Sir James Black Obituary

This picture is of red blood cells leaking from a damaged blood vessel. It was one of the winning pictures from the Wellcome Trust Image Awards 2008.

Last week saw the passing of Sir James Black, a truly remarkable Scottish scientist whose discoveries saved the lives of millions of people. He won the Nobel Prize for Medicine in 1988 and was chancellor of the university of Dundee from 1992 until 2006.

Some of his key drug discoveries included beta blockers and cimetidine for peptic ulcers which were for many years the world's biggest selling drugs. He studied medicine, and graduated in 1946 after which he joined the physiology department at the university of St Andrews. He began at to pursue an academic medical career. Initial research focused on blood flow related to rates of intestinal absorption by specific cell receptors of various substances. By 1956 he had set the goal of developing cell receptor modulators for various disorders but it was in 1963 at the university of Glasgow that he discovered propanolol and the role of beta receptors in controlling heart rate. He described winning the Nobel Prize as "the most exciting week I ever had" and the same year founded the James Black Foundation, a non-profit group of scientists engaged in new drug research. A truly remarkable man.

Also I have to say that I'm loving the BBC's "Wonders of the Solar System", hosted by 'the rockstar physicist' Professor Brian Cox, at the moment!

Cold Turkey, Blue Nails and Minimum Pricing.

Quick post this week - 4th year just seems to get busier by the week! This week I was reading the student BMJ (March) in which there were several interesting articles. Minimum pricing of alcohol was discussed, this seems to be an ongoing debate and will almost certainly have an important bearing on the next general election. I am definitely of the opinion that in the next 5-10 years there will be a massive change to the way in which alcohol is sold and consumed in the UK. The figures in Tayside alone show the scale of the financial burden to the NHS and the days of heavy boozing may soon be a thing of the past (good job my student days are nearly over then!).

The front page article on this month's student BMJ was regarding stem cell research however I've talked enough about this in previous posts (see below). Also covered in this month's journal was an insight into some disciplines which I previously had not known were present in the hospital. They are the critical care outreach teams and the bereavement officer. The critical care team can be contacted if there is a situation on the ward where a patient's state is deteriorating, presumably contactable at night, therefore it should never be the responsibility of a single doctor to manage a patient's care, nor should the doctor feel alone in this situation.

A moment for teaching: Wilson's Disease. This is an autosomal recessive inherited disorder of copper metabolism. Patients with this condition have impaired copper excretion and metabolism. Clinical signs of the disease are: eye signs (Kayser-Fleisher rings, extra-pyramidal disorders of movement eg. dystonia, psychosis and cirrhosis of the liver. Rarely the nails may appear to be a blue colour due to the effect of the copper.

Finally, there is recently published evidence that most quitters infact stop smoking without the need for additional support. Apparently often these patients are left out of trials and studies, partly because the research is not sponsored by any of the drugs companies which manufacture aids to help patients stop smoking.

Blood Pressure Variability

One of the big things which hit the health news headlines this week was the report that patients with 'occasionally high' blood pressure are at greater risk of developing a stroke than those with consistently high blood pressure. Management of hypertension is a vital aspect of preventative medicine, particularly in a primary healthcare setting. I'm seeing this alot at the moment most likely because I'm half way through a 4 week GP placement. The article appeared in The Lancet this week and a review was published today:

Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension Volume 375, Issue 9718, Pages 938 - 948, 13 March 2010

The argument is that up until now, sporadically increased episodes of blood pressure have been ignored and too much focus has been on "widespread belief that underlying usual blood pressure can alone account for all blood-pressure-related risk of vascular events". In fact clinical guidelines recommend that episodic hypertension is not treated. At the moment the NICE guidelines on management of hypertension are currently being re-written and no doubt this new evidence will play an important part in new recommendations.

On Doc2Doc there was a post from the author of the site about parking charges for hospitals, it seems that in Dundee we are not alone in having to pay for parking! In some hospitals there are monthly rates of £50 or more.

A case recently saw a doctor being taken to court for refusing to pay a £10 parking fine 'on principle' for parking in an illegal space whilst on duty. The article seems to focus alot on doctors but doesn't talk about the barrier's this poses to patients coming to the hospital which is probably more of a concern. With failure rates at appointments running at an all time high and constant chat about "increasing productivity and efficiency within the NHS to save costs" this is surely the kind of thing which needs to be looked at.

Differential Diagnosis, Doctor's Handwriting and Medicine Beyond the 9 to 5

Tom Yeoman, one of the 5th years at Dundee at the moment wrote an interesting article in the Lancet Student this week which caught my attention (Not the Flu - March 2010). He describes reports of patients being diagnosed with having swine flu who have ended up being treated from a range of conditions including appendicitis, malaria, acute myeloblastic leukaemia and meningococcal meningitis! It just goes to show that it's always important to think about the differential diagnosis even if the cause seems obvious. Whenever we write up case reports, we always list the differential diagnosis and this is the reason why, to rule out the alternative causes through methods such as investigations. In the cases of swine flu, due to the possible diagnosis of swine flu this patient had not been given a full assessment by the GP.

Reading on doc2doc this week, the medical professionals forum posts included doctor's handwriting - where a study carried out by Diabetes UK found one in six case notes to contain errors in written notes, and a guy who asks the question 'Why is Transgender still classed as a Mental Disorder'. This does seem to be medicalisation of a choice that someone might make and surely does not mean to imply that they have a mental health problem. I guess it comes back to that question which I posed earlier as to whether completed suicide implies that the person had a mental health problem. Homosexuality was deleted from DSM IV in 1973. Another article asks the queston, Would you change career after medical school? I answered yes. To tell the truth I am feeling a bit disillusioned at the moment, the same phrases do seem to be coming up alot 'burn-out', 'don't do it' etc. But a respondant put in a good quote afterwards:

“…Medicine arose out of the primary sympathy of a man with man; out of the desire to help those in sorrow, need and sickness”. …

-Sir William Osler, “The Evolution of Modern Medicine”, Yale University, April 1913.

Perhaps I need to remember this, although I do wonder if there are other ways I can help. The Dundee University Medical School MSC Symposium this week is titled "Medicine - Beyond the 9 to 5". I'll try and get along to some of this, it might give me some ideas!