A day out in Barcelona: The Gothic Quarter

Missed your hotel breakfast no worries, cup of tea and brunch at ‘La Esquina - Kitchen and Coffee’ is the perfect way to start your day. The staff were super friendly, the food super tasty and hats off to the barista for the great coffee. Located in the city centre, I learnt here that ‘Caballeros’ is Spanish for gentlemen and ‘Señoras’ for ladies, trust me it's useful when deciding which bathroom to walk into.

After you are all fuelled up and ready to go ‘Plaça de Catalunya’ is a ten second walk away. From here starts ‘La Ramblas’ the famous bustling tourist trap, lined with restaurants, hotels and ice cream shops. La Ramblas is a long street that goes all the way down to the sea and is certainly worth a visit, watch out for pick pockets in this area though. After walking down for a few hundred metres and soaking up the sights and sounds, take the second left (placa de la cucurulla). This takes you in the ‘Gothic quarter’ the heart of ancient Barcelona.

La Esquina Barcelona Instagram @laesquinabcn

You should end up in a large square, here it's easy to spot the cathedral and arty looking tourist information centre. At the info centre you can pick up tickets for ‘Sagrada la famiglia’, Gaudis incredible creation, don't miss that! You can also ask to see what events are happening, I discovered here that mueseums were all free over the Easter holiday, #winning.

Check out the interior of the cathedral, truly magnificent (but it's got nothing on Sagrada la famiglia). Next door is the gaudi mueseum and just opposite the info centre there is a private exhibition centre, when I was there it was a Salvador Dali exhibition.

If you are feeling peckish here for some quick tapas or a glass of wine, I recommend ‘Bilbao e Berria’ which is also located in the same square. You can choose as many as you want of the small dishes with cocktail sticks in, with each stick costing you €1.85. I drank here some fantastic Spanish Rioja red wine.

Bilbao e Berria, Rioja and tapas

Next head behind the cathedral down the thin medieval streets to end up in front of the city hall (Casa de la Ciutat), in Plaça sant Jaume. It's free entrance to the city hall (the entrance is located behind) and well worth a look inside. I was delighted to see a shimmering ‘refugees welcome’ banner above the door when I was there. Opposite is the ‘Palau de la Generalitat de Catalunya’.

Barcelona city with Refugees welcome banner

A sharp left down Career de Jaume takes you to the wonderful arty district of Born. I had lunch on this road at an awesome Italian restaurant/takeaway called ‘Ro.Magna’. The piada burger I ordered was incredibly delicious and cooked right there infront of my eyes. The staff were very friendly and I loved the cosy interior (also such a sweet playlist in the background).

My brother and I at Ro.Magna, guess who is the photogenic brother.

Born has got to be my favourite area of Barcelona, the small dark winding streets are full of unique coffee shops and galleries and the main Street of Born (Passeig del Born) has some of the best tapas and bars in the city. In this area you can find the Picasso mueseum, ‘basilica de Santa Maria del mar’ and the ‘mercat de born’, All three worth a visit. The Picasso mueseum contains most of the great artists work while he lived and studied in Barcelona, it's amazing to follow his progression from naturalistic art, through his various periods (notably the blue period) to cubism. Some days of the week the museum offers reduced entrance fees so make sure you plan around them.

Mercat del Born now a blossoming cultural centre contains a full archaeological dig of the old city that you can walk around. There are various little historical exhibits about the various wars and how life must of been like back then. I only discovered this wonderful centre because I was seeking the toilet, located in the back corner, very subtle signposting.

Mercat Del Born cultural centre

If you are feeling peckish yet again in born (you hungry hungry folks) there is a brilliant tapas ristorant called ‘Taller de Tapas’. Again the food was absolutely delicious, eating here I started to really feel like I could enjoy the Spanish way of life, Barcelona transfer/Erasmus maybe? If the argentinian style isn't your fancy and you want Spanish tapas then there is another ‘Bilbao e Berria’ on the same street.

If you haven't seen it already or you still have lots of time after getting lost in Born and Gothic quarter then I highly recommend a visit to the ‘Sagrada la famiglia’ church. You really shouldn't leave Barcelona without witnessing inside the fantastic abstract church. Tickets are a nightmare and I believe now you can only book online, with the tickets only allowing entry at specific fifteen minute time slots, but seriously it's worth it! You can get to the famous church using the metro, it sits on the L2 line, best to buy a ten journey ticket for €9.85.

After all that, it's probably gotten quite dark and you feel like some fresh air after the narrow streets of the Gothic quarter, or maybe just an escape from the crowds of tourists at Sagrada la famiglia, head to the beach. With your fancy metro ticket you can get the beach easily by taking the metro to the stop ‘Ciutadella I Vila Olympica’ on the L4 line. Located here is the main clubs for example Pacha and Opium, if you are into that. Barcelona has two main beaches the smaller Barceloneta beach and the larger (and in my opinion better) Icària beach. Barceloneta beach is to the right after joining the sea and Icària beach is to the left after the harbour area.

Barceloneta beach 

Fancy a bite in this area then you have too visit restaurant ‘Bestial’ just below the massive golden fish statue (I guess it's meant to be a fish). Perhaps a little toward the pricey side, the prime beach location, sea view and most wonderful food I've ever eaten should persuade you. I ate the best pasta I have ever tasted  in my life there (sorry Italy, perhaps it's an Italian chef?). If you really want to cap off your day in Spanish style, order a classic Spanish Paella and Sangria drink, la vida és bonica :)

View from the restaurant Bestial, it's a hard life, take a break.

Spotlight Barcelona

After spending all Easter in Barcelona city, there is no doubt in my mind that Barcelona is one of the coolest cities in the world.

I'm going to dedicate the next few posts to the Catalan capital itself after a glorious week in the sun. Before visiting any city I really recommend learning some of the lingo, just the basics. Having some knowledge of the language will help you get on well with the locals and make finding your way around alot easier.

Hello   hola (ah-la)

Good morning   bon dia (bon dee-ah)

Good afternoon   bona tarda (bona tarr-dah)

Good night   bona nit (bona neet)

Goodbye  adéu (ah le ooo)

Please   sisplau (ses plow)

Thank you   gràcies/merci

Thank you very much   moltes gràcies

Excuse me   perdoni (pear-dough-knee)

I'm sorry   ho sento (ooo sen-too)

Beer cervesa (sir vess sah)

Toilet   els serveis (el sir vays)

Where is….    On és… (on ess tah...whatever)

I don't understand   no ho entenc (no on teng)

How are you(formal)?   com està (come ess sta)

Fine thanks, you?   Bé gràcies, I tu? (beh gra-see-as)

Yes no   sí no (sea no)

Do you speak English(formal)?   Parla anglès (parla un-gless)

My hovercraft is full of eels   el meu aerolliscador està ple d’anguiles

Optimism and how I'd rather just laugh

It's been a long day for me, I'm writing this on the 23:33 train from Luton airport to Bedford and feeling a little philosophical. Might be a pretty boring story so I recommend cutting to the final paragraphs for the point.

Woke up this morning on the bus to university, my morning routine a blur through sleepy eyes. Morning surgery starts at 7:30am, so as usual I was on the 7:18 bus to the hospital listening to the Joe rogan experience podcast. It was episode 764 with Duncan Trussell the comedian and good friend of Joe's. Duncan had a little crazy rant about how people get annoyed so easily and the pettiness of daily life. He was saying how optimism and positivity even for the little things would make life so much brighter.

I was lucky to get to spend the entire morning in the operating theatre, put some stitches did some ultrasound, love it. The last case was gruesome, transmetatarsal amputation of the foot, seeing a toe sawn off (and it's literally sawn off with an electric bone saw) is not terribly easy to watch but the surgeon did a great job (textbook, I read about the procedure before and he matched it point for point).

The afternoon was a rush of packing, lunch (pizza to say goodbye to Italy) and goodbyes (my korean flatmate and wonderful girlfriend). Before I knew it I was going through customs.

My phone buzzed after getting through customs, “you flight details have changed”. My flight was delayed 30minutes, shit. I had booked a train that left an hour after my flight touched down. This was the start of what could of been a very frustrating evening.

Airports are funny places, people from all over the world from all different backgrounds congregate briefly in the departures lounge while they wait for their huge steel transport to fly them away. (Ever thought about planes, how the flip do those things even fly, a 747 weighs 400 tonnes, there definitely some kind of magic going on there). Screaming kids, smokers in their tiny smoking closet, old, young, businessmen, stoners, they are all here like some kind of multicultural Royal rumble.

The flight delay meant I had exactly 40minutes from flight landing to the train leaving. As I passed the lady who checks boarding passes she said the plane was too full and my handluggage and others must go in the hold and my bag was whisked away, I just managed to pull my book out just before it was gone.

The flight was pretty uneventful, well at least compared to the flight where a window blew out I was on once (I'll post about that another time, it's a good story and ends with free pizza ha). The couple next to me were very much in love or something, they spent most of the flight making out. I think she had thing for ears, the guy would turn to read part of his guidebook now and then, but she would just keep kissing in his general direction, mostly in his ear, noisy stuff. The kids behind me must of confused my seat and the couple's as a drum set or punchbag. That was the only moment the lady next to me stopped inserting her tongue in mouths or ears, she turned and gave the two ‘little shits’ (her words not mine) an angry look and they stopped.

The flight landed on time (delayed time) and we bounced down the Luton airport runway to a typical Italian applause, well done pilot for avoiding a burning wreckage. As soon as the seatbelt signs flicked off I was up out of my seat and in front of the rear door, ready to run for my train.

Looking out the rear door window I couldn't see anything happening, the air hostess then told me after hearing my plight that sometimes they only open the front door. This now put me at the very back of the queue to leave the plane. Damn. The front door finally opened and everyone slowly shuffled off with me at the very back. After getting off the plane I sprinted to passport control only to be met by the biggest queue I've ever seen winding it's way left and right to fill the entire room (and it's a big room). With this long queue and the fact i still had to collect my bag and navigate from luton airport to the trainstation. There was no way I would make my train.

Through the airport WiFi (thank God for airport WiFi!) I managed to find out there was another train home leaving in around an hour. After just missing the aiport-train link bus by a second I eventually got to the station and the eight minute delay for the train seemed like nothing compared to my mad rush through Luton terminals.

This whole story is pretty boring perhaps even frustrating but I would like to get to the point now. Optimism. I could of easily have been pissed off with the various delays, the noisy neighbours on the plane, the fact I missed my trains, but I chose to except them and even laugh at them. By stepping back and accepting that there was nothing I could do, I felt so much more relaxed. Admittedly there was a brief surge of panic when I realised I may not be able to get home but focusing on the fact I would make sure I did, alleviated that. I am alot happier with this approach to life. I laugh at the obsurdity of situations and how easy it is to be annoyed in the modern world. ‘Living in the moment’ may sound like some hippy rubbish but there is certainly some truth to it.

Discussing this approach with a friend, an important point was brought up. You mustn't be completely passive with everything happening around you. If there is something wrong it should be dealt with but without the anger or aggressiveness that usually accompanies frustration.

Moral of this story to quote easyjet: ‘you should allow two hours after arrival before connecting trains or  flights’ ha. 

Searching for a purpose in life? Ask the aged

Wonderful article by Karl Pillemer, 'why we should all ask our elders about how best to live our lives'.
Especially a good read for people who are struggling to find a purpose in life or would like to better predict their future self.

Bill Hicks

My favourite Bill Hicks quote, taken from 'Sane Man 1989';

“I was in Nashville, Tennessee last year. After the show I went to a Waffle House. I'm not proud of it, I was hungry. And I'm alone, I'm eating and I'm reading a book, right? Waitress walks over to me: 'Hey, whatcha readin' for?' Isn't that the weirdest fuckin' question you've ever heard? Not what am I reading, but what am I reading FOR? Well, goddamnit, ya stumped me! Why do I read? Well . . . hmmm...I dunno...I guess I read for a lot of reasons and the main one is so I don't end up being a fuckin' waffle waitress. Then this trucker in the booth next to me gets up, stands over me and says [mocks Southern drawl] 'Well, looks like we got ourselves a readah'"

I think everyone can learn from watching Bill Hicks, his comedy was intelligent and he often questioned 'the man', inspiring a generation of anti-establishment comedians. This article

Proof of evolution that you can find on your body

Here are the ones listed in the video, I'm sure there are many many more not listed here (vomeronasal organ, hair patterns etc):

• Palmaris longus muscle in the forearm
• The three auricularis muscles (Auricularis superior/anterior/posterior)
• Goosebumps/piloerection
• Coccyx bones
• How the human embryo resembles other other animals embryos so closely in the early stages
• Grasp reflex in newborns

Pseudoaneurysms

Interesting case in the emergency theatres today. 40yr old male with a large hematoma in the left thigh. One week ago he underwent a cardiac procedure that required the use of an intra-aortic balloon pump.
Have an idea yet?
Insertion of an IABP is through a catheter in the femoral artery, if this puncture is misplaced or compression afterwards to close the wound is insufficient then the artery can continue bleeding into the thigh and form a pseudoaneurysm.
This chap had a pseudoaneurysm for exactly that reason, in fact you could see on doppler-ultrasound the hole was in the superficial femoral artery. The superficial femoral artery is a common origin of pseudoaneurysms because when you apply compression to the leg after cath lab or interventional radiology procedures for hemostasis, the femoral bone is not behind (as it would be for a standard common femoral artery puncture), so compression is ineffective.

What is a pseudoaneurysm?
Usually the result of injury to an arterial wall a pseudoaneurysm is an aneurysm lacking all three normal elements of an arterial wall. Pulsatile flow from the ruptured artery dissects the neighbouring tissues and forms a false lumen or sac containing the hematoma.

Risk factors: are any intra-arterial puncturing procedure, which increases in proportion to the size of catheter (larger catheters having higher rates of pseudoaneurysm formation). The risk is increased when the puncture site is not the common femoral artery eg. external iliac, superficial femoral and profunda femoral arteries.

How do you diagnose a pseudoaneurysm?
Most common presentation is pain and swelling in the groin area. Often the pain is disproportionate to the pain expected from the procedure. Large hematomas can compress neighbouring nerves and veins, and even cause skin necrosis.
Conduct peripheral pulse examination, ankle-brachial index and ultrasound scan of the area.
The best intial diagnostic test is a duplex ultrasound scan (7mhz linear probe). you can find and measure the diameter of the pseudoaneurysm neck.
If a doppler US scan cannot be performed the next step is a CT scan with contrast.

Management and treatment
So after support and resuscitation (a ruptured pseudoaneurysm can lead to catastrophic bleeding).
there are four main treatments:

1. Observation: for small pseudoaneurysms, less than 2cm. these will often spontaneously heal within a few weeks. keep monitoring with regular ultrasound scans. disadvantages include prolonged hospital stays and restricted activity.
2. US-guided compression: very variable success rates, the compression has to be maintained for at least 15minutes, aim for 20minutes. the probe can be used to target the pseudoaneuryms neck accurately. disadvantages include the fact that it not tolerated well and can be challenging. 
3. Percutaneous thrombin injection: guided by US thrombin is injected into the pseudoaneurysm cavity for immediate thrombosis. the real risk of embolism limits the procedure to pseudoaneurysms with a neck smaller than 4mm. often a well tolerated and successful procedure it does require anticoagulation therapy. 
4. Open surgical repair: Best for patients with complications or contraindicated to non-surgical management. open surgical repair allows direct visualization and control of the bleeding with suturing of the puncture site or patch angioplasty. hematoma can be evacuated and compression symtoms relieved. there are of course risks with any surgical procedure with  wound infction, lymphocele, radiculopathy and myocardial infarction topping the list. (make sure you check both sides of the artery).

So our patient had intially complained of a small thigh hematoma a few days after the cardiac procedure, he was infact in ITU with respiratory problems (complicated history). The surgeon had a look and since it was small and also considering the state of the patient, opted for the observation approach. so four/five days later the hematoma had expanded rapidly and considering the blood loss and size, open surgical repair was the best option. Operation went well, chap is doing fine. the hole was easily controlled with a controlled stitch and the hematoma evacuated from the anterior thigh and inguinal area. 

(pseudoaneurysm after arterial puncture to the superficial femoral artery)

Medice Cura Te Ipsum

Today I attended a really interesting talk by sociologist Dr Jonathan Imber and his good friend Dr Lorenzo Berra, a professor of Anaesthesia at Harvard medical school. The talk was titled 'medice cura te ipsum', a latin phrase taken from the bible which is best translated as 'Physician, Heal thyself'. The phrase is best understood as 'counsel to your defects before you counsel the defects of others', an important message in complicated field of medicine.  

Jonathan Imber specializes in the sociology of medicine and its historical and religious dimensions, while Dr Berra works in the intensive care unit at Massachusetts general hospital. Imber published in 2008 the book Trusting Doctors: the decline of moral authority in american medicine, a topic I'm sure many doctors particularly older ones can relate to. 

The talk started as simple discussion about the origins of their friendship, in the shadowing experience of Imber's son who had some doubts about pursing a career in medicine. Dr Imber went on to highlight the importance of experience with people being a key factor in deciding whether to pursue a career in medicine. Medicine after all is about dealing with people, people who are in fact often suffering and at their most vunerable. Medical education itself is lacking in this aspect of teaching students about real suffering. Dr Berra described how he didn't actually learn about suffering until well after graduation when dealing with one of his own family members suffering with a terminal cancer. 

Dr Berra was very personable and delved into great detail about the personal experiences that shaped his medical career. He really pushed the importance of a good mentor, someone to share the experience of becoming a doctor, not someone who just teaches things now and there but someone who you can develop a real friendship with and can relate to your own experiences.

Two of Dr Berra's stories stood out (I have changed many of the facts, but the idea is the same). When he was just an intern only on his second rotation he was on a late shift and a young guy came in with gastroenteritis, flu-like symtoms, unable to walk. The patient became hypotensive and the decision was made with the team to give fluids, but the patients BP kept falling. Eventually the patient crashed and they had to give CPR for over an hour, and unfortunately the patient passed away. Later they found out that the chap had a viral myocarditis and perhaps fluids wasnt the best shout. 

The second story, a young guy came in after a horrendous crash after a snowmobile jump. the guy had landed flat on his back with the snowmobile on top of him. Almost every bone was broken, contusions everywhere and the spine was severed at C7. While looking at the CT with the radiologist and the team, the radiologist openly said theres no hope, what can we do, such a young guy paralysed for life. Dr Berra stood up and said lets at least try, come on. Later the father of the young guy thanked Dr Berra, he had infact been their with the team as they looked at the CT with the radiologist. The patient is now ok, many years on and able to move his hands despite the lack of sensation and mobility in his legs. 

The entire hospital was sued for the first case, many doctors became very defensive with their medicine after that. Medicine now is all about performance. People forget doctors are human and can make mistakes, and sometimes that mistake is just an inability to predict some outcomes in the future. Defensive medicine is an expensive way to deal with patients, both economically and in terms of suffering. Doctors need to also trust their own patients. A good doctor needs to do decision making without fear and in the best interests of the patients.

Dr Imber told a great story about how the editor of the NEJM (New England Journal of Medicine) became really quite ill once, needing to spend many days stuck in a hospital bed. The editor having been a doctor for many many years, only then realised how important nurses were to the patient experience. There is more to the patients experience than just the doctor-patient relationship. The patient deals with nurses, other healthcare staff, his/her own suffering and of course family and friends. 

I guess I've ranted on a bit now. In summary:

• If you are considering medicine, be around people. Try to gain experience in the human experience of suffering. Care homes for example are an ideal place to start.
• A good mentor is important
• Trust yourself and your decisions
• Never stop studying, even when you are well qualified
• There is much more happening outside the doctor-patient relationship in hospital for the patient
• Take your time with patient to take a full history and gain a complete understanding of their illness experience (10-15 minutes assigned time is a ridiculous concept). 

(Dr Joanthan Imber and Dr Lorenzo Berra, Humanitas Hospital Rozzano 2016)

Random lifehacks episode 1

When I was much younger I used to love reading Men's health magazine, it was full of random workout routines and lifehacks, great for killing time on the bus to university. I used to write down some of the little facts and lifehacks that I learnt, here are a few:

• Blue light is linked to arousal and as effective as drinking a coffee for an energy boost (Try and install a blue light filter for any screen-work on your computer/tablet/pc before bed, it will help you sleep better)

• Avoid drinking lots of fluids with mealtimes, it can dilute the effect of your gastric juices affecting digestion. It's the small things that make a difference to how you look and feel. (Drinking a glass of water just after you wake up will help you wake up and feel better)

• 7AM is the best time to do aerobic exercise for reducing nocturnal systolic blood pressure – and increasing duration of deep sleep. 7PM is the best time to do aerobic exercise for reducing nocturnal diastolic blood pressure

• The BMI on average is lower in gardeners, Gardeners also self report higher rates of self esteem and positive mood. (Plant a snake plant for 100% oxygen production, it's the plant NASA want to take to Mars, it's produces oxygen day and night). 

What is Prealbumin?

Prealbumin AKA transthyretin is a transport protein synthesized by the liver that binds thyroxine. It is used in hospital as a marker of a patients nutritional status, more specifically a measure of 'protein' nutritional status. (other markers for protein nurtional status include: albumin, retinol-binding protein, transferrin, creatinine, blood urea nitrogen). Serum prealbumin is often requested when patients are on parenteral nutrition or  other forms of nutritional support. Normal serum prealbumin concentrations range from 16 to 40 mg/dL; values of <16 mg/dL are associated with malnutrition. It has a half life of around two days, much shorter than albumin's which is around 20 days, making it a good marker to understand acute changes in nutritional status. There will also be changes in prealbumin with liver disease and chronic kidney disease. The problem is that prealbumin is related to acute phase reactants meaning that it is affected in inflammatory states, such as with injury or infections. It can help to look at C-reactive protein (CRP) when assessing prealbumin, CRP is also an acute phase protein (in fact many studies look at the prealbumin/CRP ratio). Another drawback is that the prealbumin test is more expensive than a simple serum albumin test and so in some institutions the test is not available. Some studies have been published recently that suggest that there is little relation between nutritional markers such as prealbumin and actual nutritional status probably because of too much interference by inflammatory states (source). 

Summary:

• synthesized by liver and bind thyroid hormone
• short half life, normal value between 16-40mg/dL
• marker of acute changes in protein-nutritional status
• best assessed with a complete nutritional panel and with CRP index
• nutritional markers are not a replacement for a good physical exam and history

sources: http://www.medscape.com/viewarticle/474066_6, http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/9005, http://emedicine.medscape.com/article/985140-overview, https://www.urmc.rochester.edu/encyclopedia/content.aspx?contentTypeID=167&ContentID=prealbumin, https://labtestsonline.org/understanding/analytes/prealbumin/tab/test/, http://pen.sagepub.com/content/39/7/870.long, http://www.ncbi.nlm.nih.gov/pubmed/25912205

This column will change your life

For long time I've been following the work of Guardian journalist Oliver burkman. He is the author of the column 'this column will change your life', and I love it.
The articles are short and well written and full of interesting little tit bits of information. Well worth a read, click the link above.

Why a super low calorie or crash diet isn't good for you

Many of the most popular diets at the moment make use of the process of 'Ketosis' or as it known in my textbooks 'beta oxidation'. You have probably heard of it, and lets not be mistaken ketosis will burn fat and you can potentially lose a lot of weight.

Beta oxidation is the process the body uses when its running out of sugar, a kind of rescue system for energy. The process converts your body's fat stores into 'ketones', a potent fuel source for the body and brain. These fat stores are incredibly precious to the body and the body would much rather lower your basal metabolic rate (BMR) and shut off 'non-essential' bodily functions before resorting to this ketosis phase. Your skin, hair, brain, hormones and energy levels are all effected, it can thwart your ability to heal wounds and even give you diarrhea.  

Restricting your calorie intake to lower than your BMR will leave you feeling tired, hungry and unable to concentrate. (Lets not get into the effects of lack of fibre these diets will entail either). 

don't do it. 

So what should you do?... well firstly keep your calorie intake above your BMR

See next nutrition post....

Hans Rosling and the magic washing machine (2010)

Fantastic talk by one of the most intelligent men in the world. It really gives perspective of global economics and population. visit his website GAPMINDER,ORG, it is really fantastic!

What vessel arises from abdominal aorta and supplies an organ in the pelvis? (and isnt the inferior mesenteric artery)

I was scrubbed into a vascular surgery operation the other day, a standard aneurysmectomy when the consultant asked me "whats this vessel?". I had no flipping clue, the aorta was exposed and this mysterious vessel seemed to branch from just below the renal arteries and travel down into the pelvis.

It was one of the paired Gonadal arteries! (AKA testicular arteries or ovarian arteries)

The arteries supplying the testicles or ovaries arise from the abdominal aorta at around the L2 level. This is because of the embryological descent of the gonads from the abdominal cavity to their rightful position in the pelvis or scrotum (this process starts at the 3rd month of prgenancy and ends at the end of pregnancy). 

There are a few anatomical variants where the gonandal artery arises from the renal artery or slips behind the inferior vena cava before descending, it may even originate higher than the L2 area. 

So dont forget the Gonadal arteries!

What is it like to have dyslexia?

Click on this link to find out

Haematemesis

Haematemesis (vomiting blood) can present as either bright red in appearance (a medical emergency, suggesting an acute bleed) or a dark granular so called 'coffee grounds' (suggesting the bleeding is modest or has already ceased).

Causes of Haematemesis:

• Peptic ulcer disease: most common cause, often epigastric pain a well. Most often due to Helicobacter infection or NSAID use. 
• Upper GI malignancy: patient will often have fatigue, weight loss, anorexia and early satiety accompanying symptoms. 
• Varices: formed with portal hypertension when blood is trying to find routes to avoid the liver, most commonly with hepatic cirrhosis.
• Mallory-Weiss tear: characteristic history of forceful vomiting with haematemesis following (intial vomiting clear of blood). 90% of these will heal spontaneously.
• Gastritis/Duodenitis: consequence of Alcohol abuse or NSAID overuse. nausea and epigastric pain common.
• Oesophagitis: consequence of GERD. History of heartburn typically. 
• Dieulafoy’s lesion: developmental lesion, an unusually large (5-10mm) submucosal artery in the stomach wall. The pulsatility of which causes it to eventually erode through the stomach wall and perforate into the stomach. 
• Aorto-duodenal fistula: history of recent aortic surgery. 

Management, what to do:

The priority is resuscitation, patients with haematemesis may present in shock. So ABCDEs first. If a patient does present with shock or bright red haematemesis then after they are stabilised they need urgent upper GI endoscopy.
Get urgent CBC, U+E, coag screen, cross match and LFTs 
Varices have a high mortality rate and may be suggested by known chronic liver disease or characteristic signs if liver disease.
If patient has characteristic history of a Mallory-Weiss tear then endoscopy is not needed.
If active bleeding is not suspected and patient is stable, then take a full clinical history and exam. Suspect first gastritis, duodenitis or oesophagitis and pay attention to signs of malignancy.
If the diagnosis is not obvious consider inpatient endoscopy.