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Monthly Archives: June 2013

Keep gout at bay and sleep well!

There is something special about plucking shiny red cherries fresh from the tree and tasting the succulent juicy flesh on a summers day.

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Several years ago I planted several fruit trees and nurtured them so that they are now mature trees bearing a plentiful harvest enough to eat and share with friends, the birds and the local badger who are known to love cherries. I remember when I was reprimanded by a local farmer about the state of the lower trunk telling me that I would be a hopeless doctor if I didn’t look after my diabetics legs and allowed them to get advanced leg ulcers so look after my trees trunks in the same way. I have been vigilant since and paid great attention to clearing the base of the tree and bandaging them if appropriate.

Cherries are derived from either Prunus avium, the sweet cherry (also called the wild cherry). The native range of the sweet cherry extends through most of Europe, western Asia and parts of northern Africa, and the fruit has been consumed throughout its range since prehistoric times. Interestingly,where I am talking about where I planted the trees is in the Perigord, France and known to be the home of Primitive Man. That implies ‘man’ has been eating cherries on summer days in the same place I did for a very long time!
As I am sure followers of my blogs now appreciate I am curious about the wider benefits of foods and plants and this region which has been the home of hunter- gatherers for countless generations provides a constant source of interest.

Cherries are known to contain Anthocyanins to have a marked anti-inflammatory action. Specifically, these compounds seem to be highly effective in treating gout, a condition that causes excruciating painful swelling in joints notoriously the great toe. Last year, a Boston Medical Center study reported that eating cherries reduces gout attacks by 35%.
imagehttp://www.patient.co.uk/health/gout

Cherries are also one of the few food sources of the hormone melatonin, which regulates sleep patterns.
A study published in 2011 in the European Journal of Nutrition, reported that eating tart montmorency (or morello) cherries significantly raised levels of melatonin and improved sleep.

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Melatonin is a natural hormone made by your body’s pineal (pih-knee-uhl) gland. This is a pea-sized gland located just above the middle of the brain. During the day the pineal is inactive. When the sun goes down and darkness occurs, the pineal is “turned on” by the suprachiasmatic nucleus(SCN) and begins to actively produce melatonin, which is released into the blood. Usually, this occurs around 9 pm. As a result, melatonin levels in the blood rise sharply and you begin to feel less alert. Sleep becomes more inviting. Melatonin levels in the blood stay elevated for about 12 hours – all through the night – before the light of a new day when they fall back to low daytime levels by about 9 am. Daytime levels of melatonin are barely detectable.
Besides adjusting the timing of the clock, bright light has another effect. It directly inhibits the release of melatonin. That is why melatonin is sometimes called the “Dracula of hormones” – it only comes out in the dark. Even if the pineal gland is switched “on” by the clock, it will not produce melatonin unless the person is in a dimly lit environment. In addition to sunlight, artificial indoor lighting can be bright enough to prevent the release of melatonin.
Although research is very limited, the use of melatonin for jet lag appears reasonable. Many published scientific studies conclude that melatonin can be effective for preventing or reducing jet lag, particularly for crossing five or more time zones and when traveling east. However, safe and appropriate use of melatonin needs further testing.
Some shift-workers alsobenefit from the use melatonin but using it check on the following link:-
http://www.nhs.uk/medicine-guides/pages/MedicineOverview.aspx?condition=Insomnia&medicine=melatonin&preparationMelatonin%202mg%20modified-release%20tablets

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Be Clear on Cancer (BCoC)

The next Be Clear on Cancer (BCoC) national lung cancer symptom awareness campaign begins on 2nd July 2013 and will run for 6 weeks.  This is a top-up campaign, following last year’s first ever national lung cancer symptom awareness campaign.
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Lung cancer is England’s biggest cancer killer claiming around 28,100 lives every year. Outcomes in Britain are worse than those in some European countries and it is estimated 1,300 deaths could be avoided each year if five-year survival cancer rates matched the best in Europe.  In London, just over 3000 deaths were attributed to lung cancer and by implementing the Saving 1000 Lives strategy it is estimated that we could save 576 lives in London from lung cancer if outcomes matched the best in Europe.
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Red flagNew data reveals that only one in 10 people know that a persistent cough for three weeks or more could be a symptom of lung cancer.
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The campaign is aimed at over 55s, especially those from lower socio-economic backgrounds and the message is to advise patients who have had symptoms of a cough for 3 weeks or more to see their GP. This is consistent with the NICE referral guidelines for suspected lung cancer which states that a persistent 3 weeks or more cough is a potential symptom and requires urgent referral for chest x-ray.
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The likely benefit of the July BCoC lung cancer campaign is:
• An estimated 11% increase in early stage disease (I and II) at presentation
• An estimated 16% increase in operability and therefore potentially curative surgical resection
• Potentially a 2% fall in emergency presentations with a resulting better outcome for patients (and financial savings)
• Overall 400 lung cancer patients will have better outcomes.

Posted by Dr Bayer

 
 

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How can Yew help?

Recently I posted a blog talking about the history of yew and its use in medicine but I didn’t complete the story

This remarkable tree, the Yew in the Central Himalayas, is used as a treatment for breast and ovarian cancer. But western medicine in order to satisfy their criteria had to find a way of isolating the drug from the natural source.
Pacific yew’s bark were first collected in 1962 by researchers from the U.S. Department of Agriculture (USDA) who were under contract to NCI to find natural products that might cure cancer.
When this was found to be a potential anti-cancer drug there was outcry from the environmentalists including Al Gore as when collecting the bark this led to destruction of the tree.It was then found that the leaves of European yew (Taxus Baccata)were also an appropriate source which is a more renewable source than the bark of the Pacific yew (Taxus brevifolia). This ended a point of conflict in the early 1990’s. Docetaxel (another taxane) can then be obtained by semi-synthetic conversion from the precursors.

The precursors of chemotherapy drug Paclitaxel can be derived from the leaves or needles of the European Yew Taxus Baccata
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Paclitaxel is a chemotherapy drug. It is also known by its original brand name, Taxol. The drug is made from the needles of a particular type of yew tree. It works by stopping cancer cells separating into two new cells, so it blocks the growth of the cancer. It is a treatment for various types of cancer, including

Ovarian cancer
Breast cancer
Non small cell lung cancer.
AIDS related Kaposi’s sarcoma
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We know that clippings from the Hampton Court Yews have already been used along with those from many other sources to help many hundreds of cancer patients. However it is my opinion that we need to be clear about the exact location of the batches of clipping that are used. At Hampton Court there are also avenues of yews, which are more important a source of origin than a yew hedge or maze. This is because yews in an avenue can be more readily identified as being female or male and, if it is not already becoming apparent in taxol research, it will become increasingly important to separate clippings into their gender origin. At present such attention is not given in the collection of clippings and if gathered from hedges or mazes, which are also to be found at Hampton Court, then the task of establishing gender is extremely difficult as both sexes of the yew grow so close to each other in such environments. Thus the yew avenue offers a better chance of gender selection at the outset and consequently vastly improves further research potential.

But how can you help?
If you or someone you know has a Yew hedge or tree the annual clippings can be used to produce this important anti-cancer medicine. When I lived in Isleworth those of us who had Yew trees/ hedges did this each year.
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Lime hurst Ltd offer cut-and-collect service for Yew clippings ( tel : +44(0)1243 555110. )http://limehurst.co.uk/v2/
Limehurst are involved in the harvesting and processing of medicinal & cosmetic plants and have been collecting Yew hedge clippings in the UK since 1992 for use as a cancer treatment.
Or
Another organisation offering similar service is Friendship Estates
Tel:+44(0)1302 700220
http://www.friendshipestates.co.uk/
Between July and September his company come and collect the clippings of one years hedge growth , which are then used as raw material for the production of ant- cancer drugs
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Is mental illness still a stigma?

When I blogged  a couple of weeks ago I implied that I wanted to revisit this subject.
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At that time I seemed to be overwhelmed in the media and in the surgery with patients that felt hopeless and were finding it very difficult to go on. One busy surgery on aTuesday morning I could feel the atmosphere of tension and anxiety that sometimes pervades the surgery and indeed during that morning 4 people got up and stormed out. On this occasion because of the way I perceived the vibes I decided to phone each one to see if I could give a telephone consultation or arrange to see them later. What shocked me was the fact that all 4 said they had been feeling desperate and that life was not worth living and waiting was the final straw. Interestingly each person was pleased I had phoned and in 2 cases the act of waiting then storming out angrily had made them feel much better and in effect had  ‘snapped’ them out that of deep feeling. The other 2 wanted to talk and happy to reschedule an appointment at a quieter surgery time but felt better for the phone call.
That night I re-read a paper I had recently read on depression and decided to blog some of the ideas I thought would be good to share.

Following my stumbling across his secretary and family whilst at a gathering in France I was given the privilege of reading some papers written before 2008 by a Slovenian psychiatrist,Professor Andej Marušič  who also worked at Kings College London before he  died tragically from bowel cancer aged 43yrs.
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He was brought up in the downtown area of the city Port of Koper,Slovenia  and had been aware from an early age that the incidence of suicide in Slovenia was one of the highest in the World and most of his childhood friends from that time had become either dependent on alcohol or illegal substances, or had already died a violent death. He was the only one who somehow made it through. He made the point that if it wasn’t for his upbringing he had had, he probably would have been a good drug dealer. He made it his life’s work to research ways to prevent this tragic end of life.

He presented this paper to at least 2000 health professionals in a very humble, unassuming manner. He was passionate about de stigmatising mental health, making the point that if someone had been in hospital with pneumonia or a heart attack friends and family would be keen to visit enquire about jprogress but if someone had been in John Connelly wing, St Bernard’s there would not be so much interest and people would keep away and not get involved.

This rung a bell as from an early age I had a fascination for medicine and the workings of the body aswell discovering books about the ancient Egyptians and medicine. I also found myself listening in to conversations about ill members of the family or friends. Moreover, I always wondered what was the matter with those people who always came out of hospital with wooden trays displaying a chocolate box picture (a hunting scene or thatched cottage) and woven around the perimeter (the image of one below was found on eBay and being sold as a retro vintage tray!). image
Years after this I then realised making the trays was occupational therapy following a nervous breakdown – and my observation was a display of the stigma of mental illness to cover up what the problem was which as a child seemed strange and somehow not right. It would be good to think that attitude like the tray has become retro and a vintage idea.

Professor Andej Marušič then gave the following example:-
A man; 47 years old; married, with problems, or married to problems; a father with worries –  employed or waiting to be employed; low back pain; irregular heart beat; feeling low; no appetite but not losing any weight; a warning for those who want to loose weight with depression; no libido; using sleeping tablets; no hobbies; drinking too much, and sports – our Slovenians are losing!  We will now try to diagnose the profile of our patient.  What do you think his doctors will diagnose? Burnout? The cardiologist will say “arrhythmia”, as the patient is experiencing irregular heart beats; the orthopod will say “lumbago”; the psychiatrist “depression”; the psychologist “neurotic structure with interpersonal relationship problems”; the sociologist “weak social network”; the employer “if it wasn’t for Employment Tribunal law you’d have been fired a long time ago”: his wife “I can’t reach him” because he has lost his libido and his children will say “the old man is bothering us again”. That’s probably more or less the way his therapy would also go, although sometimes the therapies overlap, for example the general practitioner and the cardiologist would both prescribe sedatives.   One would prescribe a benzodiazepine, the other a tranquiliser, while I must stress that these two are as similar as whisky and cognac – sedatives don’t cure. The orthopod would prescribe analgesics and give him back strengthening exercises, to which he would respond “I don’t have the time to do these”; the psychiatrist would prescribe antidepressants, as this is almost the only thing we know how to do; the psychologist would say “Be positive” – I am allowed to make jokes about psychologists, because I am one – The sociologists would say “If we had a left wing government you would probably feel better”; the employer would say “Place him somewhere I don’t have to deal with him”’; his wife will say nothing, until she starts talking about the divorce, while his son and daughter are too young to have acquired a treatment licence.

What is the main problem here?

The main problem we are witnessing here is that different people see health from different perspectives. One is looking at just the ground plan, another at just the elevation, while a third just sees the cross section. Nobody sees the whole picture – the overall health of one entire body. Have you heard the saying “When you are healthy, you have a thousand wishes, when you are ill you have just one wish” This unfortunate 47 year old, who is supposed to “Be positive”’ couldn’t care less who treats him, as long as he gets his health back.

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Most of my medical career we have always assumed that patients are suffering from physical illnesses even contemplating it is ‘in the mind’ and patients want it to be physical and would be offended if it was implied that it was’ in the mind’ but now for some time as doctors we are following a biopsychosocial model and when we are assessing a patient we are taking into account all three aspects of a patients health and welfare.When I visited the nursing home a week or so ago I was asked to see 2 or the residents both unable to express themselves due to dementia. One Dorothy was quiet, not eating , withdrawn and it was thought that perhaps she had an infection or was going into a decline might have even had a small stroke. Had she had a stroke, or an infection or another physical problem she would she have to leave the home to be looked after elsewhere. Inevitably, the nurse in charge and myself pondered over physical reasons. Lets check their blood, start them on antibiotics ,get an ECG, call in the Palliative care nurses etc. Then  we both said together could they be depressed and looking at it logically it was reasonable to consider that along with everything else. Indeed they were both started on antidepressant medication accordingly having examined possible physical and other mental problems and alerting staff to be attentive to their social needs within a few days they were both in the lounge chatting calmly sipping tea and enjoying a piece of cake!  The nurse manager and myself just sat and watched them with sheer delight and the ambiance  was now peaceful and calm. This wavs a demonstration of holistic care and it works!!

I feel we are making progress and I would love to have been able to tell Professor Andrej Marušič that progress is being made. I have seen a real difference in the way employers treat patients that are depressed and I hahve no difficulty in writing ‘anxiety and depression’ or ‘stress related illness’  as a cause of sickness absence. Also, most employers work actively with their employees to address issues that may be contributing or causing the problem and create good back to work plans. I now see patients who have had time off with mental illness and see them return to work and blossom handling their lives in a much healthier fashion.
In these cases we made the decision for the patient as they were lacking mental capacity:it is different when both the doctor and patient with insight and capacity are trying to make that diagnosis. It’s also a bit more than  medication, cups of tea and cake but we have made some progress from secret hideaways and woven trays!

Yesterday, I read in the News the following proposed pilot scheme :-

Nurses are to go on patrol with four police forces across England to improve responses to mental health emergencies.
The pilot scheme aims to ensure fewer people with mental health problems are detained in the wrong environment, the government says.
Street triage teams are to be tested in the Derbyshire, Devon & Cornwall, North Yorkshire and Sussex force areas.
The patrols are part of an initiative funded by the Department of Health and backed by the Home Office.

Have you heard Ruby Wax’s take on this- yes another TED talk Stop the stigma of mental illness
I would like to be optimistic and feel that progress is being made in pdestigmatising Mental Health but I am sure there are cynics who are very guarded about that impression – lets watch this space!

image I will continue a further blog on his ideas of managing depression.

 
 

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Are Yew taking a Calcium Channel Blocker such as Amlodipine ?

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In 1021, Avicenna introduced the medicinal use of Taxus baccata for phytotherapy in The Canon of Medicine.

I hope that when I explain what this means you will find it all as fascinating as I did……
Firstly, Avicenna, who is he?

Avicenna (Ibn Sīnā) was born c. 980 in Qishlak Afshona, a village near Bukhara (in present-day Uzbekistan), the capital of the Samanids, a Persian dynasty in Central Asia and Greater Khorasan. His mother, named Setareh, was from Bukhara; his father, Abdullah, was a respected Ismaili scholar from Balkh, an important town of the Samanid Empire, in what is today Balkh Province, Afghanistan.

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Avicenna had memorised the entire Qur’an by the age of 10. He learned Indian arithmetic from an Indian greengrocer, and he began to learn more from a wandering scholar who gained a livelihood by curing the sick and teaching the young. He also studied Fiqh (Islamic jurisprudence) under the Hanafi scholar Ismail al-Zahid.
He began to study medicine at the age of 16, and not only learned medical theory, but also attended the sick gratuitously and according to his own account, discovered new methods of treatment.
As a teenager, he was greatly troubled by the Metaphysics of Aristotle, (as I am sure many of you will sympathise with!!!)which he could not understand until he read al-Farabi’s commentary on the work. For the next year and a half, he studied philosophy.
Avicenna had memorised the entire Qur’an by the age of 10.  He learned Indian arithmetic from an Indian greengrocer, and he began to learn more from a wandering scholar who gained a livelihood by curing the sick and teaching the young. He also studied Fiqh (Islamic jurisprudence) under the Hanafi scholar Ismail al-Zahid.

The teenager achieved full status as a qualified physician at age 18,and found that “Medicine is no hard and thorny science, like mathematics and metaphysics, so I soon made great progress; I became an excellent doctor and began to treat patients, using approved remedies.” The youthful physician’s fame spread quickly, and he treated many patients without asking for payment. div>

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Secondly,what is The Canon of Medicine (Arabic: القانون في الطب‎ al-Qānūn fī al-Ṭibb) is an encyclopedia of medicine in five books compiled by Ibn Sīnā (Avicenna) and completed in 1025.[1] It presents a clear and organized summary of all the medical knowledge of the time. The Canon is considered one of the most famous books in the history of medicine.one of the chapters is dedicated to cardiology and treatment of hear conditions.Avicenna dedicated a chapter of the Canon to blood pressure. He was able to discover the causes of bleeding and haemorrhage, and discovered that haemorrhage could be induced by high blood pressure because of higher levels of cholesterol in the blood. This led him to investigate methods of controlling blood pressure.
Avicenna introduced the medicinal use of Taxus baccata for phytotherapy.

Phytotherapy is the study of the use of extracts from natural origin as medicines or health-promoting agents. The main difference of phytotherapy medicines from the medicines containing the herbal elements is in the methods of plants processing. Traditional phytotherapy is a synonym for herbalism and regarded as alternative medicine by much of Western medicine. Although the medicinal and biological effects of many plant constituents such as alkaloids (morphine, atropine etc.) have been proven through clinical studies, there is debate about the efficacy and the place of phytotherapy in medical therapies.
Despite Western medicines reservation about the use of herbs the herbal drug “Zarnab”(derived from Taxus baccata)was as a cardiac remedy by Avienna. This was the first known use of a calcium channel blocker drug, which were not in wide use in the Western world until the 1960s.

Taxus baccata is a conifer native to western, central and southern Europe, northwest Africa, northern Iran and southwest Asia. It is the tree originally known as yew, though with other related trees becoming known, it may now be known as English yew, or European yew.

There has been a long association of yew trees in churchyards and there are at least 500 churchyards in England which contain yew trees which are older than the building itself. It is not known why there is this link but there are many theories- from yews being planted over the graves of plague victims to protect and purify the dead (as in All saints,Isleworth where there is a lage Yew growing over a large Plague pit) image
to the more mundane in that yews could be planted in churchyards as it was one of the only places that cattle did not have access and therefore would not be poisoned by eating the leaves. Yew trees are taken as symbols of immortality in many traditions, but are also seen as omens of doom. For many centuries it was the custom for yew branches to be carried on Palm Sunday and at funerals. In Ireland, it was said that the yew was ‘the coffin of the vine’ as wine barrels were made of yew staves. As the wood is so robust, in Medieval times it has been used in making long bows.
A yew tree that many of you may have seen is the one at the entrance of the door to St.Mary’s ‘Perivale our local lovely venue for concerts.
http://www.st-marys-perivale.org.uk/
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When I read about Avicenna and his herbal medicine Zarnab, a patient called Clifford I looked after about 33yrs ago sprung to mind. This was when I worked as a GP in Maesteg,South Wales. He had been a miner but what I remember most was that he was a pigeon fancier and I remember visiting him regularly and in his lounge the walls were covered with framed photographs of various pigeons he had raced or tossed. He was now virtually bedbound and the he was considered a ‘Cardiac cripple’ which meant he could barely move without getting angina. Angiograms, coronary bypass or modern drugs for angina weren’t available and the few patients that were referred for surgery had to travel to London to the Hammersmith or the Brompton. Then one day I saw a pharmaceutical rep in surgery and he told me about a new drug called Nifedipine (Adalat) that was being recommended for angina aswell as hypertension and it was proving to be very effective, also if the patient bit the orange capsule(NO longer recommended) relief from angina was longer lasting than GTN tablets which was all that was available. I immediately thought of Clifford and was able to offer them to him and it was marvellous to see him come to the door on my next visit. This was my first experience of a Calcium Channel Blocker and experiencing its great value. Incredible to think it took the Western World mealy a 1000 yrs to rediscover this medication. Now a more refined drug called Amlodipine is first line in all patients >55 yrs and Black people for hypertension and we very rarely see patients so incapacitated by angina.
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Read more fascinating facts about Yew in my next blog
Posted by Dr Bayer

 
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Posted by on June 28, 2013 in Training and Advice

 

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Duckling update

Now 7 weeks and 3 days and 6 have survived although one tends to wander off but has rejoined the family. Mother duck is difficult to distinguish but does stand aloof and watch her brood.

They wander down that same path to the river that they did on that first day … We think 4 male and 2 female but still not certain. They are now feeding much more in the wild and seem very healthy.
The weed in the river seems to be their favourite feeding place.

Posted by Dr Bayer

 

Ealing man’s Holocaust film screened at Commons

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We would like to bring to all our patients attention the wonderful work that one of the members of our patient participation group is doing for patients with Learning disabilities.
As the article in the newspaper states “A PRO-ACTIVE man with a learning disability has made a documentary about the treatment of disabled people during the Holocaust.”

We are very proud of our member of our PPG and would like to share his visions and work with all.

http://www.ealinggazette.co.uk/ealing-news/local-ealing-news/2013/06/19/ealing-man-s-holocaust-film-screened-at-commons-64767-33497745/

 

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C-r-y

imageOne early morning in February 3 years ago the phone rang and it was the wife of our Best man at our wedding. She was letting us know that she had woken in the night to a strange sound and following attempts at resuscitation by herself and the ambulance crew he had died suddenly. He was a handsome,highly intelligent,charming doctor/dentist/medical director of a pharmoceutical company who had been negotiating with NICE to accept Aricept as a treatment for Dementia.He had also been training for his 7th full marathon which he had taken part in and raised thousands of pounds for leukaemia following the death of his son’s best friend at the age of five.It was unbelievable and a total shock to all such a loss of someone so special. The night before he had been listening to opera with friends singing along with gusto and passion as he was also a musician, a pianist with talent.The funeral was an amazing musical tribute and those who spoke talked about his life with humour and sadness. Afterwards, his friends and colleagues commented that he had seemed the healthiest of everybody and as we chatted agreed it would have been a great party but it lacked one person. He was an ordinary East End lad made good commonly known as ‘Paul boy’! His only fault was that he was a Tottenham supporter which meant many an Saturday afternoon or a Boxing Day was spent in raucous banter whilst ‘the lads’ watched their rivals play – nothing more exciting than a London Derby!
This was an adult sudden cardiac death (SCD)as there was no evidence of disease on examination of his body after death and it was presumed death was due to sudden cardiac arrest,when the heart abruptly and without warning stops pumping.
Ironically, the week after he died the drug was passed!

I was reminded of this when a young attractive 25year old lady attended surgery recently devastated as she had lost her young partner in the same way. This young man had died suddenly without warning and his young partner and family had been left devastated.
She then told me that his mother had become very keen to support the charity CRY was founded in 1995 to raise awareness of conditions that can lead to young sudden cardiac death (YSCD); sudden death syndrome (SDS); SADS. She was also taking part in the CRY Heart of London Bridges Walk 2013 on 7th July. There main reason for supporting this charity is that it funds screening of anyone who could considered at risk as shown on the link. What a brave lady, the love she had for this man was tangible and this family had also lost someone very special whose life had just begun. The family are keen to support this charity as it raises money to screen anyone at risk and support research projects aswell as support bereft families.

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http://www.c-r-y.org.uk/general_information_on_cardiac_s.htm

CRY holds ECG screening clinics for those aged 14 to 35 at a number of established locations around the UK including Belfast, Cardiff, Colchester and London.The CRY mobile screening unit facilitates various screening events at other locations in the UK – often organised by CRY supporters. Details of where these clinics are and how to book are on the website.

What happens when sudden cardiac death(SCD) occurs
When SCD occurs, no blood can be pumped to the rest of the body. It is responsible for half of all heart disease deaths.
Sudden cardiac death occurs when the heart’s electrical system malfunctions. It is not a heart attack (also known as a myocardial infarcation). A heart attack is when a blockage in a blood vessel interrupts the flow of oxygen-rich blood to the heart, causing heart muscle to die. So if the heart can be compared to a house, SCD occurs when there is an electrical problem and a heart attack when there is a plumbing problem.
The most common cause of cardiac arrest is a heart rhythm disorder or arrhythmia called ventricular fibrillation (VF). The heart has a built-in electrical system. In a healthy heart, the sinoatrial node, the heart’s natural “pacemaker” triggers the heartbeat, then electrical impulses run along pathways in the heart, causing it to contract in a regular,rhythmic way. When a contraction happens, blood is pumped.
But in ventricular fibrillation, the electrical signals that control the pumping of the heart suddenly become rapid and chaotic. As a result, the lower chambers of the heart, the ventricles, quiver or fibrillate instead of contracting, and they can no longer pump blood from the heart to the rest of the body. If blood cannot flow to the brain, the brain becomes starved of oxygen, and the person loses consciousness in seconds. Unless an emergency shock is delivered to the heart to restore its regular rhythm using a machine called a defibrillator, death occurs within minutes. It’s estimated that more than 70 percent of ventricular fibrillation victims die before reaching the hospital.
When CPR and an AED (automated external defibrillator) are used together, the chance of survival following a cardiac arrest goes up to 50%, a ten-fold increase over CPR alone.

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This is why you may see Automated External Defibrillator (AED) machines are being hung on walls in supermarkets or other public places. I have frequently seen them in French supermarkets and hyper stores.
It is amazing that the nearest limited access AED is in Twickenham in a fitness club and the nearest 24 hr public access AED machine is outside an accountants office. To see the location of AED machines click on the link below:-
http://www.aedlocator.org/AEDLocations.php
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Who should be screened?
It is recommended that screening is requested via your GP if there have been any young sudden deaths in the family. Or if there are symptoms of:

Chest Pain (exercise related)
Severe Breathlessness
Palpitations
Prolonged Dizziness
Fainting/Blackouts

This checklist has been designed to help you determine whether you have a heart rhythm problem. If you have more than one of the symptoms below, see your GP.

    • Have you fainted or passed out during exercise, while emotional or when startled?
    • Have you ever fainted or passed out after exercise?
    • Have you ever had extreme shortness of breath during exercise?
    • Have you ever had extreme fatigue associated with exercise (much more so than others of your age and level of fitness)?
    • Have you ever had discomfort, pain or pressure in your chest during exercise?
    • Has a doctor ever ordered a test for your heart?
    • Have you ever been diagnosed with an unexplained seizure or fit?
    • Have you been diagnosed with epilepsy that fails to respond to medication?
    • Have you ever had exercise-induced asthma that medication didn’t control well?
    • Are there any family members who had a sudden, unexpected, unexplained death before age 50 (including cot death, car accident or drowning)?
    • Are there any family members who died suddenly of heart problems before they were 50?
    • Are there any family members who have had unexplained fainting or seizures?
      Do you have any relatives with the following conditions:
      Hypertrophic cardiomyopathy: thickening of the heart muscles.
      Long QT syndrome: a condition that results in a very fast, abnormal heart rhythm, which can cause fainting.

What is happening by way of research?

VeniceArrhythmias, a biannual meeting started in 1989 and, year after year, has become one of the most important international congresses in the field of arrhythmology with almost 3000 attendees and with more than 400 invited speakers.
As you read many cardiologists and electrophysiologists are preparing their abstracts to be presented at the Venicearrythmia conference next held in October 2013
VeniceArrhythmias, a biannual meeting started in 1989 and, year after year, has become one of the most important international congresses in the field of arrhythmology with almost 3000 attendees and with more than 400 invited speakers.image
At other venues and during the year there will be similar events. It is through these events that there have been major breakthroughs in screening and prevention of sudden death.Research in the channelopathies and cardiomyopathies is progressing rapidly and in the future it is expected that the majority of the genes involved will be discovered.
In the future, it may also be possible to diagnose all carriers easily – even in those people who have a normal ECG reading. It may also be possible to choose the best treatment based on the type of mutations involved, and the treatment may even be designed based on this knowledge.
In the meantime, better understanding of these conditions and improvements in methods for diagnosis should still result in better management. It is crucial that, when a heart disease such as a channelopathy or cardiomyopathy is diagnosed, all immediate blood relatives should be evaluated by a specialist cardiologist to find out if they have an inherited heart disease.

IMPORTANT
It needs to be considered in sudden death in especially younger adults where the post Mortem fails to provide a cause of death, it is important to send the heart to a pathologist who specialises in this field of medicine and this may be a relative, friend or attending doctor who makes that request.
However, to help this research and appreciate the true incidence there must be a change in the Law.
In the UK, unexplained sudden death is frequently recorded as due to death from natural causes. Until the law is changed and coroners have to refer hearts on to specialists we will not know the true figures. CRY’s fast track coroner / pathology service enables the cause of death in a sudden death case to be established more quickly and accurately than might otherwise happen if left to a local coroner lacking expertise in cardiac pathology.

Tests That Predict Risk

There are a number of tests that can be performed to determine if some- one is in a group that is at high risk for cardiac arrest. These include:
Echocardiogram – a painless test in which ultrasound waves are used to create a moving picture of the heart. The test can measure the strength of the heart’s pumping function (ejection fraction) and identify other problems that may increase a person’s risk for SCD.

Electrocardiogram – A painless test in which electrodes are attached to the patient’s chest to record the electrical activity of the heart in order to identify abnormal heart rhythms. Certain arrhythmias could point to an increased risk of SCD.imageHolter monitor – A cell phone-size recorder that patients attach to their chest for one to two days, recording a longer sampling of their heart rhythm. After the recorder is removed, the tape is analyzed for signs of arrhythmia.
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Event recorder – a pager-sized de- vice that also records the electrical activity of the heart over a longer period of time. Unlike a holter moni- tor, it does not operate continuously. Instead, patients activate the de- vice whenever they feel their heart beating too quickly or chaotically.
Electrophysiology study (EPS) – This test is performed in a hospital. A local anesthetic is used to numb areas in the groin or neck and thin flexible wires called catheters are
advanced through veins into the heart under x-ray to record its electrical signals. During the study, the electrophysiologist studies the speed and flow of electrical sig- nals through the heart and paces the heart to see if arrhythmias can be induced. The physician can also determine if a patient has had a prior heart attack or evidence of prior heart damage without know- ing it. All of this information can help determine whether the patient is in a group at higher risk for SCD.There is another interesting device
The AliveCor Heart Monitor app is designed for medical professionals, patients and health conscious individuals to record, display, store and transfer accurate single-channel electrocardiogram (ECG) rhythms. These recordings could be saved on the mobile phone or shared with others (such as your doctor) via email. The app is CE-mark approved.
imageThe Heart Monitor snaps onto your iPhone 4 or 4S like a case and wirelessly communicates with the app on your phone. No pairing between your iPhone and the Heart Monitor is required. The free AliveECG app will be available for download from the Apple App Store when you receive your Heart Monitor. Once in the app, create a free account and you’re ready to begin recording ECGs. It’s that easy to get started. http://www.AliveCor.com provides you with anytime, anywhere, fully secure, online access to all of your ECGs. Once you have the Heart Monitor and the AliveECG app you can create an account that gives you access to your ECG data.

Prevention

There are a number of things people can do to decrease the likelihood of becoming a victim of sudden cardiac death. To begin with, living a “heart healthy” life can help reduce the chances of dying of cardiac arrest or other heart conditions. This includes ex- ercising regularly, eating healthful foods, maintaining a reasonable weight, and avoiding smoking.
Treating and monitoring diseases and conditions that can contribute to heart problems, including high blood pressure, high cholesterol, and diabetes, is also important.
Finally, for some patients, preventing sudden cardiac death means controlling or stopping the abnormal heart rhythms that may trigger ventricular fibrillation.

Treating arrhythmias is done in three ways:

Medications – Medications, includ- ing ACE inhibitors, beta blockers, calcium channel blockers, and antiarrhythmics, can control abnormal heart rhythms or treat other conditions that may contribute to heart disease or SCD. But taking medication alone has not proved to be very effective in reducing cardiac arrest. These medications are sometimes taken by patients who also have an ICD, in order to reduce how often it fires.

Implantable cardioverter defibrillators (ICDs) – These devices have been very successful in preventing sudden cardiac death in high-risk patients. Like a pacemaker, ICDs are implanted under the skin. Wires called leads run from the ICD to the heart, and the device monitors the heart to detect any abnormal rhythms. If a dangerous arrhythmia is detected, the ICD delivers an electrical shock to re- store the heart’s normal rhythm and prevent sudden cardiac death. The ICD can also act like a pacemaker if the heart is beating too slowly.

Catheter Ablation – In this technique, radiofrequency energy (heat), cryotherapy (freezing), or other energy forms are used to destroy small areas of heart muscle that cause the dangerous, rapid heart rhythms. The energy is delivered through catheters that are positioned through the veins or arteries to the heart. Catheter ablation is sometimes done in patients who have an ICD to decrease the frequency arrhythmias the number of ICD shocks.
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If anyone has any particular concerns Dr Livingston has a special interest in this condition and is very knowledgable and would be pleased to discuss any related problem.

Posted by Dr Bayer

 
 

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We have registered with the CQC – We are now await an inspection

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Now we are one of the registered practises and we are awaiting inspection. As you may be aware most of the questions will be directed towards patients and staff to establish what they think of the service provided.
Many of us are aware there have been problems with the CQC in their reporting of problems in various hospitals. This is the first year that they have looked at Primary care services and GP’s.This is rather strange for older GP’s as for the most part have always thought of their practise territory as a private domain.Inspections only started in 2005 in a structured manner and they were carried out internally. Independent inspections are probably long overdue particularly for some seriously underachieving practises.We sincerely hope that there will be some constructive criticism but also trust that what we do well will be recognised.
As there were some patients who want to know what is happening I felt it was important to keep you up to date and there may be someone out there who will be asked at 48hrs notice to come along to talk with the inspectors.
Meanwhile,
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The outcomes that will be looked at are as below
Outcome 1: Respecting and involving people who use services
People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run.
Outcome 2: Consent to care and treatment
Before people are given any examination, care, treatment or support, they should be asked if they agree to it.
Outcome 4: Care and welfare of people who use services
People should get safe and appropriate care that meets their needs and supports their rights.
(Outcome 5: Meeting nutritional needs
Food and drink should meet people’s individual dietary needs.)
Outcome 6: Cooperating with other providers
People should get safe and coordinated care when they move between different services.
Outcome 7: Safeguarding people who use services from abuse
People should be protected from abuse and staff should respect their human rights.
Outcome 8: Cleanliness and infection control
People should be cared for in a clean environment and protected from the risk of infection.
Outcome 9: Management of medicines
People should be given the medicines they need when they need them, and in a safe way.
Outcome 10: Safety and suitability of premises
People should be cared for in safe and accessible surroundings that support their health and welfare.
Outcome 11: Safety, availability and suitability of equipment
People should be safe from harm from unsafe or unsuitable equipment.
Outcome 12: Requirements relating to workers
People should be cared for by staff who are properly qualified and able to do their job.
Outcome 13: Staffing
There should be enough members of staff to keep people safe and meet their health and welfare needs.
Outcome 14: Supporting workers
Staff should be properly trained and supervised, and have the chance to develop and improve their skills.
Outcome 16: Assessing and monitoring the quality of service provision
The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care.
Outcome 17: Complaints
People should have their complaints listened to and acted on properly.
Outcome 21: Records
People’s personal records, including medical records, should be accurate and kept safe and confidential.
Outcome 3: Fees
People who pay for a service should know how much they have to pay, when and how to pay it, and what they will get for the amount paid.
Outcome 15: Statement of purpose
People know that CQC is kept informed of the services being provided.
Outcome 18: Notification of death of a person who uses services
People can be confident that deaths of people who use services are reported to CQC so that, if necessary, action can be taken.
Outcome 19: Notification of death or unauthorised absence of a person who is detained or liable to be detained under the Mental Health Act 1983
People who are detained under the Mental Health Act can be confident that important events that affect their health, welfare and safety are reported to CQC so that, if necessary, action can be taken.
Outcome 20: Notification of other incidents
People who use services can be confident that important events that affect their health, welfare and safety are reported to CQC so that, if necessary, action can be taken.
Outcome 22: Requirements where the service provider is an individual or partnership
People have their needs met because services are provided by people who are of good character, fit for their role, and have the necessary qualifications, skills and experience.
Outcome 23: Requirement where the service provider is a body other than a partnership
People have their needs met because services are managed by people who are of good character, fit for their role, and have the necessary qualifications, skills and experience.
Outcome 24: Requirements relating to registered managers
People have their needs met because services have registered managers who are of good character, fit for their role, and have the necessary qualifications, skills and experience.
Outcome 25: Registered person: training
People have their needs met because services are led by a competent person who undertakes the appropriate training.
Outcome 26: Financial position
People can be confident that the provider has the financial resources needed to provide safe and appropriate services.
Outcome 27: Notifications – notice of absence
People can be confident that, if the person in charge of the service is away, it will continue to be properly managed.
Outcome 28: Notifications – notice of changes
People can be confident that, if there are changes to the service, its quality and safety will not be affected.

Sangeeta Kathuria,our practise manager is working very hard to look at these outcomes in order to be as compliant as possible. Some of them may not be easily achievable but I have every confidence that under her direction we will be very near the mark.

Watch a video of Professor David Haslam explaining how they will check that we meet the essential standards. Please note: Prof Haslam is no longer our national advisor but has taken up a role as Chair of NICE.

Posted by Dr Bayer

 
 

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WATCH OUT FOR SIGNS AND ACT F-A-S-T

Yesterday a patient came into surgery and said “I am a bit worried about my mum , when I came home from work she seemed a bit confused and she was getting her words wrong she kept saying to my dad  to come and get his ice- cream when she meant to say dinner and called the cat a car. She was otherwise OK and before I went to work she wasn’t like that”
I  knew this patient had high risk factors for a stroke and infact had seen her earlier in the week so I knew this was something to act on and
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Although her speech was not slurred she had a sudden change in being able to speak normally and it is the SUDDEN onset of change that is important.
Medical students posted this poster in the surgery and then after a week asked attending patients if they had seen a poster or new how to recognise a stroke and very few knew!
By recognising the signs and getting them to hospital as soon as possible can be extremely beneficial to the patients.When you call an ambulance in West London and tell them what you have witnessed or it is happening to you they know that they must take you to either Northwick Park Hospital or Charing Cross Hospital as these are the designated hospitals with a specialised Stroke unit and are equipped to act fast and administer specialised intensive aftercare.

However if the symptoms are transient and there is a recovery within 24hrs then it is still important to get an urgent appointment or in the case of 102theavenue surgery there is walk in surgery each morning or the receptionist would fit a patient in to a later appointment surgery. If surgery is closed there are walk in clinics or phone 111 for an urgent appointment in the nearest Urgent Care Clinic.
If you want to know more about stroke and what happens physiologically use the links or watch the video below:-
http://www.nhs.uk/Video/Pages/Strokeanimation.aspx
http://www.nhs.uk/Conditions/Stroke/Pages/Introduction.aspx

 
 

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