialist, Julie Eaton in addition to two doctors, Dr Aswath Kumar and Dr Sarah Thompson. A children's psychologist, Dr Carole Martin, completes the team. There was a double celebration for Dr Kumar, as he was also nominated separately in the Doctor category at the awards.

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Prince Harry said at the awards: "The stories we have heard tonight are moving beyond words. They remind us of the utter insignificance of our everyday worries. Yet, one of the things that always stands out is the positivity shown by those in the most difficult and testing circumstances. It is heartening to hear so many stories of happiness and hope, even through the dark times."​

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Midlands Medicine

QUIZ NIGHT

Oluseyi Ogunmekan, General Practitioner, Furlong Medical Centre, Stoke-on-Trent 5.

This is a version of a quiz we have become accustomed to doing around Christmas time each year in our

practice. It proves to be a fun way of undertaking the

serious business of keeping up-to-date.

Straight leg raising is used to determine whether a patient with low back pain has a herniated disc:

6.

Undescended testes: Infants should be referred for surgery within 4 weeks of birth:

a TRUE b FALSE

7.

McMurray’s Test: A positive test is suggestive of a tear in the meniscus:

a TRUE b FALSE

INTRODUCTION

1.

Which of the following is not recommended for use in pregnancy?

a b c d

Metformin Labetalol Ramipril Methyldopa

2.

Diabetic Ketoacidosis is a recognised side effect of sodium glucose 2 transport SGLT2 inhibitors:

a TRUE b FALSE

3.

Which of the following drugs may prolong QT interval?

a b c d e

4.

Which of the following have not been implicated in causing Clostridium difficile associated diarrhoea CDAD?

a Ciprofloxacin b Cefalexin c Ranitidine d Vancomycin e Omeprazole f Metronidazole

Amitriptyline Citalopram Erythromycin Furosemide Galantamine

Volume 27, No 6, October 2015

a TRUE b FALSE

8.

Homans’ sign is linked with which of the following?

a b c d e

Benign Intracranial Hypertension Pneumonia Deep Vein Thrombosis Back pain Intra-abdominal pathology

9.

Which of the following is not a component of Centor’s criteria?

a b c d e

10.

Annual immunization against influenza is recommended for which of the following?

a CKD Category G4 or G5 b Nephrotic syndrome c Previous kidney transplant d Very overweight people e All of the above

Tender anterior cervical adenopathy History of fever Vomiting Tonsillar exudates Absence of cough

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ABCD2 score: Lower scores are associated with greater risk of stroke:

a TRUE b FALSE

12. The following may be used to manage

unscheduled vaginal bleeding related to Nexplanon:

a Cerazette b Mercilon c Marvelon d Microgynon e All of the above

14.

When should the anterior fontanelle have closed completely?

a b c d e

15.

Under the Mental Health Act: which of the following is renewable AND the patient cannot refuse treatment?

13.

Which of the following statins is the odd one out?

a Simvastatin 40mg

b Simvastatin 80mg

c Atorvastatin 20mg

d Rosuvastatin 10mg

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a b c d e

Birth 3 months 6 months 12 months 18 months

Section 2 Section 3 Section 4 Section 5 All of the above

…be kind to everyone, able to teach, not resentful.

St Paul

“

11.

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247

WORDPLAY 13: NO FEAR!

Dominic de Takats, Consultant Nephrologist

There are a great variety of phobias to consider. Their often Greek roots make for sumptuous English use Phobia [Greek = phobos] carries two senses which words at times: omphalophobia is the fear of navels; differ only in degree. The lesser simply means a thalassophobia the fear of things naval. strong fear, dislike or aversion to some thing, place or situation. The second meaning goes on a degree NOT SHORT ON ACRONYMS to “A persistent, abnormal, and irrational fear of a specific thing or situation that compels one to avoid Contractions are most commonly associated in the it, despite the awareness and reassurance that it is not mind in medicine with parturition but in language usage they are a rich source of neologisms. Examples dangerous.”1 in wider use include selfie (self photograph) and Unlike phobias which for some might have at pseudonymised (really ‘pseudo-anonymised’, not least the seed of a rational basis (fear of heights, or ‘pseudonym-ised’, but that too gets some of the drowning or even of falling asleep) triskaidekaphobia, meaning across) giving the appearance to data that an irrational fear of the number thirteen, has no the original identities of patients or subjects might be clear roots. (That is there is no clear origin to the cut off from their data whereas all that has happened is superstition, the etymological roots/routes through that readily identifiable patient data has been codified Greek, though Greek, to you are clear enough.) Here so that control of access to original data is only in triskaidekaphobia there is an elision of phobia available to those who can access the key to decode (fear) and superstition (irrational belief) in one entity. the link back. In clinical research this is a means of Triskaidekaphobia may not have a clear past but is improving the chances of maintaining confidentiality. extant, it has a present presence, and so likely it has Potentially very large pseudonymised databases a future given that even on my own inpatient ward, can be moved around with relative ease without a 21st Century building, the bed number sequence compromising confidentiality so long as the decoding key is greatly guarded. This thinking and these proceeds 9, 10, 11, 12, 12A, 14, 15. considerations are not unique to medicine, consider Thirteen is not alone as a feared or disliked number, this from a commercial data handling company: fairly common is hexakosioihexekontahexaphobia, or “Pseudonymisation takes the most identifying fields fear of the number 666. The origin of this is likely within a database and replaces them with artificial biblical where the number is quoted as that of The identifiers, or pseudonyms. For example a name is Beast, referring to, it is most generally considered, replaced with a unique number. The purpose is to the devil.2 If one were to give that credence then render the data record less identifying and therefore a rational accompanying complementary phobia reduce concerns with data sharing and data retention. would be hadephobia, fear of hell [Greek hades=hell]. Pseudonymised data is [sic] typically used for analytics Familiarity with that concept is an unlikely to be a and data processing, often with the aim of improving manifestation of ecclesiophobia, fear of church, similar processing efficiency. The process can also be used as to but distinct from hagiophobia, fear of saints or holy part of a Data Fading policy.” Now, you’re interested relics. At the extreme end of this counter-rational in what that means, aren’t you? “Data fading is a way spectrum lies uranophobia, the fear of heaven. of gracefully degrading details in customer records.

Not only numbers may be the subject of fears which Companies that do not offer a fading data privacy are neither tied to specific objects or circumstances: policy are likely to gather less information from their colours also can be irrationally disliked, feared and customers due to their privacy and security concerns avoided, hence erythrophobia, fear of the colour red, about long term data retention.”

FANCY FEARS

of red lights, of blushing, chrysophobia, fear of the Acronyms are not just collections of initial letters colour orange (or, for some, gold) and xanthophobia, from a phrase or organisation, they are a collection fear of the colour, or even the mention of, yellow. of initial letters that make a word or something rather 248

Midlands Medicine

word-like, often so much so that a commonly used acronym not previously a word may come to be used as a word over time, losing capitalisation and unifying the concept as an integral entity to the extent that newer users may have no understanding or awareness of the origin of a word as an acronym. Laser (light amplification by stimulated emission of radiation) is such an example as are radar and quango.

As a nephrologist YoDDA signifies to me the Yorkshire Dialysis Decision Aid which is a tool to help the concerned, anxious, potentially distressed, and as yet uncertain, prospective dialysis patient decide which modality (that’s our technical term for ‘type’ essentially meaning either peritoneal dialysis or haemodialysis) of dialysis they would prefer to do, all else being equal, or at the very least which they will try first should they reach symptomatic End-Stage Kidney Disease. The acronym is memorable because when spoken rather than written there are conscious and/or unconscious allusions to Yoda, “… a legendary Jedi Master and stronger than most in his connection with the Force. Small in size but wise and powerful, he trained Jedi for over 800 years, playing integral roles in the Clone Wars, the instruction of Luke Skywalker, and unlocking the path to immortality.”3 Only some of you, however, will be aware that YODA is also the Yale University Open Access Data project which is seeking to do for underlying source data what Open Access publication is doing for the papers written which interpret that data (See Mark Ormerod’s article in the Originals section).

Stamps (first discussed in Octologus ludus)4 were first coins, referring to impressing a mark in a metal blank, then the means of marking was the stamp, then the mark made by the means was the stamp, then an adhesive representation of a mark became what was meant by a stamp. Now STAMP also means a Screening Tool for the Assessment of Malnutrition in Paediatrics5, Stay Tobacco-Free Athlete Mentor Programme and Special Team for Amputation, Mobility and Prosthetics, amongst many others. Synonyms for STAMP include IMPRESS (Improving and integrating respiratory services, or Intra-Molecular Propagation of Electron Spin States) and EMBOSS (European Molecular Biology Open Software Suite) which is a further example of the trend towards Open Access to data in science “We maintain the world’s most comprehensive range of freely available and up-to-date molecular Volume 27, No 6, October 2015

databases. Developed in collaboration with our colleagues worldwide, our services let you share data, perform complex queries and analyse the results in different ways”.6 AIDS (acquired immune deficiency syndrome was quickly wordified as Aids, with the initial capital letter marking its origin as an acronym and aiding the distinction from the pre-existing word aids meaning helps. Most recently I’ve noticed the MEWS (medical early warning score) being simplified and wordified to Mews. To my taste it’s a little early, but this is how living language moves on. But when jargon becomes idiom I do wonder whether whilst it serves to communicate succinctly between professionals that it doesn’t also through up barriers between us and our patients. Something to muse on.

TAKE THE MANAGEMENT SPEAK TEST Some of you may read this, get it and see nothing wrong with this sort of English used as an ordinary means of communication. Others may understand what is trying to be said but find the language acts as a haze or a distraction between you and the core meaning that is attempted to be conveyed and wish for plain English. Others still may actually be baffled by this: “Further roll out of the exemplar ward programme: The initial phases of work have enabled us to capture key learnings and to deliver informed change. Your feedback and suggestions are continuing to be incorporated into the exemplar ward programme and the wider roll out to all wards

by November this year.” For those of you getting this stuff, here’s some more key information, for others I offer some mere bemusement with: “The exemplar ward intervention comprises a small number of simple tools underpinned by strong local leadership behaviours and a multiprofessional team approach to stamping out delays. The initiative draws on a range of existing improvement programmes such as revisions to the internal professional standards, and is also working to support the development and introduction of new processes for complex discharges.”

GETTING THE BLUES Cyanide is a salt of hydrocyanic acid. It has a strange coincident naming. Though one might, at first glance, wonder if, being a compound characterised by the presence of the ion CN-, it was simply a contrivance 249

Potassium cyanide was used in the Second World War and in the Cold War years as the active ingredient in suicide pills given to agents abroad. If they fell into enemy hands and were facing torture and the prospect of giving up vital secrets, or colleagues, they had the option of opting out by biting into a little pill secreted about their person.

It’s enough to give you cyanophobia!

“

ADDRESS FOR CORRESPONDENCE Dr D de Takats Consultant Nephrologist The Kidney Unit Royal Stoke University Hospital Newcastle Road Stoke-on-Trent ST4 6QG REFERENCES 1 www.thefreedictionary.com 2

Revelation 13 v18

3 www.starwars.com 4

Octologos ludus Midlands Medicine Vol 26 (5) April 2012 pp 223-6

5 www.stampscreeningtool.org 6 www.ebi.ac.uk/services 7 www.dictionary.reference.com/browse/ cyanide

The more that you read, the more things you will know. The more that you learn, the more places you'll go.

Dr. Seuss

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“

or mnemonic to remind one of the key constituent elements. Or, knowing that cyanide is a poison that disrupts the good workings of the electron transport chain in mitochondria so resulting in histotoxic hypoxia, one might guess that cyanide causes cyanosis.

But that would be wrong. Actually the term cyanide is cyan [Greek kyanos=dark blue] + chemical ending -ide, by analogy to chloride. This name was given to it because cyanide was first obtained by heating the dye pigment powder known as Prussian blue.7 This deep blue dye, not dissimilar to Oxford blue, has been used widely since the 18th Century. It was used in Prussian military uniforms.

Midlands Medicine

BOOK REVIEW: BEING MORTAL

BY ATUL GAWANDE Helen Alcock, Junior Doctor How do you want to die? Do you want to live a long and healthy life into old age, maintaining your independence, friendship and, interests, possibly slowing down a bit but perhaps having time to do things you hadn’t managed to do before, then, one night fall asleep in your own bed and just not wake up?

I don’t think anyone would choose a plane crash, those unimaginable moments of panic followed by oblivion.

Perhaps you would rather die at home ‘after a short illness’ or collapse suddenly on a gentle walk in the countryside?

Every week in the food supplement of our Saturday newspaper I read a mouth-watering description of an imagined final meal by a celebrity chef. The perfect setting, surrounded by loved ones, a well-planned starter, main and desert; all with nostalgic connotations.

Locally sourced, organic meat. Carefully chosen wine.

No mention of what it would actually feel like to know that you were eating your last meal or the reactions of the assembled loved ones. No pink sponges on sticks or room temperature Fortisips (the one flavour the pharmacist promised wouldn’t be delivered). These people fully expect to be able to taste and chew and swallow. Any nausea they may be experiencing will be effectively controlled. Their defunctioning ileostomy will behave itself perfectly. Many also imagine being able to source the ingredients and prepare the meal themselves.

might be important to us when they find themselves in that position. We don’t talk about it.

Atul Gawande takes us gently by the hand and walks us through the landscape of the modern experience of human mortality. And it is an experience that has recently undergone great change. Gawande explains that for much of human history death was an ever present possibility. You would be well until an accident or illness struck and then you would die quite quickly.

With the advent of public health measures and the increasingly sophisticated practice of medicine many people now experience a long period of decline. This decline could be the increasing frailty of old age or the aggressive treatment of disease. People are fighting death at the expense of the life they spend fighting it.

Throughout the book Gawande uses beautifully perceptive case studies from his practice as a surgeon and his own deeply personal experience of the deaths of friends and family. He describes the situations these people find themselves in and their experiences with exquisite clarity. He shows the reader where, how and why modern medicine is making the end of life so awful but he also tells us how it need not be like that and gives real hope that things can be different.

This is an intelligent and compassionate book that is so well written it is easy to read. Some parts are possibly too moving for the recently bereaved. Gawande wants to change the way we face our mortality in order that We don’t really think about our own mortality. When we live better lives up to the point of death. It is hard we do think about it we have unrealistic expectations. to say who should read it more urgently: the health We might have a fridge magnet that tells us to be nice professional or the not-yet-patient. If both were to to our children because they will choose our nursing read it then maybe the lives of the aged and terminally home but we don’t tell our children what we think ill could be radically transformed for the better.

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251

BOOK REVIEW: ELIZABETH IS MISSING BY EMMA HEALY Helen Alcock, Junior Doctor Maud is suffering from dementia. She forgets things.

Sometimes a carer appears in her house and she’s not sure how they got there. Her daughter tells her not to boil any more eggs. She makes a cup of tea, puts it on a shelf then goes upstairs for something. She writes herself notes on pieces of paper to try to remember things. She puts an egg on to boil. She discovers a row of cold cups of tea on a shelf and has no idea how they got there. She finds a note in her own handwriting telling her that her friend Elizabeth is missing. She mustn’t forget that. Elizabeth’s son, who can’t be trusted, has been clearing things out of Elizabeth’s house. No one will listen to her. She must get to the bottom of it after she’s worked out where that awful smell is coming from… She must find Elizabeth…

No one will listen to her.

It’s all too similar to the unsolved seventy-year-old mystery of the disappearance of her newly married sister just after the war in a time where many people took advantage of the social upheaval and simply moved away to another life. No one ever got to the bottom of that either.

her own befuddled eyes. In contrast Maud has no difficulty remembering the events of seventy years ago and the reader is quickly drawn into the lucidity of that parallel narrative. As Maud’s memory fragments through the course of the book the two mysteries coalesce in a compelling tale that you won’t be able to put down.

This book does for dementia what The Curious Incident of The Dog In The Night did for Asperger’s Syndrome.

Don’t be put off by the dementia. It is handled in such a tender and perceptive way that you will readily forgive Healey for its poignancy. Some brilliantly observed humour cuts through the heartbreak. There is also the spellbinding thriller running away with the narrative that perfectly balances the quiet devastation of the loss of self.

You will need to give Healey a tiny amount of slack: The device that no one tells Maud what has happened to Elizabeth (or at least that Maud cannot remember being told what has happened to her) is stretched a little thinly at times. However, if you do this you will be amply rewarded because throughout the book Emma Healy was inspired after witnessing her own Healy is extremely generous and does what only the grandmother’s experience of multi-infarct dementia best thriller writers are able to do: she makes her to spend five years researching dementia and post reader feel clever. war life in Britain. She writes in the present tense to completely immerse the reader in the mind of Maud, A beautiful book that will get under your skin. I still seeing the vagueness of her day to day living through wonder how Maud is getting on.

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INTERESTING IMAGES

It used to be traditional to diagnose myeloma affecting bone by doing a lateral skull radiograph and demonstrating a ‘Pepper pot’ skull. These days the lytic lesions (arrows) are just as likely to crop up on a CT scan.

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253

QUIZ ANSWERS AND EXPLANATIONS 1.

c. Ramipril

10.

d. All of the above

2.

a TRUE. The MHRA published a drug safety update on 26/06/2015 which advised that patients presenting with acidosis symptoms should be tested for raised ketones, even if plasma glucose levels are near normal

11.

b FALSE. Predicts early risk of stroke following a TIA Transient Ischaemic Atack. It uses five clinical features which are given points.

Higher risk scores are associated with a greater risk of stroke.

3.

e. All of them

12.

e. All of the above. Current advice is that, if medically eligible a combined oral contraceptive pill may be used. Such use is outside the product license. For women who are not eligible to use COC, addition of an oral progesterone is also outside the product licence and is a matter of clinical judgment.

4. d & f.

Either oral vancomycin or

metronidazole may be used in treating the diarrhoea 5.

a TRUE. The straight leg raising test is a test for lumbosacral nerve root irritation. One example of a cause of this is disc prolapse

6.

b FALSE.

7.

a TRUE. It is a rotation test to demonstrate torn meniscus 14.

c Deep vein thrombosis.

The sign is present when pain in the calf is produced by passive dorsiflexion of the foot. It is not advised by the passive dorsiflexion of the 15. foot. It is not advised for routine clinical use

as it lacks sensitivity and specificity for DVT. There is a risk of dislodging a thrombus leading to a pulmonary embolism when

trying to elicit this sign.

c Vomiting. These criteria are thought to aid diagnosis of Group A beta-haemolytic streptococcus as a cause of sore throat.

8.

9.

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13. a. Simvastatin 40mg – The others are equipotent

e 18 Months. The anterior fontanelle should have closed by 18 months after birth and the posterior fontanelle within 2 or 3 months of birth b Section 3. Section 2 is for duration of up to 28 days. Section 3 is for duration of up to 6 months. It is renewable and patients detained under this act cannot refuse treatment.

Section 4 is for a duration of up to 72 hours.

It is used in emergency situations.

Section 5 is used for a duration of 6 - 72 hours. It is not renewable and a patient detained under this can refuse treatment.

Midlands Medicine

Roy Williamson

Volume 27, No 6, October 2015

“

“

Some years ago, following a major heart attack, I was told, by one friend after another, precisely why it had happened.

Such was the intensity of their desire to get the message across to me that I began to feel quite guilty for daring to have a heart attack in the first place. One of the few people who didn’t pontificate was my cardiologist.

He had more sense. He told me how it happened. He didn’t presume to tell me why.

He said that he didn’t know.”

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