Nutrition 101: Dr Gregers annual nutrition summaries, How Not To Die

Dr Greger is an internationally recognized expert in the field of nutrition. He created the website and youtube channel Nutritionfacts.org and he wrote the New York Times bestseller 'How not to die'. Every year he gives a presentation summarizing the latest in nutrition research and current understanding of the effects of nutrition on medical diseases.
His talks are absolutely brilliant and eye-opening,  The common theme circles around the benefits of a plant-based diet and how it can reverse and be used in the prevention of many diseases. (heart disease and diabetes just to name a couple.)
I think physicians and future doctors everywhere should watch his videos.
Here are the videos for the annual talks below:

2012:

2013:

2014:

2015:

The perfect diet

"The perfect diet does not exist because you wont be happy on the perfect diet"

Said my flatmate this evening after a long discussion on diet.

I was trying to tell him about the benefits of a plant based diet, Having watched all Dr Gregers talks I posted previously. The problem is, having been a regular meat eater all my life and probably iced donuts number one fan in the world (so tasty), suddenly converting to near veganism is downright miserable. Nothing against my culinary skills, I'm becoming quite the stirfry and cauliflower rice expert actually. I just really miss bacon sandwiches and poached egg breakfasts. 

The benefits of a plant based diet are incredibly clear, almost to the point of a miracle cure. Reversing diabetes and reducing athersclerotic plaques to name a couple. Patients all over the western world would benefit hugely from this incredibly non-invasive and 'simple' change (its really not that simple though is it).

How can i expect my future patients to adopt the diet if i continue to munch on burgers and kebabs. Doctors are meant to role models, much like the smoking doctors of the 60's and 70's, how can you expect patients to stop smoking if you are puffing on one in front of them or posing for cigarette ads (see picture below). 

So anyway to the point, I'm all torn up about plant based diets and their medical applications. Huge numbers of patients could benefit, millions of pounds could be saved and the environment would benefit a huge amount as well. Shouldnt every patient have a plant based diet subscribed? 

Doctors own reluctance to try them themselves and lack of exposure to the evidence may be some of the reasons. 

Why you shouldnt use twitter for medical advice, Ross noble quote.

I was out bike riding, my mate wanted to ride my bike so I rode his bike, and basically, it didn’t have hand guards on it. So I hit this tree and broke my hand. But I thought I’d just bruised it. But instead of seeing a doctor, I took a picture and tweeted it, and said “do you think this is broken?” Almost 99 per cent of people who tweeted me back said, “nah, if you can move your fingers it’s just bruised”.

So I left it, and went out again. I’d rode my bike about three times after this point with a broken hand, then a week later, I was off riding again, and this time it was really starting to hurt. So I went to the doctor and he X-rayed it and said, “when did you break this the first time?” I said, “what do you mean the first time?”

I’d actually been wondering around for about ten days using it and then riding with it, and then snapped it a second time. I said, “oh, everyone said it was just a bruise.” He said, “who’s everyone?” and I said, “oh I took a photo of it and put it on Twitter” and this is a medically trained doctor, he said to me, “you’re a f**king idiot.”

Link here 

Sunday laugh: That Mitchell and Webb Look, Homeopathic A&E

After my last post, I guess we won't be seeing any Homeopathic A&E in the near future.

It's official now, Homeopathy doesn't work

A total of 57 systematic reviews, containing the 176 individual studies, focused on 68 different health conditions - and found there to be no evidence homeopathy was more effective than placebo on any.

Sounds of Brighton

ZIKA virus overview

Named after the Zika forest in Uganda, the Zika virus is all over the news at the moment.

The virus belongs to the Flavivirus genus which include diseases such as Dengue and Yellow fever. (other flavivirus diseases; japanese encephlitis, tick borne encephalitis, usutu virus and west nile virus). 

The Zika virus is trasmitted by the Aedes aegypti mosquito, which is endemic to South America and Africa and also responsible for the spread of Dengue and Chikungunya (fever and joint pains). 

The current outbreak is in Central and South America after starting in Brazil and French Polynesia.

Once bitten by the mosquito the incubation time is around 10 days.

Most people have little of no symptoms but it can cause a range of non-specific symptoms such as myalgias, headaches, fevers and arthritis.

The diagnosis is clinical and based on travel and exposure history. The viraemic period is short and patients will be positive for viral DNA tests 3-5 days after onset of symptoms. After that serology will be positive, look for the presence of Zika virus IgM. 

No vaccine available, although drug companies are under heavy pressure to develop one soon..

Treatment is primarily supportive care with antipyretics and painkillers if needed. Avoid use of NSAIDs or acetylsalicylic acid, because of fears of hemorrhagic syndrome or reyes syndrome. 

The disease has been brought to the attention of the news because of the possible link with Microcephaly in new borns. For this reason the brazilian government has advised against pregnancy until the disease is under control and better understood. Its also for this women who are pregnant or intending to be soon should avoid travel in the endemic areas. There is also many reported cases of Guillain-Barre syndrome (acute ascending symmetrical polyneuroathy).  

Useful  links: CDC, European centre for disease control

• Also spread by the Aedes albopictus mosquito. and some other Aedes mosquito species. 
• Genetically modified mosquitos are being explored as a potential way to combat the mosquito and disease. The possible environmental impact of this approach is being studied. 
• First isolated in 1945 from a Monkey
• Note that many of the non-specific symptoms are similar to Malaria, which is endemic to the same areas but carries a much higher mortality rate. 
• Urine will be positive for Viral RNA for ten days after symptoms onset.

Source: http://jeffreyhill.typepad.com/.a/6a00d8341d417153ef01b7c80f713d970b-800wi

Central Venous Catheter DEATH

Only about a year ago in our Hospital a patient died after a CVC was removed incorrectly. The catheter was inserted in the internal jugular vein and removed slowly while the patient was still sitting up (orthostatic position). The combination of slow removal and inappropriate positioning (central venous pressure in this position is in the negatives) caused a fatal air embolism to be sucked into the circulation.

So when removing a CVC from the internal jugular vein, make sure the patient is supine and the catheter is removed with relative speed and the wound is covered well to prevent a delayed air embolism. 
Nice guide HERE

A central venous catheter (CVC) is a catheter in which the tip lies inferior or superior vena cava close to the entrance or within the entrance to the right atrium. They are useful because they can be left in alot longer than peripheral venous catheters and can be used to give larger volumes of fluids and drugs, alot faster too. They often have mutiple lumen to attach multiple lines and give drugs at the same time.

BMJ Review on CVCs

Types of CVC:

• Tunneled CVC: catheter is tunneled under the skin after insertion (less visible and moves around less, also helps prevent infection)
• Non-tunneled CVC: fixed in pace at the site of insertion typically with a suture, like our example above in the internal jugular vein. 
• Peripherally inserted central catheter (PICC): Inserted in the arm rather than neck or chest
• Implanted port: similar to the tunneled CVC but the end if left under the skin as well, drugs are injected in the port through the skin. 

Sunday laugh; This guy struggling putting the bin out

Trying to put the bins out this morning a little frosty one could say !!!

Posted by Alun Miles on Friday, 12 February 2016

February round-up (Medical student gems)

Youtube Channel: DocMikeEvans

Dr Mike Evans whiteboard videos are incredibly simple and informative. They are incredibly good at explaining the key points of disease in a way that patients can understand easily. Already posted my favorite video of his. 

Book: Why Zebras Dont Get Ulcers by Robert Sapolsky

This guy is a world expert on the matter of stress. In his book he explains clearly the different mechanisms of stress and their various manifestations. The detailed content means its not a light read but its super interesting and well worth the effort.

Twitter accounts: @StudentBMJ @CaulfieldTim

There are so many twitter accounts to choose from, I am following so many these days. The student BMJ is a great resource for medical students especially those in the UK.Tim caulfield posts some really interesting studies quite regularly

Webpage: Which textbook to use, Cambridge recommends

The Cambridge University medical school reading list, I refer to this whenever I'm not sure which textbook to use for a certain subject. 

Film: A Beautiful Mind (2001)

This film is about famous mathematician, nobel prize winner and schizophrenia sufferer John Nash. Gives great insight into the condition of schizophrenia, also a bloody great film. 

Photography: Albert Einstein's desk when he died

In Ralph Morse’s photo of Einstein’s comfortably disheveled desk, his burdened bookshelves, his soaring thoughts rendered on a blackboard in the universal language of mathematics, we glimpse both the essence and the solid, tangible shape of one of the 20th century’s signature lives: Here, the picture says, is where Einstein worked, dreamed, lived his singular, principled life to its fullest. Few pictures have managed to convey, in one frame, so much about an imagination and intellect that traveled so far, for so long, in such rarefied realms.

Source: http://time.com/3879070/albert-einstein-last-photo-taken-of-his-princeton-office/

23 and 1/2 hours: What is the single best thing we can do for our health?

Mania and Hypomania Mnemonic

DIG FAST 

Is a mnemonic for the symptoms of mania. Diagnosis of mania requires 3 or more of these symptoms over a period of at least one week, with impairment of daily life. If there is no impairment  or disturbance of daily life (mood isn't severe enough) the diagnosis is hypomania.

• Distractability and easy frustration
• Irresponsibility and erratic uninhibited behaviour
• Grandiosity
• Flight of ideas or subjective experience that thoughts are racing
• Activity increased with weight loss and increased libido
• Sleep reduced (e.g. 3-4hrs) but still feel restored
• Talkativeness 

Interactive measles outbreak

CLICK HERE to see the Guardian interactive graphic

My attending is off work due to measles at the moment. This awesome interactive data graphic shows the rates of infection at different vaccination rates. Measles post coming soon...

Signore Ernesto Caps Has Depression

People of all ages, ethnicities, genders and backgrounds can suffer from depression. Your nextdoor neighbour, your mentor, even beyoncé could be suffering from depression. By 2020 it will be the second most common condition behind heart disease and it is already the most common psychological condition by a long shot. 

We all get sad now and then, and these fluctuations of mood are of course normal. So how do you diagnose depression:

SIG E CAPS

This mnemonic covers the eight main symptoms of depressive disorders of which 5 or more are required over two weeks or more to diagnose Major Depressive Disorder.

• Sleep- changes in sleep patterns, increased during the day or decreased at night
• Interest- loss of interest and pleasure in activities, Anhedonia
• Guilt- feelings of worthlessness or guilt 
• Energy- lack of, fatigue is a very common presenting symptom
• Concentration- difficulty concentrating or reduced cognition, increased distractability 
• Appetite- weight loss and loss of appetite (occasionally increased appetite)
• Psychomotor- agitations (like anxiety) or retardations
• Suicide- suicidal thoughts, active (planning) or passive

Elderly may present slightly differently with the so called 'quirks'. The elderly tend to have more somatic and psychomotor symptoms and present often with fatigue. Elderly tend to have a feeling of worthlessness more than guilt. The elderly may also have psychotic delusions with their depression. 

Although we understand well that problems with neurotransmitters serotonin, dopamine and norepinephrine play a role in the pathogenesis of depression (and hence why we use SSRIS to treat depression), it's interesting to point out: "There is 10 times more major depression in people born after 1945 than in those born before. This clearly shows that the root cause of most depression is not a chemical imbalance. Human genes do not change that fast."

Check out www.clinical-depression.co.uk/ for lots more information

(I wonder if anyone has ever trialed Jiujitsu as a treatment for depression....)

(there is evidence that looking at cat pictures can increase your mood temporarily)

CBT vs Psychoanalysis (great Guardian article)

Great article about the effectiveness and difference between CBT and psychoanalysis

Click on the link above to see the Guardian article by Oliver Burkman (one of my favourite authors). Currently studying for my upcoming psychiatry exam and CBT keeps coming up, its a first line treatment for many disorders e.g. Persistent depressive disorder (updated name for Dysthymia).

Ehlers Danlos syndrome

Ehlers-danlos syndrome (EDS) is a collection of inherited connective tissue disorders that all have in common defects of synthesis or structure of collagen. There are various different types and presentations. I came across an EDS patient today who had over 60 different operations on his vessels!

Types (1997 classification, 1988 classification in brackets):

• Classic EDS (formerly types 1 and 2): premature birth, skin hyperelasticity, easy bruising, joint hypermobility, poor wound healing
• Hypermobile EDS (formerly type 3): joint hypermobility, chronic musculoskeletal pain,
• Vascular EDS (formerly type 4): translucent skin, acrogeria, vessels prone to aneurysm and rupture, hollow organ ruptures,.
• Kyphoscoliosis EDS (type 6, rare)
• Arthrochalasia EDS (type 7A/7B, rare)
• Dermatospraxis EDS (type 7C, rare)

Epidemiology:

1-2/25000
Both autosomal dominant and recessive inheritance patterns
Types tend to 'run in the family', a vascular EDS patient will not have a child with hypermobile EDS.

Signs and symptoms:

Collagen is found in almost every part of the body so signs and symptoms can vary a lot. The type of EDS will determine to some extent the symtoms. 

EDS patients are usually normal at birth with normal cognitive and social development.

The classic signs of EDS are skin hyperelasticity, joint hypermobility and delayed wound healing. 

Joints:
Are hypermobile (increased ROM) and prone to frequent subluxations and dislocations, earlier onset osteoarthritis and joint pain. Musculoskeletal pain can even be mistaken for fibromyalgia.
Greater than 10 degrees extension at the elbow or knee
Greater than 90 degrees extension of the 5th MCP joint
Can place hand on the floor without flexing knees

Skin: translucent and very thin, its very easy to make out the veins below (have a look at the patients chest). skin is characteristically hyperextensible and elastic, its also fragile and tears easily. there is delayed wound healing and severe scarring. Easy bruising. Look for atrophic scars.

Face: Typical facies more prevalent in type 4, vascular EDS. Narrow nose, small ear lobes, prominent eyes, thin lips and small chin

Other:
Organ rupture (bowels, bladder)
Aneurysms
Aortic root dilation
Migraines
Blue sclera (like in osteogenesis imperfecta)
Positive Gorlins sign (can touch tongue to nose)
Acrogeriua (opremature aging)

Diagnosis:
Based on medical history and clinical observations
Genetic testing may aid in diagnosis but not necessary.
diagnostic tests that may aid diagnosis include; collagen gene mutation testing, collagen typing via skin biopsy, echocardiogram, and lysyl hydroxylase or oxidase activity.
Brighton criteria; satisfied with either two major criteria, 1 major and 2 minor or 4 minors. 

Dont confuse this with the Beighton score used within the Brighton criteria to score joint hypermobility.

DDx:
Curta Laxa, Marfans syndrome, Bleeding disorders, Scurvy, Fibromyalgia.

Prognosis:

Only really the vascular EDS type patients have an increased mortality with an average life expectancy of 50yrs. Refer to cardiologist/vascular surgeon.
Normal life expectancy for Classic and Hypermobile type EDS patients.

#medicine #lecturenotes #ehlersdanlos #eds #connectivetissuedisorder #FOAMed #MEDed

Jiujitsu: The Over Under Pass

Over under passing is an incredibly effective way to pass by controlling almost fully your opponents hips. Bernardo Faria really is the master of this style of guard passing


more below....

Bézier curves and Raster vs Vector images

So I was really lucky today to have a tutorial from the head of vascular surgery about some basic imaging concepts.

Endovascular and vascular surgery requires careful planning beforehand using mainly CT scans. Since the aorta and many vessels can have tortuous paths, it can be difficult to to appreciate the true path of the vessel using only the traditional axial views or even sagittal/frontal reconstructions offered by the hopsital pacs system.

Horos is a free open source software (for macs only at the moment)  for medical imaging viewing. Pretty damn neat, download it and get involved!
Using an open source software like Horos or Osiris (another), you can do what's called multiplanar reconstructions which can enable you to take a slice of the body from any angle.
An incredibly valuable tool in surgical planning.
(as a medical student its actually worth playing around on)

Bézier curve
Is a curve that put simply can be generated from three simple points. You may have noticed it from powerpoint or photoshop programmes.
Youtube clip illustrating bézier curves
The maths is utilized when you trace a path aong the aorta in simply points. If you put the points in the centre of the lumen, the curve of the aorta can traced and you can generate an image that perfectly follows the curvature of the aorta.

The two kinds of images
Raster and vectorial images
Raster or bitmap images are your classic PC jpeg photo file. Every pixel colour is coded in the file and the location of each pixel is recorded. So a completely black square will still have lots of information coded as each pixel reports its location and colour (black).
Vectorial images are different, the file will simply state the size of square and all black for example. If you were to place a white circle over one corner of the image, the angle of the curvature would be coded by Bézier curve maths and then the colour behind simply coded white. With a vector/vectorial image, there is a lot less information to be coded and of course the file is significantly smaller.
CT scan slices are raster images. 
A raster image is of course better for images with lots of small details.
Helpful webpage

When using a CT scan to plan surgery pay attention to the thickness between slices. Optimal thickness is 0.2mm.

#CTscan #Vascularsurgery #Béziercurve #Imaging #MEDed #medicine

Deadpool public service annoucement 2

He's back...



If you are a guy see deadpools other public annoucement in the post below

Lights out medics! (Fact)

Turning off computers and turning off lights when you are done could save the NHS £70,000 a year and more than 1400 tonnes of CO2 emissions.

(Read more: Student BMJ 2015;351:h6567)