Midlands Medicine - Vol 28 Issue 5 May 18

MIDLANDS MEDICINE MAY 2018

VOLUME 28 - ISSUE No 5

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Editor’s notes

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Aids to Reflection and PDP Development for Appraisal

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Doing Down’s Differently

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News

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Us Too

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Quiz Night

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Saudi Arabian Students’ Biomedical Research Visits to Keele University 2011–2017

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Quiz two: Syndromic conundrums

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Review: The Nuts and Bolts of Life by Paul Heiney

Assessing the Effects of Calcitriol and Nicotinamide on Rat Substantia Nigra Cells in Vitro

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Interesting Images

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Quizzes’ Answers and Explanations

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Medical Ceramics

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 English medicine pots The image on the front cover shows English drug jars from the 17th century on display in the Potteries Museum, Stoke-on-Trent. They are made of tin glazed earthenware. The larger pots were made in London, the two small ointment pots from the early 18th century were found in a moat around a Staffordshire home.

It is a painting by Anthea Bond, who started to paint when she retired from her post of Consultant Orthodontist.

In 2017 Anthea’s local art group showed their work as part of the Association of Medical Humanities conference at Keele University, including some of her paintings of ceramics used in Medicine.

Anthea also belongs to the Medical Art Society. It has an annual exhibition at the Royal Society of Medicine in London as well as various events and holidays. The Medical Art Society is open to all doctors, dentists and vets, including students, who paint or make sculptures. It has links with the Dutch group Pincet en Penseel. Anthea has shown her paintings in their exhibitions in hospitals in Amsterdam and Utrecht.

See also ‘Medical Ceramics’ on page 194 and inside back cover, page 211.

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MIDLANDS MEDICINE

CONTENTS

EDITOR Dr D de Takats

EDITORIAL

ASSISTANT EDITOR Mr C Bolger

Doing Down’s Differently Paul Laszlo

EDITORIAL BOARD Mr D Gough Dr I Smith Mr D Griffiths Helen Inwood Clive Gibson Tracy Hall Professor Divya Chari EDITORIAL ASSISTANT Spencer Smith THE NORTH STAFFORDSHIRE MEDICAL INSTITUTE President: Mr B Carnes Chairman: Professor S O’Brien 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 are solely those of the author(s) and do not reflect the views of the Midlands Medicine Journal.

All material herein copyright reserved, Midlands Medicine ©2018.

Volume 28, No 5, May 2018

Editor’s notes

Us Too Jayne Smith ORIGINALS Saudi Arabian Students’ Biomedical Research Visits to Keele University 2011–2017 Wen-Wi Li, Paul Roach & Mark Smith Assessing the Effects of Calcitriol and Nicotinamide on Rat Substantia Nigra Cells in Vitro Yasemin Zaremba Medical Ceramics Anthea Bond & Vera Cartlin Aids to Reflection & PDP Development for Appraisal Marcus German REPORTAGE News ENDPIECES Quiz Night Seyi Ogumenkan Quiz two: Syndromic conundrums Dominic de Takats Review: The Nuts and Bolts of Life by Paul Heiney Dominic de Takats Interesting Images Quizzes’ Answers and Explanations 179

EDITORS NOTES On Time My predecessor in this role was given to remarking in general terms in editorial tone on matters arising. On this occasion, I thought I might give it a go myself. The usual preview of the edition will follow presently, but first an editorial rant.

We regard calendars as solid, reliable points of reference, factual in nature. Calendars, systems of days and dates, date back a long time. But even in current times there are various such systems running at the same time.

There is a Chinese calendar, a Jewish calendar and an Islamic calendar, to name only a few. We currently use the Gregorian calendar, bestowed upon western Europe by pope Gregory XIII in 1582. But we haven’t left it untouched. Back in 1752, the civil calendar changed in England after the Calendar Act was passed: An Act for Regulating the Commencement of the Year; and for Correcting the Calendar now in use. One effect of this was to move the start of the year from 25th March to 1st January. When the year did start in March, September was the seventh month, October the eighth, November the ninth and December the tenth month of the year. In the absence of that shift of year starting date, the month names in the last third of the year would make perfect sense.

In the healthcare calendar the seasons don’t seem to be all the same length as they have been contrived to be in the meteorological calendar, In the latter, each has a three month slot with spring covering March– May; summer; June–August, autumn: September– November; and winter December to February, inclusive, in the northern hemisphere. Astronomical seasons are slightly shifted to these, paying greater heed to solstices and equinoxes. In healthcare, or at least in the NHS in England, the seasons are much shifted. They relate to the seasonal weather fairly directly, but the import in healthcare services is very different to outside this setting.

Winter, these days, in healthcare, runs from October to March; spring: April–June; and summer: July– September. Autumn is pretty much redundant as a concept in the healthcare calendar. In terms of their definitions, winter is the time when we need to have extra beds and staff in hospitals and the rest of the year is when hospitals run at their usual bed base and 180

complement of staff. This is, of course no arbitrary matter that we should see the winter six months as the time to put in the extra effort, beds and staff and the other six months as ‘normal working’ instead of seeing the capacity required to do a good job in winter as the normal capacity, needs and responsive ability of the health service and the rest of the year as a chance to retreat, repair and catch up. The reason for taking this particular view is that we now function in a financially highly constrained setting, and it would strike fear into the heart of the treasury to normalise the level of capacity and functioning seen over the winter months.

What we now do April–June when healthcare spring arrives, is spend our time finalising the accounts of the financial year just gone, closing down the extra beds, losing the extra staff recruited at great effort (and cost) some months before, take a breath, review how the winter plan worked in practice, learn some lessons and sketch the winter plan out for the coming winter now in four months’ time. Because it isn’t a surprise anymore, there will be another six-month winter crisis starting up again in October.

The healthcare summer, spanning July–September, is characterised by ticking over the clinical service comfortably, affording at last some respite to permit some front line staff recuperation. It is also characterised by not being able to quickly advance any service development or other planning, complex or vital administrative task due to key personnel serially being on annual leave or, in September, away at conferences.

It is starting to wear a little thin. And it’s not even clear that the presumption that it is cheaper to normalise the summer capacity and produce a battle plan for expanded services each winter is actually cheaper. The opportunity cost must be enormous. The sapping of time, energy and morale has the effect of stifling real change. What would be the effect if we normalised capacity and staffing over the winter and accepted that in the middle of the year there was a little breathing space to be had? We could use the less busy months for recovery, repair, restoration: managers could actually spend some time looking at more efficient and smarter ways of working, deciding which services to stop offering as they don’t really do patients any good and looking Midlands Medicine

at which services they could possibly develop. Senior nurses could spend time checking that all policies and procedures were fit for purpose, up-to-date and well disseminated. People could relax a little and enjoy their work more. That just might bring some benefit in terms of recruitment and retention for all staff groups. It just seems to me that a little relaxation of austerity in the NHS — I’m not suggesting going crazy — at this point of the political and economic cycle might bear fruit efficiently by which I mean, in treasury-speak, ‘deliver value for money’.

PREVIEW The rant above speaks to the present practical business of running a national health service under financial strain. When the economic winds blow in a different direction, as they surely will one day, that strain will ease. The scale of the health service in England looms very large and it is daily very real. No less real, but on an entirely different scale, Paul Laszlo looks at the topic of choosing not to live with or choosing to live with a child with Down’s syndrome. The prompt for this was World Down’s Syndrome Day on 21st March. This has been going annually for a number of years but gained a little more attention this time round due to being picked up by the BBC and a certain video that got a large number of views on the internet. Read the piece, watch the video.

Anthea Bond has graced the front cover and (inside) back cover of this issue of Midlands Medicine with some painted pots. These have inspired local resident, Vera Cartlin, to take a broad view of medical ceramics.

Anthea has put time into painting since retirement.

She has taken inspiration from ceramics on view at the Potteries museum and art gallery. Much of the work there is for kitchen use, or decorative. In reality, the humanitarian and technical medical uses of ceramics is enormous and Vera merely scratches the surface, so to speak. There is an entirely different way that arts and craft can have a medical role, and that is therapeutically.

This interaction is now being subjected to rigorous research. Key amongst its proponents is Daisy Fancourt, again picked up by the BBC as a New Generation thinker. More conventionally she is Wellcome Research Volume 28, No 5, May 2018

Fellow based at UCL. If you are interested in Medical Humanities or the psychological interactions between the arts, health and illness, then you would do well to check out some of her work.

Our second editorial piece, by Jayne Smith, is a little cheeky. But it asks a serious question of us: do we ever flirt in dealings with patients? If so, what messages are we sending and how can we make sure we stay on the right side of all the lines (respect, decency, professionalism, personal boundaries etc.)?

Wen-Wi Li and colleagues tell us about one of the ways they make good use of Keele University’s facilities in what otherwise might be down time. They now regularly host Saudi Arabian students and put them through their paces doing biomedical research. This is a very positive engagement all round as it teaches the students about specific aspects of medical research, about the facilities and research interests at Keele and a little of UK culture, gets some of the legwork done and brings in an income! Some more home grown biomedical research in a programme supported by the NSMI is presented by Keele Medical Student Yasemin Zaremba.

If you are short on reflective pieces for your portfolio, or frankly have little idea what it’s all about or how to go about it, Marcus German will lead you by the hand to produce some helpful reflection and craft a meaningful Personal Development Plan.

Willem Kolff is one of the most important medical pioneers you probably haven’t heard of. Find out more by reading my review of his biography; find out more still by reading the book.

We have a double helping of quizzes and a bumper edition of Interesting Images. Between Marcus German’s help on reflection and PDP and the CPD you’ll find in the end pieces (provided you do a little further reading) you’ll be well set for looming appraisal and revalidation. Glad we can be of service.

Happy reading!

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DOING DOWN’S DIFFERENTLY Paul Laszlo, Consultant Physician Down’s syndrome is named after John Langdon Down, a 19th Century English physician who first described the constellation of features that are a manifestation of trisomy 21 in man.1 Though he chose the epithet ‘Mongolian idiocy’ to describe the condition, he was not an unkind man, merely one given to expressing his observations in the language and theories then current.

Indeed, he spent a life devoted to the care of those with learning difficulties (‘feeble mindedness’). In 1965 the WHO moved the term on to Down’s syndrome.

This is what the NHS choices website2 has to say about Down’s syndrome: “Down’s syndrome, also known as trisomy 21, is a genetic condition that typically causes some level of learning disability and certain physical characteristics.”

And on screening: “Sometimes parents find out their baby has Down’s syndrome during pregnancy because of screening tests.

All pregnant women are offered screening tests for Down’s syndrome.

Screening tests can’t tell you for certain if your baby has Down’s syndrome, but they can tell you how likely it is.

If screening tests show there’s a chance your baby has Down’s, more tests can be done during pregnancy to confirm it.

These include: • chorionic villus sampling (CVS) – a small sample of the placenta is tested, usually during weeks 11-14 of pregnancy • amniocentesis – a sample of amniotic fluid is tested, usually during weeks 15-20 of pregnancy If these tests show that your baby has Down’s syndrome, you and your baby’s other parent will be offered counselling so you can talk about the impact of the diagnosis.

You may also be offered an appointment to meet a doctor or other health professional who works with children 182

with Down’s syndrome. They can tell you more about the condition and answer any questions you have.”

Interesting to note that counselling on the impact of having a child is universally offered but talking with someone who has any experience of working with children and/or adults with Down’s syndrome is only a possibility.

The commonly held presumption is that the purpose of screening antenatally for Down’s syndrome in the foetus is to allow for the possibility of terminating pregnancy if the screening and subsequent confirmatory tests show that the foetus has Down’s syndrome. That seems to be a completely reasonable assessment of the situation, and the reason that most mums-to-be undergo screening and further tests does seem to be so they can avoid the perceived difficulties which inevitably follow the commitment to care for a child born with Down’s syndrome.

The majority of positive pre-natal diagnoses of Down’s syndrome result in a termination. The rate varies from about 75% in the USA to 96% in Taiwan.3 The reasons for deciding to terminate a pregnancy leading to the birth of a baby with Down’s syndrome must be varied and complex. The amount of purely emotional response and highly rationalised consideration will vary from one couple to another, indeed, for each individual involved.

That said, fear of being overwhelmed in the face of need, cultural expectations, a lack of role models and the consequent fear of the unknown may all play into the decision making process. But, despite the screening, children born with Down’s syndrome have the commonest chromosomal abnormality and so they are here to stay.

Putting all moral judgements aside, is there any other way these couples could be thinking about children with Down’s syndrome and what that might mean? The spur to ask the question comes from what happened on 21st March 2018: World Down Syndrome Day. (Forgive the American dropping of the possessive apostrophe, as is their wont.) (Incidentally, the date chosen is a Midlands Medicine

deliberate contrivance to reflect trisomy 21.)

World Down Syndrome Day was a celebration of Down’s syndrome and all the joy and participation and support that might be had living with Down’s syndrome and with those who have it. It was first observed in many countries in 2006 and adopted by the United Nations in 2011.4 The 21st Century approach is mixed. Still we elect en masse to terminate pregnancies with a trisomy 21 diagnosis but if a child happens to get past that pinch point and be born with Down’s and make it through to childhood and then onto adult life, we really do treat them a little differently today. It really has been a long journey from the days in which living with Down’s syndrome meant an institutional life shut away from general view in a kind of state of shame, almost as if an old testament view of sins of the father being visited upon following generations still held sway. In Western societies, our institutions appear kinder, certainly more open. We are less likely to use them and more likely to support people with Down’s syndrome in their communities. People with Down’s syndrome can be more visible and don’t need to cower. This is the case on social media and ‘in real life’. Those with a social conscience are more likely to defend them if they find themselves bullied. In a more progressive spirit there is something of a move to inclusivity going on with more television programmes featuring participants with disabilities. Amongst those currently including people with Down’s syndrome are American Idol, and CBBC’s The Dumping Ground.

Actually, our UK institutional approach for adults with learning disabilities, including those due to Down’s syndrome, has had its enlightened parts since the mid20th Century. One enduring and clear example of this is the provision made by the Camphill Village Trust which has nine sites across the UK, home to around 400 adults with a learning disability.5 This is their approach: “[We provide] a home within a supportive community environment for people of all abilities. Whether in a household with others or more independently we accept and appreciate each other for who we are and encourage each other to give our best. We remain committed to the Volume 28, No 5, May 2018

benefits that a sense of community brings to everyone, whilst constantly responding to people’s changing lifestyles and support needs, along with wider regulatory requirements. We recognise the importance of combining neighbourly cohesion with individual wellbeing. To be human is to be a social being. Both the person being supported and the person giving the support are interdependent and each have the potential to benefit and grow from the relationships that naturally develop.

We understand the importance of friends and the sense of belonging that people have as part of their community.

We do not define people because of their disability and seek to align the achievements of citizenship and equality with the warmth of friendship and self fulfilment.

We recognise that we cannot exist in isolation and we all have an important part to play. Everybody’s contribution is meaningful, valued and appreciated.

Each of our communities - through our person-centred approach in which support is tailored to each individual’s needs - provides opportunities for personal growth, fulfilling work, friendship and social interaction, education and training, and cultural and spiritual inspiration. Everyone receives the support they need to participate fully in the life of our communities and their surrounding areas. Above all we value what each individual brings to the communities in which they live.”6 Life with Down’s syndrome or for those caring for children with Down’s syndrome can no doubt be difficult, at sometimes intolerable, sometimes bearable and at other times quite ordinary. But when such a life achieves ordinariness, it is perhaps an aspect of beauty. If the second offer (You may also be offered an appointment to meet a doctor or other health professional who works with children with Down’s syndrome. They can tell you more about the condition and answer any questions you have.”) happened more often; if it was more widely known that it is possible to have a happy and fulfilled life as a person with Down’s syndrome, perhaps not so many confirmed Down’s syndromes pregnancies would end in terminations.

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REFERENCES

FURTHER INFORMATION

1. Down JL Observations on an Ethnic Classification of Idiots (1862) London Hospital Reports Vol 3 pp259-62

Please watch this video: 50 Mums/50 Kids/1 extra chromosome: www.youtube.com/watch?v=Biex1XR_mpo

2. www.nhs.uk/conditions/downs-syndrome/ 3. http://www.downsyndromeprenataltesting.com/ more-women-aborting-continuing-down-syndromepregnancies/ (Declaration of interests: the author of this website has a daughter with Down’s syndrome)

Down’s Syndrome Association: www.downs-syndrome.org.uk Camphill village trust: www.cvt.org.uk

4. worlddownsyndromeday.org/about-wdsd 5. www.cvt.org.uk/about-us/history 6. www.cvt.org.uk/about-us/what-we-do

Miracles only grow where you plant them.

Cecelia Ahern

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US TOO Jayne Smith, neighbour and doctor Somewhat at odds with the #metoo zeitgeist my 75year-old neighbour has started wolf-whistling at me over the garden fence after fourteen years of much more gentlemanly behaviour. I initially wondered if this was an early sign of the onset of dementia but his ability to behave impeccably in the presence of his wife and his encyclopaedic knowledge of his stockpile of banned herbicides and pesticides suggests otherwise.

It was when he began to recount his recent encounters with the NHS over his long-neglected type two diabetes mellitus and its emerging complications that I started to wonder if his newly acquired confidence has been bolstered by his interactions with medical staff.

We have all had elderly patients make flirtatious remarks. It is possible to brush them off and not respond to them. It would be extremely difficult to challenge them and object to lewd and suggestive behaviour. It does seem to be universally accepted that inappropriate comments made by people above a certain age are harmless and as such need not be challenged. However, many healthcare professionals seem to go further than this and actively engage with and perpetuate this pseudo-flirtatious behaviour.

Why is it that, when people become a certain age, behaviour that would be challenged, objected to or reported in a younger person becomes acceptable to the point where professional staff accept and respond to it in kind? We wouldn’t join in racist, homophobic or politically extreme behaviour of our patients. We wouldn’t collude with a psychotic delusion. We certainly wouldn’t flirt with a patient of a similar age.

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In the current series of the BBC’s Ambulance we watch paramedics flirting continually with very elderly people of both sexes who have fallen at home and been unable to get up so have had to suffer the indignity of accepting the help of total strangers. While the flirting in these circumstances seems to be initiated by the patient in an attempt to diffuse the distressing situation they find themselves in it is fuelled and perpetuated by the professionals. They take it and run with it. The kindness and empathy shown towards their patients is obvious: they aren’t engaging in this pretence with the intention of demeaning a vulnerable person. They aren’t patronising them. But should we be asking if this is an appropriate way of respecting and preserving the dignity of our most senior citizens? Should we not try to better understand the reasons behind the behaviour and find other ways of engaging with them?

I haven’t challenged my neighbour over his behaviour.

I still remember the row about replacing the fence, and the ongoing dispute over whether our tree is interfering with their broadband is never far from the surface. I find myself retreating to the other side of the garden when the familiar whiff of cigar smoke heralds his proximity. As he is not my patient I will allow myself the satisfaction of quietly resenting him.

ACKNOWLEDGEMENTS Jayne Smith is a pseodonym.

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SAUDI ARABIAN STUDENTS’ BIOMEDICAL RESEARCH VISITS TO KEELE UNIVERSITY 2011–2017 Wen-Wi Li, Lecturer in Analytical Biochemistry, Keele University; Paul Roach, Senior Lecturer in Biomaterials and Interface Science, Loughborough University and Mark Smith, Research Institute Manager, Keele University INTRODUCTION For the past seven years Keele University’s Research Institute for Science & Technology in Medicine (ISTM) has hosted visits from groups of undergraduate medical students from Saudi Arabia. The focus of their visits has been the Guy Hilton Research Centre (GHRC) located immediately adjacent to the North Staffordshire Medical Institute, and the David Weatherall Building on Keele’s campus. Over the past decade there has been a general developing of interest in research within Saudi Arabia, particularly within the medical field. The initial concept of the programme, which has remained central to its development, was to bring the very best academic medical school undergraduates and give them a taste

for research within a leading UK framework. This year marks a change of direction in the Saudi visiting medical student programme, due to Dr Paul Roach, one of the leaders from the start, moving from Keele to Loughborough in December 2016. The formation of a new Research Institute for Applied Clinical Sciences within the Faculty of Medical & Health Sciences also means that in future the visits might span more clinical areas. Recent perspectives on Keele’s international visit programmes suggest there is a great deal of interest in how to start and grow this sort of activity1, so this paper takes stock of what has been achieved and the experience gained through offering the programme.

Figure 1: Saudi Arabian students group photo August 2014 at Lowlands House. Photo by Ruth Smith

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ORIGINS In early 2011, Keele was one of several UK universities contacted through an independent agent for higher education, on behalf of their client, an unspecified medical school in Saudi Arabia. The specification called for: “…interested universities that would like to undertake a four week research training program from 1st July – 31st July 2011 [for] 1st and 2nd year undergraduate medical students in groups of 10 to have exposure to the basic skills required for biomedical research (a maximum of 20 students per university).

The core topics of the course should be: 1. Understanding disease mechanisms 2. The discovery of disease biomarkers 3. The discovery of innovative therapeutic approaches 4. An introduction to research to one or more of the following subject areas:

a. Obesity

b. Cancer

c. Infectious diseases Neurological disease

d. Traditional medicine Key requirements for participating universities are as follows: 1. English should be the official language.

2. The availability of a supervising professor to prepare, supervise and coordinate the training program.

3. The availability of sufficient number of supervisors (PhD holders), so as not to exceed supervisor to student ratio 1:4.

4. Nearby housing and transportation from housing to the centre as well as from and to the airport 5. Provision of a certificate at the end of the training program.

6. A weekly schedule for the research training and a list of available research projects.

7. Enriching activities outside the scientific program (e.g., sport facilities, weekend local visits).”

It was clear that Keele could deliver on all these criteria, including several of the listed subject areas, but at that time ISTM was only offering summer research placements to UK students. Expansion to international students was seen as a potentially profitable new activity, both financially but more so for the Research Institute to increase its international profile. So, in conjunction with Professor Gordon Ferns (then the

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Director of ISTM), a specification was drawn up and submitted it to the agent in May 2011. On working out the projected costs and setting the price it was clear that the optimum number of students to come to Keele was between 16 and 20, so the pricing structure was scaled to encourage a group of that number from year two onwards. The students all come from the College of Medicine, Al Imam Muhammad ibn Saud Islamic University in Riyadh, Saudi Arabia. Being initially founded in 1974 and now having approximately 24,000 students and 1,300 faculty staff, the medical school at this University was still relatively new and was looking to enhance its external visibility via the development of a research profile. The long-term goal of the international programme from their perspective was to nurture their top students into becoming research active clinicians.

ACTION After some rapid negotiation on terms and price, the first students arrived on Keele campus on 3rd July 2011. Being a Research Institute focussed on PhD/ DM/MPhil and hosting some Masters level courses, largely being based off-campus at the GHRC hospital site, this was the first time ISTM had hosted any groups of undergraduate students. The first visit was a steep learning curve for staff and and a culture shock for the young men who arrived, most experiencing for their first time a European country. After first using a small local hotel, the need to reserve campus accommodation subsequently was abundantly evident, and this has become an important part of the Keele experience that has ensured the student groups return year after year.

The Al Imam University College of Medicine views these visits not only as a very valuable experience for their students, but also for the development of their staff.

Their vision for a Faculty Development Programme was set out in a paper by Bin Abdulrahman K A, et al2 as part of the overall plan to encourage academic staff in Arabian Gulf universities to study for a PhD themselves and become more active in research. The student group is always accompanied by an Academic Tutor from the College of Medicine, and their specialties and research interests have included dermatology, paediatrics and family medicine. To help to achieve this goal, the College of Medicine set up funded programmes with universities in the USA, Malaysia and Australia.

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SHARING OUR LEARNING There have been several other key features of the programme that have emerged and may be useful to others who have the opportunity to host visitors from the Middle East.

1. Capacity: Sufficient lecturers and tutors for the students’ projects need to be identified and signed up well in advance, as the visits occur in July or August when many colleagues can be away on leave. Sometimes members of their teams have stepped in to cover for a week or two, but the students do need and expect input from an experienced member of research-active academic staff for their projects; that is what they are paying for. The hierarchical social aspects of Saudi Arabia are quite firm, with respect of the highest order shown to those higher up this societal ladder in terms of age and experience. The leader of a group is seen to be the main person from whom these students can learn, and be networked with in terms of helping with their future career. This was a very important aspect from the visiting students’ perspectives, and echoed entirely by their accompanying Academic Tutors. ISTM has opted for a 1:2 basis of supervision rather than the specified 1:4. The choice of projects needs to be done well in advance. Allocation is done by the Al Imam University Director of Visits as there is often a hierarchy also within the student cohort – this we found was based on student performance in examinations with the highest achieving students allowed first choice of the projects.

2. Gender and culture: ISTM offers an entirely mixed-gender, culturally diverse medical research environment which the students have to accept and adapt to. But culture-shock in coming to the UK can be acute, as many of the students have not been outside the Middle East before, where gender, class, religious and nationality divisions are often very entrenched. The only concession to this is the booking of an entire floor of 18 en suite campus accommodation to meet cultural requirements, ensuring the students have a safe space such as kitchens in which they can relax as a group in the evenings.

3. Professionalism: Many of the students seem comparatively immature and so sensitive guidance is given around the conduct that is expected in lectures, when contacting members of clinical and research staff, and the self-directed learning for their projects. A tutor from Al Imam University has accompanied the students for at least part of their stay and can assist in broaching any difficult issues. Timekeeping and punctuality can be a cause for concern; the students need occasional reminders about attendance, so registers have been kept for key sessions.

4. Cultural activities: A part of the original brief, some cultural activities have always been provided so the students get a broader idea of what life and work in the west is like, not just the typical tourist’s view. In the first few years, weekend visits included a museum or a castle, and a church, as well as a tour of Keele Hall as a typical English country house to explore a little about history, architecture and class. More recently this has varied to include visits offered through Keele’s International Office, and a social evening of traditional fish and chips at the home of one of the authors. The latter has been an experience of different foods, eating and socialising habits, and a chance for the students to see ISTM staff alongside their families, with children and partners brought along to the social evening to further broaden students’ interaction with western culture. This has been very well received and is always a point of reflection during student feedback sessions. The students have gained in confidence over the years, based on the experience of those who visited Keele previously and also the recognition of Keele’s programme within Al Imam.

Students now tend to organise their own excursions, including Old Trafford, Alton Towers, Manchester, Chester, Liverpool and London, being a mix of fun and adventure, alongside those who want to learn more about English culture.

Figure 2: Experiments in rehabilitation research July 2013.

Photo by Mark Smith

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5. Economies of scale: A further development this year has been the expansion of the summer visit programme to encompass a separate group of 20 Chinese students, from Yangzhou University, hosted by Professor Ying Yang. This has achieved economies of scale by running certain activities like induction days and lectures together. It is hoped to combine similar visits in this way in the future, wherever possible.

A long-term objective of running the Saudi medical student visit programme here at Keele has always been to encourage some of the students to return to Keele for a Masters level course or a PhD. There have been many very bright and well-motivated students, and this year there has been a desire to stay on and continue lab experiments beyond the official end of the programme.

There have also been some visits from individual students in their later years for deeper research or clinical experience, but so far none have opted to come to Keele to register for study for a higher degree.

Tangible outputs from the programme have included several posters and journal articles, the visiting Saudi tutors have explored research links with Keele, and in all other respects the programme has met its objectives.

There has been interest in the new Keele MMedSci in Oncology to suit those students finishing their medical degree and with an interest working in medical research before specialising.

So far there has been a total of 110 Saudi undergraduate students visit Keele under this programme with a total of £210,000 income generated. Of this, direct payments are made to staff who supervise their individual projects, this money is then used to fund research projects in ISTM’s laboratories so Keele’s research has benefitted by at least £60,000. Once all staff costs and overheads have been accounted for, the clear profit made by the programme is over £30,000, which ISTM has re-invested into new initiatives, including the encouragement of international links. In addition the students and the accompanying tutors have brought accommodation bookings to the University exceeding £60,000 over 7 years, a clear benefit for the local economy.

Overall, the success of the programme has been the internationalisation of our research teams, the stimulation of having new students in the labs over the summer, and the generation of ideas for new international postgraduate programmes to tap new markets. The former Dean of Medicine & Health Sciences, Prof Andy Garner, flew out to Riyadh in 2015 and signed a Memorandum of Understanding with the Dean at Al Imam University, which cements the relationship. Under the direction of the Keele’s new Dean of Medicine Prof Pauline Walsh, and the Dean of Internationalisation, Prof Richard Luther, It is hoped that in the future the programme can be expanded, possibly to also bring female undergraduates from the same medical school.

Figure 3: Saudi students and staff in a group photo by Suzanne Murray

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ACKNOWLEDGEMENTS

REFERENCES

The authors would like to thank the following colleagues who have helped the Saudi visiting medical student programme to flourish:

1. Robinson ZP et al The Rise and Fall of a Collaboration: reflections on the benefits, challenges and lessons learned from a joint England-China teaching initiative

Lecturers and tutors in Keele’s Faculty of Medicine & Health Sciences who took part in the programme, members of the Royal Stoke University Hospital who helped with tours of hospital clinical and research facilities. Special thanks to Prof Josep Sule-Suso for his constant support Faculty Dean and Directors of ISTM including Prof Andy Garner, Prof Gordon Ferns, Prof Alicia El Haj, Prof Nicholas Forsyth Keele International Office team: Elissa Williams, Lisa Stoker, Natasha Corke, Sian Colley and Mark Coates.

Facilitators: Paula Marsh, Joseph Clarke, Amy Chell, Katy Cressy, John Misra and everyone on the technical and reception teams at GHRC who have helped maintain a high standard for our visitors.

Figures: 1. Saudi Arabian medical students and tutors group photo at a social evening at “Lowlands House” in August 2014, with Mark Smith and Josep Sule-Suso (left), Andy Garner, Wen-Wu Li and Paul Roach (right). (photo by Ruth Dann).

2. Saudi Arabian students taking part in rehabilitation research experiments at Keele in July 2013, watched by Dr Sami Aldaham, their Academic Tutor and Director of Visits at Al Imam University College of Medicine. (photo by Mark Smith)

JADE, International Edition, March 2016 pp32–56 2. Bin Abdulrahman K A, Siddiqui I A, Aldaham, S A & Akram S Faculty development program: A guide for medical schools in Arabian Gulf (GCC) countries.

Medical Teacher (2012) Vol 4:sup1, S61–S66 DOI: 10.3109/0142159X.2012.656748 Note: A version of this article covering the first six years of the programme first appeared in The Journal of Academic Development & Education, issue 8, August 2017, pp25– 31 (https://jadekeele.wordpress.com/).

ADDRESS FOR CORRESPONDENCE Mark Smith Research Institute Manager Guy Hilton Research Centre Thornburrow Drive Hartshill Stoke-on-Trent ST4 7QB m.e.smith@keele.ac.uk

3. On a glorious sunny day at the end of their visit, the August 2017 cohort of students and some of their tutors standing outside the Guy Hilton Research Centre, Hartshill. (photo by Suzanne Murray)

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ASSESSING THE EFFECTS OF CALCITRIOL AND NICOTINAMIDE ON RAT SUBSTANTIA NIGRA CELLS IN VITRO Yasemin Zaremba, Medical Student, KUSoM INTRODUCTION Parkinson’s Disease (PD) is neurodegenerative; depleting dopamine neurones of the substantia nigra (SN) in the midbrain. 4% of the world’s population suffer from PD. Vitamins play an important role in health and development throughout life. Calcitriol (D3) has been shown to attenuate neurotoxicity in dopamine neurones1. Nicotinamide (B3) has recently been identified as a possible neuroprotectant2.

AIMS The aim of this research was to use primary SN cells as an in vitro model to determine whether or not vitamins D3 and B3 have a neuroprotective or neurotoxic effect on midbrain dopamine cells that had been selectively injured with 6-hydroxydopamine (6-OHDA) to mimic PD. METHODS Primary neurones of the SN were obtained from embryonic day 14 rats. Cells were cultured for seven days with 10mM nicotinamide and/or 10nM calcitriol.

Cells were then treated with either 100mM 6-OHDA dissolved in 0.015% ascorbic acid vehicle or the ascorbic acid vehicle alone for 25 minutes. A control that received only media changes with no treatment was also included. Cells were then left to recover for 2 days in their conditions. Cover slips were then fixed with 4% paraformaldehyde and stained for β-III-

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tubulin, tyrosine hydroxylase (TH) and mounted in 4’,6-diamidino-2-phenylindole (DAPI) mounting medium. Imaging was carried out and cell numbers under each condition were counted and analysed.

RESULTS There were clear differences in cell morphology between conditions. Under both vehicle and 6-OHDA conditions, neurones treated with D3 were significantly higher in quantity with long, thick, complex processes (figure 1). However, in conditions treated with B3, neurones were much lower in number with thinner less complex processes (figure 2).

A two-factor ANOVA revealed that vitamins significantly altered total cell and neurone number, p<0.001 (figures 3 and 4). There is also a significant interaction, p<0.05 meaning the effect of vitamins on cell and neurone number is dependent on the 6-OHDA/ vehicle treatment. Further analysis using Bonferroni’s multiple comparisons test showed significantly more cells in D3 treated conditions than in control, B3 and B3+D3 conditions (figures 3 and 4).

Data collected from random sampling of the coverslips provided a low, unrepresentative number of TH cells.

Therefore, whole coverslip images were collected and total number of TH cells per coverslip were counted.

Two-Factor ANOVA results showed a significant difference in the total number of TH cells between vitamins p<0.05 (figure5).

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CONCLUSION The cell and neurone count was much higher for D3 treated cells than cells treated with B3 or B3+D3.

D3 appeared to have a neuroprotective effect on overall cell, neurone and TH number whilst B3 had a neurotoxic effect at the concentration of 10mM. Repeat experiments need to be carried out to confirm results.

Further work could involve treating cells with lower concentrations of B3 to determine an accurate neurotoxic concentration. This suggests that supplementing PD patients with D3 may protect dopamine SN neurones from degeneration, while excessive quantities of B3 may be a risk factor.

Figure 1: 6-OHDA treated primary cells with D3, β-IIItubulin red, DAPI blue

Figure 2: 6-OHDA treated primary cells with B3, β-IIItubulin red, DAPI blue

Average cell number per 0.3cm2 Control

B3

D3

***

2500

*** ***

2000

Number of nuclei

B3D3

1500

1000

500

DA H 6O

ic le Ve h

DA H 6O

ic le Ve h

DA H 6O

ic le Ve h

DA H 6O

Ve h

ic le

0

Treatment condition Figure 3

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Midlands Medicine

Average number of neurones per 0.3cm2 Control

B3

B3D3

D3

***

250

***

***

Number of neurons

200

150

100

50

DA H 6O

6O

H

Ve hi c

le

DA

le Ve hi c

DA H 6O

le Ve hi c

DA H 6O

Ve hi c

le

0

Treatment condition Figure 4

Number of TH+ cells per coverslip Control

B3

B3D3

D3

*** 100

50

DA H 6O

le ic Ve h

DA H 6O

le ic Ve h

DA H 6O

le ic Ve h

H 6O

ic Ve h

DA

0

le

Number of TH+ cells

150

Treatment condition Figure 5

REFERENCES

ACKNOWLEDGEMENTS

1. Wang JY, Wu J-N, Cherng T-L, Hoffer BJ, Chen H-H et al.

Vitamin D attenuates 6-hydroxydopamine-induced neurotoxicity 3 in rats Brain Res (2001) Vol 904 pp67â&#x20AC;&#x201C;75

Supervisor: Professor Rose Fricker Department in which project was based: Huxley School of Life Sciences

2. Anderson DW, Bradbury KA and Schneider J S Broad neuroprotective profile of nicotinamide in different mouse models of MPTP-induced parkinsonism Eur J Neurosci (2008) doi.org/10.1111/j.1460-9568.2008.06356.x Volume 28, No 5, May 2018

This work was part of the Aspire programme to encourage medical research. This is supported by grants from the NSMI.

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MEDICAL CERAMICS Paintings: Anthea Bond, Retired Consultant Orthodontist Words: Vera Cartlin, Local Resident INTRODUCTION

HUMANITARIAN CERAMICS

The word ceramic refers to non-metallic solid materials which have attained their hardened state through the (deliberate) action of considerable heat. In general the reference is to clays that have been fired to attain a baked solidity (with accompanying brittleness). But glass could be considered a ceramic material. Pottery is one dominant aspect of ceramic production and so the term is often erroneously used synonymously with ceramic. But the latter is a broader term covering all such manufactured items including sanitaryware, roof tiles, bricks, electrical insulators and so forth. The term pottery tends to be used for vessels and more decorative items. In truth, the meanings are intertwined and their more particular applications are as much a matter of custom and practice as they are of definition. If one delves, everything gets a little mixed up because the origin of the word ceramic is from the Greek Keramos (Potter’s clay).

Josiah Wedgwood (1730–95) from Burslem was a prominent abolitionist. To raise awareness of the plight of slaves he created a roundel, a ceramic medallion, bearing the following image in relief: Interestingly, the medallion was both mass produced and popular. The actual creation of the image for the mould was done by one of his modellers in his Stoke-on-Trent factory.

It was produced in a number of forms and reproduced by others as abolitionism came on-trend in the 18th Century. It was a few years after his death that the 1807 Slave Trade Act was passed.

There are other terms, perhaps used loosely by the uninformed, but which do carry distinct technical meanings. These are terms such as stoneware, earthenware, porcelain and so forth.

Stoneware results from firing clay to a very high temperature which results in a vitreous non-porous ceramic. It may or may not be glazed. The same regarding glazing is true of earthenware but it has generally been fired at a lower temperature, below 1,200 °C, resulting in a non-vitreous ceramic which is porous unless glazed.

Porcelain is a vitrified translucent ceramic material made by firing clay at temperatures between 1,200 °C– 1,400 °C. In the UK it may be referred to as china or fine china. It is hard and sonorous when struck (it chimes).

TRADITIONAL MEDICAL CERAMICS There has been some use of ceramics for medical, nursing and pharmaceutical purposes for centuries.

This has generally been in the form of vessels for bespoke purposes. Examples include medicine jars for keeping pills and ointments, or liquids (elixirs).

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18TH – EARLY 20TH CENTURY MEDICAL CERAMIC In the 19th Century ‘medical’ ceramics ranged not particularly widely. Most applications were as vessels for medicaments, although vessels for other purposes might be noted: nursing care uses which perhaps might now be forgotten included bed pans and urine bottles as well as early versions of modern plastic beakers for feeding liquids to the infirm.

Another use was in water filters to improve water quality, and one must not underestimate their contribution to sanitaryware and all that white ceramic we see in use today in both urinals and (sit upon) toilets. (White still outsells avocado and rose pink!)

Midlands Medicine

If one includes bricks as ceramic objects then one of the greatest public health ceramic-based projects was the provision of sewers to London in a project run for the Metropolitan Board of Works by Joseph Bazalgette (1819–91). This was in response to repeated cholera outbreaks in London due to a significant degree of open sewerage, using the Thames itself as a large open sewer.

Particularly persuasive that ‘something must be done’ was the Great Stink of 1858. Bazalgette oversaw the production of a brick-built system of enclosed sewers which conveyed the sewage to the eastern reaches of London (Beckton) where it could be stored until it was then dumped into the Thames at high tide so that it could then be carried out to sea on the ebb tide.

Cholera rates plummeted after this public health intervention and the Great Stink was never to recur, just replaced by Pea Soup fogs in the mid-20th Century.

MODERN MEDICAL CERAMICS In the 21st Century the use of ceramics in medicine has mushroomed and the scope of use if very wide. It includes the following, amongst others: • • • • •

X-ray tubes Pressure sensors Dental screws and bridges Femoral head implants for hip replacements Blood shear valves and peripheral components used in haematology instruments used for blood cell counts and related testing.

• Implantable devises such as pacemakers often contain ceramic parts These ceramics are produced in highly technical settings and to very high standards. One key element is to produce the material with high reproducibility so the desired characteristics are reliably present. This is done by addressing both chemical factors (such as which salts and trace elements might be used as additives) and mechanical ones, such as the temperature, pressure and duration of firing.

Some of the traditional uses of ceramics in medicine and nursing have been supplanted by plastics and cardboard, but many persist and, as can be seen from the inexhaustive list above, many newer uses continue to be developed.

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PICTURE CREDITS AM I NOT A MAN AND A BROTHER? From Wikimedia Commons as a public domain image.

Vessels painted by Anthea Bond Editor’s note: Please see note inside the front cover to learn more about Anthea Bond.

FURTHER INFORMATION The Potteries Museum www.stokemuseums.org.uk/pmag/ The Wedgwood Museum www.wedgwoodmuseum.org.uk/ www.morgantechnicalceramics.com/en-gb/markets/ healthcare/ www.thomasnet.com/articles/custom-manufacturingfabricating/medical-ceramics ADDRESS FOR CORRESPONDENCE C/o The Editor North Staffordshire Medical Institute Hartshill Road STOKE-on-TRENT ST4 7NY antheabond@hotmail.com

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AIDS TO REFLECTION AND PDP DEVELOPMENT FOR APPRAISAL Marcus German, Life Coach INTRODUCTION Doctors are not the only ones being expected to develop reflective practice and to undergo appraisal. This has become normative, the status quo. There’s little use kicking against the pricks, that way lies sore feet and no forward progress. Far better to accept that this is the way things are now, and to master these practices.

Unsure of yourself? Not entirely confident to proceed?

Help is at hand. If you work through the following exercises, taking them seriously without poking your tongue deep in your cheek, and make notes, you will have ample material for your portfolio.

Many professionals derive some or much of their self esteem from being busy all the time. They get a buzz from being needed, to some extent they may be flattered by being hassled, unless it gets to be too much.

This approach leaves all too little time for reflection.

But as already stated, the new normal is to gather up your reflections, type them up and upload them to your portfolio. Regrettably, many professionals are uncomfortable with the idea that they have to be told to reflect, feeling that the thoughts that drift through their head as they walk into work or lie in the bath are reflection enough. However this is not so. Once you have yielded to the notion that this simply has to be done to comply with the powers-that-be, the following sections can be of some help to you.

Warning, if you do this properly, it will take more than an hour!

PAUSE FOR THOUGHT You could skip through the questions below, skimreading them and quickly conclude that this article is baloney. And you could thereby determine it as such.

To get some worth out of engaging with this, please spend at least one minute contemplating each question (or subpart thereof) that follows. If a train of thought departs, follow it to its journey’s end and then make notes.

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“Your actions are determined more by your convictions than by your circumstances.”

Is that statement true? Does it apply in all places and at all times. How about when it comes to how you chose to spend money? To vote? How you behave with your partner? Your children? Your friends?

Please now consider your professional interactions with each of your different team members. Where do these qualities come in the interactions you have with each team member? (I mean from your side, not judging them, particularly.)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Gentleness Humility Excellence Confidence Competence Fairness Firmness Self promotion Arrogance Impatience Meanness

At work, do you get anxious? If so, what do you get anxious about? Why do you get anxious about that in particular?

Who do you answer to in your professional life? Who are you formally accountable to? To whom do you owe your loyalty? Similar questions these, but they need not have exactly the same answers. In a football club, as a manager, you might answer to the media pundits and the fans in a very real way, you might be accountable to the chair and the board but you may owe your loyalty to the club, the players and the fans, perhaps in that order.

Now go again and add another layer of depth to your thoughts.

Midlands Medicine

PDP DEVELOPMENT

CODA

The personal development plan is just what it says, a plan to allow you to progress and/or grow professionally.

Or it could be to get you to develop a special interest, or move sideways from an area you don’t thrive in, or wind down to retirement in a controlled and discrete way. It is to your advantage to manage this. The key to success is to have a clear idea of where you would like to get to (even if that clear idea is that you would rather nothing changed) and to keep sufficient control for the PDP to be congruent with your aims. In the end, a PDP boils down to a list. But it is a list full of meaning and intent, and against which you will be held to account the following year. It pays to put in some effort and to get it as right as you can.

Now put your notes in a safe place and make an appointment with yourself and read them back, review and hone them. Hopefully different sections will have sparked off deeper trains of thought which you can then develop as small written reflective pieces for your portfolio.

First, identify key areas of your practice and your key professional interests. List them. Add in achievements and milestones not yet reached. Now add in characteristics you admire in others and would like to have yourself, and principles you would like to follow.

Consider who you would like to be professionally, and what you would, realistically, like to be doing.

ADDRESS FOR CORRESPONDENCE

For each item on your list, ask yourself each of the following questions, in so far as they can be made to apply: How far do you fall short of the ideal? How far behind someone you can identify as an aspirational role model in regards to the quality under consideration do you find yourself? How far are you from where you think you could reasonably be expected to be within a year?

For each of the qualities, goals, developments that you have come up with a SMART* aspiration for, try to plot yourself a course from where you are now to where you would like to be. Think in terms of a series of steps. Be detailed, specific and linear. Consider how each step might be achieved and how long it might take. This exercise might make you realise that you just don’t know how to get to where you want to be. (That would be a prompt to talk things over with someone else, hopefully well chosen for their approach and their relevant technical knowledge.) A distillation of the above should get you a PDP that is bespoke and smart, in all senses.

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*S Specific M Measurable A Achievable R Relevant T Timebound

Marcus German C/o The Editor North Staffordshire Medical Institute Hartshill Road STOKE-on-TRENT ST4 7NY

You don’t need any knowledge to have an opinion.

Brian Archer (of The Archers)

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NEWS North Staffordshire researchers have been awarded £18,450 to develop a new treatment for chemo-resistant cancers.

The group, led by research pharmacologist Dr Alan Richardson, hopes to extend the lives of thousands of patients with breast, ovarian and lung cancers that have stopped responding to chemotherapy drug paclitaxel.

They aim to develop a new drug to stop cancer cells producing a protein that makes them resistant to the therapy.

Dr Richardson and his team will receive the grant from the North Staffordshire Medical Institute.

He said, “Patients who get ovarian cancer respond well to chemo, but they often suffer a relapse and when they come back they become resistant to treatment. At that point the number of options left are limited and there’s not a lot that can be done.”

He explained, “Our goal is to discover drugs that make cells sensitive to chemotherapy again.”

ENDING DRUG RESISTANCE Paclitaxel is normally given to patients through an intravenous drip and works by stopping cancer cells from dividing and growing.

The scientists, based at Keele University’s Institute for Science and Technology in Medicine (ISTM), have found that paclitaxel-resistant cells make too much of a protein called branched chain keto-acid dehydrogenase kinase (BCKDK).

They plan to test a range of chemicals in the lab with samples of pure BCKDK in a bid to block the gene that tells cancer cells to produce it.

Dr Richardson said: “I used to work at the Institute for Cancer Research in London and I started a screen to identify genes that contribute to drug resistance.

“Since then we’ve identified one gene and if we inhibit it, it makes the cancer cells more sensitive to paclitaxel.

So we’re going to make drugs to inhibit this gene and hopefully extend people’s lives.”

Dr Richardson’s team will use the money to buy the state-of-the-art equipment they need to set up the initial tests. This will help them to apply for more funding to develop the drug further and eventually test it in patients.

The greater the ignorance, the greater the dogmatism.

William Osler

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OTHER NEWS The Royal College of Physicians of London is celebrating its 500th anniversary this year with events scheduled to mark the occasion.

The president elect, Andrew Goddard is a Consultant Gastroenterologist from Derbyshire. The RCPL website has the following information about him: “He was appointed as a consultant physician to the Derby City Hospital (now called the Royal Derby Hospital) in 2001.

He has published over 50 peer-reviewed papers, book chapters and review articles and is the lead author for two national guidelines. His current research interests are iron deficiency anaemia, Barrett’s oesophagus and bowel cancer screening. His main clinical interests are inflammatory bowel disease and bowel cancer screening – he is clinical lead for the Derbyshire bowel screening programme.

He first got involved with the Royal College of Physicians in 2003 when he was elected onto the New Consultants Committee which he chaired between 2005 and 2007.

He was director of the Medical Workforce Unit between 2008 and 2013, and as College EWTD lead in early 2009. During this time he oversaw the RCP’s annual census of consultant physicians and registrars.”

Sadly, in Breaking News, reports are coming in of some significant mishandling of registrar (ST3) post applications reminiscent of the MTAS debacle. Some complex administrative slippage suggests that hundreds of junior doctors may have been given the wrong information regarding their posts in August.

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As we go to press, this is a situation in evolution. A Royal College release reads as follows: “We appreciate that some candidates would have wanted to review their preferences before the first round of offers starts.

The decision taken yesterday, after consultation with a range of people including from the BMA and the RCP trainees committee, was to move more quickly and straight to offers with preferences set as they were on Friday 4 May. This was viewed to be the fairest approach, but we recognise that for some candidates this may have an adverse effect. We will work with partner organisations involved in recruitment from the four nations to ensure individuals are supported.

Once the offers start, individuals affected will be able to contact us to review their situation.

If you are aware of friends and colleagues who are affected by this situation who may not have heard (e.g. if they are on leave), we would greatly appreciate any efforts you can make to alert them.

We would also like to reiterate our sincere apology to all those caught up in this issue and assure you all that we do not underestimate the upset it has caused. Your welfare is of paramount importance and we hope you are able to support each other in these difficult times.

Please also think of using services such as the BMA Counselling and Doctor Adviser service if you are struggling and need support.”

If this does not get sorted soon it threatens to overshadow the 500th anniversary celebrations.

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QUIZ NIGHT Oluseyi Ogunmekan, General Practitioner, Furlong Medical Centre, Stoke-on-Trent 1. Which of the following is not advisable to use with clopidogrel? a) Ranitidine d) Rabeprazole

b) Lansoprazole e) Esomeprazole

c) Pantoprazole

2. What is the earliest time after delivery is it recommended that a cervical smear can be performed? a) 3 months c) 6 weeks

b) 4 weeks d) 6 months

8. What is the normal intraocular pressure (in mmHg)? a) 25-30

b) 30-40

c) 12-22

d) 40-50

9. Cyclical vomiting syndrome: which of the following statements is false? a) It only affects children b) It can last for decades c) Sumatriptan & Propranolol can be used as treatments d) Gastroparesis is a recognized complication

3.Which of the following can be used for the treatment of essential tremor?

10. Which of the following is a secondary cause of Dyslipidaemia?

a) Propranolol c) Gabapentin e) Topiramate

a) Poorly controlled diabetes c) Untreated hypothyroidism e) All of the above

b) Primidone d) Pregabalin f) All of the abve

b) Alcohol d) Nephrotic syndrome

4. How many cervical smears will be taken in total as part of the UK Screening Programme?

11. The DAS 28 is a measure of disease activity in which of the following conditions?

a) 4

a) Multiple sclerosis c) Rheumatoid Arthritis

b) 6

c) 12

d) 8

e) 7

5. Takotsubo cardiomyopathy: which of the following is a recognised cause? a) bereavement c) acute asthma e) all of the above

b) arguing with spouse d) winning a jackpot f) none of the above

6. Prehnâ&#x20AC;&#x2122;s sign is useful in determining pain from which organ? a) Kidney d) Thyroid

b) Liver e) Breast

c) Testis

7. PERC Score: relates to which medical conditions? a) Asthma b) Pulmonary Embolism c) Heart failure d) Rheumatoid Arthritis e) Inflammatory bowel disease

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b) Parkinsonâ&#x20AC;&#x2122;s Disease d) Heart Failure

12. Regarding the timing of blood sampling when measuring drug levels, which of the following can be done within 30 minutes of the first dose? a) carbamazepine d) theophylline

b) digoxin c) phenytoin e) all of the above

13. MAGGIC risk calculator estimates 1 and 3 year mortality in which condition? a) Renal failure

b) Heart failure

c) Liver failure

14. Purple urine bag syndrome: Which of the following bacteria have NOT been implicated? a) Klebsiella pneumoniae c) Proteus mirabilis d) Pseudomonas aeruginosa

b) Escherechia coli d) Staphylococus aureus

Midlands Medicine

QUIZ TWO: SYNDROMIC CONUNDRUMS Dominic de Takats, Editor, Midlands Medicine Syndromes, acronyms, and eponyms. These may not be classic best of five but they should tickle the grey cells, particularly those of the hippocampus. Remember, this is for fun, and the answers should prove illuminating and instructive … unless you know it all already!

1. Which of the following are recognised syndromes, and what are the conditions? a) Green man d) Red man

b) Ice man e) Stiff man

c) Lax man

2. Which one of the following signifies a condition and what is the pathology? a) AMAS d) MSSA

b) EMAS e) MTAS

c) MCAS

6. Give the modern formulation for these conditions: a) Churg-Strauss syndrome c) Kussmaul disease e) Wegener’s granulomatosis

b) Hughes’ syndrome d) Plumbism

7. Which of the following are masquerading? a) Hysterical conversion b) Imposter syndrome c) Munchausen syndrome d) Stockholm syndrome e) Munchausen syndrome by proxy

3. Collate the following features to make as many syndrome constellations as you can:

8. Which of the following mitochondrial cytopathies do you recognise and which is the imposter?

• deafness • Pregnancy • Thrombocytopaenia • Hypoalbuminaemia • diabetes mellitus

a) MERRF d) MELAS

• Proteinuria • Heamolysis • Oedema • high LDH • Hypertension • AKI • dilute urine • OA • High alkaline phosphatase

4. Which of the following is not a genuine medical syndrome? a) Alalgile d) Monarch

b) Bartter’s e) Salem

c) MELAS f) TORCH

b) Chiari e) Rendu h) Danlos

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c) NEHAL

9. Which is the odd one out out and what do the remainder have in common? a) Alport’s syndrome c) Fanconi’s syndrome e) Hypophosphataemic rickets

b) Dent disease d) Lowe’s syndrome

10. Which one of the following syndromes turned out to be all too ironic?

5. Name the missing collegues: a) Anderson d) Moon g) Stokes

b) NARP e) LHON

c) Marie f) Sachs

a) Down’s syndrome c) Kartagener’s syndrome e) Zollinger-Ellison syndrome

b) Hughes’ syndrome d) Trusseau’s syndrome

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REVIEW: THE NUTS AND BOLTS OF LIFE BY PAUL HEINEY Dominic de Takats, Consultant Nephrologist, UHNM From bench to bedside was a recent trope summarising the relatively new discipline of translational medicine.

The idea is that molecular biology comes up with discoveries about how cells work, gains understanding of cellular systems and pathologies caused as these systems go awry, tests strategies (usually boiling down to compounds to be tried) eventually leading to drug development and then through the phases of clinical trials: first safety testing in whole human physiology.

(These days, always initially in a series of single individuals, following the events at Northwick Park Hospital in North-West London in March 2006 when eight healthy volunteers were paid to take part in a Phase 1 clinical trial of a monoclonal antibody. The two volunteers given placebo were fine, but the six given the investigational medical product became violently and seriously ill.) After establishing safety, then safety and efficacy in whole humans with the target pathology takes place in Phase 2 and Phase 3 clinical trials. After evidence of safety and efficacy have been amassed, submissions to the appropriate medicines regulatory agencies are made. If approval for the medicinal product is forthcoming, then a licence is issued for human use of a drug for a particular indication, at a particular dose.

This route, though rooted in the 20th Century, starting with the serendipitous observations of Alexander Fleming and the pioneering work of Sir James Whyte Black in designing beta blockers (specifically propranolol) and H2 antagonists (specifically cimetidine), is very much a 21st Century model. In the earlier 20th Century, and perhaps for a long time beforehand, inspiration to seek help or cure was often taken from the plight of sick patients, inspiring those with a mixture of compassion, inventiveness and a refusal to stoically accept the status quo. They would then cast around rationally, but with a limited knowledge base, for some potential therapy. From Sir James Whyte Black onwards, and particularly with the advent of cell biology and then genetic understanding 202

and the very substantial technological advances that mean that knowledge can be manifested as effects, there has been a move to design drugs to interact at particular points in molecular biological pathways. In parallel, compound screening for effects in cell culture systems is very much still alive today. Both these approaches have in common that they start with the molecular and the cellular and hope to have beneficial effects in whole sick people one day. The intellectual and physical flow is largely unidirectional: from bench to bedside.

The Nuts and Bolts of Life by Paul Heiney is subtitled: Willem Kolff and the invention of the kidney machine.

Willem Kolff really is someone you should have heard of, but probably haven’t. Though he had little to do with computers, much of modern mechanical medical technology owes him a debt. Many devices and machines were either driven, made functional or inspired by him. Or made by people competing with his ideas and prototypes.

Willem Kolff, effectively the father of synthetic organ replacement technologies, did things slightly differently – from bedside to workshop and back to bedside. This approach led to the development of the first successful (eventually) artificial kidney/dialysis machine and many other artificial organs, notable amongst them the Jarvic artificial heart, named after a colleague working under Kolff.

Paul Heiney, the author of this biography of Kolff, might be remembered by some as a reporter on Esther Rantzen’s That’s Life programme in the 1970s. Since then he has continued broadcasting and writing with a 10 year period where he put to the foremost a life centred on tradional farming with horses in Suffolk.

Just as his time as a farmer was coming to an end, he met Willem Kolff and, captivated by his spirit, decided to tell his story in a book.

Midlands Medicine

Heiney is a journalist and broadcaster with no particular medical background. Quite why he picked Willem Kolff ’s story to tell isn’t made perfectly clear.

But like any good journalist, he knows a good story when he happens upon it. And this is a good story, one that deserves to be told, to be known.

Kolff started life as a gauche and youthful figure with the same interests, concerns and appetites as many other young doctors. But he was also distinct, distinguished by a certain combination of characteristics. These included the compassion that many a doctor brings to their work, a certain ingenuity, a pragmatic problemsolving approach and an engineering eye. He was able to employ a combination of unjustified optimism and the rigorourous application of observation and the experimental scientific method.

It would be wrong to miss out another key ingredient: obstinacy. The combination of a physician with a mechanical engineering sense is key to the development of heamodialysis. The obstinacy allowed Kolff not only to plough on in the face of poor outcomes, but to do so in the midst of the Nazi occupied Netherlands as the Second World War unfolded. This also allowed him to push on in good conscience, and apparently unflinching, as patient after patient after patient died. But, with the first successful bridging of a patient with acute kidney injury to recovery in 1945, proof of principle had been achieved. From all the failures much had been learned, including features that would inspire Kolff to work on the artificial heart-lung machine, pacemakers and implantable artificial hearts, among others.

Puul Heiney tells this story step-by-step. Kolff died in 2009. This book was published in 2003. In terms of source material, Heiney had met Kolff and with members of his family, and had the run of his personal archive material. He also had published papers and reports to read and other accounts to collate, not least of which was pre-eminent UK Nephrologist Stewart Cameron’s The history of the treatment of renal failure by dialysis. This direct access to its Kolff, now lost to us, gives Heiney’s biography a unique advantage, never to be repeated, consigning any future such account to the realms of mere historical research.

The only warning to give you is that Heiney, not having a medical background, comes at the medical material from a lay perspective and this can be readily appreciated. So, if imprecision, inaccuracy and minor medical misunderstanings matter to you to the extent that they may jar and grate, The Nuts and Bolts of Life will be a difficult read for you in places. But if you can ease past such things and get to the heart of the story of a man’s life dedicated to medical invention, you may find yourself encouraged and inspired. At the very least, you should find yourself better informed with an improved appreciation of the basis of some of the widely used medical devices that affect the lives of millions every day.

This biography has been crafted to fit the popular science paperback format. The early chapters concentrate on the original conception and development of a haemodialysis machine, against the odds under Nazi occupation.

Following the end of World War 2, Kolff moved to the USA where he had a struggle to establish himself but, once he had done so, he became a considerable leader in medical innovation. Though relatively few know his name, his influence ripples on to this day.

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INTERESTING IMAGES

All these images are of cavitating lung lesions. They occur in slightly different circumstances. In the first three images, the cavitation is due to ANCA positive vasculitis in a 51-year-old male.

These next images are from a man in his mid-twenties with a history of bronchiectasis who then required immunosuppression for an inflammatory condition. He developed a cavitating Pseudomonas infection which responded well to a prolonged course of intravenous antibiotics. As in the first case, it is unlikely that the diagnosis would have been made without CT scanning.

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In times past, cavitating chest lesions were to be found on chest radiographs as rings or moon-like lesions of a spherical outline with air-fluid levels. These days, cavitating lung lesions are more likely to be found on CT scanning which is far more sensitive.

A mixture of peripheral cavitation and consolidation is seen.

This man in his fifties was initially treated for pneumonia. Only after prolonged courses of antibiotics failed to improve his situation did an alternative diagnosis of ANCA vasculitis surface. Treatment of that then led to the patientâ&#x20AC;&#x2122;s recovery. The predominantly unilateral disease made this a difficult diagnosis to make.

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Cavitating lung lesions have numerous causes. These vary in different populations and over time according to prevailing aetiologies. Causes include a variety of infections such as staphylococcal infection, tuberculosis, nonmycobacterial TB, aspergillus and septic emboli from infections elsewhere may cause lung abscesses. Other granulomatous conditions such as sarcoidosis and vasculitis may cause lung cavities, as shown in these CT cross sectional images. Rheumatoid disease can also be a cause.

Cancer is also a condition which may cavitate in the lungs.

IMAGE COMPETITION One of the key challenges to producing a good edition of Midlands Medicine is to source the cover image and the other is to source the interesting images. We would like to give you the opportunity to help us out with that by submitting your beautiful, spectacular and interesting images for publication in the journal. In addition to the kudos of publication, monetary prizes of suitable worth will be made if your submissions are published.

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Midlands Medicine

This lady presented aged 21 years with sudden onset of breathlessness and a severe systemic illness. The picture was initially, and for quite some time, very confusing. A CTPA had shown multiple PEs but there were also cavitating lesions which could have been due to pulmonary infarction, but the PEs were not of that order and there was not prodromal history. Having presented, systemic unwellness, fevers and hypoxia were all noted and she was treated with broad spectrum antibiotics to no avail.

Left parasagital section An autoimmune serology screen was sent and she was found to be ANCA positive. Treatment then changed to include steroids and rituximab and her clinical course turned a corner.

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These CT cross sections are at similar levels to the previous images:

They were taken at an interval of two years with the patient on low dose maintenance immunosuppression. The cavities have all resolved and the condition of the lungs is considerably improved, although some nodules persist.

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QUIZZESâ&#x20AC;&#x2122; ANSWERS AND EXPLANATIONS QUIZ NIGHT: ANSWERS AND EXPLANATIONS 1. e) Esomeprazole Omeprazole or esomeprazole reduces the ability of clopidogrel to inhibit platelet aggregation thus attenuating its cardio protective effect.

2. a) 3 months It is not advisable to have a cervical smear during pregnancy or up to 3 months after delivery. Pregnancy can make the result of the smear difficult to interpret.

3. f) all of the above Benzodiazepines e.g. clonazem may also be tried.

Anticholinergics are indicated in Parkinsonian tremor 4. c) 12 The NHS Cervical Screening Programme was introduced in the 1980s. Women aged 25 to 49 years are invited every 3 years and those aged 50 to 64 are invited every 5 years.

5. e) all of the above This has also been known as stress cardiomyopathy and sometimes broken heart syndrome. It is a form of nonischaemic cardiomyopathy and can lead to heart failure, lethal ventricular arrhythmias or ventricular rupture.

6. c) testis The physical lifting of the testicles relieves the pain of epididymitis (positive sign), but not pain caused by testicular torsion.

7. b) pulmonary embolism PERC stands for Pulmonary Embolism Rule out Criteria.

It is a score that considers age (greater than 50), heart rate (greater than 100), oxygen saturation and the presence of a unilateral leg swelling, haemoptysis as well as recent surgery or trauma.

8.

c) 12-22 mmHg

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9. a) It only affects children It mainly affects children but can affect adults too. The aetiology is unknown but there may be a link with migraine.

Many people with CVS develop migraines and migraine medicines have been shown to help to treat the syndrome.

10. e) all of the above Other possible causes include cigarette smoking, obesity, polycystic ovarian syndrome and the metabolic syndrome.

Statin therapy should be discontinued when the liver transaminase level are more than 3 times the upper limit of normal.

11. c) Rheumatoid Arthritis DAS stands for disease activity score and the number 28 refers to the joints that are examined in the assessment. A DAS 28 score of greater than 5.1 implies active disease, less than 3.2 low disease activity and less than 2.6 remission.

In the UK a score equal or greater that 5.1 is one of the mandatory criteria required to be eligible for NHS funded treatment with biologic therapies.

12. a) Carbamazepine Carbamazepine, digoxin and phenytoin should be taken within 30 minutes before dose. Phenytoin should be taken before the AM dose. Digoxin should be taken 30-60 minutes before dose and at least 6-8 post dose. With theophylline, either a peak or trough level will provide adequate information regarding dosing.

13. b) heart failure MAGGIC is an acronym of Meta Analysis Global Group in Chronic heart failure. The heart failure risk calculator presents 1 and 3 year all-cause mortality estimates for people with heart failure. It considers the age, ejection fraction, systolic B/P, BMI, Creatinine, smoking status as well as the use of a beta-blocker and an ACE inhibitor.

14. d) Staphylococcus aureus Purple urine bag syndrome occurs in people with urinary catheters and co-existent urinary tract infection. This results in a purple discoloration of the urine. People with this syndrome do not usually have symptoms.

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SYNDROMIC CONUNDRUMS: ANSWERS AND EXPLANATIONS 1.

d) Red man

e) Stiff man

Red man syndrome occurs when vancomycin is infused too quickly and causes a generalised erythrodermic response.

Not a true allergy as it can be avoided by giving the infusion over at least an hour.

Stiff man syndrome is a neurological disorder which is incompletely understood but in which truncal rigidity is a characteristic feature.

6. a) Churg-Strauss syndrome: eosinophilic granulomatosis with polyangiitis b) Hughes’ syndrome: antiphospholipid syndrome c) Kussmaul disease: Polyarteritis nodosa d) Plumbism: lead poisoning e) Wegener’s granulomatosis: granulomatosis with polyangiitis

7.

2.

c) MCAS

MCAS, mast cell activation syndrome. MTAS is the medical training application service.

c) and e)

Hysterical conversion is not a conscious masquerade.

Imposter syndrome occurs when you really are in a position but don’t believe it yourself: the opposite of masquerading.

Munchausen syndrome is a factitious illness, so a masqurade.

3.

Possibilities include:

Munchausen syndrome by proxy, similarly.

d) Monarch

Stockholm syndrome is the genuine develoment of a sympathy towards a captor when a hostage. The captor may be masqurading with their kindness of manner, nut not the person with the syndrome.

HUS, DIDMOAD, HELLP, nephrotic syndrome and PET.

4.

Alalgile syndrome is a multisystem genetic disorder centering on the hepatobiliary system Bartter’s syndrome is comprised of genetic disorders of ion transport in the Loop of Henle.

MELAS is an acronym of mitochondrial encephalopathy, lactic acidosis and stroke-like episodes. These result from a mitochondrial cytopathy.

Al Gazali Aziz Salem syndrome is a rare genetic cause of short staure, learning disability a webbed neck and heart disease.

TORCH syndrome is infection in utero causing a pattern of damage. It is named after recognised caysative agents and others: toxoplasmosis, others, Rubella, CMV and herpes simplex.

5.

a) b) c) d) e) f) g) h)

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Anderson: Fabry Chiari: Arnold or Budd Marie: Charcot and Tooth Moon: Laurence and Biedl Rendu: Osler and Weber Sachs: Tay Stokes: Adams Danlos: Ehlers

8.

MERRF NARP NEHAL MELAS

LHON

myoclonic epilepsy with ragged red fibres neuropathy, ataxia and retinitis pigmentosa Is entirely made up mitochondrial encephalopathy, lactic acidosis and stroke-like episodes Leber’s hereditary optic atrophy

9.

c) Fanconi’s syndrome

10.

d) Trusseau’s syndrome

Fanconi’s syndrome can be the end result of a number of different processes and conditions which damage tubular transport. All the others are specific X-linked genetic disorders.

Trusseau’s syndrome: Thrombophlebitis migrans as a paraneoplastic phenomenon, an association first described

by Trousseau and later diagnosed by Trousseau in himself.

This turned out to be due to gastric cancer.

Midlands Medicine

Painted by Anthea Bond (See also ‘Medical Ceramics’ on page 194)

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