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Monthly Archives: August 2013

DUCKLINGS – SOCIAL INTERACTION

Social interaction appears to be an extremely important part of ducklings growing up.

The ducklings are now visiting us on a regular basis and there seem to be a variety of visitors including ducklings of mixed race or in the duck world known as hybrids. Mallards interbreed with other species of ducks and a thoroughbred mallards is becoming rarer.it is becoming more obvious which are male am
N which are female. There is still some rivalry and at least two of the ducks hav paired off and remain aloof from the main group but seem to tag on behind and follow the group eventually.

Similarly Social interaction is very important in the human world and a recent studies by Doctor McClintock, Director of the Institute for Mind and Biology, compared lonely and social humans and although the trial is still running, early indications show the lonely people didn’t recover as quickly from illness, didn’t sleep as well and had higher systolic blood pressure. The early trial conclusions state that social interaction helps to make people healthier and live longer.

This has also been found in other studies including Cacioppo, who found lonely people show a number of adverse cardiovascular changes compared to people with friends. They have faster heartbeats, higher blood pressure and poorer sleep. So this closely mirrors McClintock’s findings.

There is also good evidence that social support has a favourable influence on a wide range of illnesses including heart disease, cancer, hypertension and respiratory disorders.

However, good social interaction is a key part of living well. Study after study lists good friendships, family relationships and health as the most important things to have in order to be happy and fulfilled.

As doctors we are always interested in a patients social network and I can recall numerous cases to illustrate this.
However, I also feel that being in our own space is extremely important and can be extremely beneficial in some instances. As always it is striking a good balance.

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HAS YOUR SKIN SURVIVED THE SUMMER?

image“And so with the sunshine and the great bursts of leaves growing on the trees, just as things grow in fast movies, I had that familiar conviction that life was beginning over again with the summer.”
― F. Scott Fitzgerald, The Great Gatsby
After a glorious summer where motivation has increased, our Vitamin D has been topped up and we have managed to get out and go to places we haven’t been to in years, sadly, there are some ill effects of summer.
Besides the passing tummy bugs or heat exhaustion the one thing we must be vigilant about is our skin.
Melanoma is the 6th most common cancer overall in the UK (if non melanoma skin cancer is excluded). More women than men get melanoma.

Every month it is worth doing a self-examination of the skin especially if you are at greater risk such as:-

Moles – the more moles you have, the higher your
risk
• Being very fair skinned – especially with fair or red
hair, or having lots of freckles (although people
with darker skins can still get melanoma)
• Sunburn – getting badly sunburned increases your
risk of melanoma, particularly in childhood
• Where you were born – fair skinned people born
in a hot country, such as Australia or Israel, have a
higher risk of melanoma throughout their life
• Sun exposure – on holiday, as well as sitting in the
sun or sunbathing at home
• Sunbeds – using sunbeds, particularly before the
age of 35.
• Sunscreen – using sunscreens may protect you, as
long as you don’t spend too long in the sun.
There are other less common risk factors such as Family History involving more than 2 close relatives – these other less common risk factors can be found on the website link later in this blog.

How to perform a self-examination of the skin

Firstly find a bright room and use a large mirror where appropriate.
Look at the whole body front and back
imageWhen you have isolated a skin lesion that looks different or you think has changed using the acronym ABCDE to confirm your suspicions.
A Asymmetry – the mole halves don’t match
B Borders – they are uneven
C Colour – this is not uniform
D Diameter – this is larger than 4mm
E Evolution – the mole grows and may become inflamed and itchy

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Where to look

Bend the elbows and look at the forearms, underarms and the palms. Your palms, bottom of the feet nails and nail beds – these are places where it is more likely to acquire acral lentiginous melanoma (ALM) which is more common in women especially with dark skin.
Check the back of the legs and feet including in between the toes and the soles of the feet and toenails. New and unusual bands on the nails could be a sign of sign of cancer.
Examine the back of your neck and scalp with a hand mirror. Ideally, it is better if you can get a friend or partner to help by using a blow dryer as this will allow a closer loo
If you find a mole that fits the above criteria it is important you are seen by your GP.

If you are not sure it is worth taking a photograph of the mole alongside a ruler and storing it on your PC to observe changes when you repeat the photograph a month later.

NICE guidelines for urgent referral follow the 7 point scale

The NICE guidelines say that all GPs should use the 7 point scale for assessing changes in moles. The scale has 3 major features and 4 minor ones.

The major features are
*Change in size
*Change in colour, such as getting darker, becoming patchy or multi shaded
*Change in shape

The 4 minor features are
*7mm or more across in any direction
*Inflammation
*Oozing or bleeding
*Change in sensation, such as itching or pain

The doctor counts 2 points for any of the major features. Any of the minor features scores 1 point. If your mole scores 3 points you need urgent referral to a specialist. But the guidelines say that if there are strong concerns about any one feature, urgent referral is also reasonable.
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If you are not sure it is worth taking a photograph of the mole alongside a ruler and storing it on your PC to observe changes when you repeat the photograph a month later.

More information can be obtained from:-
UK website http://www.cancerresearchuk.org/cancer-help/type/melanoma

PS
If you have had a melanoma always be vigilant.

David’s story

I remember a patient many years ago called David
He never went to the doctor and made it his business to keep well away under all circumstances. I knew his wife well and she attended very regularly and in passing had often remarked about her husbands dislike of doctors. Infact, the only notes on his record were a record of his childhood immunisations.
One day, on a Friday evening she appeared very anxious and said her husband had taken to his bed upstairs, because if he even attempted to move he was very short of breath and he had refused to call a doctor. Understanding her predicament and always enjoying the challenge of sorting out a difficult patient I decided to visit him. When I entered the house climbed the stairs, there was David in bed, sitting up with at least 5 pillows and so breathless he was unable to voice his disapproval of my presence. When I examined him more closely he was extremely swollen with fluid to the level of his waist- totally waterlogged!
I gently suggested a hospital admission and needless to say he summoned up enough breath to refuse outright. In situations like this negotiations are on a par with making a peace treaty between warring countries. After a while we negotiated a plan helped with the knowledge that his first grandchild was due – he would take the medicines I prescribed and if they worked he would attend the surgery on Monday morning before the doors ‘opened’, I would take blood and he would go to the hospital for a chest X-ray. If he was no better he would have the option of deciding the next move. We shook hands on this and I arrived Monday morning wondering if he was alive or dead and whether he would appear. I was not long in the surgery when the bell went and in walked David with his wife and I have say hardly breathless and a look of submission on his face.
I had the X-ray form prepared and proceeded to take blood. As he rolled up his sleeve there before me on his forearm a classical, fulfilling all criteria malignant melanoma. I remained calm as one must with a patient like this as they are likely just to get up and leave precipitantly.
After his remark of “is that it,doctor?” I retorted with ,”not quite, you did say you would go and have a chest X-ray and perhaps Hammersmith would be a better hospital for you and by the way could you just pop in to this clinic whilst you are there!” I quickly scribbled a note for the Walk-in skin clinic hoping that I was right in thinking I had him in my hand and that he would arrive at the clinic and not have to wait.
Later that day his wife phoned to tell me that he had done everything I had suggested and he had been admitted but was wanting to take his own discharge. The hospital doctors had made the diagnosis of malignant melanoma with spread to the lungs and heart failure. He had refused all treatment except what I had prescribed.
He soon came home and was told he was terminal. I visited him and even after lengthy discussion he was adamant that he was not going to have any treatment for this cancer. The Macmillan nurse arrived and he dismissed them as he could manage his own death and he had a lot of things to sort out and he didn’t have enough time to talk to nurses and doctors. The first most important thing to do was to phone the council and have the large tree removed from the family grave as the grave would be needed very soon – he felt it was disgusting how graves were looked after.
This was done by the council in record time.

David never appeared at the surgery again, failed to attend hospital follow ups but continued to take the medicines I originally prescribed. I kept in touch when his wife attended and she collected his medication. I only ever saw him across the road when he was on his way to the graveyard with his trowel and bucket to carefully maintain the grave. He would always wave and shout over , “How are you, doctor?” to which I would reply,”Fine , how are you?” and he would retort,”Fine” and continue about his business. He not only enjoyed the birth of his grandson for 4 other grandchildren and lived for almost 5 years of a good quality life but finally quite suddenly he died to go to the grave he had so lovingly tended.

The point of this story is that for some reason this tumour can become inexplicably dormant but then recur at a later stage even years later.

 

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GUT WEEK 2013 – ARE YOU CHEWING OVER YOUR EATING HABITS?

In my blogs regarding gut week I got as far as the stomach and although we are aware that what you put in your mouth must go down there are more hazards to come!
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Moving down past the stomach the resulting thick liquid passes slowly into the small intestine.
*The small intestine – food particles move along this intricate tubing (about 6 metres long) and are broken down into simpler molecules, of carbohydrate, protein and fat. These are then absorbed into the blood stream.
*The large intestine – the remaining food particles spend 12-48 hours here. Here, water and minerals are absorbed while bacteria break down undigested food stuffs.
*The pancreas – not strictly part of the digestive system but this secretes an alkaline juice which neutralizes stomach acid, and enzymes that break down protein, fat and carbohydrates.It is also a gland that produces important hormones such as insulin.
* The liver – the chemical factory and warehouse of the body. Receives nutrients from the gut via the blood.
* The gall bladder – concentrates bile and squeezes it into the small intestine, where it helps digest fat.
Having understood how your gut works it is important to be in tune and be aware of signs that something is going wrong.

If you’ve never listened to your gut, you may be pleased to know that you’re not alone. In fact a recent Love Your Gut survey has shown that the majority of the nation (81%) are clueless about the health signs their gut is giving them. Almost three quarters (74%) even admit they rarely get concerned about the health of their digestive system.

But the digestive system is unique in the sense that it communicates signs – healthy and warning signs, using all of the five senses to provide health indicators. So by listening, tasting, seeing, smelling and feeling more, you can really tune in to your gut. This is why loveyourgut week was launched. If you want to know more about your gut follow the website below and download an information pack.
http://www.loveyourgut.com/download-gutweek-packs/
Gutweek leaflets include:-
Coeliac UK leaflet:

Coeliac disease is an autoimmune disease caused by intolerance to gluten. Damage to the gut lining occurs when gluten is eaten. There is no cure or medication for the condition and the only treatment is a strict gluten-free diet for life.
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Gluten is a protein in wheat, barley and rye so is commonly found in flours, bread, cakes, pasta, cereals and even sausages. 1 in 100 people have coeliac disease but misdiagnosis is high and a quarter of patients with an irritable bowel syndrome (IBS) diagnosis actually have coeliac disease.
Symptoms can include:-
Bloating, diarrhoea, nausea, vomiting, wind, constipation, tiredness, anaemia, mouth ulcers, headaches, sudden or unexpected weight loss, hair loss, skin rash (dermatitis herpetiformis), short stature, osteoporosis, iron deficiency, vitamin B12 deficiency, depression, infertility, recurrent miscarriage, joint/bone pain.

IBS Network leaflet
Irritable bowel syndrome [IBS] is a widespread condition which can continue for years without affecting the patient’s general health.
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A debilitating disease and the IBS network offers support and help to live with this condition.
http://www.theibsnetwork.org/
symptoms can include:
. abdominal pain
. urgency/ incontinence
. bloating
. back pain
. nausea

Bristol Scale
The Bristol stool scale or Bristol stool chart is a medical aid designed to classify the form of human faeces into seven categories.

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Types 1–2 indicate constipation, with 3 and 4 being the ideal stools (especially the latter), as they are easy to defecate while not containing any excess liquid, and 5, 6 and 7 tending towards diarrhoea.

Looking after your insides
imageThis leaflet is issued by CORE http://www.corecharity.org.uk/
which is a charity that raises awareness and funds research into gut and liver disease.
WE ARE WHAT WE EAT
And, although we may all start life with just milk
on the menu, it is astonishing to think of the variety
of what passes our lips thereafter as we grow into adult life. However, eating and drinking ‘unwisely’ over long periods may lead to trouble.
Although some of us may claim to possess ‘cast iron guts’, many individuals need to be much more careful in their choice of what to eat and drink. So, the advice in this leaflet is trying to help you find ways of giving your guts the best chance of coping.
If you occasionally stray outside the guidelines we suggest, it’s very unlikely to cause you much harm. So, whilst you might come to regret choosing to eat that tempting but particularly spicy curry, it is unlikely to give you anything more than a short-lived heartburn or stomach upset. But if you regularly eat or drink unwisely, you might be building up longer- term troubles for yourself.
This leaflet answers many questions concerning our diet and what effects our digestion.

Love Your Gut leaflet
A comprehensive leaflet illustrating how using your senses you can appreciate the health of your gut and 2 very good questionnaire which can help to detect IBS or bowel cancer.

Good Bowel Health Book
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This guide to good bowel health is issued by bowel cancer UK who produce useful guides and support for those with bowel cancer or those undergoing investigation such as colonoscopy or sigmoidoscopy
http://www.bowelcanceruk.org.uk/
The following red flags are important to note if you are concerned about this
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*Bleeding from your bottom and/or blood in your poo
*A change in bowel habit lasting for 3 weeks or more especially to looser or runny poo
*Unexplained weight loss
*Extreme tiredness
for no obvious reason
*A pain or lump in your tummy
You may experience one, some or none of these however if you have any concerns or if things just don’t feel right, go and see your doctor.
Everyone in the UK is sent a testing kit at the age of 60yrs to detect blood in the stool as a screen for Bowel Cancer. If you have not received a kit request one from your GP

The IBS Self Care Plan
This shows you how you can plot your symptoms on any given day and this will help find out how your IBS responds to the changes in your life, diet or medication/therapy.

St.Mark’s and You Leaflet
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St Mark’s is part of Northwick Park Hospital and is the country’s leading specialist hospital for colorectal and intestinal disease.
The beginnings of St Mark’s Hospital were in a small room at No 11 Aldersgate Street where, in 1835, Frederick Salmon opened ‘The Infirmary for the Relief of the Poor afflicted with Fistula and other Diseases of the Rectum’. There were just seven beds and in the first year 131 patients were admitted. One of the benefactors was Charles Dickens.
Thirteen years later, a site in City Road was purchased from the Dyers’ Company and the almshouses that occupied it were converted to a 25-bed hospital. This was opened on St Mark’s Day, 25 April 1854, and took the name of St Mark’s Hospital for Fistula and other Diseases of the Rectum.
By the 1870s, ever-increasing demands on the Hospital caused rebuilding to be considered. The adjacent site, occupied by rice mills, was acquired but could not be developed for some years due to lack of funds. Eventually, building began and in January 1896 the ‘New St Mark’s’ was opened. There was considerable difficulty in meeting the costs of maintaining the new building and it was the entertainment industry that finally came to the rescue. Lillie Langtry organised a Charity Matinee at her theatre in Drury Lane and the Hospital was saved. In 1909, the name of the Hospital was changed for a second time to St Mark’s Hospital for Cancer, Fistula etc.,
St Mark’s was taken over by the new National Health Service in 1948.
St Mark’s remained part of the Barts NHS Shadow Trust (later Barts NHS Group) until April 1994, when the changes envisaged by the Tomlinson Report came into force. At this point, Bart’s joined with the Royal London and the London Chest Hospitals to form the Royal Hospitals NHS Trust (later Barts and The London NHS Trust).
St Mark’s became part of the North West London NHS trust and moved to the same site as Northwick Park Hospital. The hospital maintains strong teaching ties with Imperial College School of Medicine.

I hope now on the final day of Love your gut week by reading these blogs about the gut and using the links suggested you will be better informed as to improve the health of your guts and be aware when something is wrong and seek the appropriate help.

 
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Posted by on August 25, 2013 in Training and Advice

 

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GUT WEEK 2013 – LOVE YOUR GUT – MOVING DOWNWARDS

Earlier this week I blogged about the importance of what we introduce into the gut by mouth. The food then enters the digestive system and the important nutrients are digested.
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In the mouth the tongue pushes food to the back of the mouth and through the act of swallowing passes into the muscular tube called the oesophagus ( from the Greek meaning entrance to eating and often referred to as the gullet) The oesophagus releases mucus to lubricate food and muscles push the meal downwards by peristalsis into the stomach.
A patient came into this week very concerned that she was having a tube put into her sarcophagus(is a box-like funeral receptacle for a corpse)did that mean things were very serious! She was due to have an endoscopy so I was quick to reassure her that things were not that bad.

The stomach is a j-shaped organ found between the oesophagus and duodenum. Its main function is to help digest the food you eat. The other main function of the stomach is to store food until the gut is ready to receive it. You can eat a meal faster than your intestines can digest it.

Digestion involves breaking food down into its most basic parts. It can then be absorbed through the wall of the gut into the bloodstream and transported around the body. Just chewing food doesn’t release the essential nutrients, so enzymes are needed.

The wall of the stomach has several different layers. The inner layers contain special glands. These glands release enzymes, hormones, acid and other substances. These secretions form gastric juice, the liquid found in the stomach.

Muscle and other tissue form the outer layers. A few minutes after food enters the stomach the muscles within the stomach wall start to contract (tighten). This creates gentle waves in the stomach contents. This helps to mix the food with gastric juice.

Using its muscles, the stomach then pushes small amounts of food (now known as chyme) into the duodenum. The stomach has two sphincters, one at the bottom and one at the top. Sphincters are bands of muscles that form a ring. When they contract the opening, the control closes. This stops chyme going into the duodenum before it is ready.

It is when this process goes wrong that problems occur. Almost everyone knows what it feels like to have indigestion also known as dyspepsia,heartburn or nausea. The Chinese call it reversal of Qi as stomach Qi should descend. This should occur as a ‘one-way’ movement but reflux can occur when food or drink travels back up from the stomach and into the oesophagus. This is not the same as vomiting, which is a violent reaction, reflux can occur without people even realising. At the lower end of the oesophagus, there is a ring of muscle which is there to stop reflux. This generally works efficiently – when we eat or drink, the muscle relaxes but it then tightens up when we have finished. However, if the muscular ring gets too slack, reflux can occur. If reflux occurs repeatedly, it may lead to oesophagitis – inflammation of and damage to the lining of the oesophagus. In most cases, there seem to be no obvious causal factors leading to the slackening of the oesophagus’s muscular ring, although eating an excess of rich, fatty foods does seem to increase reflux. Treatment generally takes the form of medication – although lifestyle modifications can help too.
It is estimated that 40% of people have a digestive symptom at any one time usually describing one of 4 symptoms:-

abdominal pain
changes in bowel habit (usually constipation or diarrhoea)
indigestion
heartburn

Hence, it’s not surprising that when I sit in an out of hours clinic that so many people present with one of these symptoms.
Most digestive problems are to do with lifestyle, the foods eaten, or stress. Another common cause is the use of non-steroidal anti-inflammatory drugs(NSAIDS) such as ibuprofen, aspirin, naproxen or diclofenac.
Taking steps to change your lifestyle can help, and often prevent, many of these problems. There is a wide choice of pharmacy remedies for heartburn, indigestion and similar problems that are very good for the short-term relief of symptoms but it is interesting that very few of these people have tried anything before they are seen by a doctor.
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I remember as a child my father taking either white medicine or sucking white tablets. Then early one morning he was taken by emergency ambulance to hospital and had emergency surgery for a perforated ulcer. He was in hospital for almost 4 weeks and then sent to a convalescence home.
When I was studying medicine and when I qualified this type of patient was not uncommon and I spent many hours holding a retractor assisting surgeons carrying out varied types of surgery, cutting nerves, removing part of the stomach in order to eleviate these symptoms in an emergency or as an elective procedure. Then there was a major breakthrough and drugs such as cimetidine and ranitidine (Zantac) were introduced. These decreased the amount of acid produced and often cured the digestive symptoms. These drugs are now readily available over the counter. However, I remember in the small Welsh town where I worked that the value was such that a doctor and pharmacist were prosecuted for trafficking these drugs to Asia! The doctor was my Registrar so I had instant promotion.
One day in 1982 I was reading Scientific American,a favourite journal for many years, and I was drawn to a very interesting article written by 2 Australian scientists who had been examining gastric mucosa for many years and they had observed a bacterium called Helicobacter pylori was frequently seen (in 80% of specimens)but assumed to be insignificant but they were the first to show that it played a part in the formation of ulcers. Individuals infected with H. pylori have been shown to have a 10 to 20% lifetime risk of developing peptic ulcers and a 1 to 2% risk of acquiring stomach cancer.

The Helicobacter pylori enter the stomach and attach to the protective mucus lining of the stomach wall. The bacteria are able to survive in the strongly acid environment of the stomach because they excrete the enzyme urease which neutralized the acidic environment of the stomach by converting urea into the basic ammonia and buffer bicarbonate. Inside the mucus lining of the stomach wall, the bacteria cannot be killed by the bodies immune system.
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The Helicobacter pylori produce toxins such as vaculating cytotoxin A (VAC A) that cause the cells in the lining of the stomach to die. This allows the bacteria to better access of nutrients as it decreases the competition from stomach lining cells.
The bacteria invade the protective inner lining of the stomach so that they can be protected from immune system. The bacteria then kill the cells that they invade which creates holes in the mucus lining of the stomach, causing the formation of ulcers. Additionally, the substances released by the bacteria during the invasion, hurt the stomach cells ability to absorb calories from food in the stomach.
This is the reason why patients with stomach ulcers and cancer can lose significant amounts of weight.
At least half the world’s population are infected by the bacterium, making it the most widespread infection in the world.
It used to be said that in the developed World that the prevalence of infected people increases with age and is the same percentage as age – 50% of 50 year olds were infected but this is now changing.
In 1979 the first of a new class of drug, omeprazole that controls  acid secretion in the stomach (proton pump inhibitor-PPI) was discovered.
Once H. pylori is detected in a person with a peptic ulcer, the normal procedure is to eradicate it and allow the ulcer to heal. The standard first-line therapy is a one week “triple therapy” consisting of proton pump inhibitors such as omeprazole and the antibiotics clarithromycin and amoxicillin. Variations of the triple therapy have been developed over the years, such as using a different proton pump inhibitor, as with pantoprazole or rabeprazole, or replacing amoxicillin with metronidazole for people who are allergic to penicillin. Such a therapy has revolutionized the treatment of peptic ulcers and has made a cure to the disease possible; previously, the only option was symptom control using antacids, H2-antagonists or proton pump inhibitors alone.
Now, the modern medical student or junior doctor will have never seen surgery for this condition and the majority patients are treated and cured in the community.

It is important that anyone aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone should also have endoscopy.
imageAlso alarm signs at any age such as
weight loss,
vomiting,
haematemesis,( vomiting blood)
anaemia
dysphagia
require urgent referral for endoscopy.

 
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Posted by on August 23, 2013 in Training and Advice

 

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FLU IMMUNISATION – 2013/14. – EXTENSION TO CHILDREN

After several years of acquiring good evidence from other countries the Department of Health now recommend that all children aged two to 17 are going to be offered a flu immunisation every year.
image At present, annual flu immunisation is offered only to children with underlying health problems, as well as all over 65s and anyone with long term health conditions such as heart and lung disease or diabetes.

The Chief Medical Officer for England says that even if only one in three children are immunised, hospital admissions will drop by 11,000 and 2,000 lives will be saved each year. But the full programme may not be introduced for another two years.

Although most children who suffer from influenza recover completely within a week or two, they spread the disease among the population more than any other group. Some children, of course, do get serious complications and having the immunisation will greatly reduce this risk. But the big benefit comes from increasing ‘herd immunity’ – if more children are protected, there will be a much smaller pool of susceptible children to pass on the virus, reducing its spread in the community. That means people most vulnerable to major complications (including pregnant women and grandparents) will also be protected.

Each year, the viruses that are most likely to cause flu are identified in advance and vaccines are made to match them as closely as possible. The vaccines are recommended by the World Health Organization (WHO).
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This year’s flu jab protects against:
H1N1 – the strain of flu that caused the swine flu pandemic in 2009
H3N2 – a strain of flu that can infect birds and mammals and was active in 2011
B/Wisconsin/1 – a strain of flu that was active in 2010

This will be the first non-injection flu vaccine for children – the national immunisation expert committee, the Joint Committee on Vaccination and Immunisation (JCVI), has recommended using a nasal spray for childhood immunisation. This will certainly make the procedure less uncomfortable for children, and the vaccine, called Fluenz® has now been used for several years in the USA. It has evidence from scientific trials involving 20,000 children, so we know it has a good safety record as well as being effective.

There are two elements to the children’s flu immunisation programme this year:
 a routine offer of vaccination to all two and three year olds (but not four years or older) on the 1 September 2013; and
 geographical pilots for four to ten year olds (up to and including pupils in school year 6).
Extending the flu programme to all children will involve considerable planning and work in order to obtain a high level of uptake. For this reason, the programme will be rolled out over a number of seasons and will include pilots, allowing Public Health England and NHS England time to ascertain the most effective way of implementing it.
The Department of Health has secured Fluenz® vaccine for use in 2013/14 to allow the roll-out of the programme to all two and three year olds through general practice, as well as through a small number of local geographical pilots targeted at four to ten year olds.
If you have any worries about the flu immunisation the following link may be useful

http://www.nhs.uk/Livewell/winterhealth/Pages/Flu-myths.aspx

 
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Posted by on August 23, 2013 in Training and Advice

 

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GUT WEEK – 2013 – LOVE YOUR GUT – IT STARTS AT THE MOUTH

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The digestive system (or gut) is responsible for processing all that we eat and drink so that the essential nutrients can used to keep our body  provided with fuel.  There are millions of people in the UK who suffer with digestive problems but for most of us, abdominal issues may just be warning signs that we are doing too much, things are upsetting us, or we are eating the wrong foods and not giving ourselves enough time to relax and digest it. But there are some symptoms that could be caused by gastrointestinal disease, for which you need to see a doctor.As I thought about this blog I noticed that when I was doing my out of hours sessions that more than 50 % of those attending the Urgent Care Centre were complaining of abdominal pain with or without vomiting or bowel symptoms. They are anxious  and fearful and  attend at all hours
One father attended with his daughter who had come home from school gone to the fridge, drunk cold milk and the had instant abdominal pain. The father put her in the car and rushed her to A&E worried she might have had a serious reaction.
There are those that attend who have eventually plucked up courage to admit they are experiencing significant problems.
  Many people appear within an hour of vomiting and very concerned about starving and nearly always ask the  question “when can they eat?”
To understand our gut we need to start at the beginning….
imageIt starts at the mouth and the desire for nourishment starts the moment we are born. I remember my third child, who was ‘born in the car’ on her way to the hospital,  within minutes off birth was rooting for food and indeed she had her first feed  before she arrived at the hospital. I was also ravenous after delivery and enjoyed not only my breakfast but my husbands aswell. He was driving and  lost his appetite as he had the task of sorting out the car and caring for the other two children.
 I now understand why when I  witnessed my first births in Africa that the women always rushed to the entrance gate of the hospital to get food from the food sellers after they had delivered.
This illustrates how there is an instinctive need to eat,  but in times of fear and anxiousness(fight and flight) the desire goes away. We all know that lack of appetite before an examination or important social occasion.
The mouth is an important entrance to the gastrointestinal tract and it should guarded carefully
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Now less people are in touch with their bodies they lose that instinct and eat out of habit rather than real need . Plates are piled high and many feel they have to finish every morsel whether they need to or not. We often don’t give ourselves enough time to eat and think carefully what we are eating and  whether the plate is  showing a balanced diet and whether our body actually needs it. There is an argument for saying grace at the beginning of a meal,as I remember in school, to allow the body to prepare itself for eating, activating the salivary glands and reflecting on what was to be eaten and starting the pace leisurely rather than leaping forward like an Olympic runner aspiring to win the race. Saliva not only lubricates the food but also contains enzymes that start chemically digesting your meal and special chemicals that help bacteria causing infections. Teeth break down large chunks into smaller bites. This gives a greater surface area for the body’s chemicals to work on. Recently articles have appeared in the press talking about a study of brain samples from deceased dementia patients and how unusually high levels of Porphyromonas gingivalis, a type of bacteria which causes gum disease were found.
Although the bacteria live in the mouth, they can enter the bloodstream during eating, chewing, tooth brushing or dental surgery, and potentially reach the brain, experts explained.
Inflammation caused by gum disease-related bacteria has already been linked to various health problems including diabetes, heart disease and stroke.
Researchers say they have uncovered how bacteria may set off a chain reaction leading to bowel cancer.
Fusobacteria, commonly found in the mouth, cause overactive immune responses and turn on cancer growth genes, two US studies reveal.
Dental care has deteriorated due to dental costs to patients and less care taken by individuals regarding dental hygiene and poor diet.
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If you haven’t visited the dentist recently perhaps this will be a good promptThis is the link for our local dentists in and around West Ealing :-
http://www.nhs.uk/Service-Search/Dentists/W138la/Results/12/-0.319475322961807/51.5176773071289/3/0?distance=25
The same link can be used to find dentists throughout England.
imageIt is so important to introduce chewing foods at an early age as this encourages the appropriate muscles to work together around the mouth and jaws and to stimulate  the production of saliva containing enzymes to. break down food into a  more digestible form. It is also important in the development of speech in formation and articulation. Many years ago, when I was doing paediatrics looking after children with cerebral palsy, the speech therapist fed the children initially to start the therapy  and emphasised the importance of chewing foods.
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It is through the mouth that we can introduce substances that damage our health seriously whether its excessive carbohydrates,
image alcohol, drugs or simply placing a cigarette between the lips.
imageFizzy drinks, cakes, biscuits, crisps and desserts are frequently eaten despite the fact that they may increase the risk of bowel cancer, according to a new study.
The tongue
The taste buds on the tongue allows use to experience the sensation of taste.
A bad taste in the mouth could be linked to a number of issues, including; constipation, loosely fitted crowns and gingivitis (inflammation of the gum tissue). A sour taste may be linked to acid reflux, where regurgitated stomach acid enters the mouth. Metallic tastes in the mouth may occur in women at the start of pregnancy, individual taking antibiotics, or those with a zinc or vitamin B12 deficiency.
The tongue is important manipulating food in mastication and in phonetic articulation of speech.Lips are a visible body part at the mouth of humans. They are soft, movable, and serve as the opening for food intake and in the articulation of sound and speech.
Trying to open a child’s mouth  is extremely difficult,like a vice, to keep things out and to keep things in. It is these muscles that allow us to suck fluids with a straw.
Lips are a tactile sensory organ. I always remember my mother checking if the washing was dry by putting the crisp shirts to her lips and seeing if eggs had not gone off by putting each en to her lips. Try it – one end should be warmer than the other.
They are the sensory gates and we have a choice what we allow to enter.

But we must not deny the fact they are tactile sensory organ giving pleasure in kissing! What better way of reminding us to love our gut…..
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Posted by on August 19, 2013 in Training and Advice

 

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WHAT’S YOUR GUT FEELING?

*Are you one of the millions of people in the UK suffering from digestive problems?
*Feeling nervous or embarrassed and unsure where to turn for help?
*Or do you just want to learn more about how to keep your gut healthy?
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GUT WEEK August 19th – 25th

imageimageGut week is the annual digestive health awareness campaign, organised by Core ( fighting gut and liver disease) http://www.corecharity.org.uk/ and the IBS Network (supporting people with irritable bowel disease) http://www.theibsnetwork.org/ in association with Yacult UK Limited.
It is supported by Bowel cancer UK and St Marks Hospital Foundation.
Call 020 8839 3258, email info@gutweek.org.uk
Or visit http://www.gutweek.org.uk for your FREE information pack

Thousands of patients have commented over the years how difficult it is at first for others to take their symptoms seriously. People think it’s a laugh – rushing to the loo all the time, always carrying a change of underwear. When they realise that you have such a lot of pain and that sometimes you don’t even make it to the loo they see it is no laughing matter. As one patient powerfully observed in a letter to Core, “You could die of embarrassment”!
I have to admit that I didn’t appreciate bowel incontinence until I had a severe bout of food poisoning a few years ago and experienced probably the most embarrassing moment of my life. I was in a friends house and staying for the first time and found myself having bowel incontinence – it came without warning as I stood up in my friends sitting room. Thankfully she was incredibly kind and only showed concern and helped me sort myself out and has never mentioned it since.One of my patients who has severe Crohn’s disease had been turned down for a ‘blue badge’ and she had described severe bowel incontinence so after this episode I made a strong appeal which was upheld. My experience was a mere 2 days I cannot imagine how terrible it is to live with it.
If you have Irritable Bowel Syndrome, The IBS Network can help. We are a membership charity, so while you can get a lot of information for free from our website, by joining us you not only enable us to continue our work, but you also gain access to the following benefits:

imageCan’t Wait Card
Helping you get access to a toilet in an emergency

imageAccess to The Symptom Tracker
Helps you to identify which foods aggravate which symptoms.

imageGut Reaction – The Quarterly Magazine
Latest news and events for members.

 
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Posted by on August 15, 2013 in Training and Advice

 

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Aside

When I see someone with depression at their lowest ebb when everything seems black and whatever I suggest is met with profound negativism. They present in many different ways and may have some insight or may be in total denial.
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Churchill referred to his depressive episodes as ‘the black dog’ and it has been suspected that it was Churchill’s recurrent episodes of depression that allowed him to realistically assess the threat of Germany.
Psychiatrist Anthony Storr described how Churchill used his experiences of depression to inform his political decisions: “Only a man who knew what it was to discern a gleam of hope in a hopeless situation, whose courage was beyond reason and whose aggressive spirit burned at its fiercest when he was hemmed in and surrounded by enemies, could have given emotional reality to the words of defiance which rallied and sustained us in the menacing summer of 1940.”
The quote that I find illustrates what I want to say is:-
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“A pearl is a beautiful thing that is produced by an injured life. It is the tear [that results] from the injury of the oyster. The treasure of our being in this world is also produced by an injured life. If we had not been wounded, if we had not been injured, then we will not produce the pearl.” Stephen Hoeller
Over the years I have seen a huge variety of people with depression, head teachers, lawyers, research scientists, doctors, infact people of all ages from all walks of life. They all present with hopelessness and dwindling lack of interest in life and I see it as my job to help them discover a gleam of hope in order to work themselves out of this painful state.
They usually claim they have tried everything but nothing works, they don’t trust anyone and they don’t see a way forward.
However, as I reflected on the different people I have seen over the years and followed them up I feel uplifted by the fact that most of them have emerged out of this state to be happier, more fulfilled people and have turned around their lives in a positive way and this empowers me to feel hopeful about true recovery.
Something that I have suggested on many occasions that has been a help to some people is a simple idea based on the fact that collecting lots a minute pieces of positive experiences that would normally go unnoticed can subtly create a gleam of hope.
These minute positive experiences could be some food that tasted pleasant, making a note of a random smile from someone, the sun shining or simply a ray of sunshine through a crack, a pleasing picture or piece of music, anything that Seems momentarily pleasing. Saving a bus ticket, wrapper or newspaper cutting or putting a word on a scrap of paper as a reminder and then saving them in a ‘ chocolate box’ or equivalent and putting the box in a drawer( I suggest an underwear drawer – somewhere private) and to get the box out on a black day and trawl through these personal items.It is surprising how these minute events mount up in a short time and the overall effect can make life seem less hopeless.
When this gleam of hope is found and this may take a variable length of time and may need several consultations to build up a mutual trust in working together then a patient can embark on the 7 steps of recovery.

1)firstly in depression aswell as other chronic illness,it is important to accept help from people who really want to help us, from people who are really interested in our problems and listen to us, not just because it is their duty as doctors, but because they really want to help, and those people prescribe us medication, give us advice, and cognitive therapy. Allow yourself to accept such help, as it is genuine.
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2) that you have to understand yourself. Meditation, yoga, anything. And above all, ask yourself, why did this mental illness occur? If you can answer this question, and I am sure you can, then this is already a great step forward.
We are now talking about the concept of mindfulness which I will be writing a separate blog shortly.

3)Change your eating habits.
We know that omega-3 fatty acids have innumerable health benefits. Recently, scientists have revealed that a deficit of omega-3 fatty acids is associated with depression. In one study, researchers determined that societies that eat a small amount of omega-3 fatty acids have a higher prevalence of major depressive disorder than societies that get ample omega-3 fatty acids. Other studies show that people who infrequently eat fish, which is a rich source of omega-3 fatty acids, are more likely to suffer from depression.
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Sources of omega-3 fatty acids: fatty fish (anchovy, mackerel, salmon, sardines, shad, and tuna), flaxseed, and nuts.
Sources alpha-linolenic acid (another type of omega-3 fatty acid): flaxseed, canola oil, soybean oil, walnuts, and dark green leafy vegetables.
Also it has been found that people with low Vitamin D and or folic acid (spinach and advocado) tend to be more depressed.

4) We also need to change the way we communicate with others.
As one psychiatrist quoted,
“When a patient tells me his wife nags him I tell him to turn the tables on her. When she says: ”look at you in front of the TV again watching too much TV Football leaving me to do the washing up once more”, stand up and say:«you are right dear, I will do the washing up today.”
I think she will feel weak at the knees and you will gain something, because you have surprised her and, by doing so you have gained, and become more charming because you reacted differently. When the patient comes to me the following week he says: ”I surprised her, but I didn’t do the washing up”.”
I have used this in consultations using personal situations. Many years ago I remember this series of consultations.
Mr T had been going on holiday by himself for a few years because his wife was too miserable and depressed and I suspected he was depressed but in denial. When she went in hospital he came to have a routine blood pressure and complained how his wife was in hospital and even more miserable. She had seen me before going into hospital and complained as to how unsympathetic and miserable he was and how glad he was going on holiday by himself. (As patient confidentiality is paramount in any consultation neither party knew I had consulted the other.)
When I saw Mr T I suggested that it would be good if he took her flowers when he went to see her although it was something he had not done in many years.
When I saw Mrs T after she was discharged I reviewed her and she then said with a smile on her face “guess what doctor, my husband visited me in hospital and he brought me flowers!” I replied ” how lovely, I hope you said ‘thank you’ ” she replied, ” oh dear, I don’t think I did”
When Mr T consulted again he said, ” I did what you said doctor and eventually she even said ‘thank you’!
When I consulted them a few months later each one in turn gave me a bar of chocolate from Spain and reported how they had had a nice holiday together.
On each occasion I just smiled and later shared the chocolate with my family when they greeted me in the evening with “late again for supper,mum”!

5)We all need to find a better balance between work and leisure, find another pattern. Some of us have a pattern of 20 hours to 4 hours. It would be much better to have a pattern of 20 minutes to 4 minutes. Or better still 4 hours: 1 hour. Changing the rhythm doesn’t mean that you have to work less, just change the rhythm. Otherwise you risk burnout.
I often suggest to those people, who adamantly claim that they have to work late every night, to choose one or preferably 2 days a week to leave ‘on time’. The first week colleagues will question this ‘leaving early are you?’ But hold the head up high and leave with no reason given. The second week on leaving ‘on time’ the comments may be ‘leaving early again’ and again leave with head held up high and no reason given. The third week as you linger dreading a comment it will probably be ‘isn’t it today you leave early?’ It works and can be a chance to develop space for leisure even a quiet undisturbed cup of tea or a walk in the park.

6)Change your interaction with nature. To those of you who enjoy being outdoors I say: ”What do you think about when you for a walk in the park . About your problems. Why? Why is this wrong? Because every muscle cell has a memory. When we do stomach exercises, all our stomach cells are attuned to work with us . When we do push-ups, all our cells do push-ups. If we think about our problems every time we run uphill, then our cells will be full of problems whenever we run uphill. So, when we get depressed, somatisation causes pain in all those cells. It’s very simple. Every cell has a memory. I suggest that it is a good idea to change – go to Tai Chi before going for a run or alternatively concentrate on something else. When you run, imagine yourself in an ideal situation with the perfect partner, the perfect job or in a dream location.
Change your interaction with nature. If you used to go mountaineering take up caving, jogging take up rambling.

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Take a trip to ‘Lammas Park or Walpole Park instead of Pitshanger Park. In short: make a change, because by doing this you will move from West Ealing to another place. Even if only for half an hour a day.
“Trying something new alters the levels of dopamine, which is associated with pleasure, enjoyment, and learning.”

7)What is most important?

For me the most important thing is to change your attitude towards music and dance. Listen to music for fun, sing or hum along with it with ear phones or in the shower if you don’t want to upset the neighbours. Sing in the car on your own, with your partner or children with feeling and passion!! Great on the school run…

Dance on you own, with your partner or children or your imaginary partner!
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Dance to have fun try ‘strictly come dancing’ or karaoke in your own home  or wherever… If you used to dance the Foxtrot, then dance the Waltz. If you used to dance the Salsa then dance the Zumba…
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How to find a recovery from depression

 
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Posted by on August 15, 2013 in Training and Advice

 

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What is Diabetes? | Diabetes Matters

If you are interested to learn more about diabetes and how to manage it you may be interested to download a monitoring diary or view a short video using the link below:- image “https://www.diabetesmatters.co.uk/what-is-diabetes#.UgstikAWTu0

 
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Posted by on August 14, 2013 in Training and Advice

 

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ADOLESCENCE IN THE DUCK WORLD

They are now 3 months old and there have been significant changes in their social development. The presence of their mother is less apparent and recently they decided to invite ducklings from another brood to eat with them. ‘Our ‘ ducklings recognise the call of ‘Quack,quack’ human sound and the tapping of the tin but the new brood don’t know the call.
 
 Our family came up the usual way waddling up the bank to the feeding dish and they are unperturbed by the clanking sound of their beaks against the  dish but the newcomers are wary and anxious but typical of adolescents they deal with this awkwardly either by timidly staying clear or out and out bullying so with head down one of the newcomers charges at our ducks and tries to prevent them feeding.one poor duck has been wounded in the process and is now limping. It has eased the situation by putting out another dish!
It was such a surprise to see this behaviour.
They are not sure and neither are we  if they are male or female as they apparently don’t develop their distinctive plumage until the breeding season. They don’t communicate in a friendly way infact they bully to get their own way.
Adolescence is tough and a hard transition process.
Bullying has been something that has been highlighted recent weeks and the exposure of cyber bullying is proving to be a new concern
If you want to learn more about how to recognise or deal with bullying you may find either of these websites useful

imagehttp://www.bullying.co.uk/
http://www.nhs.uk/livewell/bullying/pages/bullyinghome.aspx?WT.mc_id=101001

Those of us who have read ‘Lord of the Flies’ remember the account of bullying which makes us realise that unfortunately it can be part of society unless we can find ways of identifying it and finding ways to prevent it occurring.

One of my memories of being a young teenager is when I was practising for my Bronze Medallion Life Saving in my early teens and I was unfortunate to be partnered with a 13 year old boy who rescued me  by an unsophisticated stranglehold approach, got me out of the pool  as if landing a large fish and grunted something that I wanted to believe was ‘are you all right’ but was probably something else! At this age social interactions are often awkward and clumsy.

13year old boys particularly are confused about their development and sometimes they turn up in surgery usually with their mothers, unable to get a word out and the look on their face that tells me what’s coming.
They are developing breasts, have a flabby belly and their penis is the size of a party sausage and  they are not sure what is happening and they look petrified wondering what an earth is going on.
Their look of relief when I explain it is normal and  related to the production of male hormone.
Before they go I manage to get something out of them by asking which football team they support, something which makes them look up and respond by saying which team they support or how they hate football!
But now I see them years later and see them  growing into well balanced, good looking individuals with a normal physique.
Adolescence is tough and it seems that in the duck world it is no different…
 

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