Midlands Medicine - Vol 29 Issue 4

MIDLANDS MEDICINE SUMMER 2021 VOLUME 29 - ISSUE No 4

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Editor’s notes

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Case Report: Unusual Journey of an Auditory Canal Skin Cancer

160 Quiz Night

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Ivan Illich: Flawed Prophet – Part 1

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Medical Philately: Slogan Postmarks

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Wordplay Comes of Age

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Schwartz Rounds: Humanity and Compassion in Healthcare

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Phlegmasia: A Case Report and Brief Literature Review

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Three Thoughts

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Case Report: Shropshire Hand Treated by Metacarpophalangeal Joint Replacement

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More Medical Ceramics

168 Interesting Images

141 Deceased Donor Organ Donation in 2021

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159 News

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Answers and Explanations

Midlands Medicine

COVER IMAGE The Garden of Earthly Delights, A tryptic by Hieronymus Bosch. These images are very familiar at first glance, but reward repeated detailed scrutiny with delight and glee. No-one really knows what on earth is going on in these three paintings. It may be anarchic allegory, pleasure, pain or critique. It is also fun and is presented here to add a little cheer after the very difficult year.

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MIDLANDS MEDICINE

CONTENTS

EDITOR

EDITORIAL

Dr D de Takats

Editor’s notes

EDITORIAL BOARD

Ivan Illich: Flawed Prophet – Part 1 Paul Laszlo

Mr J. Muir Dr I Smith Mr D Griffiths Helen Inwood Clive Gibson Tracy Hall Professor Divya Chari EDITORIAL ASSISTANT Jacqueline Robinson THE NORTH STAFFORDSHIRE MEDICAL INSTITUTE President: Mr B Carnes Chairman: Mr J Muir Deputy Chair: Professor Murray Brunt Honorary Treasurer: Mr M Barnish

Schwartz Rounds: Humanity and Compassion in Healthcare Lorraine Corfield ORIGINALS Case Report: Shropshire Hand Treated by Metacarpophalangeal Joint Replacement Sai Ramesh & Nicholas Neal Deceased Donor Organ Donation in 2021 Tariro Mangwiro Case Report: Unusual Journey of an Auditory Canal Skin Cancer Joshua Pettit & Ajith George Medical Philately: Slogan Postmarks Dominic de Takats Phlegmasia: A Case Report and Brief Literature Review Aiden Watson, Mona Mossad & Sriram Rajagopalan

Please forward any contributions for consideration by the Midlands Medicine Editorial Board to the Editor c/o Jacqui Robinson

More Medical Ceramics Anthea Bond

By email: jacqui@nsmedicalinstitute.co.uk

REPORTAGE

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 ©2021.

News ENDPIECES Quiz Night Oluseyi Ogunmekan Wordplay Comes of Age Dominic de Takats Three Thoughts Dominic de Takats Interesting Images Answers and Explanations

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EDITOR'S NOTES England lose on penalties! Again.

I hope this summer edition finds you well. The CoViD-19 pandemic has been a huge disruptor. It has left its marks, and some of you will have been personally and deeply touched by its more damaging reach. It is why England lost the Euro-2020 final at Wembley in the summer of 2021. It is why this edition of Midlands Medicine is later in the year than usual, and why there was only one issue last year.

For Midlands Medicine it’s too early to write the history of, or to draw profound lessons from, the pandemic but, doubtless, such reflective retrospectives will come when they are ready, and they’ll be welcomed with open editorial arms. Midlands Medicine has made a change: issues will now be tied to seasons and not specific months, just to give more flexibility in their production.

The other benefit, perhaps, is that tying the editions to a season rather than a month may give them a longer shelf life during which they’ll be read more thoroughly and by more people. They are produced to be read and not just for the sake of it, so please do read through them and then pass them on to potentially interested parties if you would otherwise discard them.

Turning to the contents of this first Summer issue, we first have an account by Paul Laszlo of some of the thoughts of Ivan Illich, a man you might know little about, but whose writings are like a literary version of a Hieronymus Bosch painting. His dense and highly annotated prose can be skipped through and a general gist of an argument gleaned, or he can be inspected phrase by phrase and layers of insight and perspective will continue to be revealed at each re-visit. Paul’s piece is just a taster with more to come in future issues.

Lorraine Corfield has undertaken the not inconsiderable task of introducing Schwarz rounds into UHNM. Since I was unfamiliar with them, I’ve asked her to write explaining exactly what they are, what they’re about and what they’re for. With surgical efficiency, Miss Corfield executes the task with aplomb, and you will know the answers to those questions if you read her piece.

This humble organ may have within its covers a world first. It certainly seems that way. That’s the thing with specific phenotypes reflecting classic Mendelian inheritance in uncommon mutations, particularly if they occur in families not much given to travelling.

And so it may be with the variant of Shropshire hand and the particular surgical fix used. I am indebted to 128

Sai Ramesh and Nicholas Neal for their account. Two other case reports are presented, the first, by Joshua Pettit and Ajith George, describes an unusual journey of an auditory canal skin cancer. The title alone should draw you in, but this is more a surgical odyssey than a mere journey. The second, from Aiden Watson, Mona Mossad and Sriram Rajagopalan, takes us into the world of phlegmasia (again, unfamiliar) in some detail and will leave you more knowledgeable, warier but better able to cope if and when you come across this condition yourself.

The three Case Reports are each accompanied by an article of a different sort. The first is a serious look at what has happened to deceased organ donation in the 2020-21 period in the light of two major changes of circumstance, one planned and one imposed. The planned change was the coming into force of the Organ Donation (Deemed Consent) Act 2019 in Spring 2020 and the other was the CoViD-19 pandemic which disrupted normal NHS functioning from about the same time. Huge change in circumstances, no change in the mission: how did it pan out? The other two accompanying articles are lighter, information for interest’s sake with no earnest message behind them.

But I do think them worth your attention. First, I’d like to introduce you to Medical Philately, if you’ve not come across it before, or hold your interest if you have, by taking a look at a small sample of medically-related slogan postmarks. Lastly in the Originals section, Anthea Bond presents more medical ceramics, building on previously featured jars, she is steadily educating us in this area.

We close this issue of the journal with our usual treats, an educational quiz courtesy of Oluseyi Ogunmekan, a play on words and some interesting images.

Eagle-eyed readers may have noticed the absence of an Assistant Editor this time. I’d like to express my thanks to Chris Bolger for his support over many years in the role of Assistant Editor. After all his loyal service, a period of illness about which he reflected memorably in this journal, and the disruption wrought by the pandemic, Chris has stood down since the last edition.

His contributions will be much missed, and I wish him well as he moves on.

Here’s wishing you a good break over the summer and I hope you’ll find time to read through this issue of Midlands Medicine.

Midlands Medicine

IVAN ILLICH: FLAWED PROPHET – PART 1

Paul Lazslo, Consultant Physician

Ivan Dominic Illich was a 20th Century JewishChristian from central Europe, born in Austria in 1925.

He was a polyglot and a polymath, a Catholic priest in New York and a social philosopher.1,2 He spent a lot of time ruminating on the human condition, but instead of majorly considering the relationship of a man’s soul with his maker, he was concerned with the effects of organised society and the edifices of state and the government on people at large. He had both socialist and libertarian leanings but was distrustful of any regime aiming to corral and organise its citizenry. He felt that big government deprived people of individual responsibility and, thereby, the self determination to make their own assessment of the meaning and purpose of life, and denied them the opportunity to come to terms with the harsh realities, vagaries and vicissitudes of life on their own terms.

Unlike many who have contrary views, rather than ranting or rhetoric, Illich was in the habit of constructing arguments laden with explanation and studded with evidence, often referenced in the form of extensive footnotes. He read widely, both current theories and historical texts, not just in English but drawing far more widely from European works from Russia to Portugal. His first major excursion into laying out his social philosophy concerned the field of Education.3 He was against compulsory organised schooling in the traditional form. To summarise his approach, précised beyond the reasonable, it was that formal education, the passing on of what we already know, pre-digested, limited insight and stifled innovative free thinking. Illich, demonstrating such free thinking himself, had many ideas, one of which was peer-to-peer support across a computer network with some artificial intelligence assisting. This at a time when the internet was in a proto form and the world wide web was not an extant concept. It is these glimmers of genuine prediction and insight, rather than the philosophical constructs in which they sit, that make Illich a prophet; the constructs, which have not fared so well but dated

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like flower power, free love and New Age thinking make him a flawed prophet.4 The book that concerns us here, however, is one in which Illich brings his philosophy, analysis and critique, as well as his great ability to contextualise both socially and politically, to bear on healthcare systems. It is a book written over several iterations, published in its final form in 1976 with its awkward three-phrase title: Limits to Medicine. Medical nemesis: The Expropriation of Health.5 As already explained, the overarching idea that healthcare systems deliver nett harm and should be largely dismantled and can have little traction and little sympathy today. But to disregard some of the specific points and examples that Illich leverages in support of his defunct thesis would be to miss pearls, or nuggets of gold, that indubitably lie in the swill, chucking the baby out with the bathwater. So, as a starting point, it is worth listing some of the specific ideas concerning medicine, life, death and the main critiques of organised healthcare systems made by Illich. Each of these then bears some explanation and examination.

• • • • • •

Good Doctors Dangerous Hospitals Bad Survival Protocolisation of Medicine Use of Aggregated Data Good death

GOOD DOCTORS In Limits to Medicine Illich consistently rails against the medical establishment. (I get the strong impression that he had problems with authority structures and their effects more generally.) He was a libertarian, naively hopeful for a world in which people are free to make their own choices, live to a reasonably material standard in small communities and accept “limits to population,

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of aging, of incomplete recovery and ever-imminent death”.6 Conflating the ideas of society, organised healthcare systems and actual practice of medicine and surgery into a single conglomerate complex at which he directs his ire Illich regards organised healthcare system involvement (“interference”) in people’s lives as necessarily unhealthy, seemingly blinded by his bile to the sometimes-needed help and succour that such entities can give. He goes on “Healthy [by which he means free from interference] people need minimal bureaucratic interference to mate, give birth, share the human condition and die.

“Man’s consciously lived fragility, individuality and relatedness make the experience of pain, of sickness and of death an integral part of his life. The ability to cope with this trio autonomously is fundamental to his health. As he becomes dependent on the management of his intimacy he renounces his autonomy and his health must decline.” Despite the tide of antipathy, there is an acknowledgement that some healthcare might be necessary: “A world of optimal and widespread health is … a world of minimal and only occasional medical intervention.”7 Given this approach, it is perhaps a little unfair to take something that Illich means to apply generally and consider it more particularly as applying to the medical profession, but here it is: “Knowledge encompassing desirable activities, competent performance, the commitment to enhance health in others - these are all learned from the example of peers or elders.” Substitute, if you will professional attitudes’ for ‘desirable activities’ and you have something very much akin to “Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues…”8 Though Illich doesn’t think much of doctors, he has somehow managed to encapsulate the essence of a good medical professional culture in a very few words.

Through the rest of what he has to say, by warning against all the possibilities of bad practice, he also contributes to good medical practice.

in the United States are technically unnecessary, yet 20 to 30 percent of all children still undergo the operation.

One in a thousand dies directly as a consequence of the operation and 16 in a thousand suffer from serious complications. All lose valuable immunity mechanisms.

All are subjected to emotional aggression: they are incarcerated in a hospital, separated from their parents, and introduced to the unjustified and more often than not pompous cruelty of the medical establishment. The child learns to be exposed to technicians who, in his presence, use a foreign language in which they make judgments about his body; he learns that his body may be invaded by strangers for reasons they alone know”9 His assertions are not necessarily correct and the death rate may have been a tenth, at I in 10,000 and immunity may not have been compromised, but an estimated 100 deaths a year were in the US were directly attributable to tonsillectomies10 and we have come to agree subsequently that many were unnecessary. So Illich has several points to make here. One is that hospitals are places where unnecessary procedures are done which cause inherently avoidable mortality and morbidity.

Furthermore, even where no physical harm is done, hospitals psychologically traumatise the impressionable young and condition them to be pliant or submissive and accepting of professional medical care rather than questioning or partnering patients.

Illich reviews the history of hospitals and finds them to be regarded very poorly in the Europe and Arabia from the late Middle Ages through to the 19th Century. They are described as “pestholes” and he observes: “Until the late eighteenth century the trip to .. hospital was taken, typically, with no hope of return. Nobody went to a hospital to restore his health. The sick, the mad, the crippled, epileptics, incurables, foundlings, and recent amputees of all ages and both sexes were jumbled together; amputations were performed in the corridors between the beds. Inmates were given some food, chaplains and pious lay folk came to offer consolation, and doctors made charity visits.”11 That is all as it may be, but this observation is key: “[hospitals] are inevitably places for the aggregation of the sick and breed misery while they stigmatize the patient.”12 Think for a minute of the nosocomial transmission of CoViD-19 and all the DANGEROUS HOSPITALS A couple of examples. The first is that of tonsillectomy, arguments about when to transfer patients to nursing the practice of which used to be very different to that homes and you will have to agree that Illich very much of today. Regarding practice in his time, Illich states: has a point. “more than 90 percent of all tonsillectomies performed

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PROTOCOLISATION OF MEDICINE Illich fully accepts the inexorable move towards the practice of evidence-based medicine and implies that it will require a system of rules for its implementation, what we refer to these days variously as guidelines, guidance or protocols, once again correctly predicting what subsequently came to be. However, because of his peculiar perspective, which highly prizes individualism over a systematised approach, he sees in the enterprise the very opposite outcome of the effect being sought. He decries it thus, “By turning from art to science, the body of physicians has lost the traits of a guild of craftsmen applying rules established to guide the masters of a practical art for the benefit of actual sick persons. It has become an orthodox apparatus of bureaucratic administrators who apply scientific principles and methods to whole categories of medical cases.”13 Stating his case in the extreme, he says “Medical science applied by medical scientists provides the correct treatment, regardless of whether it results in a cure, or death sets in, or there is no reaction on the part of the patient. It is legitimized by statistical tables, which predict all three outcomes with a certain frequency.”14 In reality, Illich is making a distinction between guidance used to guide independent competent practitioners of medical art treating individual patients each with their own characteristics, complexities and needs versus slavish following of protocols applied to patients as a group held together only by sharing a particular diagnosis, with no regard for their broader context. I find it difficult to disagree.

part of a scientific team. Experiment is the method of science, and the records he keeps—if he likes it or not— are part of the data for a scientific enterprise.” Just to make the case very clear that Illich was able to predict the future: “From September 2021, NHS Digital will start collecting patient data from GP medical records in England about any living patient, including children, and any data about patients who died after the collection started.

“This is called the General Practice Data for Planning and Research data collection, and NHS Digital says it will be used to help the NHS improve health and care USE OF AGGREGATED DATA The use of aggregated data from willing participants in services by allowing it to plan better, prevent the spread clinical trials is a good thing and can mean reaching of infectious diseases, help with research and monitor the answer to important clinical questions, as we the long-term safety and effectiveness of care.”16 have recently seen from the evaluation of the use of dexamethasone for the treatment of sever CoViD-19 in BAD SURVIVAL the RECOVERY trial.15 Very few would argue against As part of his argument around there being a reasonable that being both a fantastic achievement of joint effort notion of a good death, peaceful acceptance of the and a very good thing. However, as can be seen from inevitable at the natural end of life, be that after an the figure, there is another type of health care data illness or trauma or after a long span, Illich counterposes the notion of bad survival in this succinct but graphic collection on the horizon.

Illich both predicted and had grave concerns about the account: “. I know of a woman who tried, unsuccessfully, drive to amass personal data and to treat healthcare to kill herself. She was brought to the hospital in a coma, institutions as laboratories: “As a member of the medical with a bullet lodged in her spine. Using heroic measures profession the individual physician is an inextricable the surgeon kept her alive, and he considers her case

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a success: she lives, but she is totally paralyzed; he no longer has to worry about her ever attempting suicide again.” This could easily lead one to the territory of Brian Clark’s 1972 play Whose life is it anyway?17 but the general point can take us to other places such as the fact that it rare, when discussing DNACPR decisions with patients and relatives to talk about bad survival. We seem happier to talk about success or failure by which we mean whether or not the patient is alive or dead at the end of the attempt, but it seems that we don’t much enter into the details of that state in which someone might be alive afterwards. The same conundrum exists when choosing to ventilate patients who have suffered devastating brain injuries for prognostication. Many will die, a small percentage will make a good recovery, but we don’t necessarily address the higher percentage who make a recovery with significant residual physical and/or mental impairment and altered personality.

This begs the question; What price hope?

GOOD DEATH Illich ends his chapter on pain: “The new experience [of pain] that has replaced dignified suffering is artificially prolonged, opaque, depersonalized maintenance.

Increasingly, pain-killing turns people into unfeeling spectators of their own decaying selves.” He means this as a criticism, not mere observation. But the position we occupy today is that we embrace unfeeling prolongation of life over dignified suffering and death, particularly if you can read painless for unfeeling. Today we find dignity elsewhere than in suffering: comportment, kindness, compassion, reputation, integrity etc.

In his chapter on death, Illich takes many in perspectives ranging across cultures and centuries to understand how we have coped with death during the majority of human experience, before socialised healthcare was a thing. It is not possible to go into detail here but I can summarise his views quite succinctly: Death in the community, respecting the traditions and rites that have been passed down and learned, that are held in high regard; death surrounded by friends, family and neighbours seems to me what Illich is in favour of whilst the medicalisation of the process of death and removal to hospital seem to be things he is against (hospitals being ‘big buildings with patients’19 and not part of the community).

In trying to understand some of the less enduring ideas around death that Illich purveyed, it might help top understand that he was a catholic priest, steeped in

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the notion of a fallen earth, the redemptive powers of suffering and the inevitability of death. It seems to me that this is the background that he brought to his views on pain and death, and I think many of his thoughts, with roots in the Middle Ages will sit uncomfortably in a 21st Century context. Yet in all this, his notion that there might be Quality of Death worthy of equal consideration as Quality of Life is, somehow, very modern.

CONCLUSION Medical professionalism, iatrogenesis, nosocomial infection, quality-of-life considerations, widespread use of guidelines, collation of information and dignity in death: In each of the subject areas above, Illich was a visionary, bringing them into the public sphere in the mid-1970s. To see that these were matters worthy of serious examination and to identify some of the concerns in detail was prophetic, given that some of the issues are only emerging to a greater extent now, approaching 50 years later. But his tendency was to view these matters through a blinkered anarchic lens of his own which allowed him to see only so far ahead, for example not beyond big data to personalised medicine.

Therefore, Illich sits before you as someone who observed and commented on the current practice of his time with keen insight and correctly identified issues for future decades, but could not predict their detailed outworking; a flawed prophet, indeed.

REFERENCES 1. Wikipedia 2.

Hartch T (2015) The Prophet of Cuer- navaca: Ivan Illich and the Crisis of the West Oxford University Press

3.

Illich I Deschooling Society

edical Nemesis 40 years on: the enduring legacy M of Ivan Illich

J R Coll Physicians Edinb (2016) Vol 46 pp134-9 http://dx.doi.org/10.4997/ JRCPE.2016.214 4.

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I llich I (1976) Limits to Medicine, Medical neme- 11. sis: The Expropriation of Health

Calder and Boyars, London 12. https://ratical.org/ ratville/AoS/MedicalNemesis.pdf 13.

Ref 5 pp156-7

6.

ibid pp274-5

ibid p254

7.

ibid p274

5.

14.

ibid p157 ibid p253

15.

The RECOVERY Collaborative Group (2021)

Dexamethasone in Hospitalized 8.

GMC (2013) Good Medical Practice

Patients with Covid-19 https://www.gmc-uk.org/-/media/

N Engl J Med Vol 384 pp693-704 DOI: documents/good- 10.1056/NEJMoa2021436 medical-practice---english-20200128_ pdf-51527435.pdf?la=en&hash=DA1263358C 16. https://fullfact.org/health/nhs-data/ CA88F298785FE2BD7610EB4EE9A530 17.

Clark B (1972) Whose Life is it Anyway?

9.

Ref 5 p112

ISBN10 0435232878 ISBN13 9780435232870 10.

JAMA (1965) Tonsillectomy Mortality

Vol 194(7) p824 doi:10.1001/jama.1965.03090200132029

18.

Ref 5 p154

19. Film: Airplane (1980)

Time you enjoyed wasting was not wasted.

John Lennon

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SCHWARTZ ROUNDS: HUMANITY AND COMPASSION IN HEALTHCARE Lorraine Corfield, Consultant Vascular Surgeon, UHNM “I have learned that medicine is not merely about performing tests or surgeries, or administering drugs... For as skilled and knowledgeable as my care givers are, what matters most is that they have empathized with me in a way that gives me hope and makes me feel like human being, not just an illness” Ken Schwartz1 Ken Schwartz was a 40-year-old American health-care lawyer. His experience of facing terminal cancer and the interactions he had with healthcare professionals led to his legacy for the establishment of the Schwartz Center in Boston2 and the international adoption of Schwartz Rounds.

“In today's fast-paced healthcare environment, crowded with competing priorities, the human connection is too easily overlooked leaving caregivers burned out and patients and families fearful and suffering.” Schwartz Center2 The Schwartz Center in the USA and the Point of Care Foundation in the UK3 both aim to improve health care by recognising that good quality care can only be achieved if caregivers also receive practical and emotional support, and treat each other with compassion. Schwartz Rounds form one aspect of this approach. Any organisation wishing to run Schwartz Rounds in the UK needs to do so in conjunction with the Point of Care Foundation.4 There is a fee for the licence to run the rounds and for the training, support and mentorship provided by the Foundation.

organisations where individuals may rarely interact outside their immediate teams.

Each round is centred on a particular theme. The round starts with an introduction from the facilitator(s) leading the round. Usually, three panellists then speak about their experiences relevant to the topic of the round for approximately five minutes each. The facilitator next opens up the discussion to the audience. Attendees are welcome to speak, sharing their own emotions, experiences or reactions to the panellists’ stories, but are equally welcome to sit in silent reflection. The facilitator will draw the round to a close at the appropriate time.

Schwartz Rounds are usually held monthly and provide Each round lasts for 45 to 50 minutes. a structured forum where staff from any background (clinical and non-clinical) can come together to There have been several studies looking at the objective discuss the emotional and social aspects of working in and subjective benefits of Schwartz Round attendance. healthcare. The purpose of the rounds is to discuss the Psychological distress has been shown to reduce challenges and rewards that are intrinsic to providing significantly in those attending rounds.5 An extensive care, not to solve problems or to focus on the clinical review article reported that the percentage of those aspects of patient care. Sharing the difficult or positive in the study group with poor psychological wellbeing experiences and feelings that most, if not all, of those reduced from 25% to 12% for those attending rounds, involved in healthcare have also normalises these but remained unchanged for non-attenders.6 Although reducing psychological distress is important, rounds feelings and therefore reduces distress. are not counselling or debriefing sessions but function All rounds start with lunch or similar refreshments. This via sharing experiences, reducing any perceived or is a requirement of the Point of Care Foundation as not actual hierarchies and by normalising the feelings and only does it ensure attendees are fed and watered, but it emotions held by most, if not all, of those involved in also shows that the organisation running the round is caring for patients or working in an organisation that willing to invest in supporting its employees. Probably does so. most importantly it allows attendees to meet and chat prior to the round. This is particularly valuable in larger

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They are not primarily about dealing with severe distress but about allowing the realisation that we are all in the same boat and often feel much as others do.

Furthermore, attendance at Schwartz Rounds leads to better teamwork and a heightened appreciation of the roles and contributions of others.7 This significantly increases with the number of rounds attended. Following round attendance, individuals feel more supported, less stressed and less isolated.7 A study of pilot Schwartz Rounds at several institutions in the UK has shown that 70% of attendees found the rounds to be excellent or exceptional.8 However, perhaps the best advocates are individuals who made the following comments following attending a round:

OUR EXPERIENCE Schwartz rounds have been running at the University Hospitals of North Midlands NHS Trust (UHNM) since June 2020 and are held at both the Royal Stoke University Hospital and County Hospital sites. Any employee of UHNM or Sodexo is very welcome to attend, as is anyone who works or is a student at UHNM but is not directly employed by the Trust. Recent topics for rounds have included:

I’m human too Our experience of Covid-19 The patient I’ll never forget When my best isn’t good enough The day I made a difference (a Christmas special round “Sometimes when we’re very stretched, you feel it’s just celebrating the positives!) you that’s carrying this burden – and then you realise that actually the whole team is around you and they’re All rounds start with a free lunch at 12.30pm. The round carrying it too.” (social worker)9 proper starts at 1pm and is finished at or before 2pm.

Come along to a round and see what happens…it may “They [Schwartz Rounds] allow us to look at how just change your working life. working in the trust has an impact on us as human beings and on how we interact with the patients that we FURTHER INFORMATION are caring for. We don’t often think about the human cost – the impact that caring has on us as clinicians, but Anyone who would like to attend, be a panel speaker or also the impact that we will have on our patients, their who would like further information about the rounds relatives, and so on.” (palliative care consultant)9 should contact schwartzround@uhnm.nhs.uk “Generally, we are quite siloed and some teams work more collaboratively than others. People do need to acknowledge the impact of their work on each other.

Schwartz rounds are likely to affect how they work together.”9 “It's been so valuable hearing from different professional groups and learning that they too are vulnerable. When I was a newly qualified nurse there was one consultant who I was so terrified of that I used to hide in the toilet so that I would have to accompany them on the ward round. If I had known at the time the consultants have the same emotions as me then I wouldn’t have had to hide myself away.”9

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REFERENCES 1.

Schwartz KB (2012) A patient’s story Boston Globe July 14th 2012 h t t p s : / / w w w. b o s t o n g l o b e . c o m / m a g a zine/1995/07/16/patient-story/q8ihHg8LfyinPA25Tg5JRN/story.html 2. https://www.theschwartzcenter.org/

6.

Maben J, Taylor C, Dawson J, Leamy M, McCarthy I et al (2018) A realist informed mixed-methods evaluation of Schwartz Centre Rounds in England Health Services and Delivery Research Vol 6 Issue 37 https://www.journalslibrary.nihr.ac.uk/hsdr/ hsdr06370#/abstract https://doi.org/10.3310/hsdr06370

3. https://www.pointofcarefoundation.org.uk/?g- 7. Lown B and Manning C (2010) The Schwartz Center Rounds: Evaluation of an Interdiscipliclid=EAIaIQobChMI4b7hxN_98AIVZbR3Chnary Approach to Enhancing Patient-Centered 32cAqeEAAYAiAAEgLEMPD_BwE Communication, Teamwork, and Provider Support Academic Medicine Vol 85(6) pp1073-81 4. www.pointofcarefoundation.org.uk/our-work/ schwartz-rounds 8.

Goodrich J (2011) Schwartz Centre Rounds®. Evaluation of the UK pilots 5.

Dawson J, McCarthy I, Taylor C, https://www.kingsfund.org.uk/sites/default/ Hildenbrand K, Leamy M et al (2021) files/field/field_publication_file/schwartzEffectiveness of a group intervention to reduce center-rounds-pilot-evaluation-jun11.pdf the psychological distress of healthcare staff: A pre-post quasi-experimental evaluation rounds: BMC Health Services Research Vol 21 a392 9. Cornwell J (2014) Schwartz Spread ‘small acts of kindness’ amongst staff https://doi.org/10.1186/s12913-021-06413-4 Health Services Journal. 17th November 2014 https://www.hsj.co.uk/schwartz-roundsspre ad-sma l l-ac ts-of-k indness-amongstaff/5076549.article

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CASE REPORT: SHROPSHIRE HAND TREATED BY METACARPOPHALANGEAL Sai Ramesh, Medical Student, KUSoM Nicholas Neal, Consultant Trauma and Orthopaedic Surgeon, UHNM INTRODUCTION This report describes an unusual case of a 71-yearold male with an atypical presentation of trigger finger like symptoms. Radiographic investigation showed the second metacarpal head was separate from the metacarpal shaft and he was diagnosed with brachydactyly. A number of patients presenting with brachydactyly in the West Midlands area have been observed to have come from one particular village in Shropshire, hence the description of Shropshire Hand.

This case report follows the journey of this patient, of which to date, there is no similar case in the literature.

flexor tendon sheath (the A1 pully).2 However, typically, trigger finger affects the metacarpophalangeal and interphalangeal joints, but upon further examination it was apparent that in this patient only the second metacarpophalangeal joint was getting stuck in flexion (Figure 1). Further investigation of previous radiographs taken at the rheumatology clinic demonstrated that the metacarpal head was separate from the metacarpal shaft, indicating a possible problem with the secondary centre of ossification during bone development. This disconnected head was subluxing volarly underneath the shaft and becoming jammed causing the patients trigger finger-like symptoms (Figure 2).

CASE REPORT A 71-year-old Caucasian male presented to the hand clinic with locking of the second metacarpo-phalangeal joint on his right index finger, that was painful when “reduced”. This had been an ongoing problem and the patient was usually able to click his finger back to normal.

However, the patient had presented to the Emergency Department around three to four times previously to have this “reduced” and therefore decided to get this checked at the hand clinic. Upon examination, it was clear that there was no tendon swelling and there was no pain present, unless the finger itself was jammed. The patient has a history of rheumatoid arthritis, but this was under control with methotrexate. Furthermore, his past medical history confirmed a diagnosis of spondyloepiphyseal dysplasia. This is only relevant to his spine but could cause changes in any growth plate.1 This condition does cause shortness of stature and although this patient was short, he was not achondroplastic.

However, it was also noted that his fingers were short.

On first examination, it was presumed that this patient had all the symptoms of trigger finger on his right index finger. A trigger digit starts with a “click” on flexion and subsequently over time the finger may jam as the flexor tendons become stuck at the narrowed mouth of the Volume 29, No 4, Summer 2021

Figure 1: (a) Representation of typical trigger finger presentation

Figure 1: (b) Representation of patient’s right index finger presentation

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Figure 2: A Schematic representation of the patient’s 2nd metacarpal bones on his right hand as seen on the X-rays compared to a normal anatomical representation of a metacarpal bone. (a) Normal metacarpal bone – posteroanterior view (b) Representation of patient’s metacarpal bone, metacarpal head separate from shaft (two separate pieces of bone) – posteroanterior view (c) Normal metacarpal bone – lateral view. (d) Representation of patient’s, metacarpal bone, metacarpal head separate from shaft (two separate pieces of bone) – lateral view. (e) Metacarpal head separate from shaft. Head subluxing volarly (on palmer side) underneath shaft causing finger locking on flexion.

Furthermore, given the shortness of the patient’s fingers and the problems with bone development in the metacarpal bones, the patient was given a diagnosis of brachydactyly, of which Shropshire Hand is a subtype. This disease is characterised by short fingers and/or toes and bone dysostosis.3 The name Shropshire Hand comes from the fact that the largest group of patients that are affected in this country reside in a village in Shropshire.

The treatment options available to this patient were limited. However, these were discussed between the surgeon and patient. The first option was a ‘wait and see’ approach. However, the patient was in a lot of discomfort and was unhappy with the locking of the metacarpo-phalangeal joint.

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The second option was to have a metacarpo-phalangeal joint replacement to remove the piece of bone causing the problem and replace this with a silastic metacarpophalangeal joint. The surgical option was the chosen course of treatment.

The patient underwent a metacarpo-phalangeal joint replacement with a silastic prothesis on his second metacarpal. Follow-up confirmed that the treatment was successful. The patient had functional range of movement in this finger with no locking of the joint.

Due to the success of this surgery a further metacarpo-phalangeal joint replacement was performed on the patient’s third metacarpal (Figure 3). This was because similar symptoms were evolving and on previous radiograph it was seen that this metacarpal also had a separate metacarpal head from the bone shaft.

Midlands Medicine

Figure 3: Patient X-rays after the silastic metacarpophalangeal joint replacement of the 2nd and 3rd metacarpophalangeal joint. (Consent gained from the patient to use images)

ossification had not joined together, therefore forming two separate bones - a separate metacarpal head and This may have been a unique presentation and, metacarpal shaft (Figure 2). therefore, the first report of such a case. It is important to consider the patient’s medical history when viewing It is interesting that the patient also has a diagnosis of this case. It is likely that although the rheumatoid spondyloepiphyseal dysplasia. This condition affects arthritis was under control, this could be a contributing the spine and long bones causing shortness of stature factor to the progression of the discomfort the patient but does not typically affect the fingers and toes. 1,5 was feeling. The patient was a retired labourer which However, epiphysial refers to the fact this condition may have also affected the progression of the subluxing affects the ends of the bone. This is important to bone fragment due the physical demands of his work. note when considering why the metacarpal bones of this patient are in two separate pieces and may The problem the patient presented with is a mechanical be a contributing factor to this patient’s condition. problem, rather than an inflammatory one, which Interestingly, there has been research to suggest there should be considered when viewing this case. It is may be a link between brachydactyly and spondylotherefore prudent to fully understand why this patient epiphyseal dysplasia via the aggrecan gene, which could help to link the patient’s history to his symptoms.6 presented with these symptoms.

DISCUSSION

The fragment of bone that was disconnected from the metacarpal shaft was likely due to a problem during bone development. Endochondral bone formation primarily has two centres of ossification. Bone formation starts at the primary centre of ossification. During normal bone development this primary centre will combine with the secondary centre of ossification, seen at the epiphyseal plate, to form a single bone.4 However, in the case of this patient, the primary and secondary centre of Volume 29, No 4, Summer 2021

The treatment options for this patient were limited, and given the nature of the case, the choice of a silastic metacarpo-phalangeal joint was thought most appropriate. The surgery itself involved a longitudinal dorsal incision over the second metacarpo-phalangeal joint. The joint was entered between the extensor tendon and the reflected retinaculum. The remnant of the second metacarpal head was removed, and the head of the metacarpal and base of the proximal phalanx was 139

trimmed. Following this, the medullary canals were prepared using bone awls and a high-speed burr. The definitive silastic prosthesis was inserted. Following confirmation of stability, the capsule was repaired, and the skin was closed. The patient had the finger splinted for three weeks and mobilisation was carried out under supervision of the occupational therapist.

Although this patient did not have any complications post-surgery, it is important to consider the potential complications. Early complications include infection, prosthesis dislocation, finger stiffness and wound dehiscence. Late complications include prosthetic loosening, fractures around the prosthesis, late infection, late dislocation, late stiffness and silastic prosthesis breakdown which can lead to swelling due to breakdown products7 These were all carefully monitored

CONCLUSIONS On presentation it was possible to consider this a variant of a simple trigger finger but radiographs revealed the unfused metacarpal head and shaft. This was solved with a seemingly simple solution of a metacarpo-phalangeal joint replacement. The complex nature of this patient’s medical history is likely to have contributed to the presentation as the spondylo-epiphyseal dysplasia and brachydactyly are both genetic conditions that affect bone development. It is likely the brachydactyly in this patient further contributed to the insufficient space for the tendons to appropriately glide and contributed to the jamming of the metacarpo-phalangeal joint.

ACKNOWLEDGMENT I would like to thank the patient for his consent to publish this case report.

REFERENCES 1.

Jurgens J, Sobreira N, Modaff P, Reiser CA, Seo SH et al (2015) Novel COL2A1 variant (c619G>A, pGly207Arg) manifesting as a phenotype similar to progressive pseudo-rheumatoid dysplasia and spondyloepiphyseal dysplasia, Stanescu type Hum Mutat Vol 36(10) pp1004-8

2. MakkoukAH, Oetgen ME, Swigart CR and Dodds SD (2008) Trigger finger: etiology, evaluation, and treatment Curr Rev Musculoskelet Med pp1(2):92-6

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3. Temtamy SA and Aglan MS (2008) Brachydactyly Orphanet J Rare Dis Vol 3 a15 DOI: https://doi. org/10.1186/1750-1172-3-15 4. Long F and Ornitz DM (2013) Development of the endochondral skeleton Cold Spring Harbor Perspectives in Biol Vol 5(1):a008334 DOI:10.1101/cshperspect.a008334 5. Terhal PA, Nievelstein RJ, Verver EJ, Topsakal V, van Dommelen P et al (2015) A study of the clinical and radiological features in a cohort of 93 patients with a COL2A1 mutation causing spondyloepiphyseal dysplasia congenita or a related phenotype Am J Med Genet A Vol 167A(3) pp461-75 DOI:10.1002/ajmg.a.36922 6.

Sentchordi-Montané L, Aza-Carmona M,

Benito-Sanz S, Barreda-Bonis AC et al (2018)

Heterozygous aggrecan variants are

associated with short stature and

brachydactyly: Description of

16 probands and a review of the literature

Clin Endocrinol (Oxf) Vol 88(6) pp 820-9 7. D r a k e M L , S e g a l m a n K A ( 2 0 1 0 ) Complications of small joint arthroplasty

Hand Clin Vol 26(2) pp205-12

Midlands Medicine

DECEASED DONOR ORGAN DONATION IN 2021 Tariro Mangwiro, Medical Student KUSoM INTRODUCTION The first successful blood transfusion occurred over two centuries ago by Dr Blundell.1 This was followed by the identification of blood groups and later the formation of blood banks.2 The first solid organ donation occurred just over half a century ago between the Herrick twins. The Herrick twins were identical, so rejection was not a concern.3 In 1967 Louis Washkansky was the first person to receive a heart transplant, although he only lived 18 days following the surgery before dying of pneumonia.4 This was a major step because the introduction of immunosuppression drugs allowed organs to be transplanted between people who are not genetically identical.5

backgrounds as they are more likely to require an organ6 but Black and Asian people are much less likely to donate an organ when compared to their white counterparts. This remains true, even when socio-economic class and education are taken into account.8 Due to the lack of suitable organs through usual programs, there is an illicit trade in kidneys for transplants, where the poor and disenfranchised are exploited.9 While low donation rates are agreed to be a problem there have been many differing attempted solutions.

SYSTEMS OF CONSENT

There two ways in which consent for organ donation is As the global population both ages and becomes more gained. The first is explicit consent and the second is affluent, long-term conditions such as heart failure, di- deemed consent. For explicit consent the patient states 6 abetes mellitus and Chronic Kidney Disease increase their consent, either in writing or verbally. in prevalence and an rise in the need for transplanted organs follows. Organ demand outstrips supply, in the UK and worldwide.6 Waiting lists for vital organs with φ Correctly used, the term consent is an active agreement no alternative replacement therapy will never be very by a participant in an action, process or event; no person large because people die waiting. Therefore, the wait- can give consent on anyone else’s behalf. As the donors ing list will not reflect the true potential need. Dialy- are dead they are unable to consent at the time but they sis is an effective way to keep people alive, albeit with a are they are able to consent in the form of an advanced lower quality of life than living with a successful kidney directive either actively by signing the organ donor register transplant. Because potential recipients are kept alive, or, since May 2020 in England, passively by not removkidney transplant waiting lists are longer. Though other ing themselves. Families are not the donor and cannot solid organ transplants are more obviously life-saving, give consent on their behalf; technically what they give is kidney transplants are at least life-transforming. Since assent. As consent is currently used by the NHS in this the first Kidney transplant in 1954 new technologies context this paper will use consent, when assent would and drugs have meant that organ recipients now live be more technically correct. The families are expresslonger and better-quality lives. Organs can be trans- ing agreement or giving approval rather than consenting. planted from a living or a dead donor. The majority of transplanted Kidneys are donated by deceased donors.6,7 To consider all aspects of solid organ donation is beyond the scope of this paper, therefore discussion will be limited to the supply of deceased donor kidneys for transplantation. Kidney transplants are more cost-effective than other replacement therapies such as dialysis. Those most affected by the shortfall of organs are those of (Black, Asian and minority Ethnic) BAME Volume 29, No 4, Summer 2021

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Systems requiring explicit consent are often referred to as opt-in systems. Under an opt-in system, consent must be gained from the patient ante-mortem. In the UK, this is done by joining the organ donor register.10 Deemed consent is also known as the opt-out system.

The opt-out system presumes that a person has consented to organ donation upon their death unless they have explicitly stated otherwise.11 A person may register their opposition or agreement on the organ donation register.

The manner in which systems of consent are administered can be either ‘soft’ or ‘hard’. In a soft system, family consent is always sought; in a hard system, it is not.

A hard system acts on the status quo at the time of the potential donor’s death without reference to the family’s wishes; a soft system seeks the family’s views and takes them into account, regardless of the potential donor’s views.6 Up until May 2020, England operated under a soft opt-in system.11 In 10% of cases where a person had been on the organ donor register families refused to consent for organs to be donated.10 The soft opt-out system allows for collaboration between the healthcare and the family.

In an opt-in system, a person needs to put in conscious effort to be a part of the organ donor register. In England, the majority of the population were not on the organ donor register.10 Whether that was due to inertia or true objection was not known by the medical professionals and often the patient’s family. The current opt-out system in England allows those with objections to take themselves off the register by opting out, it also allows people to endorse the register by opting in. But where inertia would otherwise prevent someone joining the register and there are no genuine objections, such people are now on the register and a working assumption is made that they support organ donation at best and at least have no strong objections to donating.

ORGAN DONATION LAWS IN THE UK In May 2020 the Organ Donation (Deemed consent) Act 2019 came into force in England. Certain groups are not covered by this Act. They are: children under 18 years; adults who lack capacity; those in England for less than 12 months; and those in England involuntarily. England currently operates under a soft opt-out system with family consent being sought before donation takes place.11 A similar approach was taken by Wales in 142

2015. Deemed consent became law in Scotland on the 26th March 202112 and Northern Ireland are currently in the consultation phase of bringing forward a similar law.13 Most people in the UK agree that organ donation is good, an immeasurable gift that is given to a person and their family, preventing people from dying or suffering unnecessarily, preventably. However, the vast majority have not registered their wishes. Under the weight of grief families have often opted to keep all of their loved ones including their organs, ‘unviolated’.12 The opt-out system was introduced with the intention of increasing donation rates in England. In the years before the Bill was introduced, 60% of the UK population stated that they were in favour of organ donation with this number being as high as 90% in some surveys.10 However, only 25% of the UK population had stated their wishes using the organ donor register. Under the old opt-in system, organs could not be donated without the explicit consent of the patient or their family. Families were 30% more likely to donate their loved one's organs if they had on the organ donor register.10 Families were loath to make the wrong decision and often went with the ‘safe’ option of not donating their relatives’ organs.12 It was this gap between the theoretical willingness of the public to donate and their engagement with the organ register that the architects of the opt-out system desired to close.10 REQUESTING ORGAN DONATION The organisation responsible for transfusion and transplantation in England is NHSBT (National Health Service Blood and Transplant).6 Around 1% of people die in circumstances that allow them to be potential organ donors.14 The majority of donors have been declared dead by neurological criteria (often referred to as donation after brain death DBD). Following technical advancement, those whose hearts have stopped (often referred to donation after circulatory death DCD) can also donate.15 Death is defined as the “irreversible loss of capacity of consciousness or the irreversible loss of the capacity to breathe”.16 The diagnosis of death must be made by two doctors with one of them being a Consultant. No member of the transplantation team should be involved in the diagnosis of death. Tests to support the diagnosis of death by neurological criteria must be carried out on two separate occasions with the same two doctors performing these tests wherever possible.

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Prior to the testing, all sedation is withdrawn. The two doctors will work together, one will perform the tests and the other will observe, on the second occasion, they will swap. Families are often invited to witness the second set of brain stem death tests, allowing them to be involved and so better accept the diagnosis.

It is only reasonable to remove essential organs from a person if you believe that they will never experience personhood again. Families often question if their loved ones are truly dead, and how the medical teams can be sure. This may be fuelled by media articles claiming people have regained consciousness after being declared brain dead. When performed correctly in the correct clinical context, brain stem death tests are infallible; doctors must be sure of the irreversibility of the condition before they embark on the tests.16

beliefs without first speaking to their loved ones. Most organ donors tend to be young healthy people whose death comes as a shock to their family and friends.

Young people are less likely to discuss their death and their wishes with their families. In instances where the decision is unknown the resources on the NHSBT website suggests that the SNOD/SR should approach the family with care and sensitivity while nevertheless assuming consent.19 Rather than asking for consent, it is suggested that the SNOD asks the family to support the patient's deemed consent.19 This the major difference in the current approach to families. The change is subtle but important, the burden of having to decide is now taken away from the family. This approach will have the most impact on those families who were afraid to make the wrong decision, because under the law by not opting out their famIn England, NHSBT recognise how difficult families can ily member has decided to have their consent deemed. find the situation. A sensitive, professional approach is If the family chooses not to support their loved one's needed. To do this as well as possible, highly skilled deemed consent, that decision will be honoured.19 nurses discuss organ donation with families and support them through the process (Specialist Nurses in Or- Having a decision recorded in advance is some sort gan Donation, or SNODs) Even amongst the SNODS, of comfort that they are carrying out their loved one’s the initial approach to the family requires experience wish. It is more distressing when the family is uncerand training to gain the role of Specialist Requestor tain of what their loved one would’ve wanted. Asking (SR). They SRs do not work alone, but in partnership a family to support deemed consent is a stronger, more with other SNODs and with the medical and nursing reassuring, position from which to start the discussion teams in the Critical Care setting. According to agreed of organ donation and the hope is that this will lead to best practice, discussing organ donation should only more family consent. happen once the family has understood that their family member is dead or that death is inevitable.17 Following THE IMPACT OF THE COVID-19 PANDEMIC the testing and the diagnosis, and answering any medical questions the family may have, the Consultant will The CoViD-19 pandemic had a profound impact on organ donation in England. Healthcare professionals often leave the SNOD/SR to guide the family through involved in transplantation were repatriated to Critical the next steps. Every effort should be made to keep Care units and other CoViD-19 projects. The maximum the same professionals involved, for continuity of care. donor age was decreased from 85 years to 60 years for According to NHSBT consent rates for transplantation donors declared dead by neurological criteria, reducing are increased when a SNOD is present.18 A SNOD gen- the potential donor pool. People who had tested postly guides the family to honour the patient's decision. itive for CoViD-19 were barred from donating. There When discussing organ donation, it is encouraged that was a 68% decrease in deceased donor transplants when compared with 2019-20. It was in this context that the the SNOD starts by discussing its benefits.17 Deemed Consent Act became law. The pandemic also led to a phased introduction of the law into practice.19 When approaching patients from different religious Since the introduction of the opt-out system in Engbackgrounds SNODs are told to use a humble ap- land, 3.2% of the population have opted out, compared proach.19 Islam has often been seen as against organ do- to 20% of people opting out in the Netherlands.21 This nation, with some papers showing a decrease in dona- may give some confidence that this law is popular with tion rates among Muslims.18 Singapore which operates the English public. Of the people who have opted-out under a hard opt-out system has incorporated Muslims in England around 80% have been from minority ethas part of their excluded groups.10 However, it is not nic backgrounds. By March 2021, 299 people had had their consent deemed since the introduction of the law, possible to know how tightly a patient held on to their a 66% consent rate.

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The overall consent rate remains at 68%. While people system but has a lower donation rate than Ireland which may find it discouraging that the consent rate has not operates under an opt-in system.22 changed one year since the implementation of the law, it took three years for Wales to see an increase in consent Therefore a deemed consent law in isolation does not rates.21 A similar trend might be seen in England.8 automatically lead to an increase in donation rates.

Chile has a good health infrastructure with 80% of peoDISCUSSION ple using publicly funded healthcare and 20% of people using private healthcare.23 When Chile introduced its Opt-Out Systems and Organ Donation Rates own deemed consent law there was a decrease in doThe legislation surrounding organ donation in any nation rates. This has been attributed to the ease for country will reflect the customs and sensibilities of its citizens to opt-out when applying for drivers' licences people. In Austria, physicians have the right to remove and passports, and they did so in large numbers. the organs of every person who has not opted out of the organ donor register. Families are not consulted. In 1998 Brazil enacted a deemed consent law despite When asked about introducing a similar law in the UK opposition from physicians and the public. There was a survey recipient responded, “if I give you my organs a great deal of misinformation surrounding the law it's a gift but if you take them it's theft.” 12 change, with people concerned there would be a deGreat care has been taken to keep the discussion around crease in the quality of their care to facilitate organ reorgan donation limited to it being a gift rather than an trieval. Quite quickly organ donation rates appeared obligation. This is reflected in the soft implementation threatened rather than improved and Brazil revoked the England has chosen. Patient autonomy is an important law a year later and returned to an opt-in system. Under principle, with people having the right to make unwise the former opt-in system, educating the public through decisions. While the ability to opt-out does allow for media campaigns had already helped to increase conpeople to formally object, a hard approach to opt-out sent rates.23 In the UK media coverage of healthcare, does not allow for those who have not updated the reg- scandals are often associated with a decrease in consent ister, due to being busy or disorganised, to voice their rates.12 Over the past year, the consent rates were highopinion. Forcing people to update the register or have est during the worst parts of the pandemic.21 The covertheir organs taken would go against the traditions of the age of heroism of healthcare worker and the ‘clap for the English society.10 If the state had the right to take organs NHS’ maybe behind the increase in donation rates.21 from the body of the person, it could be argued that The introduction of deemed consent laws has also been they now own the body and are responsible for funeral associated with a decrease in living donation22 but that arrangements; this may be one reason why a hard ap- is more properly causally attributed to the CoViD-19 proach has not been taken in the UK. While it may be pandemic and the reluctance to electively expose doargued that procuring organs would be easier under a nors to increased risk. hard opt-out approach, this is not necessarily the case.

The UK population is against legislation that does not Disregarding public attitudes in England could potenincorporate the family's wishes when it comes to organ tially lead to more people opting out and a reduction donation, as would be seen in a hard opt-out system. in organ donation as seen in Brazil.12 While the donaThe majority of SNODs and SRs are also against a hard tion rates in Austria are higher than those in England, implementation of the opt-out system.12 Austria had a lower donation rate when compared with the United States which operates under an optDeemed consent has been shown to increase donation in system.22 Therefore, opt-out systems do not always rates in some countries where it is the law. Wales was outperform opt-in systems when it comes to donation the first of the UK nation to adopt the opt-out system, rates. In England, a hard opt-out could have had the following the lowest donation rates of all four home na- side effect of alienating the public without the guarantions.12 Spain has the highest donation rates in the world tee of increasing donation rates. So, a soft opt-out was and it also has a deemed consent law. There seems to implemented allowing for partnership between healthbe an overall association between deemed consent and care professionals and families. The hope is that this high donation rates. Greece operates under an opt-out will accommodate the sensibilities of the English public while raising donation rates.

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The Future As the law ages, an increase in donation rates is expected, following an inevitable change in culture when a new batch of SRs, who have been trained after deemed consent became law, are established. There may also be a culture change within the NHS giving current SRs more confidence. This change in culture, increased confidence of healthcare professionals and the increased familiarity of the public with deemed consent law will, it is hoped, lead to an increase in donation rates. Media campaigns are being used to increase public awareness of deemed consent.

is reasonable to hope that the introduction of deemed consent will generate an increased willingness in the BAME communities to donate. However, this law change comes from the very institutions that they do not trust which is part of the reason for the high opt-out rates in BAME communities. Building trust between these communities and healthcare teams may be more effective than a change in law in terms of increasing organ donation consent rates from BAME donors.12

The Deemed Consent law was passed with the intent of increasing donation rates by increasing consent rates In April 2019 NHSBT launched the ‘Pass it on’ cam- among the families of deceased donors. The low optpaign to increase awareness of the law change around out rates do seem to suggest public support for deemed organ donation. ‘Pass it on’ was not a particularly wel- consent, following increased consent rates in Wales come statement during the CoViD-19 pandemic and there is an expectation of similar success in England. therefore the campaign was pulled. After a re-think However, due to the CoViD-19 pandemic and the short the new strap line is ‘Leave them certain’. The inten- timespan that has elapsed since the introduction of tions behind this campaign are to encourage more deemed consent it is unclear if the intended outcome family conversations around organ donation and to will be reached, especially within BAME communities. normalise the topic of organ donation with the public. This hope is that, if they are ever in the regrettable position of losing a loved one in circumstances where organ donation is possible, they have a better under- * A single BAME community entity does not exist and is standing of donation and its benefits and will be more a construct that allows for some reasonable generalisalikely to support deemed consent for their loved ones. tions to be made. BAME individuals come from many difBAME Communities and Organ Donation Patients from the BAME community* wait longer for a kidney transplant compared with White patients.

The reasons behind this include a higher prevalence of hard-to-match Human Leukocyte Antigen (HLAs) in BAME communities and a low donation rate.24 There has been a change in the allocation process to make it easier for those with hard-to-match HLAs, and those who have been on the transplant list for a long time.

The change has led to an increase in transplantation rates for hard-to-match patients.27 There is still a need for donors from the BAME communities. Deceased donor rates are low with 42% of families agreeing compared to 71% of White families.25 The opt-out system must be impactful in all communities, especially the communities that are most in need of kidney transplants. There must be an increase in the number of BAME deceased donors. One of the main barriers to donation rates is the mistrust of the medical teams.26 It

Volume 29, No 4, Summer 2021

ferent communities with differing perspectives.

It would

be prohibitively impractical to take into account large numbers of distinct communities varying by race, background, culture, religious beliefs, geography, social class and degree of integration or ghettoisation. BAME is a term used by official bodies, in a way that is generally understood and has utility. As such it is used in this paper.

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Manara A, Mumford L, Callaghan C, Ravanan R and Gardiner D (2020) Donation and transplantation activity in the UK during the COVID-19 lockdown The Lancet Vol 396 pp465-466 DOI: 10.1016/S0140-6736(20)31692-5

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23.

Zúñiga-Fajuri A (2015) Increasing organ do

nation by presumed consent and allocation

priority: Chile Bulletin of the World Health Organization Vol 93(3) pp199-202

24.

NHSBT 2020 Organ Donation and Transplan

tation data for Black Asian and Minority Eth

nic (BAME) communities

https://nhsbtdbeblobcorewindowsnet/umbra co-assets-corp/19692/bame-report-201920.pdf 25.

Kierans C and Cooper J (2011)

Organ donation genetics, race and culture: The

making of a medical problem

Anthropology Today 27(6) pp11-4 https://doi.org/10.1111/j.1467- 8322.2011.00837.xls 26.

Irving M, Tong A, Jan S, Cass, A Rose et al (2011)

Factors that influence the decision to be an

organ donor: a systematic review of the

qualitative literature

Nephrology, Dialysis & Trans Vol 27(6) pp2526-33 27. NHSBT (2021) World Kidney Day celebrates shorter waiting times for hard to match patients https://wwworgandonationnhsuk/get-

involved/news/world-kidney-day-celebrates- shorter-waitingtimes-for-hard-to-match- patients

Time you enjoyed wasting was not wasted.

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CASE REPORT: UNUSUAL JOURNEY OF AN AUDITORY CANAL SKIN CANCER Joshua Pettit, Medical Student, KUSoM Ajith George, Consultant Head and Neck Surgeon, UHNM In 2019, the patient presented with an ulceration within the right ear canal. A CT scan showed the BCC was This case report describes the journey of a 74-year-old occluding the ear canal with some spread into the temmale who noticed increased wax in and discharge from poral bone (Figure 1). When this was conveyed to the his right ear. Upon investigation a lesion was found patient, consent was gained to proceed with the radical and then excised. Unfortunately, the lesion proved to surgery that was put forward previously. be an infiltrating basal cell carcinoma (BCC) and the excision showed incomplete margins. This was the start of a 6-year journey that culminated in a radical surgery involving multiple teams of surgeons in an attempt to remove all cancerous tissue and give the patient comfort and time to enjoy his later years.

INTRODUCTION

CASE REPORT A 74-year-old male initially presented to his GP with discharge from his right ear, along with a noticeable increase in ear wax in that ear. The GP referred the patient for urgent investigation as a lesion was noticed within the ear canal. It was decided that the lesion would be excised, and histology done to investigate for any malignancy. Unfortunately, the lesion was shown to be an infiltrating BCC and the excision had incomplete margins. The patient declined further treatment at the time.

Some time later, in 2015, the patient returned to the GP with discharge from the right ear. Indeed, the BCC had grown, and the patient consented to a second local excision. Histology confirmed the resurgence of the infiltrative BCC and unfortunately again showed involved margins.

In 2016, the patient consented to a wider excision that included removal of all the skin within the external auditory canal, up to the tympanic membrane. The wider excision proved unsuccessful in removal of all cancerous tissue as histology showed medial margin involvement.

The case was discussed in both Dermatology and Head and Neck MDTs and in 2017, the patient was presented with the option of having radical surgery with a view to removing all cancerous tissue. The patient refused this option, electing for a more conservative approach of ‘wait and see’.

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Figure 1: CT scan showing comparison between right and left external auditory canals (labelled). Shows occlusion of right canal by tumour with increase in size of temporal bone due to tumour invasion.

Before the surgery could happen there were a few considerations. The patient was taking warfarin for atrial fibrillation and was advised to stop taking this tablet five days prior to the surgery.1 An echocardiogram was done to check whether the patient’s heart was functioning well enough to manage the surgery as it was going to take considerable time due to the intricacies of the operation, eventually lasting an approximate 7.5 hours.

The surgery was performed in three broad stages. First, a partial pinnectomy and conchal bowl excision were carried out. Due to the majority of anterior blood supply to the ear needing to be removed, the surgeons opted for an anterior incision as to take care not to compromise posterior blood flow to the pinna with the external temporal artery located posterior to the ear. Following this, a lateral temporal bone resection was performed (see Figure 2). This was done using a diamond burr drill and extreme caution not to damage the facial nerve, of which both motor and sensory branches travel through the temporal bone.

Midlands Medicine

A device was used to identify areas where the facial nerve travelled to enable the surgeon to minimise the risk.2 During this section of the operation, the tympanic membrane, incus and malleus were all removed (see Figure 2). Sections of tissue from resection margins were sent for histology to investigate for cancerous involvement.

the surgery due to the location of the lesion. Non-melanoma skin cancer, of which BCC is the most common at about 75%, has an incidence of approximately 152000 cases each year.3,4 However, carcinomas located in the external auditory canal, including squamous and basal cell, have an annual incidence of approximately one per million5 and within this group, BCC is less common.6 Exposure to ultraviolet radiation is the largest risk factor year7 and would contribute to this case through the patient’s previous occupation of HGV driver.

An interesting part of BCC physiology is that they normally rarely metastasise due partly to their large cell size, with most symptoms a result of mass effect3. This patient had already lost his conductive hearing in this ear thus mass effect in the canal was only causing a minor hinderance through discharge. Once the tumour had spread to the temporal bone, there was risk that with further growth and invasion, the mass effect of the tumour could push on the brain causing more significant effects. This would have been included in discussions with the patient when deciding treatment options and is likely the reason he eventually consented for the radical surgery. At the age of 74, it is understandable that he had previously been less inclined to proceed with radical surgery to remove something that so far had only been causing some ear wax and discharge. InterestingArea obliterated during the surgery ly, whilst reading around this case after the surgery had happened, I discovered research that suggests BCC of Figure 2: Diagram showing areas involved in various forms the external auditory canal can behave more aggressiveof temporal bone resection2. In this case, a lateral temporal ly than BCC in other areas.8 bone resection was performed, which extends to removing the tympanic membrane as well as incus and malleus of the inner ear bones.

Post-surgery, the patient became quite unwell and spent almost two weeks in hospital receiving intravenous fluFinally, the third stage of the operation was to recon- ids and antibiotics. Once recovered, he attended the struct the patient’s ear. This was achieved using a tem- maxillofacial clinic to be reviewed by the surgeons inporo-parietal flap technique, liberating loose areolar volved in the case. Thankfully scans showed that the tissue and superficial periosteum from the scalp, then cancerous tissue had been completely removed. repositioning the flap into the space that the resection had left. This technique was chosen to enable re-epithe- As with all operations, a variety of complications exist lialisation and thus the barrier function that had been and must be considered. The two main complications removed with the ear canal tissue. A skin graft was also applicable to this complicated surgery were the risk of taken from the left leg of the patient to cover the wound. compromise to the blood supply to the ear and also the facial nerve. As explained earlier, the risk to the blood supply was reduced by opting for an anterior approach DISCUSSION to the ear, aiming to spare the superficial temporal artery that travels behind the ear.

The interesting nature of this case does not arise from the rarity of the condition but from the complexity of

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The facial nerve was delicately manoeuvred around using an intraoperative device that monitored where the nerve travelled via its electrical conduction properties.

Other complications included, infection of the wound, deformity to the pinna, hearing loss and residual/recurrent disease.

CONCLUSION In conclusion, this case’s interest lies in the unusual location of the BCC and the complexity of the radical surgery. Being in the external auditory canal, and close to the temporal lobe of the brain, careful consideration was necessary due to the effects it could have and most likely would have caused with infiltrative spread. However, the patient’s age caused him to be apprehensive when it came to considering radical surgery initially.

Radical resection of the outer/middle ear and drilling of the temporal bone removed the cancerous tissue. The temporo-parietal flap created from layers of the scalp then enabled reconstruction of the ear and retention of barrier function via re-epithelialisation.

5.

Kuhel WI, Hume CR and Selesnick SH (1996) Cancer of the external auditory canal and tem poral bone Otolaryngology Clinics of North America Vol 29 pp827-52

6.

Moffat DA and Wagstaff SA (2003) Squamous cell carcinoma of the temporal bone Current Opinions Otolaryngology Head Neck Surgery Vol 11 pp107-11

7.

Marzuka AG and Book SE (2015)

Basal Cell Carcinoma: Pathogenesis Epidemi

ology Clinical Features Diagnosis Histopathol

ogy and Management

Yale Journal of Biology and Medicine Vol 88(2) pp167-79 8.

Vandeweyer E, Thill MP and Deraemaecker R (2002)

Basal cell carcinoma of the external auditory canal

Acta Chirurgica Belgica Vol 102 pp137-40

ACKNOWLEDGEMENT I would like to thank the patient and his wife for giving me consent to follow and report this case.

REFERENCES 1.

NICE, Treatment summary, Oral anticoagu

lants https://bnf.nice.org.uk/treatment-sum mary/oral-anticoagulants.html

2.

Magliocca KR, Ballestas SA, Baddour HM,

Hudgins PA, Pradilla G and Solares CA (2019)

Update in Temporal Bone Resection Outcomes

Current Otorhinolaryngology Reports Vol 7 pp58-64 3.

Cancer Research UK Skin Cancer Types Can

cer Research UK https://www.cancerre searchuk.org/about-cancer/skin-cancer/types 4.

Cancer Research UK Non-Melanoma Skin

Cancer Statistics Cancer Research UK

https:// www.cancerres

earchuk.org/health-professional/can cer-statistics/statistics-by-cancer-type/

non-melano ma-skin-cancer#heading-Zero

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MEDICAL PHILATELY: SLOGAN POSTMARKS Dominic de Takats, Editor, Midlands Medicine SUMMARY The purpose of this article is to serve as a gentle introduction to an area to which few people may have given more than a passing thought. The structure of this article is simple and traditional, in the form often used in philatelic journals. The paper will start with an introduction to the topic areas of Medical philately and slogan postmarks which will be followed by examples the intersection of these (medically relevant slogan postmarks) presented thematically.

INTRODUCTION Philately in its narrow sense refers to the collection and study of stamps. More broadly, it encompasses postal history which is not so much the history of postal services, though that is included, but the study of history through postal items as artefacts. Though mainly concerned with envelopes, and cards that have been posted and their stamps, postmarks and contents, the scope of postally-related items is broad, and can include handstamps, post office hardware, books of regulations etc. Medical philately is a vast area and holds many philatelists’ interests. It may capture the attention of those who are not primarily philatelists at all, but whose principal interest lies in Social history, or Medicine, or the History of Medicine. This is because it draws on all of medicine, surgery, mental health, science and innovation, and from the pools of all stamps ever issued anywhere and all aspects of postal history.

Clearly it would be impossible not to merely glide over the surface of the subject if an attempt were made to compass such breadth of matter. Instead, this paper seeks to introduce one small aspect of Medical philately, confining itself to a selection of postmark slogans of medical interest used in recent years in the UK. Postmarks are quite literally marks on made on post.

In other words, they are marks made after the entry of envelopes and parcels into the postal system as they pass through the mail. They are made by the authority conveying the post and largely, but not entirely, as we shall see, related to postal administration. Originally manuscript, more formal stamped postmarks were inVolume 29, No 4, Summer 2021

troduced by Henry Bishop, the Postmaster General, in the 17th Century to prevent untimely delivery caused by carriers holding back mail to a more convenient time; the key minimum data set for this purpose comprises the date, time and place the mail first entered the sorting part of the system.

These marks are different to stamps and other indicators of pre-payment such as franking and are generally concerned with creating an audit trail of the passage of the mail through the system; most commonly. A distinct additional function, previously separate, but now usually incorporated with the date and place of entry into the postal system, is the marking ‘obliteration’ of the adhesive stamp or other pre-payment mark to effect cancellation, to prevent re-use. Postmarks may also explain if an item is out-sized, overweight, under-paid or damaged in transit.

When a letter is received it is regarded on the front aspect, albeit for a moment, to check the addressee before opening. In that moment, as the eyes scan it, information may be taken in quickly. This notion had not escaped the commercially minded who from the 19th Century would often include printed advertising matter on the address side of their envelopes.

(For example, see Figure 1.)

Figure 1: An example from the US of a printed envelope serving the dual purpose of also being an advertising circular. Note the use of colour and symbols referring to patriotism (superior), heritage (foundational) and verbal assurances.

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The British Post Office and later Royal Mail saw this trend and understood that they had the power to do something similar with vastly greater reach by incorporating slogans into the postmark/cancellation device.

Actually, initially there was quite some resistance from the Post Office and it was government pressure to advertise war bonds to help finance the latter part of the First Word War that finally changed practice.1 (See Figure 2.)

When date stamps were mechanical, slogans would need to be engraved and cast, but today much of the marking is done by inkjet technology and it is relatively easy to agree a design and then email it out for immediate use. This allows short lead-in and turnaround times for these slogan postmarks compared with 20th Century conditions. This allows scope for Royal Mail to engage in both paid-for advertising and public service in their slogans. They can also encourage in a self-interested way (see Figure 4).

Figure 4 MEDICALLY RELEVANT SLOGAN POSTMARKS

Figure 2: The first slogan postmark to be used by the British Post Office. A rolling dye was used with the wavy lines and slogan with a typeset insert changed according to location, time and date.

A small sample of medically relevant slogan postmarks is considered. Most are from recent times, but they range over more tha half a century.

During the Second World War, sloganising was commonplace and the Post Office continued to play its part.

(For example see Figure 3.)

Figure 5 Postmarks can record something of social history.

There’s a lot of information contained in just a few lines.

In Figure 5, the two columns on the left have postal information, the wavy lines on the right cancel the stamp.

The third column caries a ‘slogan’ which tells us a few points of social history. At the top, the familiar NHS lozenge in rendered in italics within a rectangle rather than the more correct slanted parallelogram. Then we have ‘Blood and Transplant’. NHS Blood and Transplant has been with us since 2005 when it was formed from the merger of UK Transplants and the National Figure 3: This envelope from April 1941 bears the Blood Service as a cost-saving exercise but it may be slogan post mark GROW MORE FOOD, DIG FOR that the real effect has been to place an overarching buVICTORY. War Comfort Funds were local charities reaucracy since the original parties now continue as designed to supply extra comforts for troops. Note also branches within NHS Blood and Transplant, but rethat West Bromwich was then in Staffordshire and not named as Organ Donation the West Midlands 152

Midlands Medicine

and Transplantation (ODT) and Blood Donation, respectively.

In 2017, what was to subsequently become ‘Max and Kiera’s law’ was still at a discussion stage and the entire ODT campaign was based on the prevalent opt-in system. The following month the Prime Minister, Theresa May, let Max Johnson, a 10-year-old heart transplant recipient know her plans to push for an ‘opt-out’ register. During 2018 there was a three-month consultation following which the bill went through parliament. It passed its third reading in February 2019 and received royal assent in March 2019. The Organ Donation (Deemed Consent) Act 2019, slipped quietly into practice during the spring of 2020 with a much muted fanfare compared with what was intended, drowned out by daily updates on CoViD-19, something else that we only started to get to grips with in 2020. The central concept of the Act is summarised as Max and Kiera’s Law, after both Max Johnson and Kiera Ball, his donor.

Figure 7

Figure 7 presents a similar pairing with Royal Mail declaring its support for a specific health charity, The Stroke Association3 in the upper example and helping to raise awareness of autism, now more commonly referred to as autism spectrum disorder, in the lower example. Both are inkjet postmarks, most likely applied by integrated Editor’s Note: See also Tariro Mangwiro’s article in this mail processor machines (IMPs). issue, Deceased Donor Organ Donation in 2021.

Figure 6

Figure 8: #Let’s Talk Loneliness

During the nationwide lockdown in the UK used to reCancer has proved an enduring topic for awareness-rais- duce spread of SARS-CoV-2 through much of 2020 there ing. In sensitive and specific areas of health, formerly was an increasing awareness of the risk of a reduction the Post Office and now Royal Mail tend to work in con- in mental health for many people as they isolated and junction with charities to help raise awareness at a par- good neighbourliness and a recognition of the problem ticular time or to support a specific campaign. These of loneliness were both promoted in the public sphere. examples (Figure 6) are from 1969 and 2013 supporting In Figure 8 there are two examples of slogan postmarks a particular cancer charity, Tenovus2, and raising aware- used six months apart, using shares specific elements, ness regarding prostate cancer, respectively. but differing in detail. The logo and the hashtag are common elements, but their relative locations differ.

The slogan element switches from ‘Loneliness awareness week’ in the upper example from mid-June to ‘We can all help each other stay connected’ by December 2020.

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As well as drawing attention to loneliness, a contributor to and cause of mental anguish, the term mental health, now commonly replacing mental illness as a phrase in the public arena, was used directly in slogan postmarks over the same period (see Figure 9).

Figure 9: Mental Health

Tenth and finally, regarding Figure 10: The CoViD-19 pandemic and the related 2020 lockdown, and its justification as a means of protecting the NHS from being overwhelmed, produced a certain camaraderie and associated nostalgia for the Second World War wartime spirit. That and an 8 O’clock clap each Thursday evening between 26th March and 28th May 20204 were some of the odder social responses. Stepping into this mix, literally. enter Captain Tom Moore, approaching his 100th birthday and hoping to raise a modest sum to support the NHS in its hour of need along the way. He got him self sponsored, crowd funded, to do lengths of his garden, bowling along using his walking frame for support. His altruism, commitment, spirit and overall positive spirit and approach captured the public imagination and he raised well over £30 million pounds before he turned one hundred. He received much recognition and much publicity for his efforts, amongst which a slogan postmark.

I hope you’ve enjoyed this brief look at one specific aspect of Medical philately and that perhaps it’ll prompt you to take a second look at slogan postmarks as you sort through your post.

REFERENCES

In Figure 9, the three IMPs have been set up in the same way, as mentioned above, with four columns 1. https://www.postalmuseum.org/blog/100containing, in turn, the Royal Mail logo, local and years-of-slogan-postmarks/ postal details, the slogan and finally the wavy line cancel, In the upper two cases, again examples of Roy- 2. https://www.tenovuscancercare.org.uk/ al Mail supporting a specific health charity, only the second column differs, whilst the bottom example 3. https://www.stroke.org.uk/ is again related to a specific awareness-raising week.

4. https://en.wikipedia.org/wiki/Clap_for_Our_ Children were out of school for a good part of the Carers year of 2020 and due to recurrent contacts, many INFORMATION have been taken out of school for periods for isola- FURTHER tion. The lack of social contract first as a group and later on an individual basis has proved very wearing www.medicalphilately.com for many young people in particular which lends con- https://www.actionforchildren.org.uk/ text to the support for the charity Action for Children. https://en.wikipedia.org/wiki/Captain_Tom_Moore

Figure 10: Captain Tom Moore

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PHLEGMASIA: A CASE REPORT AND BRIEF LITERATURE REVIEW Aiden Watson, Medical Student KUSoM, Mona Mossad knee popliteal artery on the left side (Figure 2). None of the arteries distal to the popliteal showed angiogram Phlegmasia is a severe and relatively rare complication opacification. The arteries of the right leg had no visible of deep vein thrombosis (DVT), causing compromise or clinical compromise. to tissue perfusion at micro-circulatory level. However, instances have been known where significantly higher All the evidence gathered via imaging, in the context compartment pressures can lead to compromise in the of the clinical picture, pointed towards a diagnosis of flow of larger vessels. In this article we explore the case phlegmasia, a rare but serious complication of deep of an 80-year-old lady who presented with symptoms vein thrombosis where resultant venous hypertension caused by such a compromise to blood flow. is sufficient to impair arterial inflow, causing ischaemia.

INTRODUCTION

CASE REPORT

Mrs S was managed conservatively with intravenous unfractionated heparin infusion and elevation of the afMrs S was an 80-year-old lady who living with her hus- fected left limb under the vascular team. Following 48 band. Her medical history included chronic obstruc- hours of treatment, Mrs S’s symptoms of an ischaemic tive pulmonary disease and hypercholesterolaemia. leg had completely resolved with all foot pulses became She was treated with atorvastatin and with inhaled palpable, the entire lower limb swelling started to rebronchodilator and steroid. duce and there were no signs of any lasting permanent ischaemic damage.

The previous winter, she attended the Emergency Department (ED) with a swollen, cold, and diffusely pain- She was discharged with long term anticoagulation and ful left leg. She had woken up with these symptoms. a follow-up within four weeks. During follow-up her On clinical examination, the entire left leg girth was leg swelling was minimal and all pulses remained palfound to be significantly larger than the right and was pable. She was completely asymptomatic. Compresdiscoloured with a bluish hue. There were no signs of sion stockings were prescribed for the post thrombotic cellulitis. Peripheral vascular examination of the left limb. limb revealed a palpable femoral pulse and absent distal pulses. Hand-held Doppler ultrasound examination of DISCUSSION the left foot demonstrated a monophasic pedal signal.

She was otherwise systemically stable.

Phlegmasia is a rare but serious complication of DVT, where high venous pressures cause disruption to arteThe clinical impression was of an Ilio-femoral DVT due rial flow in a large vessel.1 Untreated, phlegmasia can to entire leg involvement, and a Doppler ultrasound progress to the more severe phlegmasia cerulea dolens, scan confirmed femoral DVT. Whilst in the ED, the pa- in which the limb becomes cyanotic and the limb is extient complained of new onset numbness and increas- cruciatingly painful.2 Subsequently patients with the ing foot pain and a vascular surgical referral was made. more severe form of disease can develop permanent isTheir assessment suspected arterial compromise, be- chaemic damage such as venous gangrene in 40-60% of cause of her continuous foot pain, sensory impairment reported cases and patient mortality is also significantand monophasic signals in the foot; a CT angiogram ly higher.3 Hence the early identification and prompt aorta was requested to assess the arterial supply. management of this condition is of critical importance in the prevention of morbidity and mortality.

The CT confirmed a proximal iliac vein DVT (Figure 1) and also demonstrated poor opacification from the distal third of the superficial femoral artery and the above Volume 29, No 4, Summer 2021

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Just as in this case, involving Mrs S, phlegmasia affects the left limb more often than the right, by a ratio of around 4:1.4 It is hypothesised that this difference is related to differences in the venous anatomy, which is also the presumed of cause of iliac vein compression syndrome where the right Common iliac vein compresses the left common iliac vein (May-Thurner Syndrome).5 Above those normal risk factors for the development of a deep vein thrombosis, phlegmasia is thought to be particularly associated with dyslipidaemia, obesity and poorly controlled hypertension, although this last condition is disputed in some sources.6 Mrs S only had one of these risk factors present which was hyperlipidaemia, treated with atorvastatin, highlighting the fact that patients may not necessarily always have multiple risk factors for the development of phlegmasia.

The management of phlegmasia is generally conservative. if the condition is diagnosed within a suitable timeframe to avoid the development of complications.

Thrombolysis and thrombectomy are used in selective cases on risk benefit balance. This lady was elderly and had limiting COPD and was unable to lie flat for any intervention, hence she was medically managed. Unfractionated heparin infusion was used for anticoagulation, however, it is also recognised that a low molecular weight heparin or a direct oral anticoagulant may be used.6

Figure 1: CT scan showing thrombus-laden left common iliac vein marked between four white arrow heads. Note the IVC opacification in comparison to that of the Iliac vein.

Learning points: •

Phlegmasia is a time critical pathology; the longer it is left undiagnosed and there fore untreated, the greater the risk to patient of limb loss and indeed mortality.

•

It is important to bear the possibility of phleg masia in mind when assessing a limb with DVT that also has ischaemic symptoms.

•

Early diagnosis and pharmacological interven tion will save limb and life.

•

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All patients will not be ideal for thrombolysis due to concomitant co-morbidities but full anticoagulation and timely clinical assessment and watchfulness makes all the difference in outcome.

Figure 2: CT angiogram showing opacified Femoral artery (black triangle) and non-opacified above knee popliteal artery (White arrow head)

Midlands Medicine

ACKNOWLEDGEMENT My sincere thanks go to the patient involved in the case who kindly consented for the use of their case and images for the purposes of this case report.

REFERENCES 1 .

Hasegawa S, Aoyama T, Kakinoki R, Toguchi da J and Nakamura T (2008) Bilateral phlegmasia dolens associated with Trousseau's syndrome: a case report Archives of physical medicine and rehata tion Vol 89(6) pp1187-90

2.

Sidawy A and Perler B (2018) in Rutherford's Vascular Surgery and Endovascular Therapy E-Book, Elsevier Health Sciences

3. Chinsakchai K, Ten Duis K, Moll FL and de Borst GJ (2011)

Trends in management of phlegmasia cerulea dolens

Vascular and endovascular surgery Vol 45(1) pp5-14 4. Huang L Li J and Jiang Y (2016) Association between hypertension and deep vein thrombosis after orthopedic surgery: a meta-analysis

European journal of medical research Vol 21(1) pp1-7 5.

Lee s and Rajagopalan S (2019) Vascular Com pression Syndromes: Squash or be Squashed Midlands Medicine Vol 29(2) pp65-7

6.

Kearon C, Akl EA, Comerota AJ, Prandoni P

Bounameaux H et al (2012)

Antithrombotic therapy for VTE disease: an

tithrombotic therapy and prevention

of thrombosis: American Col lege of

Chest Physicians evidence-based clini cal practice guide

lines Chest Vol 141(S2) ppe419S-96S

DOI: 10.1378/chest.11-2301

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MORE MEDICAL CERAMICS Anthea Bond, retired Consultant Orthodontist

STORAGE JAR FOR DRY MEDICINES In the journal of December 2020, the only one during the first year of the Coronavirus pandemic, there was a description of a storage jar for wet medicines. The bulbous shape was used for oils and syrups. This ovoid medicine jar with a splayed base and everted neck was used for dry medicines. It is also made of tinglazed earthenware, a process not used in the ceramics industry in Stoke-on-Trent, but it is shown in a display of rare items in the Potteries Museum and Art Gallery in Hanley. In making these pots, a newly thrown earthenware pot is allowed to dry before the first firing at a low temperature. After the firing it is known as bisque ware.

This pot was probably made in London in the second half of the 17th Century. The earlier jars made before the middle of the 17th Century did not show the names of the contents; the apothecary would know the contents from the different designs on the jars. These jars were usually at least 17 cm high and were used for herbs, powders and ointments. Smaller jars of the same shape were used for pills and lozenges.

The blue decoration here includes cherubs, flowers and a shell with a cartouche containing the inscription “THER: ANDR”. ANDR is an abbreviated form of Andromachi, a preparation traced back to Andromachus, a physician to the Emperor Nero (AD 37). “Ther” is short for The lead glaze liquid is made white and opaque by adding Theriacum, a treacle. It was supposed to be an antidote tin oxide. The pot is dipped in the glaze and when dry to all poisons, including snake bite poisoning. In the it has a powdery surface. Decorations are painted on 1600s it was used to try to prevent the plague. The Royal this powdery surface, often in blue, using cobalt oxide, Pharmaceutical Society has a collection of 172 English before the second firing. This is at high temperature to apothecary jars made of tin glazed earthenware, forty produce a shiny, glass-like surface which is not porous. are dated. Their excellent book English Delftware Drug Unfortunately, it chips easily. this example is in very Jars is edited by Bryony Hudson. The museum is close to the Tower of London and well worth a visit. good condition.

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NEWS Jacqueline Robinson, Editorial Assistant, Midlands Medicine The Medical Institute has been through a succession planning programme of meetings, identifying gaps and future requirements. We are happy to announce that four new trustees have been appointed and we look forward to knowing what will be needed over the next few years.

Professor Murray Brunt has taken on the role of Deputy Chair of the Medical Institute Murray graduated from Westminster Medical School in 1983. He was appointed Consultant Clinical Oncologist at the University Hospitals of North Midlands in 1991 and in 1996 became the Trust’s first Director of Cancer Services.

Murray moved from clinical practice in 2020 to a substantive Chair at Keele University School of Medicine (KUSoM).

Murray specialised in breast and skin cancer at UHNM and was an academic clinician with a research interest in breast cancer. He still leads the FAST-Forward breast cancer radiotherapy trial which has changed national practice and is influencing global breast radiotherapy. His breast radiotherapy research remains active and with an international reputation he continues to be involved and lead on a number of national and international initiatives.

Professor Nachiappan Chockalingham Professor Nachi Chocka lingam is a Fellow of the Institute of Physics and Engineering in Medicine, Chartered Engineer, Chartered Scientist and a Principal Fellow of the Higher Education Academy. He directs the Centre for Biomechanics and Rehabilitation Technologies at Staffordshire University and leads the biomechanics team and research. He makes an extensive contribution to human performance research and has been appointed to the Panel of Experts (UoA 24) within UK Research Excellence Framework. Also, he is listed as an expert to the European Parliament in policy areas relating to the assessment of new and emerging technologies, and foresight on long-term scientific and technological trends.”

PROFESSOR JUNE KEELING Professor June Keeling qualified as a Registered General Nurse (RGN) in 1988, and a Registered Midwife (RM) in 1992. Her first degree was a BSc (Hons) in Women’s Health, followed by a Master’s in Professional Education, and then a PhD exploring women’s disclosure of domestic violence and interactions with statutory agencies. Committed to raising the profile of Women's Health, Prof. Keeling works with colleagues at a local, national, and international level. She joined the School of Nursing and Midwifery at Keele University in 2019 as Professor of Women’s Health.

MR IAN COTTERILL Having studied locally at Staffordshire University and becoming a qualified member of the Royal Institution of Chartered Surveyors (RICS) while holding the position of Principal Estates Surveyor at Britannia Building Society based in Leek, Ian has an affinity and deep-rooted connection with Staffordshire as an area. Ian has in excess of 20 years’ experience within the commercial property industry working with Britannia Building Society, Marconi and The Co-operative Group.

As a Director of Louis Taylor, independent Chartered Surveyors and Estate Agents, Ian holds responsibility for the Stafford office based at Beacon Business Park.

The Medical Institute look forward to advertising the new date for the Grant Application programme within the next few months. www.nsmedicalinstitute.co.uk

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

1. SNOT test is used to determine the best mode of treatment for which of the following conditions?

5. Which of the following may cause Type 3 diabetes mellitus?:

a) common cold b) sleep apnoea c) rhinosinusitis d) CoViD-19 e) hay fever

a) cystic fibrosis b) pancreatic cancer c) pancreatectomy d) pancreatitis e) all of the above

2. A bubble echocardiogram is best used to diagnose which of the following conditions?

6. Gitelman’s syndrome is a cause of hyperkalaemia:

a) heart failure b) endocarditis c) patent foramen ovale d) mitral regurgitation e) aortic aneurysm 3. Candy Cane Syndrome is a complication of which of the following operations?: a) amputation b) gastric bypass c) hip replacement d) knee replacement e) cochlear implantation 4. Capgras’ syndrome can be caused by which of the following? a) Alzheimer’s disease b) Paranoid schizophrenia c) Brain injury d) All of the above e) None of the above

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True or False?

7. Aspirin may be prescribed in pregnancy to reduce the risk of pre-eclampsia: True or False?

8. B12 injections need to be administered for life after gastric bypass surgery: True or False?

9. Which of the following drugs is the recommended treatment for trichomoniasis? a) mebendazole b) clotrimazole c) metronidazole d) amoxicillin e) clindamycin

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10. The Braden scale is used for evaluating which of the following conditions?

12. Once daily oral iron is just as effective as twice or thrice daily dosing:

a) Anxiety b) Dyspnoea c) Optic atrophy d) Pressure ulcer risk e) Tinnitus

True or False?

11. The following may interfere with the interpretation of testing for Helicobacter pylori from stool samples: a) NSAID b) bismuth preparations c) omeprazole d) All of the above e) None of the above

13. Which condition specifically uses Patient global assessment to monitor disease activity? a) depression b) epilepsy c) heart failure d) obesity e) rheumatoid arthritis

14. This image is produced unaltered in its entirety, what is the main problem?

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WORDPLAY COMES OF AGE Dominic de Takats, Consultant Nephrologist, UHNM It so happens that the 21st outing of Wordplay falls in 2021. It feels like a birthday, and that I should get a key to a door, or some such. One reason this has come about is that there have been delays to this production brought about by CoViD-19. It does seem paradoxically both odd and perhaps unsurprising that all our lives remain touched by CoViD-19 in 2021.

Odd, because that nineteen firmly roots the origin and recognition temporally, literally dates the start of the pandemic, whilst making it feel dated, yet we know it’s current, whilst hoping it’ll soon be past; Interesting, because though we’ve decided to anchor the pandemic in time, we’ve decided to detach it (and all subsequent variants) from its geographic origins (Wuhan, China) for largely political reasons. Unsurprising, because the last unfamiliar 20th Century pandemics of Spanish Influenza (26 months in 1918-20) and HIV/AIDS (1981-present) were not over in a trice. So, at 21 it’s time to get a little more serious …

SERIOUS ABOUT LANGUAGE Language is important. Expressing oneself correctly and accurately matters. One concrete example is that until the WHO declared the CoViD-19 pandemic a pandemic, many national governments were either not able to put in place restrictive public health measures for legal reasons or they did not feel able to do so.

Once the WHO declared CoViD-19’s pandemic status, across the world governments were able to put in place prescriptive personal prohibitions and international travel restrictions which likely limited the pace of spread at that point, mitigating mortality rates in the early phase, or the first wave, as we dubbed it.

Philosophers have long held that language both distils concepts and gives us thought blocks to mentally manipulate. Languages culturally affect the way we think, so that different language groups may approach different material matter differently.1 Put simply, language at the very least, determines much of the mechanics of how we think because it determines the

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tools with which we think (geniuses and iconoclasts get a partial by), and the way we think determines the way we behave. Many people are onto this, A topical example would be those wishing to be recognised as gender nonconforming, by asking to be addressed as ‘they’. More interestingly, we have certain research groups making the change from referring to those taking part in clinical trials not as subjects, but as participants. This is doubleedged. It changes the attitude of the participants to that of collaborators in a grand scheme of discovery rather than the traditional term subject or, in the vernacular, guinea pig, which casts them not so much as subject but as objects. For the clinical trialists, from the other side of the glass, a similar transformation may be effected by this simple word substitution: subjects might be seen as specimens to be prodded, poked, given investigational medicinal products and observed, but participants have agency, they are volunteers, they are human, not guinea pigs, and naturally command all the dignity that comes with the designation.

Along the same lines, note the significant change in tone that results from renaming the NHS Litigation Authority as NHS Resolution. The former name conjures up visions of an adversarial contest, confrontational combative and conflictual, a fight to the bitter end. Saving money and the reputation of the NHS by fighting hard on its behalf. The very name invokes, and possibly thereby provokes, entry into the justice system and use of courts and judges to decide cases. On the other hand, the name NHS Resolution suggests something different: compromise, comfort and closure; “Let’s talk and see what we can come up with.

Maybe there’s a way out of this that we can both agree on…” and so forth. Change the name, and you change the tone, the mood, the expectation and, as a result, the behaviour, with more complainants willing to settle out of court. Now that’s a result!

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opposable thumb in shaping human culture. (My money is on the controlled use of fire, but it’s arguable Pointing out faults, pointing the finger, involves casting that it might be difficult to strike a match or operate aspersions, directing blame, accusing, and fingering a lighter without an opposable thumb.) Many animals metaphorically may lead to literal fingering, feeling with a pentadactyl limb have feet that resemble their the collar, , as the accused is manhandled, arm-locked, hands, despite differential function evident between arrested and manacled. The English word Finger is their forelimbs (hands) and their hind limbs (legs). remarkably well-preserved in Northern European Consider, in this regard, small rodents such as mice, rats, languages but its prior origins are uncertain. hamsters. Consider also how distorted and adapted the mammalian pentadactyl limb becomes when it is, for Fingering the point, on the other hand could lead to a example, the scaffold for the membranous wings of bats. prick. Kicking against the pricks2 is definitely advised against literally, to avoid injury, and metaphorically due Bradydactyly (short digits) [prefix from Greek: bradys to futility. meaning slow or delayed, used here to imply slow or delayed development or growth or both, so slow, in Fingers are the digits of the hand, toes those of the fact, that development is arrested, growth has stopped, feet. As you may have read earlier, deformities of ending up in short digits] has been covered in the case fingers or toes can be genetically determined, due to report on Shropshire Hand, but other selected dactylies developmental malformation, or acquired by (usually are worthy of consideration. There’s polydactyly (many unintentional) interaction with bandsaws, axes, table digits) [prefix from Greek: poly meaning many] refers saws or industrial machinery with faulty or discarded to a situation in which there are more than the usual guards (dis-guarded), or by (usually intentional) number of digits oligodactyly, on the other hand, [prefix interaction with hand or trauma surgeons. The word from Greek: oligo meaning few] refers to the opposite: a we use in medicine (and surgery and paediatrics and few fingers short of a handful. genetics and primary care) to make points about fingers and toes is dactyly [ancient Greek: daktulos] which is an Syndactyly refers to the fusing together of two or more adverbial-style adjective meaning regarding/referring digits. [Prefix from Greek: syn, Ancient Greek: sun, to fingers or toes but also having the state of fingers or Proto-Indo-European: ksun, cognate with Russian: so toes referred to. Having or living with just are, they are and Sanskrit: sam means, in its simplest form, with, simply existential and require no effort or action but to but commonly has the expanded sense of ‘in a group be and to have are verbs so dactyly describing a certain together with’ or jointly – most apt here. We are familiar digital form is an adjective, but when it refers more to with this latter sense from all those lottery syndicates living with the different digital form it’s an adverb. All we come across.] This produces situations in which a that said, it is rare for dactyly to be used without a prefix web joins two toes, or fingers are joined by a membrane that defines a digital difference; dactyly is essentially and also situations in which digits, toes or fingers are meta rather than actual. (Dactyly without a prefix completely fused along part or all of their length, always compared with with a prefix is seen about as often as from the base forwards, as far as it goes. Pulps and historiography (the study of how history is written) is nailbeds usually remain distinct. written compared with how often history is written.)

POINT THE FINGER

Pterodactyl [Prefix from Greek: pteron meaning In general, dactylies refer to specific standard wing] refers to an extinct clade of flying reptiles with arrangements of digits at the end of the limb, in membranous wings like those of bats. humans, specific dactylies usually refer to congenital variations from classic pentadactyly. The standard human, primate, mammalian, fairly pervasive fivefingered hand (and five-toed foot) shapes piano playing and raises the controversy of the importance of the

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LITTLE USAGE, NEW USAGE AND NEOLOGISMS App: A contraction of application which, in this context, doesn’t mean a putting something into practice, or working hard, or trying to join a workforce or a club, or trying to acquire a passport or licence, it means what we were previously happy to call a computer program.

Effectual: meaning the opposite of ineffectual, not commonly used because effective is preferred.

‘Hygiene theatre’ is a CoViD-19 pandemic phrase which refers to the practice of making ostentatious cleaning manoeuvres as much for the show of making them, and any reassurance that might thereby be afforded, as for any actual infection prevention and control effected.

Issue: has replaced the word problem in the majority of instances. It is a like-for-like substitution.

music is not just about the notes, but about the spaces in between them. If the object is to be clear, then it can be helpful to modulate expression of the same information according to the intended recipient. Thus, in a radiology report, a nodule might be reported as 4 mm × 5 mm × 5 mm, but it might be better conveyed to the patient being described as pea-sized. This has been known for a while, which is why many surgeons carry in their brain fruit-and-nut scale to help communicate the sizes of lumps, tumours, abscesses and the like to their patients. Pea, peanut, walnut (whole, often in reference to the prostate) and orange all tend to feature in this scale commonly, raisin, grape, plum and chestnut less commonly. Wo betide any watermelon situations! Interestingly, given the sporting prowess of many surgeons, there’s not much call for a ball scale (not meaning orchidometer which is a ball scale) as an alternative: marble, table-tennis ball, tennis ball, football, basketball. It would work, and is sometimes used, but tradition dictates and practice tends to prefer the fruit-and-nut scale.

Mental Health: As used in the phrase “I have Mental health” is a contraction of Mental Health Issue (see When the shape is not spherical, fruits, nuts and balls above) meaning mental health problem, meaning could be used to help patients to visualise the matter at mental ill health, previously referred to as mental illness. hand. Lemon, avocado and pear might better match the shape of some organs or fluid collections. The walnut Pingdemic: Another CoViD-19 pandemic gift, a (open) might be useful when talking about a brain but a neologism referring to vast numbers of people being star fruit might not have much use. notified (pinged) by their smartphones via the NHS Test and Trace app (see above) and told to self-isollate CONTEXT OR PRECISION? (see next).

Which is the better way to avoid mistakes? When Self-isolate: A further CoViD-19 pandemic term, again TLAs or FLAs have much in common or are, ina substitution for the previously used quar-antine, deed, are identical, it is possible to read them wrongly. meaning to quarantine on advice, in your own natural Sometimes subtly different forms, if ad-hered to, can environment, essentially unsuper-vised, relying on your help to make the distinction easier. As a Nephrologist, good citizenship for you to keep it up for the prescribed eGFR means estimated glomer-ular filtration rate and period. to an Oncologist EGFR means epidermal growth factor receptor.

Stroking: Public pools often have signs up exhorting: No Running, No Bombing, No Petting No Diving eGFR is an estimate of the total amount of filtrate and so forth. The word stroking has been applied to produced at the glomeruli collectively in an indi-vidual executing a stroke, in other words, swimming. But a per unit time. It is very difficult to measure directly sign allowing stroking could be misinterpreted, seeming and is closely related to renal blood flow and to solute to contradict, or at least delimit, the No Petting rule. clearance, though it is not exactly the same as either.

Nor is it the same as urine vol-ume (except when both SIZE MATTERS are zero) due to reabsorption of water in the Loop of Henle.

Language is about effective communication, which includes the specifics of what is being said or written and, in the context, what is not, in the same way that

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EGFR is significant in cancer biology and therapeutics because many tumours express epidermal growth factor receptors on their cell surface and if EGF or a related peptide binds to the EGFR of tumour cells that promotes their growth. EGFR is a receptor tyrosine kinase and sits within the ErbB family of such receptors, derived from the name of a viral oncogene to which these receptors are homologous: erythroblastic leukaemia viral oncogene.2 On being bound by its ligand, conformational change sets off intracellular signalling pathways. Targets for therapeutic intervention exist blocking the receptor site, inhibiting the tyrosine kinase effect of the EGFR when bound and the intracellular signalling pathways.3 (Notice how the area of cell biology is thick and rich with a language all of its own, or jargon.)

REFERENCES 1. Boroditsky L (2011) Scientific American Vol 304 (2) pp62-5

How Language Shapes Thought https://web.uvic.ca/~dbub/Cognition_Ac

tion/SpecialTopicsEssays_files/How%20Lan

guage%20Shapes%20Thought.pdf or: www. jstor.org/stable/26002395

2. https://idioms.thefreedictionary.com/kick%20 against%20the%20pricks#:~: text=If%20you%20kick%20against%20the%20 pricks%2C%20you%20show,jabbing%20 them%20with%20sticks.%20See%20al so%3A%20kick%2C%20prick.

There is, perhaps, significant scope for confusion when 3. the dose of the chemotherapy for an EGFR-positive

tumour needs to be adjusted according to the eGFR.

MORE PUNS PLEASE

Normanno N, De Luca A, Bianco C, Strizzi L, Mancino M et al (2005) Epidermal growth factor receptor (EGFR) sign aling in cancer Gene (2006) Vol 366(1) pp2-16 DOI: 10.1016/j.gene.2005.10.018

• A screening questionnaire for eating disorders has the 4.

Morgan JF, Reid F and Lacey JH (1999) BMJ Vol contrived mnemonic SCOFF.4 319 p1467

The SCOFF questionnaire: assessment of a new Do you make yourself Sick because you feel screening tool for eating disorders uncomfortably full? doi.org/10.1136/bmj.319.7223.1467

Cite this as: BMJ 1999;319:1467 Do you worry you have lost Control over how much you eat?

5. www.civilserviceworld.com/news/article/cross

government-unit-targets-drug-misuse-and- Have you recently lost more than One stone in a deaths 3-month period?

6.

A canal boat (unwisely?) called this as a name

moored at Rode Heath on the Trent and Mer Do you believe yourself to be Fat when others say you

sey Canal. are too thin?

Would you say that Food dominates your life?

It is scored simply: One point for every “yes”; a score of ≥2 indicates a likely case of anorexia nervosa or bulimia.

• The new Joint Combating Drugs Unit.5 • The government’s road map to decarbonising transport.

• Let the fun be gin6

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THREE THOUGHTS Dominic de Takats. Editor, Midlands Medicine TURING TEST Artificial Intelligence (AI) is not all that. Specifically, if, as seems to have seeped into popular culture, we consider AI in terms of fixed algorithms rather than in terms of machine learning or deep learning, it really isn’t. (…all that intelligent, as you have already filled in for yourself because you are not an AI algorithm and bring a little more cognition to the table than AI.) It is still stymied by human input and hasn’t escaped the lack of programmers’ imagination* to get to a place that functions anything like thought or consciousness.

ENDURING PROFESSIONALISM Compare the following extracts from guidance to a group of workers. The first is taken from the Great Western Railway rule book of 1905 and the second from Good Medical Practice by the GMC. I offer then for your own comparison and reflection, without further comment.

Employees

MUST

(i) see that the safety of the public is their chief care under all circumstances.

(ii) be prompt, civil and obliging, afford every proper facility for the Company’s business, give Consider for a moment the CoViD-19 proximity app. correct information, and, when asked, give Two workers in any factory or facility where there is their names or numbers without hesitation. shift work and they generally change when at work, a changing room and lockers are provided and they are not allowed to have their smart phones with them whilst at work. They have adjacent lockers. One works *Human intelligence is not just an individual matter but more the night shift and the other the day shift. The colleague of a joint enterprise distributed unevenly but shared e.g. through communication and culture, institutions and rules. arriving for the night shift and gets changed, hanging their clothes in the locker and placing their smart phone (iii) when on duty be neat in appearance, and, on the locker shelf. They are going to be identified as where supplied, wear uniform number and badge a close contact of someone who has tested positive for SARS-CoV-2 before the night is out. But they won’t (iv) if required, make good any article provided by the see the alert on their phone until the morning. It takes Company when damaged by improper use on their part. them six minutes to complete getting changed and walk Good medical practice describes what it means to be into the facility to They conduct a socially distanced a good doctor. It says that as a good doctor you will: handover with their colleague on the day shift, lasting eight minutes and it’s another seven minutes before the • make the care of your patient your first concern colleague is on their way out. Their smart phones have • be competent and keep your professional knowledge and skills up to date been within two metres for 20 minutes. When the first • take prompt action if you think colleague is alerted that they have been in proximity patient safety is being compromised of a PCR-confirmed case, the second colleague is • establish and maintain good partnerships alerted to being a contact of a contact and advised to with your patients and colleagues isolate for 10 days. You, as the reader, can see how • maintain trust in you and the profession by things have gone wrong, but a simple algorithm has no being open, honest and acting with integrity. thought process. By the way, there are another eight lockers within a two-metre radius. You can imagine how the scenario might play out; AI could compute all possible scenarios in order of probability, if given the necessary data and asked to run the query. Therein lies a clear difference in the approach, but what will we think when the distinction becomes less clear?1 166

Midlands Medicine

SLOWER, LONGER Why do we say “Em-Oh-Tee” and not “Mot”?

For information: the most correct form of the singular is ‘MoT’ and the plural: MoTs.

REFERENCES 1.

Turing AM (1950) COMPUTING

MACHINERY AND INTELLIGENCE

Mind, Volume LIX, Issue 236, October

1950 pp 433–460 doi.org/10.1093/mind/ LIX.236.433

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INTERESTING IMAGES

Bladder diverticulae, demonstrated on these ultrasound images taken from a scanning session in an elderly gentleman (arrowed in the first frame to help get your eye in) are one cause for double micturition, or pis-en-deux. The mechanism is thought to be that when the bladder contracts during the first voiding, the necks of the diverticulae are pinched off and the urine in these sacks remains put. Once voiding has stopped and the bladder relaxes, the urine from the diverticulae then flows in from the all at once, partially re-filling the bladder instantly thereby giving an early sensation of having to empty the bladder another time.

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ANSWERS AND EXPLANATIONS 1 c) The Sino-Nasal Outcome Test consists of 20 9 c) Metronidazole questions used to determine the severity of chronic rhino-sinusitis 10 d ) The Braden scale is used to determine the risk of developing a pressure ulcer.

2 c) Patent foramen ovale. It can also be used to diagnose an atrial septal defect 11 d) Antibiotics, proton pump inhibitors PPIs and bismuth preparations e.g. Maalox) may suppress the 3 b) This is a rare complication of Roux-en-Y gastric growth of Helicobacter pylori. PPIs and bismuth bypass surgery1 with symptoms attributable to a preparations must be withheld for at least 2-4 weeks long Roux loop which hands down in a ‘Cany Cane’ for antibiotics) before obtaining a stool sample conformation. testing for Helicobacter pylori.

4 d) Or Capgras’ delusion and named after a French 12 True. Not only is this associated with improved Psychiatrist, Joseph Capgras is a delusion in which concordance, it has fewer side effects. someone believes that someone they know has been replaced by an imposter. This has led to it 13 e) Rheumatoid arthritis. It is part of a holistic and being referred to as Imposter syndrome, but that broad approach to appreciating how the disease is erroneous because Imposter syndrome already and its treatment are impacting on the patients’ exists and refers to an unjustified internal sense of wellbeing. High numbers indicate worse perceived masquerading in a role that one is not qualified for disease activity or overall health. or not genuinely capable of doing. [Editor’s note: To call Capgras’ syndrome Imposter syndrome would itself be an example of masquerading!] 14 The image is unaltered. The patient is unidentifiable.

Once separated from the patient’s notes it is useless.

5 e) All of the above. It is sometimes referred to as ‘’pancreatogenic diabetes’’. It results from severe damage to, or removal of, the pancreas. It can also REFERENCE occur secondary to haemochromatosis 1. ht t p s : / / w w w. s o a r d . o r g / a r t i c l e / S 1 5 5 0 7289(17)30175-2/fulltext 6 False. This rare disorder causes the kidney to waste magnesium, sodium and potassium in the urine. It can result in hypokalaemia. Consider also Bartter’s syndrome.

7 True. Although it is not licensed for use in pregnancy, it is recommended for women who are pregnant and have more than one risk factor for pre-eclampsia. A dose of 150 mg daily is taken daily from 12 weeks gestation to delivery.

8 True. The British Obesity and Metabolic Surgery Society recommends lifelong supplementation of iron, multivitamins and vitamin D for all who have had a gastric bypass or sleeve gastrectomy.

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