The slog

Can't believe its been 5 months since I managed to post here.  Well, maybe I can.. here's a little reminder of part of my world...

and here's this weeks favourite toon ...   More very soon

The Black Keys Tighten Up !!

When your heart goes Boom Diddy Boom Diddy Boom Boom Boom !

The old songs are the best !!

Oh Doctor I'm in trouble ..

Chairing a meeting tomorrow on anticoagulant drugs in Atrial Fibrillation (or AF) - the most common abnormal heart rhythm. 
  
A few facts :

• More than 1 in 200 people over 50 have it - and 1 in 10 over-80's. 
• AF increases your risk of having a stroke 5 fold  
• The reason why people who have AF suffer with strokes is because the top chambers or atria of the heart are beating irregularly and clots form in them, in particular in the left atrial appendage (LAA), a small blind ending pouch off the main left atrial chamber. The clots then break away and travel up through the blood vessels to the brain where they interrupt the blood supply to cause a stroke.  (This ‘appendix’ of the heart is not necessary for normal heart function and is routinely removed during certain types of heart surgery. With the LAA removed the chances of having a stroke are greatly reduced and patients do not need to take warfarin.)
• AF-related strokes are particularly nasty ones, doing more damage or being more likely to prove fatal than strokes not caused by AF. 
• If someone has AF, and another major risk factor for stroke (such as heart failure) they are usually advised to take treatments which thin the blood. 
• This has, until know, meant treatment with warfarin - or rat poison to the man in the street.  
• Warfarin is not easy to control, many other things can interfere with its action, and it involves regular blood tests to monitor - many patients aren't taking enough of the drug  - at least 50% are under treated and so not protected, while over treatment leading to nasty haemorrhages is also fairly common.   
• New drugs have just got their licences - they give  a much more regular control than warfarin - but at about £2.50 a day they work out at twice the cost of warfarin (which is cheap as chips) + the monitoring costs involved with warfarin (total £1.18).  There are hundreds of thousands of people on warfarin, so the NHS will only fund the new drugs for a few. 

On the wards in our hospital (which has a specialised Stroke rehab unit) we help lots of people juggle their warfarin dose. But we will have to wait to hear what our Pharmacy Protocol says before we    prescribe the new drugs (Rivaroxaban or Dabigatran). Given the endless financial strains/overspends/cutbacks, warfarin may remain the only treatment on the menu for now. 


If you don't fancy rat poison, here's a different option - looks like a jellyfish but the Watchman Device is like a tiny fishing net inserted into the major blood to catch clots before they hurtle up to the brain.  

Trials suggest the Watchman device may be as effective as warfarin

Of course, there are many other important aspects of AF that need consideration - 

For more on AF, here's a wonderful poster by the manufacturers of dabigatran. 

or hook in to The Atrial Fibrillation Association  

The only Heavy Metal I need has the atomic number 79..

Especially for those of the Heavy Metal persuasion....

A Swedish report in an journal published by the The Neurological Society of India warns that headbanging can be dangerous..

(is headbanging big in India ?  To the sitar ???)

The risks, it seems, are mostly about damage to the arteries in the brain. The violent movement of the head and neck can shred the delicate blood vessels, causing them to split open or clot up, leading to a potentially fatal stroke

In other words there may be sudden damage to the brain rather than just a gradual loss of brain cells - although we also know that repeated minor trauma to the head such as in boxing, increases the risk of dementia later in life, so when the generation who invented headbanging grow old we may discover a higher rate of dementia among them. 

To quote the article :  

"Head banging is a type of dance which involves violently shaking head in time with music, most commonly heavy metal music. Head banging can be up-down, circular swing, full body, or side-to-side. It is considered that head banging to loud music, while "making you more metal," has associated risks other than acquired hearing loss. Several case reports have indicated the inherent risk in this activity, especially of head and neck injury. We describe a patient with a history of intensive head banging and basilar artery thrombosis (BAT).

A 20-year-old man presented with neck and head pain and vertigo of three weeks duration. His medical history was otherwise normal including drug exposure or abuse. He was a musician and had a history of intensive head banging. He had sought medical help for these symptoms at other facility, but was not worked up to establish the diagnosis. The symptoms progressed in severity and he had intermittent loss of consciousness. On physical examination, vitals were normal and neurological examination revealed left hemiplegia with dysarthria. Computer tomography of brain, electrocardiogram, electroencephalogram, complete blood picture, and blood biochemistry were essentially normal. Magnetic resonance imaging including angiography could not be performed as he was very anxious. Possible diagnosis of basilar artery thrombosis was suspected and he underwent cerebral digital subtraction angiography under general anesthesia, which revealed basilar artery thrombosis. No underlying dissection or vascular malformation could be detected. He was treated with intra-arterial fibrinolytic agents. However, the outcome was complicated by a locked-in state and no obvious improvement has been observed during the follow-up."

Sadly the 20-year old in this case was left  "locked in" - aware but unable to move a muscle, with a very bleak future  ...  

The article explains that there have been reports linking headbanging to all sorts of unpleasant head and neck trauma, with  neurological complications of intensive head banging including subdural hematoma, vertebral artery aneurysm, carotid artery dissection, whiplash injury,  odontoid fracture, and vertebral artery dissection with vertebrobasilar ischemia or infarction.

Terry Balsamo

Terry Balsamo, guitarist from the heavy metal band Evanescence, had a stroke thought to have resulted from head banging.  

The Swedish report warns :

"A high index of suspicion of vascular injury in young persons presenting with persistent unilateral head or neck pain even after a minor trauma should be maintained. This index of suspicion should be even higher in patients with posterior circulation symptoms with antecedent trauma."

The report also lists the following as examples where trivial blunt trauma to the head and neck resulted in vertebral artery dissection (splitting of arteries at the back of the neck which are an important supply to the brain) :

• chiropractic manipulation (beware chiropractic !)
• tennis
• seat belt use
• yoga (gentle, huh ?)
• head banging...

Vertebrobasilar ischemia or infarction (stroke to the part of the brain supplied by the vertebral arteries) as a result of extremes of movement of the cervical spine is probably due to the fact that the vertebral arteries are fixed in the transverse foramina (a hole in the skull where the arteries enter to get to the brain) rendering them susceptible to occlusion or shearing from extremes of neck motion.

Rotation occurs first at the atlantoaxial joint before any rotation occurs in the cervical spine, leading to stretching and compression of the vertebral artery. Occlusion and spasm of the artery has been documented. An tear in the intima (the lining of the artery) can occur with formation of a clot or thromubs blocking the lumen or central space of the artery, which may result in embolization (clotting) in the posterior circulation (the posterior part of the brain's blood supply).

So, if I didn't have enough reasons already, there's another to explain why the only Heavy Metal I need is one that doesn't have headbanging habits..

Now..doesn't a gentle bit of folk music sound nice ?  

Banjolele bananas !!

"Godalming pubs are at the forefront of a new musical phenomenon!"
The Surrey Times

They are talking about Ukejam !!

Its been several months since I was recommended UkeJam and this week I finally picked up my shiny Banjolele and nervously went along - Bazinga !! what have I been missing....

so shiny !!!

Originally in Godlaming it's now based at the Royal Oak in Guildford, and meets every fortnight. 

 I don't find it easy to stroll into a pub full of about 100 people, who all seem to know each other and how it goes, on my own - maybe thats why I've put it off for so long.   But the friendly welcome hits you right between the ukulele strings.  Within seconds people left and right of me were welcoming me into their circle, finding me a songbook or opening theirs wider so I could join in.   The laughter and grins on people's faces said all you needed to know - this was going to be massive fun ! 

The generosity of spirit of the Ukejam is wonderful - just come in, get your instrument out or trill up your vocal cords, and join in.  Ukejam provide their songs books to download for free on their website, with lyrics and chords.  Songs range from traditional to recent pop hits, Gershwin to GaGa, Guns 'n Roses to Gnarls Barkley.  Songs you can't imagine would sound great played en-masse by 60 or more players/singers of all ages just stormed along (all thanks to the Ukejam leaders Adam and Penny).  

Here's a few samples of how the Ukejam sounds :

 Ukejam Price Tag  

Ukejam Chasing Cars

 Ukejam Staying Alive

Can't wait to go again !!

* Technical point :    It was the first time I had played my banjolele and I read some info on the web beforehand which told me that it was bad form to wear a strap on your ukulele because cradling it in your arms helped give the right position for good strumming technique. Stupidly I imagined this was true of my banjolele too - despite the fact it weights about 10 times as much and had sharp metal bits all over the sides of it.   Even a quick practice at home hadn't let sense dawn on me.   The pain as I scratched and cut my forearm trying to hold the darn thing massively interefered with any ability to get some nice chords going. I now have a very nice strap. 

Tell me ..I forget Involve me... I learn

If you are passing through Waterloo Station in the next few weeks and a swarthy bunch of middle aged men looking suspiciously like Middle Eastern secret agents suddenly pop up and do a swift rendition of Row Row Row Your Boat, clattering coconut shells in accompaniment, then I can notch up another milestone in my medical career.  

Mystified ?  Just practice the singalong and I'll explain ..

I've taken two days off for education - Continuing Professional Development (CPD) being an essential part of every doctors remit these days.

We have to collect as least 250 CPD points over 5 years which can be quite a tall order.  Ideally I would give priority to clinical courses - updates on disease areas like "The latest thoughts on treating pneumonia in the Crimean War Veteran" or "Screening tests for dye allergy in women who enjoy a blue rinse" but courses can be expensive  - a weeks salary for a days course - so free courses laid on by the Deanery have a certain appeal.   I wasn't particularly looking forward to this one but it offered 10 free CPD points, so I gave up a day and a half of my "spare" (writing) time to go. And, suprisingly, it was very good (thanks to a great teaching team including Dr Simon Cooper, a consultant physician working with the elderly in Taunton). 

Based on Confucius's words :

Tell me - I forget

Show me - I may remember

Involve me  - I learn

.. we were shown how to teach effectively by involving our students using all sorts of techniques, one of which was a 10 minute "micro-teach" session that we all had to try out.

Choose something non-medical to teach was the advice. I could have got them making a nice cocktail but 10 in the morning seemed a little early for Death in the Afternoon, and most of you know my kitchen skills are dangerously limited. More importantly the rest of my group, who I was to teach, consisted of overseas doctors, predominantly middle aged Muslim men well versed in surgical microsuction in the middle ear or the challenges inherent in replacing a hip joint.  It was hard to guage what other interestes or knowledge they might have but undoubtedly mid-morning alcohol was not a good idea. 

So in a sudden brain wave I decided to teach them how to perform as a Flash Band  

("Why ???" you are no doubt immediately rising in your chair to wonder - the tutor examining me thought much the same - and assumed my microteach was

doomed from the start.)

Fearless, I made my pitch. First I introduced the concept - none of them had a clue so I used my ipad to demonstrate with a YouTube clip or two : 

A flash mob song ?

A Flash Dance ?

or even a flash freeze ?

  

Suitably impressed with the idea, we then spent a minute brainstorming what we would need :   

SINGERS

INSTRUMENTS

LYRIC SHEETS OR MUSIC

  

plus a Bandleader/Conductor .. and a big heap of guts !!


By now I was sweating and shaking - would they understand what to do... could they play the simple percussion instruments I had borrowed from my children...  would they even sing in front of their colleagues ?

To my astonishment, the guys delivered - with enthusiasm and gusto !! We had a couple of shaky verses at the start (my poor direction), a brief hiccup as I rearranged them into pairs when they looked nervous about singing alone, and then we took the world of rivers and rowing boats by storm.   Forget scalpels and stethoscopes, these doctors have new skills, so watch out Waterloo ! 

Quite how I (and they) are going to put this to further practice in the hospital isn't quite clear though ..     

Shock news from the hospital : part 1: There is no "Critical List"



Muamba still on the "critical list" ? 

An update on the radio this morning cautiously warned us that while Bolton midfielder Fabrice Muamba, who collapsed in the middle of a game last week, is showing signs of improvement in a London hospital, he remains on the critical list.

Mysterious.

What is he doing lurking on something that is no more than a figment of a hack's imagination?  He's not going to get better hanging round there.

Journalists and novelists love to think that beady-eyed administrators clutching clipboards wander the hospital wards looking for people whose pale skin and sunken eyes hint at imminent collapse of their kidneys or heart, and so who deserve to be added to

 the "critical list" .. 

  

.. that instead of getting on with the mundane business of treating patients, nurses or doctors spend their time continually weighing up heart rates, blood urea levels or CURB scores before ringing up Joe in the office to say "yeah, put him on the list, guys.." 

  

And what would the hospital do with such a list ?

Use it to drum up publicity about in the local paper about the heavy demands

on the hospital's hardworking healthcare team and how threatened budget cuts would mean a speedy demise for those on The List ? 

Wave it in front of litigation lawyers  ?

Reassure relatives that their loved one has a special place in the hospital's daily bulletin ?

   

I don't know of a hospital anywhere in the country which has a "critical list"

There is NO critical list. Get over it.  

Music that stirs the spleen is good for transplants

Keep your transplants strong !

Few would deny that music has a fundamental affect on humans. It can reduce stress, enhance relaxation, and provide a distraction from pain. Don't ask me to explain the exact mechanisms just yet because the link isn't well understood, although there is some evidence that music may act on part of the autonomic nervous system - the nervous system which acts automatically to regulate the bodily functions that we have no conscious control over, including digestion.

But now new research suggests it may reach far deeper into the physiology of the body, stirring the spleen into helpful action.

Research from Japan published in the Journal of Cardiothoracic Surgery this week demonstrates that music can reduce rejection of heart transplants by influencing the immune system.  I pause here to point out that the study was in mice, so interpretation for humans needs care. But even so, the scientists found that certain types of music increased the time before the transplanted organs failed. There were lower levels of the chemical messages that the immune system generates during rejection such as interleukin-2 (IL-2) and interferon gamma (IFN-y), and higher levels of protective anti-inflammatory chemicals IL-4 and IL-10, as well as increased numbers of  specialised CD4+CD25+ lymphocytes - cells which regulate the immune response.  They pinpointed the source of this proection to the spleen.

But what seems to be critical is the type of music.  So if you are the sort of person who likes those gentle wafty wave noises or tinkling of silver bells in the breeze - the sort of New Age thing you can pick up in the local craft shop, or just a touch of Ambient, you may want to think again. I'm sorry,

Mr Eno         

.... and Mr Schulze 

but these toons simply don't get your spleen going enough.   Open your lugholes to something else and try a bit of Verdi or an Ode to Joy (the choral part of Beethoven's 9th). 

The Japanese team found that opera and classical music could both affect the immune system but single frequency monotones and new age music did not. They admitted they hadn't tried Screamo, Dubstep, Gospel or Punk so clearly lots more interesting research is needed.

But for now get loud and get venting your spleen !!