Tag Archives: Red flags

Educating readers about Important health symptoms and signs which need urgent attention.


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
• 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


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
*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.
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

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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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!
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.
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.
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.

A debilitating disease and the IBS network offers support and help to live with this condition.
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.

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
which is a charity that raises awareness and funds research into gut and liver disease.
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
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
The following red flags are important to note if you are concerned about this
*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
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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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.
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)

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.
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.
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,
haematemesis,( vomiting blood)
require urgent referral for endoscopy.

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Posted by on August 23, 2013 in Training and Advice


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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.
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.

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.
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.

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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