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Monthly Archives: April 2015

Choosing Wisely

Each year Dr Livingston and myself attend a days course consisting of a comprehensive selection of topics. It mainly focuses on significant changes of management and evolution of relevant aspects of medicine in General Practice in the past year. The emphasis is on promoting patient – based , evidence – informed medicine but also finding ways of encouraging patients to work with doctors to refrain from expecting unnecessary investigations, avoiding unnecessary medication and choosing wisely in deciding with the doctor appropriate management of their condition. This youtube video was shown as some light relief during our break and I would like to share it with you.

 
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Posted by on April 25, 2015 in Training and Advice

 

INDEPENDENTLY MANAGING MINOR AILMENTS IN EALING

As a child I can never remember being taken to the doctor or calling a doctor out unless it was something very serious such as tonsillitis or my mother having pneumonia or my father having a burst ulcer.Every year, millions of us visit our GP with minor health problems that our local pharmacist could resolve.

It is estimated that every year, 50 million visits to the GP are made for minor ailments such as coughs and colds, mild eczema and athlete’s foot.
But by visiting your pharmacy instead, you could save yourself time and trouble.
Instead of booking and waiting for a GP appointment, you can visit your local pharmacist any time – just walk in.

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All pharmacists can recognise many common health complaints.

They can give advice or where appropriate medicine(s) that will help clear up the problem.

ÎIf your problem is more serious and needs the attention of a GP, your pharmacist will recognise this and advise you to see your GP instead.
What’s more, many pharmacies are open in the evenings and on the weekends.
If everybody went to a pharmacist with common health problems, more time would be freed up for our GPs. This might make it easier to get a convenient appointment with your GP next time you need one.
So, if you have a common health problem, a trip to your local pharmacy is an option.

WHAT IS THE MINOR AILMENTS SERVICE?

  • With this in mind the Ealing Community Commissioning Group ( ECCG) have created the Minor ailments Service to allow patients to access treatment for various minor ailments from their local pharmacy.
  • Instead of booking an appointment with your GP you can receive a free consultation with your pharmacist who is a registered health care professional.
  • If you normally receive free prescriptions then your treatments will be free.
  • If you pay for your prescriptions you will not be charged more than the retail cost of the item.

If  it is necessary they will refer you to another health care professional – using this service does not affect your access to other services.

WHO IS THE MINOR AILMENTS SERVICE FOR?

Anyone who is registered with a GP practice withe the Ealing CCG ( although other CCG throughout the country have adopted similar schemes)

To provide proof or registration you must provide ONE of the following:-

  •   leaflet stamped by your GP practice 
  •   repeat section of a prescription that states the name and address of your GP practice
  •   an NHS card
  •   child health red book with details of GP practice

You will then be given a Minor Ailments Passport  by the pharmacist which is used to record up to FIVE visits. You can hold on to this and take it to any pharmacy for treatment. When this is completed you can give it back to the pharmacist and can be given another one for further treatments.

Some age groups and people with additional conditions may not be able to receive treatment under this scheme – the pharmacist will discuss this with you and signpost you to an appropriate  health care professional.

WHEN CAN YOU USE THE MINOR AILMENTS SERVICE?

If you are suffering from any of the conditions below you may be able to obtain treatment:-

* ATHLETES FOOT                                                       * INSECT BITES/ STINGS

* CONJUNCTIVITIS ( Bacterial)                                   * MOUTH ULCERS

* CONSTIPATION                                                          * MUSCULAR -SKELETAL PAIN, SPRAINS/ STRAINS

* CONTACT DERMATITIS                                             * NAPPY RASH

* CYSTITIS                                                                     * NASAL CONGESTION 

* DIARRHOEA                                                                * SCABIES

* EAR  WAX                                                                    * SORE THROAT

* FEVER                                                                          * TEETHING 

* HAY FEVER                                                                 * THREADWORMS 

* HEAD LICE                                                                  * VAGINAL THRUSH

* HEARTBURN / INDIGESTION                                    * WARTS/ VERRUCAE

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The following pharmacists in the local Ealing area have signed up for the Minor Ailments Service. 

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Posted by on April 16, 2015 in Training and Advice

 

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FLORENCE NIGHTIGALE AND WILD GARLIC

Last weekend I decided to take advantage of the sun and go for a stroll down the tow path past Kew to Richmond. It was a glorious afternoon  and one of the thrills at this time of year is gathering willd garlic which grows in  abundance on the towpath. The rich slightly acidic clay soil is perfect for this delicacy and nibbling the leaves and white flowers on the way home gets your mouth in shape for a simple supper of gently simmered wild garlic added to pasta tossed in a good quality olive oil  and sprinkled with Parmesan or blue cheese. Alternatively, it can be a good substitute for Basil to make a tasty pesto.

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Allium ursinum or ramsoms often grow alongside bluebells in deciduous woodlands with moist soils, preferring slightly acidic conditions. It flowers before deciduous trees leaf in the spring, filling the air with their characteristic garlic-like scent. The flower stem is triangular in cross-section and the leaves are broadly lanceolate similar to those of the lily of the valley. Check first by gently rubbing the leaves in your hands an d smelling the characteristic smell.

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When I visited Jekka’s Herb farm near Bristol it was during our discussion about herbs that she told me that Florence Nightingale used to mix this with English white wine to make a concoction and use it as an antiseptic on the wards.

Hence, with  its antibacterial, antibiotic, antiseptic and anti … well, just about everything, properties, it makes sense to pack as much into your diet as you can. The headline health benefit of garlic is its effectiveness in reducing blood pressure and, hence, heart disease and the risk of stroke. Although all garlic has this property, wild garlic has the greatest effect on lowering blood pressure.

Jekka Mcvicar for those who don’t know has a know established reputation of being a herb guru but describes herself as an organic herb grower.  She cultivates more than 500 varieties of herbs and has written an excellent illustrated book discussing the culinary and medical use of herbs aswell as an acclaimed cookbook. She shows at Chelsea Flower Show and has been visited by well known chefs such as Raymond Blanc, Jamie Oliver and Heston Blumenthal. Her big claim to fame is that she played and sang at the first Glastonbury in 1970 which impressed my daughter on our last visit. With credentials like those, visiting her at her farm near Bristol where you can listen to one of her talks , browse her herbs now in raised beds and termed a Herbetum and more importantly  have chance to purchase some potted herbs is something I enjoy immensely and thoroughly recommend to keen gardeners. I have to say I make a point of visiting the farm at least once a year.

http://www.jekkasherbfarm.com

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ABOVE AND BELOW – THE ART OF OBSERVATION

The weekend before Easter my daughter treated me to a weekend in Paris primarily to see films she has been working on which are being shown  at the ‘Louvre’ and a smaller trendier gallery ‘the Bal’. She felt very pleased as Le Monde had recommended this as one of the 10 things to do in Paris for that weekend. imageimage Le Monde – Dix raisins de sortir ce weekend Difficile de ne pas être hypnotisé par les vidéos du Canadien Mark Lewis, qui, en une petite dizaine de minutes, vous emportent comme sur les ailes d’un oiseau au-dessus d’une forteresse italienne perchée sur une montagne, ou lelong d’une autoroute urbaine qui défigure la ville de Sao Paulo au Brésil. Le silence règne, qui rend les mouvements de caméra d’autant plus fascinants. Les micro-événements de la vie – des joggeurs qui transpirent, un homme qui fume tranquillement dans un café – prennent tout à coup un relief étonnant. L’artiste présente ses œuvres au BAL à Paris ainsi qu’au Louvre où il a réalisé des films à l’intérieur du musée. image image Mark Lewis the director is a Canadian Artist, who makes short films that take stillness and explore it in motion. Many of these films have been shot in London, where he has lived since 1997 as a professor of fine art at Central Saint Martins. On viewing it is not difficult to be hypnotised by them. The exhibition we saw are his recent productions: in one of them for about 10 mins you feel as if you on on the wings of a bird flying over an Italian fortress perched on a mountain. He uses various techniques with the camera to get a serpentine effect. One video was filmed inside the Louvre in the foyer and then concentrating on several paintings in detail as if it was through the eyes of a fly circling around and then settling.  Invention au Louvre   – exhibited until August 31st, 2015 at Le Louvre, Paris The video that particularly interested me was filmed above and below an elevated highway which passes through the city of São Paulo in Brazil. – Above and Below – exhibited at Le Bal,  6, impasse de la Défense, 75018 Paris http://www.le-bal.fr/ image image The Minhocão, officially Via Elevada Presidente Costa e Silva, is a 2.2-mile (3.5 km) elevated highway in São Paulo, Brazil, which travels within metres of residents flats. Following a protest suggesting that the proximity of the road was an invasion of residents privacy it was decided that between  9:30 PM and 6:30 AM on weekdays and all day on Sundays, the highway would be closed to car traffic, allowing dedicated use by pedestrians and cyclists. The road is named after the minhocão, a quasi-fictitious earthworm-like creature. Local urban planners have long advocated tearing down the road in order to promote urban renewal. The film is silent which makes the movements of the camera  imore fascinating. The trivial events of life – above perspiring joggers passing by and underneath a man wandering under the highway chatting on his mobile phone and visiting a café. We watched the video reclining on large beanbags on the floor allowing you to ‘people watch’ as they passed by; watching families and their interactions, people taking their dogs for a walk , cyclists as well as those just stopping and sitting to chat on the central reservation. Apparently, a visitor to the exhibition had actually recognised someone walking on the highway validating the authenticity and the closeness of observation.

The reason this video particularly fascinates me in that my job as a doctor is all about observing people not only the physical signs of disease but  facial expressions, personal interactions and their demeanor.

The great Canadian Physician, William Osler said, ” medicine is in observation… but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man  on the right path, is all that we can do.”

Many great medical teachers through the ages have emphasized the paramount importance of the art of observation. Chief among these were Joseph Bell – the Edinburgh surgeon who inspired the creation of Sherlock Holmes.  I’m sure you’ll agree that Joseph Bell’s lesson on the art of observation is one that should never be forgotten.

I distinctly remember in my early days of medicine when attached to a respiratory medicine firm ( as we called it then) how it was my job each morning to examine every patient’s sputum noting the quantity, colour, consistency and smell and report this on the ward round.

It was instilled into us by senior doctors that we should go through the ritual of observation of the patient firstly at a distance and then at closer quarters, observing and examining  every part of the body. It still remains my practice to observe the patient from the minute I set eyes on the patient in the waiting room as I call them to the consulting room. In my first practice  the patients sat on a bench against the wall.

I remember on one occasion going out to call the next patient and as I observed the row of patients my eyes caught sight of one gentleman who looked distinctly grey and pale with his eyes closed and was propped up by patients either side. As I called him I realised he was seriously ill, infact he was having a heart attack and had to be admitted urgently to hospital.

When I teach medical students, the younger students on meeting the patient want to find out what is their diagnosis and want to obtain clues by asking about medication. As a teacher I have to train them to observe and build a picture bit by bit so that by the time they reach finals this becomes second nature and something to build on for the rest of there career. When they leave the surgery I tell them that when they board a bus or tube to get used to looking and observing the people around them perhaps working out if someone has a medical condition simply by observation.

.“Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.” – William Osler

Yet learning the art of observation is difficult, and may seem an insurmountable task to the novice. Osler well knew the size of this challenge, and he encourages us from the past to persist. Only by observing countless patients over many years can we learn to truly see, and our mastery will grow until the day we each hang up our stethoscopes. Yet, no matter how feeble and immature our talents of observation are, exercising them can reap unimaginable rewards.

As Dr livingston and myself were trained in the same way,  if we are puzzled by the diagnosis of a patient we get together with the patient and go back to basic observation and examination and by doing this  between us are able to formulate a plan to obtain the diagnosis .

Similarly, if we come across a new or unusual observation we make a point of sharing it to perpetuate our ongoing learning. “Get the patient in a good light. Use your five senses. We miss more by not seeing than we do by not knowing. Always examine the back. Observe, record, tabulate, communicate.” – William Osler

I started to really understand medicine when I qualified and alongside more experienced doctors who passed on their observations. I was on a wardround as a junior attached to an Obstetric and Gynaecology firm and as we arrived at the bedside of a pregnant lady she suddenly started to exhibit bizarre movements, wherby she stared straight ahead and then her eyes deviated upwards then converged as her neck arched backwards and laterally, she then opened her mouth and protruded her tongue. The consultant became quite alarmed and asked the sister accompanying us on the ward round to summon the medical registrar immediately. ” Excuse me sir, this patient is taking Metoclopramide I think this is an oculo – gyric crisis which is a side effect to this drug and will be reversed by taking another drug or simply stopping the Metoclopramide”. At that point the medical registrar entered who agreed with my diagnosis. The reason I knew about this was because  a medical colleague had called around the night before and had described the condition, albeit unusual, in a patient he had seen that day, but the consultant had never seen this before.

“Medicine is learned by the bedside and not in the classroom. Let not your concepts of the manifestations of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first. No two eyes see the same thing. No two mirrors give forth the same reflection. Let your word be your slave and not your master.” – William Osler

 
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Posted by on April 6, 2015 in Training and Advice

 

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CHOCOLATE – IS THIS A SUPERFOOD?

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I am sure that over the Easter holiday a large majority of people will have enjoyed the pleasure of eating Chocolate and a gift of chocolate will have given joy and excitement to many. Chocolate companies have referred to a variety of subjects to make it attractive to a wide range of people of all ages. From chocolate Kitty’s to chocolate frogs and boxes displaying a wide range of flavours and tastes  with nuts, chilies and fruit. It seems never ending. Some of the first advertisements promoted chocolate. Maybe some of you will recall the adverts where the daring hero bravely combats precarious weather conditions and situations to a supposedly inaccessible lady  to deliver a box of chocolates with the catchy words ” all because the lady loves Milk tray”!

As a child chocolate was something we only ate at Christmas and Easter and birthdays and was considered a real treat. However, every night before bedtime my father made a cocoa drink for my brother and sister and me. I was fascinated about the consistency of the cocoa in the milk as if was difficult to blend and how it was important to mix it with a small amount of milk before filling the mug with warm milk. It was always welcomed on a cold, frosty night the comfort of warm mug of cocoa, especially as we had no central heating. My father often told me stories about the people who grew and prepared it in the Caribbean where he had travelled many times as a young sailor. It was not surprising, how excited I was, at the age of 7yrs when my teacher, Miss Baird ordered a pack from the Caribbean embassy to demonstrate the stages of cocoa and chocolate production. I still feel the excitement writing about receiving that pack, even though I have been able to travel to see it grown for myself and visited factories where chocolate is made.

When we lived in France and the children attended school in a small village I realised how important chocolate was in French life. Our youngest child attended the ‘Maternelle, ( the nursery) and it became apparent that each child was gently settled into school by being given small pieces of chocolate at regu!lar intervals to settle them in. All the children at 4 o ‘ clock every afternoon for ‘ gouter’ were given a piece of baguette with a piece of chocolate. It is not surprising that my daughter is now a chocoholic! In the school were poor country children who had virtually no toys but were never deprived of chocolate! Likewise their parents always have a cup of coffee with a piece of chocolate.

Moreover, when I visited Kew Gardens this weekend, low and behold, the event for children was to discover was where chocolate comes from and how it is made.

http://www.kew.org//visit-Kew-gardens/what’s-on/easter

Besides a visit to these beautiful gardens there is still a chance to take part in this event encouraged by Shaun the Sheep! A visit to the Palm house or the Princess of Wales Conservatory to find the cacao tree with the hanging pods and then follow a trail to Joseph Banks building to take part in the workshops.

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From bean to chocolate baa

Chocolate beans in a pod
Chocolate workshops showing you how chocolate is made, from the cacao bean to the chocolate baa – run by Chocolution experts in all things chocolaty.

Event date:

28 March 2015 to 12 April 2015, 11am to 4pm
Event details:
Pre-booked 30 minute timed sessions, pre book online 24 hours prior to your sessions or the wo
Price:
Adults £5; Members and children £4; Families £15 (2 adults, 2 children); Families members £13; (entry to the gardens not included)
Venue:
Joseph Banks Building

Theobroma ( meaning food of the gods) cacao also cacao tree and cocoa tree, is a small evergreen tree in the family Malvaceae, native to the deep tropical regions of Central and South America. Its seeds, cocoa beans, are used to make cocoa mass, cocoa powder, and chocolate.

The cocoa “beans” that form the basis of chocolate are actually seeds from the fruit of the cacao tree. The seeds grow inside a pod-like fruit and are covered with white pulp.To make chocolate, cocoa farmers crack open the pods, scoop out the seeds, ferments them and dries them.

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The beans are shipped to factories, where manufacturers inspect and clean them, then roast and grind them into a paste called chocolate liquor. More pressing, rolling, mixing with sugar and other ingredients, and heating and cooling yields delicious chocolate.

Researchers observed that the Kuna Indians of Panama, who drank cocoa as their main beverage, had very low blood pressure, a leading cause of heart disease and stroke.

Today chocolate is the ‘sweet snack of the people’ but many years ago, as a part of their rituals, Mayan and Aztec nobles drank their cocoa beans ground and brewed with chillies. When it first arrived in Spain in the 16th century some didn’t like it, one even proclaiming it ‘fit for pigs’. Sugar was added and it grew in popularity especially with the ladies of the Spanish court. Chocolate became a European luxury, with chocolate houses frequented by the elite springing up in the capital cities. Debates centred around its medical value, and whether it was it an aphrodisiac. Chocolate went on to be used as emergency rations for armies, navies and rescue teams, and eventually became a ‘luxury’ that everyone could enjoy.

 Cocoa is a good source of iron, magnesium, manganese, phosphorous and zinc. It also contains the antioxidants catechins and procyanidins.
Brand experts have sought to associate chocolate, and in particular dark chocolate, with the supposed health benefits of cocoa, which include protection against cancer and stress relief.

IS CHOCOLATE A SUPERFOOD?

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Blood pressure
A well-conducted 2012 review of the best available evidence on the effects of chocolate on blood pressure concluded that cocoa products – including dark chocolate – may help to slightly lower blood pressure. However, most of the studies were of short duration (between two and eight weeks) and there were some weaknesses in the available research. The authors of the review say longer term trials are needed to further our understanding of cocoa’s effect on blood pressure and cardiovascular health.

Cancer
Some limited animal and laboratory research suggests a cocoa-rich diet could offer protection against bowel cancer. However, it’s impossible to conclude from research carried out in a laboratory that cocoa can protect people against bowel cancer.

Stress
In a small study from 2009, 30 healthy people who were given 40g of dark chocolate a day for 14 days experienced a reduction in stress hormones. However, the study, which was funded by a major chocolate manufacturer, had several limitations, including its short study period, and does not provide any evidence that chocolate as any benefits or effects on stress.

The dietitian’s verdict
Alison Hornby, a dietitian and British Dietetic Association spokesperson, says it’s important to remember that the studies on the health benefits of chocolate have focused on cocoa extracts, not chocolate.

She says: “A range of health benefits from the consumption of cocoa products have been investigated, particularly in relation to cardiovascular disease, with early results showing promise.
“However, the potential health benefit of some compounds in the chocolate have to be weighed against the fact that to make chocolate, cocoa is combined with sugar and fat.

“This means chocolate is an energy-dense food that could contribute to weight gain and a higher risk of disease. As an occasional treat, chocolate can be part of a healthy diet.

Sorry! Eaten too frequently, it is an unhealthy choice, but some cocoa nibs (unprocessed cocoa beans broken into bits) in a smoothie might be a better choice ! ( obtained in Holland & Barrett)

However, I am sure many people have enjoyed a Happy Easter by sharing some chocolate.

 

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MEDICAL APPS

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