Midlands Medicine - Vol 29 Issue 2 December 2019

MIDLANDS MEDICINE DECEMBER 2019 VOLUME 29 - ISSUE No 2

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Editor’s notes

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Towards Quality Improvement Through Meaningful Measurement

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Vascular Compression Syndromes: Squash or be Squashed

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More Medical Ceramics

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News

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Award winners

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Notes from Meetings

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50th Wade Lecture

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Quiz Night

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Word Fun 1: Quizzes and Puzzles

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Wordplay 19

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Interesting Images

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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 Portrait of Richard III. Please read the about story of the discovery and identification of his body in the report of our 50th Wade lecture. Public domain image sourced via Wikipedia.

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MIDLANDS MEDICINE

CONTENTS

EDITOR

EDITORIAL

Dr D de Takats

Editor’s notes

ASSISTANT EDITOR Mr C Bolger

Towards Quality Improvement Through Meaningful Measurement Paul Laszlo

EDITORIAL BOARD Mr D Gough Dr I Smith Mr D Griffiths Helen Inwood Clive Gibson Tracy Hall Professor Divya Chari

ORIGINALS Vascular Compression Syndromes: Squash or be Squashed Sean Lee & Sriram Rajagopalan More Medical Ceramics Anthea Bond

EDITORIAL ASSISTANT Spencer Smith

REPORTAGE

THE NORTH STAFFORDSHIRE MEDICAL INSTITUTE

News

President: Mr B Carnes Chairman: John Muir Honorary Secretary: Mr J Kocierz Honorary Treasurer: Mr M Barnish Please forward any contributions for consideration by the Midlands Medicine Editorial Board to the Editor c/o Spencer Smith, Editorial assistant.

By email: spencer@nsconferencecentre.co.uk Or by post: North Staffs Medical Institute, Hartshill Road, Hartshill, Stoke-on-Trent ST4 7NY Views expressed in articles and papers are those of the author(s) and do not necessarily reflect the views of the Midlands Medicine Journal or the NSMI, nor imply any agreement with, nor condonement of, those views.

All material herein copyright reserved, Midlands Medicine ©2019.

Volume 29, No 2, December 2019

Award winners Notes from Meetings 50th Wade Lecture

ENDPIECES Quiz Night Oluseyi Ogunmekan Word Fun 1: Quizzes and Puzzles Wordplay 19 Dominic de Takats Interesting Images Answers and Explanations 59

EDITOR'S NOTES Long live the King! You will see that our front cover is adorned by a rich and splendid portrait of king Richard III. This I hope will direct you to our account of the 50th Wade lecture, a splendid occasion at which professor Turi King (yes, she does see the irony of her surname and her role in identifying Richard III) set out in quite some detail just what a long and involved journey it was to discover and then identify with certainty the body of the long-deceased monarch. Her lecture was excellent, our account may whet your appetite to know more, but can only be a pale reflection of the talk itself. But it’s definitely worth reading!

This issue of Midlands Medicine is perforce seasonal by virtue of its lateness in the year. There are a number of reasons why this issue comes to you in December.

Some are due to wanting to wait until various events in October and November had taken place so that they could be relayed in this issue. Another reason is the lack of material submitted, this is a journal which needs your contributions in order to have content worth publishing. Our last issue did very well with a series of interesting and very good case reports, and we may be able to do well again next Spring, but on this occasions fewer articles came in for consideration. The final reason is my own business. As a Consultant in the NHS in the middle of a recruitment and retention crisis and the increasing bed pressures, more keenly felt at this time of year, putting each issue of the journal can sometimes slip down the priority list.

Next we have a syndromic tour, with Sean Lea and Mr Sriram Rajagopolan acting as our guides. These we have enjoyed before and this time should present no exception as we contemplate the squashers and the squashees that make up a four of the recognised vascular compression syndromes.

Once again we have a contribution from Anthea Bond with a picture of a Barber’s bowl. The interesting images at the back are related to the same subject area and the two taken together will give some interesting historical insight into earlier thoughts and practices of surgeons and physicians.

Please take a look at the heart of the issue where you will find some news about NSMI and, very importantly, information about medical student prizes and research awards, this activity is core to the purposes of the NSMI and you support is valued. Please take a look at what we support with our awards.

This issue finds itself running a number of historical themes. Richard III and bloodletting are two of them.

Stochastic determinism results in genuine coincidences, occasionally serendipitiously, unlike buses bunched in groups which is probably explicable. For whatever reason, the Vietnam war is twice reference in this issue of Midlands Medicine. For those of you who like challenges, perhaps you could read your way through and see if you can spot them both. For those of you who like quizzes (sadly not a possible Scrabble word) Having gotten the preamble done, let us take a look at please note that Dr Ogunmekan has once again kindly this edition’s contents. supplied us with a quiz which both challenges and educates. Many thanks to him for his stalwart support The editorial by Paul Laszlo which follows on from of the journal. This is preceded by an extra, word-based, these notes is an insightful piece warning about getting quiz, with compliments of the season. caught between process and outcome. More specifically it warns of measuring the wrong things at the wrong Happy Christmas time in the wrong way and attaching such importance to Happy reading! numbers, both measured and derived, that the object of the measurements in the real world are lost to sight and free to fail unfettered whilst people hunch down over a laptop screen displaying out-of-date stats. Perhaps I’ve not explained it all that well, and you’d be better reading it for yourself.

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TOWARDS QUALITY IMPROVEMENT THROUGH MEANINGFUL MEASUREMENT Paul Laszlo, Consultant Physician concept (victory in war, not unlike delivery of good healthcare) and reduce it to a single metric and then The term Quality Improvement implies that quality is give that metric primacy over all other information/ perspectives. This has been neatly summarised measurable. somewhat satirically by Daniel Yankelovich as follows: In order to improve the quality of a clinical service or a patient experience, a usual audit cycle or quality “The first step is to measure whatever can be easily improvement project will start by obtaining a snapshot measured. This is OK as far as it goes. The second step of the current situation. Data will be gathered and is to disregard that which can't be easily measured or to analysed and considered and then a plan to improve the give it an arbitrary quantitative value. This is artificial metrics will be drawn up. (That’s where clinical audit and misleading. The third step is to presume that what often stopped but where Quality Improvement Projects can't be measured easily really isn't important. This is should now be taking things further, into the realm blindness. The fourth step is to say that what can't be really doesn't exist. This is [intellectual] of implementing change and re-auditing.) But what if easily measured 3 the measurements are wrong? By which I don’t mean suicide.”

THE DANGER OF FALSE IDOLS

inaccurate, though that is a problem in its own right, but the wrong measurements, capturing an irrelevant Another, broader, metaphor for focussing attention erroneously for similar reasons of ease is termed The feature rather than a key aspect of care. What then? streetlight effect. The oft-repeated story is of a drunk at The danger of measuring what is easy to measure night looking for his keys on all fours under a streetlight. and the ascribing excessive importance to it because A policeman asks him what he’s about and he says he’s the alternative of finding a way to capture, measure looking for his keys. The policemen asks him where he and understand what you really want to grasp is too lost them. He says he lost them in the park, but he can’t difficult, is well recognised. There are even books about search there because it’s dark so he may as well search it1; it means that you are not effectively counting the here where he can see. Makes sense only when you’re cost, thereby paying a price. This phenomenon has not thinking straight. been recognised more than once, in different fields at different times, and has names to prove it. One such name is the quantitative fallacy, another is the McNamara Fallacy, named after Robert McNamara, the US secretary of defense from 1961 to 1968.2 He decided that the overriding metric by which to gauge success or failure in the Vietnam war was to look at the absolute number of deaths on each side and to think that victory could be couched in terms of more Vietcong having been killed than US soldiers when the final whistle was blown. (More football references will follow.) He was wrong: vastly more Vietnamese died than US military personnel but no-one considers the Americans to have won that war. The fallacy was to take a big and complex Volume 29, No 2, December 2019

Another example of missing the point would be making control of fever in infections an outcome measure as a surrogate for effectively treating the underlying infection which could inadvertently skew practice.

In a target-driven setting, all sorts of unintended consequences could flow from such an approach: the prioritising of antipyretics over antibiotics, fans over fluids, systematically miscalibrating thermometers to give lower readings, false or absent recording of fevers.

The intention was to treat infections more effectively but a misplaced target could work against the intended result instead of towards it.

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We should all be able to agree that giving priority to an outcome statistic over the thing it’s trying to reflect and failing to measure what really matters are errors best avoided in healthcare. (And that it’s sad when gaming is tacitly encouraged such as putting up a plasterboard partition in an Emergency Department (ED) and getting better trollies one side of the partition and calling that a Medical Ingress Unit in order to manipulate the 4-hour wait statistics.)

TOWARDS MEANINGFUL MEASUREMENT The first step to solving a problem, once recognised, is to gain a good understanding of the problem, to define it. The problem that is under consideration here is that of measuring meaningfully in healthcare systems.

Here are some suggestions regarding what meaningful measurement might look like, which only have a place in any scheme after you have first really understood what it is that you are trying to evaluate.

Validity

tells you just the same. But because you always get people who’ll argue that one is a more direct measure than the other or that some hospitals will prioritise the ED waiting time more than car parking, the latter lacks face validity; in other words, many will dismiss hospital car parking as a distant and irrelevant metric, though it probably is not. For your metric to be taken seriously and engage all those it needs to, it isn’t good enough to be a valid metric, it must appear to be so at first glance.

Football leagues have this nailed. Though fans sometimes argue that the better team lost, they do not dispute league standings at the end of the season.

What’s different in football is that the outcome and its measurement are essentially one and the same. The object is to win matches by scoring more goals than are conceded. Three points for a win, one for a draw and none for a loss are tallied in a season in which each club plays each other club twice, once home and once away. Subsidiary measures of total goals scored, total goals conceded, red cards and yellow cards, and derived scores such as goal difference all allow deeper analysis of the games. Not one of those measures lacks face validity.

How far a player runs in a match, tactics, style and skill can all be debated, but the fundamental alignment of the object of the sport and its measurement leave little argument at the end of the season about what success looks like.

The measure must reflect the object of measurement.

Death is a hard outcome measure and properly adjusted mortality statistics are really hard to argue with. The rub lies in the correct adjustment. Rigorously researched methods of adjustment allowing comparisons that bear scrutiny stop people arguing with the data and starting Relevance and Relatability to examine underlying causes for any discrepancy.

This, at one level, is similar to face validity, but not for all-comers but for those teams closely involved in the Face validity delivery of care. It is important that people working in a particular discipline and being held to account for a Face validity is about meaningful measurement. particular performance metric accept that it is relevant Meaningful in the sense that people readily understand to their practice, or it’ll become their practice to ignore what the metric is about at first glance. Meaningful it. in the sense of relevant. Let me give you an example: unadulterated, the 4-hour wait in ED is a real and When it comes to comparisons, other aspects of relevant measure of demand and patient flow and stress relevance determine relatability. These are the geography on the system. In real time, you could probably get just of the data. Do they cover an area (CCG, district, as good an idea of how busy and stressed the hospital ward, department, trust, region etc.) that is readily was by looking at how full the car park was. And in the relatable? And are they timely? If they precede recent longer term, the 4-hour wait statistics for an ED tell reorganisation or change in practice, they are likely to you about how well organised and how well resourced be dismissed out of hand as applying to a situation as it a hospital might be. How well the car parking is run was before.

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ACCURACY

CONCLUSION

Data need to be gathered with good methodology. And then they need to be cleaned and verified. The methods used for these processes need to be transparently available, open to challenge and revision (themselves subject to a continual process of quality improvement).

And data fraud needs to be brutally exposed.

There is no doubt that a rationalised set of reliable metrics recognised as important, understood in terms of what they refer to and what they mean and relatable both vertically (how to we compare to national performance standards?) and horizontally (how do we compare to our neighbouring trusts?) would underpin quality improvement efforts and allow benchmarking that made sense.

Reliability and Repeatability Data need to be released and circulated in consisted formats at a useful periodicity; reliably in the sense of at a pre-determined time that doesn’t vary; in a timely way, in the sense of being temporally close to the data acquisition period; reaching all members of the intended audience. Data presentations should contain comparisons between similar geographical areas and over time, including different time periods (e.g. the last eight quarters, each the last five years, the last two 5-year periods etc. and some preliminary analysis and commentary (but not detailed analysis at first release because good data speak for themselves, detailed analysis would entail unhelpful delay and people are much more likely to take heed of conclusions they worked to for themselves from the data than complex conclusions laid out on a plate which they did no work in deriving.

Limited Beyond complexity and any attendant difficulty understanding the metrics there is the matter of sheer volume of measurements to get your head around: A recent report looking at quality measurement in three clinical areas (breast cancer care, children and young people’s mental health and renal medicine) found that, on average, over 50 quality measures were in general use.4 Unless each department has its own data analyst, there is a danger of such data piling up unread like a pile of old print journals on an absent professor’s desk.

Volume 29, No 2, December 2019

Gauging the quality of care is complex: all datasets have their limitations, and most indicators are pointers rather than absolute markers of performance.5 What would make sense would be to have a limited set of metrics agreed by all stakeholders* (patients, policymakers, administrators, managers and clinicians), some specialty specific and some generalisable, collected automatically and reliably and published as close to real time as feasible. This needs to be complemented by local Quality Improvement Projects which need to operate in a QIP culture and supported by adequate resourcing.

I’m not holding my breath, but this is at least an outline for how we might proceed.

POSTSCRIPT Some of you will be aware of the NHS GIRFT (Getting it right first time) initiative which I have evaded mentioning. This is a data-driven exercise. It is also data heavy. In amongst the data are those which fulfil some or all of the criteria for meaningful measurement which I have outlined above, and hopefully those will be used to support quality improvement activity, and there are also data which are poorly validated or not fully relevant. Hopefully the quality of the data will be open to scrutiny and incorrect and irrelevant data will be called out as such and discarded.

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2.

O’Mahoney S (2017)

Medicine and the McNamara fallacy J R Coll Physicians Edinb 2017; 47: 281–7 * One model for how this might be done is the SONG doi: 10.4997/JRCPE.2017.31 initiative (Standardised Outcomes in Nephrology).

Though in a different clinical area, that of clinical Yankelovich D (1972) trials, the process is one which bears scrutiny and is 3.

Corporate Priorities: A continuing study of the probably adaptable to clinical practice and healthcare new demands on business quality measures). This is a project and a process that is attempting to standardise outcome measures in Stamford clinical trials so that studies are comparable in a way in Al-Zaidy S, Molloy A, Turton C and Thorlby R which they are not if each clinical trial invents its own 4. definitions for outcomes. In trials with cardiovascular (2019) Briefing: The measurement maze: A snapshot system outcomes, MACE (major adverse cardiovascular

of national quality indicators across three events) is becoming widely used and allows meaningful

clinical areas, and their impact on clinical teams comparisons between trials.

Report by The Health Foundation

REFERENCES 1.

Joanne JE and McEachen J Making the Important Measurable, Not the Measurable Important (2015) ISBN-10: 0692389598; ISBN-13: 978-0692389591

5.

Raleigh VS and Foot C (2010)

Getting the measure of quality: opportunities

and challenges

The King’s Fund (www. kingsfund.org.uk/ sites/default/files/Getting-the-measure of-quality-Veena-Raleigh-Catherine-Foot-The KingsFund-January-2010.pdf).

And thus I clothe my naked villany With old odd ends stolen out of holy writ; And seem a saint, when most I play the devil.

King Richard in Richard III by Shakespeare Act 1, Scene 3

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VASCULAR COMPRESSION SYNDROMES: SQUASH OR BE SQUASHED Sean Lee, Year 4 Medical Student, KUSoM Sriram Rajagopalan, Consultant Vascular Surgeon, UHNM

INTRODUCTION As a year three medical student I chose to spend one month attached to vascular surgery for my student selected component. During this time, I came across patients with rare syndromes, wherein arteries and veins were involved in the compression of other bodily structures. This made me wonder: in a world where you exist as a vessel in the human body, would you rather squash your neighbour or be squashed by them? To help you answer the challenging question, this article explores the presentations of four vascular compression syndromes, arising due to variations in vasculature.

NUTCRACKER SYNDROME Unfortunately for the left renal vein (LRV), it is occasionally prone to compression between the aorta and the superior mesenteric artery (SMA). This phenomenon is known as nutcracker syndrome, owing to the anatomical resemblance of crushing a nut. The symptoms are primarily attributable to the subsequent LRV hypertension and pelvic congestion. They include: haematuria, orthostatic proteinuria, left flank abdominal pain and for women dysmenorrhea, and for men varicoceles, left testicular pain. Due to smaller angles between the aorta and the SMA, the syndrome is most commonly found in those who are tall and thin.

Diagnosis relies on Doppler ultrasonography to reveal a pressure gradient of more than 3 mmHg between the LRV and inferior vena cava,1 whilst imaging can confirm the anatomical variant (Figure 1).

Figure 1: CT scan image demonstrating compression of the LRV between the aorta and SMA, causing LRV dilatation.

MAY-THURNER SYNDROME

Another vessel occasionally compressed, the ‘squashee’ is the left common iliac vein (LCIV). The ‘squasher’ this time being the overlying right common iliac artery (RCIA). The main manifestation of this syndrome is an increased risk of DVT which could be up to eight times higher in the left leg compared to the right.2 Stasis of blood flow in the deep veins occurs as a result of the compression – a factor which enhances predisposition to blood clots. Symptoms of chronic venous insufficiency such as oedema and venous ulcers are also common. May-Thurner syndrome usually presents in the second to fourth decade of life and predominantly The management includes weight gain and surveillance affects females. The main diagnostic tool is venography for children, angiotensin converting enzyme inhibitors with transverse pressure measurements, although other for reducing proteinuria and surgical intervention imaging techniques also have a role (Figure 2). Again, for those with severe symptoms. Of the surgical the solution relies on endovascular stenting or open interventions available, endovascular stenting and LRV surgical intervention, not forgetting thrombolysis of any existing clots.3 transposition are used most frequently.1 Volume 29, No 2, December 2019

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A conservative approach to management alleviates symptoms in most cases. Weight gain, nutritional support, nasogastric decompression and IV fluids are first line. Surgical intervention, most commonly a duodeno-jejunostomy, is only necessary when conservative methods fail.4 DUNBAR SYNDROME The median arcuate ligament (MAL) connects the two crura of the diaphragm together and forms the anterior aspect of the aortic hiatus. In the majority of people, this ligament is found superior to the coeliac Figure 2: CT image demonstrating the LCIV being trunk. However, in as many as 24% of individuals, the compressed by the overlying RCIA. MAL is found anterior to the coeliac trunk and coeliac ganglion, which can cause a degree of compression. The WILKIE SYNDROME resulting compromised blood flow to foregut structures produces Dunbar syndrome, which includes signs and Yet again, the aorta and SMA work together to symptoms such as: epigastric abdominal pain which ‘squash’ another neighbouring structure to produce may be associated with eating, weight loss, nausea and Wilkie syndrome. This time, the third portion of the an abdominal bruit. The typical patient with Dunbar duodenum becomes compressed by these merciless syndrome will be a thin female in their second to fourth vessels. Consequently, the signs and symptoms relate decade of life.5 CT angiography can reveal a classical to duodenal blockage and include: early satiety, nausea, hook-shaped coeliac trunk, indicative of a diagnosis vomiting, post-prandial abdominal pain, abdominal of Dunbar syndrome (Figure 4). In those with severe distention, burping and reflux. Rather than a normal symptoms, the MAL can be divided laparoscopically to angle of 38° - 65° between the aorta and SMA, Wilkie provide relief of the compression.5 syndrome manifests when the angle is less than 25°. Aortomesenteric adipose tissue increases this angle by shifting the SMA anteriorly, therefore being underweight or suffering from a cachexic condition are predisposing factors.4 Diagnosis remains difficult and is usually one of exclusion, using upper GI endoscopy and studies with barium, with a role also found for CT or MR angiography (Figure 3).

Figure 3: CT image demonstrating the duodenum being compressed by the aorta and SMA (between white arrows).

Dilatation of the proximal duodenum is also shown.

Figure 4: Sagittal CT angiogram image showing the classic ‘hook’ shaped coeliac trunk (yellow circle), caused by compression from the MAL (blue arrows).

CONCLUSION

4.

These rare syndromes can pose as somewhat of a mystery for physicians, explained by their variable presentations with non-specific signs and symptoms. The difficulty in establishing a diagnosis has sparked discussion about their existence, however imaging tools have been proven useful for spotting the anatomical anomalies.

Management plans always involve alleviating the 5. compression, with surgery reserved for the most severe cases.

REFERENCES 1.

Gulleroglu K, Gulleroglu B and Baskin E (2014) Nutcracker syndrome World Journal of Nephrology Vol 3 p277-81

2.

Oguzkurt L, Tercan F, Pourbagher M, Kizilkilic O, Turkoz R and Boyvat F (2005) Computed tomography findings in 10 cases of iliac vein compression (May–Thurner) syndrome European Journal of Radiology Vol 55 pp421-425

3.

Ahmed H and Hagspiel K (2001) Intravascular ultrasonographic findings in May-Thurner syndrome (iliac vein compression syndrome) Journal of Ultrasound in Medicine Vol 20 pp251-6

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Chrysikos D, Troupis T, Tsiaoussis J, Sgantzos M, Bonatsos V, Karampelias V et al (2019) Superior mesenteric artery syndrome: a rare case of upper gastrointestinal obstruction Journal of Surgical Case Reports 2019 Issue 3 https://doi.org/10.1093/jscr/rjz Horton K, Talamini M and Fishman E (2005) Median Arcuate Ligament Syndrome: Evaluation with CT Angiography RadioGraphics Vol 25 pp1177-82

PICTURE CREDITS All figures are taken from Radiopaedia, an open source for radiology images. Available at: http://radiopaedia. org/cases Figure 1. Case courtesy of Dr Mohammad Farghali Ali Tosson, Radiopaedia.org, rID: 55941 Figure 2. Case courtesy of Dr Donna D'Souza, Radiopaedia.org, rID: 4373 Figure 3. Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 17992 Figure 4. Case courtesy of Dr Domenico Nicoletti, Radiopaedia.org, rID: 45205.

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MORE MEDICAL CERAMICS Anthea Bond, retired Consultant Orthodontist

BARBER SURGEON’S BOWL Barber surgeons were known in 1000 AD, the barbers had sharp tools and they were allowed to use these for minor surgery such as dental extractions and blood letting. By the 17th Century, the barber surgeons recognised the need for more education for physicians and surgeons, by 1745 the surgeons had split from the barbers with the introduction of the Royal College of Surgeons.

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This barber surgeon’s dish is in the Potteries Museum and Art Gallery in Stoke-on-Trent and can be seen along with other rare items. The fragile earthenware with white tin glaze has a rim shaped to fit the customer’s neck. The blue enamel pattern under the glaze shows a range of instruments used by barber surgeons at the time, 1681.

Midlands Medicine

NEWS NEW WADE HALL Thursday 7th November 2019 was a very good evening for the North Staffordshire Medical Institute, not only both handing out more awards but also having some reporting back from previous research award recipients.

What was extra special, however, was the opportunity to do all this in the newly refurbished Wade Hall. In the last issue of Midlands Medicine I referred to plans afoot for the refurbishment of the main Wade lecture hall which were to proceed with confidence due to promised generous financial support arranged by Jeremy Wade.

Everything came to fruition as hoped. Unlike many institutional projects and large-scale building projects, I am pleased to report, and NSMI are proud of the fact that these significant refurbishments were delivered both on time and on budg SIX DECADES OF PROGRESS A film with the above title was premiered on that evening, showing off the audio-visual facilities in the new Wade Hall. It was a film made by Ray Johnson MBE of the Staffordshire Film Archive. This charted the development of NSMI as a concept, a group, as fundraisers and the work that led to the building in Hartshill. The official opening day was captured on film and relayed. Personalities involved in the Institute then, back in the 1960s through time to the current day, were interviewed to reminisce and to explain the changing role of the NSMI over time.

The previous role was as the first postgraduate medical centre in England, a place for doctors and dentists to meet and to be educated in the latest developments, hear lectures and visit the library. The current role of NSMI is largely in funding medical research locally at Keele University and in University hospitals of North Midlands NHS Trust. Such a change in emphasis has been largely driven by changes to the location and the facilities at what is now Royal Stoke University Hospital. Important moves have been the establishment of the undergraduate medical school building of Keele University. Closely related to that in time and space was the differently funded Clinical Education Centre (CEC) which took on many of the roles formerly played by the NSMI building in Hartshill, such as seminar and meeting room provision and a medical library. Further changes followed the migration from the Central Outpatients Department to the former City General site. The NSMI and the Central Outpatients sites are contiguous, so this was effectively a social severance of a significant degree. Eventually the Renal Ward (ward 29) and the dialysis unit moved down the hill from the Royal Infirmary site which was relegated to car park duties, which it continues to fulfil to this day. Where previously doctors and other staff might have popped into the NSMI for lunch or a social drink, or to visit the library, there was no longer any convenience or reminder to do so and, in the absence of demand, such provision ceased. The building in Hartshill has had another role for many years as a conference centre. It also has permanent residents who are happy in their home. But the NSMI is not the building that bears its name but rather an organisation with clear charitable aims of supporting medical research and medical education and remains dependent on and grateful to the generosity of its donors.

MORE INFORMATION www.filmarchive.org.uk https://nsmedicalinstitute.co.uk/

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AWARD WINNERS As just stated at the end of the previous page, the two main aims of the North Staffordshire Medical institute are to support medical education and medical research.

NSMI KEELE UNIVERSITY MEDICAL STUDENTS

MEDICAL INSTITUTE

MEDICAL INSTITUTE

KEELE MEDICAL STUDENT AWARD YEAR 2

KEELE MEDICAL STUDENT AWARD YEAR 4

Harpal Patel

Catriona Turnbull

NSMI RESEARCH AWARDS

Antimicrobial nanoparticle platforms enhancing capacitabine efficacy in pancreatic cancer.

Novel Targeted Therapy against ovarian cancer

Dr Clare Hoskins, Dr Tony Curtis, Dr Andrew Lamb

Dr Wen-Wu Li, Prof. Murray Brunt, Dr. Sarah Hart, Dr. Alan Richardson

£19,079.24

£19,900.00

Reducing overcrowding in emergency department by facilitating better discharge planning Dr Md. Asaduzzaman, Dr. A.Davy, Dr K. Watts, Dr Uchitha Jayawickrama, Helen Wright-White and Guy Smallman £14,988.00

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NOTES FROM MEETINGS Dominic de Takats, Editor, Midlands Medicine These literally are just notes in case of interest.

LEARNING Here are six key elements to good learning taken and adapted from a talk given by Dr David HIRSH MD, The George E. Thibault Academy Associate Professor and Director, Harvard Medical School Academy, Cambridge, USA at DENEC (Developing Excellence in Medical Education) in December 2019:

A CORONER’S PERSPECTIVE ON ORGAN DONATION Midlands Regional Collaborative, 27th November 2019 Organ Donation from Coroners’ perspectives, James Bennett, Area Coroner for Birmingham and Solihull Coroners now appointed are all experienced lawyers.

Judicial powers to summons and to fine or imprison for contempt of court

Test-enhanced learning: Attempting recall helps learning, Quizzing, explaining to others, writing things “Putting the bereaved at the heart of the coroners’ out on a blank piece of paper all help. service” Desirable difficulties: Being stretched helps: a little twist on the method, amd extr step in the thinking required to solve a problem, a level of challenge that engages but that doesn’t overwhelm can be very helpful.

National consistency of process Mixture of legal process and compassionate consideration Who, where, when & how (mostly ‘How?’) No longer verdict, now ‘conclusion’ Spacing: Putting things aside and returning to them Prevention of future deaths report mandating action by later will enhance long term memory. Looking at things people in a position to take action in detail and letting them go completely in between seems good. In a two or three year course, a monthly Chief Coroner’s guidance re organ donation look at a topic will very likely enhance memory very Applies in reportable deaths effectively. www.judiciary.uk/wp-content/uploads/2017/12/ guidance-no-26-organ-donation.pdf Interleaving: Just as they do at school and universities: Not giving permission rather being asked if there is any topics are taught for an hour or two and then you move objection. What is required: on to another.

Detailed chronology Know your own learning style: Find out what it is, if you Circumstances can, acknowledge, apply and master it for best results.

Third parties Deliberate Practice: Skills more than knowledge, such Drink or drugs? as musical instruments, arithmetic, geometry etc. all Admission bloods available? benefit from this approach. But to get the most out of it, Has a full body CT scan happened? Is the cause of death you need to be coached, corrected when you are wrong, clear? shown hoe to do it right and then made to practise it Police involvement? Who, what seniority? Is a crime over and over until doing it right is what comes easily. suspected? Will organ donation impair evidence?

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50th WADE LECTURE On 3rd October 2019 the North Staffordshire Medical institute was delighted to host professor Turi King, Professor of Public Engagement and Reader in Genetics and Archaeology at the University of Leicester, presenting a lecture entitled King Richard III: the resolution of a 500-year-old cold case. We were treated to an account of a delightful journey of discovery in which the most modern techniques in DNA sequencing, archaeology and genealogy all needed to be brought together in one coordinated project to both find and then confirm the identity of the remains of Richard III, having done exactly that, king Richard III was then ceremonially reinterred in Leicester cathedral in March 2015.

The story started with history, accounts of Richard III killed the battle of Bosworth in August 1485 allowing Henry Tudor to ascend to the throne as Henry VII. His body was removed from the battlefield and buried hastily in Greyfriars priory church in Leicester. The marking of the grave was lost in time, possibly removed deliberately during the reformation, and Greyfriars church itself had long since disappeared. A misinformation campaign had suggested centuries ago (fake news of its day) that Richard III’s remains has been thrown into the River Soar, perhaps to dissuade anyone from looking for him, either for the purposes of veneration or desecration; let him lie in peace.

Several historians, however, over time, each few decades, especially in the 20th Century were unconvinced by the stories of Richard having been thrown into the Soar and held that it should be possible to identify the prior site of the Greyfriars priory church in Leicester and make a search for Richard III’s remains. The cause was taken up by the Richard III Society and after feasibility checks and permissions sought and gained, an archaeological excavation in a car park in Leicester started in August 2012.

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The skeleton of a male was found very early on in digging but was not explored in detail initially but covered over whilst other exploratory trenches were dug and a sense of the plan of the building gathered. When, quite some time later, the skeleton was excavated in detail, it was fond to have fatal battle injuries and humiliation injuries and scoliosis. Professor King described getting an excited urgent message at an inopportune moment which stumble out the headlines “Youngish male, head injuries, hunchback”. At that point the odds narrowed considerably and in essence it was clear that they had discovered (literally) the remains of king Richard III. All that remained was to prove it. (Bad joke warning: Context: the skeleton had no feet due to a Victorian era wall’s foundations having bee dug across them but it paves the way for this aural (awful?) joke that professor king proffered: ‘Why did Richard III’s skeleton have no feet?’ Answer: ‘Because he was defeated in battle.’)

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To clinch the identification, something more was needed. The circumstantial evidence, was compelling but not absolutely so. Radiocarbon dating was supportive, but more was needed, just to be sure:If it were possible to somehow extract DNA from Richard III’s skeleton and match it to living descendants, that would secure the assertion that this was indeed king Richard III’s skeleton. Technicians and geneticists were indeed able to whole genome sequence Richard III from material extracted from tooth pulp. Genealogists got to work and managed to trace a male and a female living descendant, excluding non-paternity events along the way, focussing on Y chromosome material from the male line and mitochondrial DNA in the female line.

The final matches were good. They were very good and provided the confident level of confirmatory evidence that allowed the skeleton found under a car park in Leicester in the 21st Century to be identified as that of king Richard III killed as Bosworth field in the 15th Century.

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We thank professor King for a fantastic tour of multidisciplinary teamwork, history, archaeology science, genetics and serendipity that led to this conclusion.

PICTURE CREDITS Professor Turi King, used under a creative commons licence, original image: East Midlands Snapper.

Richard III’s remains in situ, used under a creative commons licence, source: w w w. c a m b r i d g e . o r g / c o r e / s e r v i c e s / aop-cambridge-core/content/view/ EB678293FE20EF21D246D149766A95F4/ S0003598X00049103a.pdf/king_in_the_car_park_ new_light_on_the_death_and_burial_of_richard_iii_ in_the_grey_friars_church_leicester_in_1485.pdf Authors: Richard Buckley, Mathew Morris, Jo Appleby, Turi King, Deirdre O'Sullivan, Lin Foxhall

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

1. CPEX:This is a way of assessing how one's body would respond to the stress of major surgery under a general anaesthetic: True or False?

2. The wobble sign is useful when assessing which of the following? a) cerebellum b) eustachian tube d) eye e) leg

c) naevus

3. Spurling test is used to assess nerve root pain in what part of the body? a) tooth

b) back

c) neck

d) hand

4. Individuals affected by pica have been known to eat which of the following? a) hair b) paper e) all of the above

c) stones d) faeces f) none of the above

5. The HEART score can be used for patients presenting with acute coronary syndrome True or False?

7. The Scarf Test is used to identify pathology in which joint? a) knee d) neck

b) hip e) ankle

c) shoulder

8. Panda eyes is a sign of which of the following ? a) ME d) DIC

b) Influenza f) Basal skull fracture e) leukaemia

9. Battle sign :Which of the following is false? a) It was named because it was first identified in war injuries b) It is also known as mastoid eccymosis c) It is an indication of a fracture of the middle cranial fossa of the skull d) It is usually seen after head injuries resulting in injury to the mastoid process leading to bruising

10. Right shift in relation to a blood film in the neutrophil count may be caused by which of the following conditions? a) megaoblastic anaemia c) chronic infection e) All of the above

b) iron deficiency d) uraemia

6. Cawthorne-Cooksey exercises are used in the treatment of which of the following conditions? a) back pain d) plantar fascitis

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b) tennis elbow e) golfer's elbow

c) BPPV

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WORD FUN 1: QUIZZES AND PUZZLES Dominic de Takats, Editor, Midlands Medicine

1. Reversible word pairings: how many of these can you come up with for yourself?

Traffic light; light traffic (2 points) Yellow bee; be yellow (0 points) Skirt around; a round skirt (1 point)

2. Which country name contains all vowels, each only once, but not in the usual order?

3. Look for real and uncontrived words with long vowel strings: Erythropoiesis (3) Factitious (4) Queueing (5)

4. Look for real and uncontrived words with long consonant strings: Workplace (4) Erythropoiesis (5) Rhythm (6) Rhythms (7)

Volume 29, No 2, December 2019

5. Which is the only word in English to start and end in ‘und’?

6. Words within words: Find as many words in this sentence that exist within the existing words: Please don’t flush paper towels down the toilet

7. Words within words: Apprenticeship (App, rent, ice, tic, ices ship, hip) is an example of a word that contains many words. What words can you come up with that perform similarly or better in this respect?

8. How many letters v, x and z can you get into a phrase or sentence without it seeming contrived?

9. Can you write a narrative starting each word with the letters of the alphabet in sequence?

10. What does floccinaucinihilipilification mean?

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WORDPLAY 19 Dominic de Takats, Consultant Nephrologist, UHNM It’s very difficult to think of the number nineteen in the context of words and wordplay and not thin back to Paul Hardcastle’s 1985 hit of that name, 19. This was a focussed look at the fact that very young American soldiers were in combat in that war. Selected lyrics speak for themselves: In 1965 Vietnam seemed like just another foreign war, but it wasn't It was different in many ways, as so were those that did the fighting In World War 2 the average age of the combat soldier was twenty-six In Vietnam he was nineteen In Saigon a US military spokesman said today More than seven hundred enemy troops were killed last week In that sensitive border area In all of South Vietnam The enemy lost a total of two thousand six hundred eighty-nine soldiers All those who remember the war They won't forget what they've seen Destruction of men in their prime Whose average age was nineteen Half of the Vietnam combat veterans suffered from what psychiatrists call Post-traumatic stress disorder Many vets complain of alienation, rage, or guilt Some succumb to suicidal thoughts Eight to ten years after coming home Almost eight-hundred-thousand men Are still fighting the Vietnam War

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MORE BACRONYMS POLiCE: procedures of limited clinical effectiveness SLAM: service level activity monitoring (Perfect initialism.)

TiME trial: Time to Reduce Mortality in ESRD (Very close.)

BETonMACE: They did and apparently they lost: An international, multi-center, randomized, doubleblind, placebo-controlled trial, BETonMACE is the first study to explore whether epigenetic modulation with a selective bromodomain and extra-terminal (BET) protein inhibitor is safe and effective in reducing cardiovascular end points (MACE). Safe it appears to have been. Reductions in MACE were small and failed to achieve statistical significance, though the tends were favourable.1 These two are rather clunky: both trying to shoehorn their way into the positive dynamic aura that surrounds the word transform: Advancing Renal TRANSplant eFficacy and safety Outcomes with an eveRolimus-based regiMen2 That’s a very contrived effort indeed, picking off letters as needed to fulfil a predetermined brief with an overdeveloped regard for the backronym but no true respect for the form. This next is a slightly better effort with the same word: TRANSFORM-HF: ToRsemide compArisoN with furoSemide FOR Management of Heart Failure At least the last three words conform.

Others have done this sort of thin with much more…

FINESSE: Filtration In the Neuropathy of End-Stage kidney disease Symptom Evolution As a link to the next section, note that initialistic backronyms can have more than one significance: FINESSE: Fast Infrared Exoplanet Spectroscopy Survey Explorer MACE: in clinical trials, major adverse cardiovascular events; in Staffordshire, media archive for central England.

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“2. ICPs TLAS MEANING MORE Building on from our established Integrated Care Model (described further in our Key Service/Pathway Of course, TLAs can mean two letter abbreviations as Developments section), we expect greater progress at well as three letter abbreviations. Here are some of both pace in developing ICPs over 2020/21 leveraging the which can mean different things depending on where progress we have had around the alliances that are now you find yourself. established at a local level. We will be working with providers to ensure that the capability currently within ED: Erectile dysfunction and Emergency Department the CCGs that can be aligned to ICP development is ID: Infectious diseases, identity, identify included. The CCGs recognise the centrality of Primary OD: Overdose, Omni Dei (Once daily) Care to the development of ICPs in particular. As such, PP: Per Pro (for and on behalf of), peak pressure, we expect the system to work together with General polypropylene; pp: pages Practice to develop these new delivery vehicles and RMS: Revalidation management system, Referrals the CCGs, along with the rest of the ICS, will continue management system, root mean square to support General Practice and PCNs to strengthen TLA: did that one already, see start of section. and develop the capability and leadership that will complement the changes we expect to see.

THE THICKNESS OF LANGUAGE The following quotes are taken from a letter circulated on behalf of Staffordshire CCGs. Some of you will lap this up because you’re fully bought into the culture and language that makes this verbiage intelligible. Others may defend the right to write so turgidly, stating that complex and detailed plans can only be conveyed in complex and detailed language. I’m not sure that the plain English campaign would agree. And I do think there’s a degree of skill involved in making the complex understandable.

Having opened thus, I now present these paragraphs unexpurgated, un-Bowdlerised, unamended and without comment, in their original layout.

“1. ICS and Strategic Commissioning The LTP represents a significant opportunity for us to develop at an accelerated pace some of the strategic developments the system has been working on from 2016 through our STP arrangements. Providing strategic leadership and capability, we will support the system to build on our collaborative working arrangements and establish a shadow Integrated Care System board during 19/20, strengthening those arrangements over 2020 and ultimately develop into a fully maturing ICS by 2021. Over the same period we will further develop our Strategic Commissioning offer that will propound a step change in commissioning, moving from a predominantly tactical commissioning approach to a much more strategic commissioning approach based on population health management.

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“3. New Contract Models During 2020/21 the CCGs will explore and consider options with system partners around the appropriate contractual vehicles required to support the changes outlined above. Our expectation is to move from largely activity driven contracts to an outcomes based contract with an appropriate financing and incentive scheme. This will also include scoping options around how the secondary care contract might evolve given the changing primary and community care delivery mechanisms and moving from episodic and curative approaches that have characterised historical delivery and commissioning to a pathway and whole systems approach.”

Like I said, no comment.

In our local NHS trust there are some very wellintentioned developments taking place to support staff.

But one can’t help wondering if all this jargon facilitates or obfuscates. Again, I quote directly from a circulated document.

“One of the key Divisionally driven elements of the plan is to appoint Wellbeing Leaders who will act as a point of contact and ambassadors for wellbeing, identify and drive the wellbeing elements of the Divisional People Plans, help with the implementation of corporate activities and provide wellbeing support and guidance to colleagues.”

Some simplification of the language and a little more punctuation would have had me sold on that one.

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ADDRESS FOR CORRESPONDENCE

REFERENCES

Dominic de Takats Consultant Nephrologist The Kidney Unit Trent Building Royal Stoke University Hospital Newcastle Road Stoke-on-Trent ST4 6QG

1. https://www.mdmag.com/conferencecoverage/aha-2019/betonmace-no-benefit-ofapabetalone-for-mace-in-highrisk-patients 2.

https://clinicaltrials.gov/ct2/show/ NCT01950819

3.

https://clinicaltrials.gov/ct2/show/ NCT03296813

We're all expendable.

We think the world's going to stop when a pope dies, or a king.

And then... life goes on.

Sylvester Stallone

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Midlands Medicine

INTERESTING IMAGES

Barber surgeons were craftsmen, good at their skills but with limited education. In a world that believed in bloodletting as a curative craft, a scientific veneer was lent to the process by theories expounding the right places to cut to deal with particular ailments. The relatively uneducated barber surgeons were not expected to have this knowledge but were able to refer to manuals, atlases, demonstrating where but to cut in order to effect treatment under different circumstances.

Anyone really prefer eminence-based medicine over evidence-based medicine given this chequered past?

Picture credit: Wellcome collection, used under a creative commons licence. https://wellcomecollection.org/works/pahxx24t Volume 29, No 2, December 2019

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Blood letting by cutting (see More Medical Ceramics) came to be regarded by physicians as barbaric and leeches were their preferred means of releasing blood from patients in a practice erroneously thought to be helpful. A pseudoscience developed around leeches and it was thought that placing them carefully particularly mattered.

Handling and directing leeches to fasten where they must and not where they will proved tricky, so these glass tubes were developed to aid the more precise placement of the leeches.

Picture credit: Wellcome collection, used under a creative commons licence. https://wellcomecollection.org/articles/XKyzchIAAPeWNq1l

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Midlands Medicine

ANSWERS AND EXPLANATIONS WORD FUN 1: QUIZZES AND PUZZLES

4 e) All of the above. Soil, glass and chalk are also known to have been eaten.

2 Mozambique 5 a) True. HEART is an acronym of its components: History ECG Age Risk factors and Troponin. Each of 6 ease, as, lease, do, don, flu, us, lush, sh, pap, ape, per, these is scored with 0, 1 or 2 points. pert, to, tow, owe, do, own, he, to (again), toil, oil, let 5 Underground

10 The act of dismissing or counting something as It helps emergency clinicians risk stratify chest pain worthless, not worth bothering with, or the tendency to patients into low, moderate and high risk groups. behave in that way.

6 c) BPPV. These exercises form the basis of the Epley manoeuvre.

QUIZ NIGHT 1 a) True. CPEX is cardiopulmonary exercise testing 7 c) Shoulder. It i also known as the Cross Arm and this involves exercising on a stationary bike while Adduction test. It is a test for acromioclavicular joint measuring how the heart and lungs respond to increased injury or pathology. workload.

2 c) Naevus. The sign may be useful during dermoscopy to distinguish pappilomatous melanocytic nevus from a stable sebborrhoeic keratosis.

8 c) Basal skull fracture. It is sometimes known as raccoon eyes. It can be also be a sign of neuroblastoma or amyloidosis.

9 a) The sign is named after William Henry Battle, a 3 c) Neck. The test is used during a spinal or neck Surgeon who worked in a few hospitals in London in examination to aid the diagnosis and assessment of the 19th Century. cervical radiculopathy.

10 e) All of the above.

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King Richard III, depicted in stained glass in Cardiff castle. In the original photograph these windows are adjacent.

Picture credit: VeteranMP - Own work, used under a creative commons licence,CC BY-SA 3.0 https://commons.wikimedia.org/w/index.php?curid=30408894 82

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Anne Neville, the younger daughter of the Earl of Warwick and wife of Richard III, depicted in stained glass in Cardiff castle.

Picture credit: VeteranMP - Own work, used under a creative commons licence, CC BY-SA 3.0 https://commons.wikimedia.org/w/index.php?curid=30408894 Volume 29, No 2, December 2019

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