Ground breaking genetic research suggests this young child has a desire to go into a career in the health sciences. Who gave him the scalpel?

It sounds obvious, but it puts advice into perspective that its lack of exercise that is the most important factor in childhood obesity. With the alarming rise in obesity in Western Europe and North America, and the failure of recent pharmacological therapy to provide an answer in adults (sibutramine whipped off the market by teh European medicines agency in the UK because of the cardiovascular risk profile: myocardial infarctions and stroke disease), the evidence now suggests we should be switching the three times a week exercise regimes for our children to three times as less packets of crisps in the lunch boxes.But where do these findings come from, can we trust them, and how do you go about finding out these things?

The answer is in a cohort study. A cohort study is a study where you follow up a group of people who may not have a disease (in this case obesity, but it could be anything, multiple sclerosis, rheumatoid arthritis, motor neuron disease) over time (longitudinal) and see what happens to them. This way you can look at all sorts of factors, and see how they appear to influence other outcomes (obesity , depression, getting a job).

Lets take a look at some of the key findings of this cohort study:

Children’s activity not determined by environmental opportunity- Green spaces and sports centres do not influence the physical activity of children
Like most things biological, a child’s activity level seems to be ‘set’
by the brain, and therefore strongly defended against change

These things may seem common sense, but someone needs to go out and prove it.

Healthy weight for life? Start at birth. Most excess weight (90% in girls) is gained before the child ever starts school

That’s more like it. Its because this is a well designed cohort study that this question can be answered. They didn’t go back and look at the records of obese children and compare them to children of normal weight (a case control study), and there are obvious advantages in the (often expensive) cohort design.

So where do we go from here with genetics, and our long term health?  Well good medical research is all about how you go about answering these difficult questions that  life poses.

Only a few days ago in the news more evidence (from the journal Neurology) from a cohort study of patients with depression suggests the following. Again this is more cohort study data. More info here.

Depression is associated with an increased risk of dementia and AD in older men and women over 17 years of follow-up.

The largest longitudinal genetics study of its kind has just finished recruiting in the UK. Visit their homepage.

What this is showing is the potential power of a well designed cohort study: groups of children followed up over time with data collected on their health, allowing comparisons between the children in the cohort, or other patients. Its more cohort studies like these that will hopefully provide the answer to a number of the outstanding genetics questions that are being posed at present. The UK Biobank study is the largest of its kind in the UK has just finished recruiting. Find out a little more from this excellent BBC coverage of the project in the video below.

Finally lets have some views from the students. Suppose we need to know more about a what causes a rare form of myositis (e.g. 1 in 1 000,000)/ or haematological cancer? What’s the best approach to designing a study to look into this. Would a cohort study like these do the job?And what about the consent for the Biobank project. Can people ever really know what they are letting themselves in for? More questions, we’ll have to wait for the answers. Comments please…

1. Medical Protection: The Medical Protection Society

The MPS has a range of online resources and clinical information to help guide medical students and healthcare professionals through their medical training. One thing we like is their magazine for newly qualified junior doctors which are handy for a quick read through relevant junior doctor experiences of life at work. New Doctor magazine can be found here, and Medical Student pages (UK) here.

2. Mnemonics: Medical Mnemonics

We love Mnemonics. Take this one for joint pain.

SOFTER TISSUE:
Sepsis
Osteoarthritis
Fractures
Tendon/muscle
Epiphyseal
Referred
Tumor
Ischaemia
Seropositive arthritides
Seronegative arthritides
Urate
Extra-articular rheumatism (such as polymylagia)

They missed trauma out but hey, nobody’s perfect.

3. Anatomy Guides: Cross sectional Anatomy from anatomy atlases .

We think this picture is of a brain. It’s definitely not the glenohumeral joint.

4. Radiology Help: IMIAIOS

We like this sitter from IMAIOS, who provide detailed pictures like the one you can see here of the famous Scottie dog. We thought it looked like a lumbar spine. How wrong we were.

By the way, you won’t see many more lumbar spine radiographs because your local radiologist will probably have a heart attack if you try to request one! This is because they are notoriously useless at picking anything important up, other than fractures.

5. Stats Advice: BMJ Stats Pages

The BMJ weigh in with a great free resource which requires no subscription. The BMJ really are helping doctors make better decisions (we’re aiming to help you as a medical student make the best decision).

6. iPhone App: IResus

We love this app from the developers at Imobilemedic.com.  You might get a few funny looks from doctors over45 at the next cardiac arrest if you whip this out, and remember not to spill your coffee on your iPhone.

7. Apps for all Smartphones: Med Calc

Thought the Anion Gap was a tourist attraction north of Watford? We’ve got new for you….

If you need to work out a BMI, GCS or Disease Activity score quick? Check out Med Calc… It works on most smart phones. As one contributor said: “I use this most days at work”*

We are fairly certain this is just to show off, but we love this app.

8. General Information: GP Notebook

Most of the GPs that we deal with from medical educator would be doing well to be dealing with most of the complex stuff listed on here. Need to know the classification system for bone tumours? Look no further.

9. Quick information: Wikipedia

Wikipedia is still top of our list for those obscure things you need to know about. As students you always need to be sure to check your sources, however there comes a time when you need fast reliable information, or when you need to read round a topic.  The Journal Nature found that Wikipedia was as good as the Encyclopaedia Britannica across a range of scientific areas. That’s good enough for us, this represents web2.0 in action!

10. Free MCQs & video: Medical Educator

You didnt think we would leave ourselves out did you? If you don’t know already, signing up is completely free and gives you access to loads of our sample multi-questions, videos and podcasts.

Got any other top free resources that you know, use and love? Leave a comment and share the joy!

“Scalpel or Sword? Because sometimes you need a sword”.

That wins our vote for best medical blog tag line, beating “unprotected text” to a close second. We would always however use a scalpel.**

*Recently defunct research project

**none of us can work out what we’re supposed to do with those mini scalpel blades that come in our suture and dressing packs which don’t have a scalpel handle. If anyone knows the answer to this please tell us. If you make the packs, pleas put a handle on the end of our scalpels, it makes us look more professional.

So what better way than to start with saving a bit on food. The food waste mountain is huge now, and lots of retailers such as Jack Fulton and Poundland offer great bargains on best before date food.

Note that the ‘best before’ date isnt the ‘use by’ date – and in most cases food is still fine after the best before date.

A couple of ‘best before’ date sites to check out are Approved Food and Food Bargains. These sites can deliver to your door which means trawling round town with carrier bags is no longer a problem.

For example – a tin of tuna for 60p, pot noodle for 25p, or a packet of custard creams for 39p.

Go on, get saving! And let us know if you have some penny-saving tips of your own.

Medical students need to be careful about what they do and say on line. The boundaries between social media sites like Facebook and Twitter can bring both doctors and students closer to their patients. What’s said online can often be trailed and followed. One contributor to Medical Educator recalls the following at the Universty of Birmingham:

“A prank went wrong when a couple of our friends decided to ask some of the medical student freshers to reveal some ‘personal’ details about themselves by standing up. The subsequent photos, not widely circulated nearly led to the pair being kicked out of medical school. The whole business was a bit of a disaster for the medical students taking the pictures. The dean was not impressed. In the current climate of social networking it could have potentially been a lot worse!”

Sara Williams form the Medical Protection Society, a sponsor of Medical Educator has written some wise words on the topic. The whole article is available here but here’s some practical advice:

“Keep it confidential – make sure you set strict security settings on your social network sites, so only people you know can access your details.

Professional vs personal – You are expected to behave professionally and not bring the profession into disrepute, whether that be on or offline. When social networking you have to bear in mind all your professional responsibilities, and write as if you’re going to be identified. Even inappropriate pictures on Facebook could be subject to criticism.

Tweeting while you work – Tweeting or Facebooking your friends with amusing stories about work may seem innocent at the time. But such anecdotes will often involve unusual symptoms or other sensitive information. It is unsurprising that a patient learning that their experience was being shared online could suffer distress.”

Consider what you are saying and the potential impact of it

So the advice from those ‘in the know’ is don’t be tempted to blog about that ‘interesting rash’ you just saw in the infectious disease clinic.

“The crucial thing to remember when interacting with medical blogs and social networking sites, or when taking part in forum discussions, is that anonymity is a myth,” says MPS Medicolegal Adviser Dr Chris Godeseth. “You should write everything as if you are signing it with your name.”

You can read the full article from the MPS here.

Some procedures are done ‘blind’ such as a knee aspiration to assist aspiration of synovial fluid. Even here USS can be helpful in difficult cases.

X marks the spot! Remember when you’re watching or learning any practical procedure, placement is often the key to its success. Whilst simple procedures like a knee aspiration can be performed without any marking its becoming increasingly recognised that marking sites for any aspiration (pleural fluid, ascitic fluid) and where possible direct visualisation of the needle (central line insertion) is safe, and improves success rates.

Medical students should try and familiarise themselves with ultrasound procedures: why not go and find a friendly USS technician or radiologist and sit in on some simple procedures to help get your basic groundings for a skill that will be valued and needed for most trainees involved in any acute care. Having a go whilst watched by an experienced practitioner is a useful experience. Doing some of these procedures now without USS guidance would be operating in many cases outside of local and national guidelines.

Get more tips like this: signup for free today!

We were a interested in a report from the The Independent (a leading British newspaper) highlighted the case of one British Medical Student. It relates to students from University College London, specifically the transfer of student information to the United States Central Intelligence Agency (CIA). The case in question is that of Umar Farouk Allmutallab, arrested in the US over terrorism charges from Northwest Airlines Flight 253 on Christmas Day.  To refresh your memory on this, read reports on this here from The Times and here from the BBC. He was, of course the former student and president of the University College London (UCL) Islamic Society. There now seem to be repercussions for other Muslim students studying at UCL.

One British medical student has apparently had personal information passed to US authorities as a result of being a member of the UCL Islamic Society. He was quoted by the Independent on the 1st April as saying the following.

I feel frustrated and outraged. To pass on 900 student details because they were members of UCL Islamic Society is ridiculous. The reason I joined the society was for socio-cultural reasons. I’ve never seen the guy [he's referring to Abdulmutallab]. I wasn’t here when he was at university.

Is does seem a little extreme. One of our main contributors (who happens to be British Muslim) had the following to say.

It seems a little curious that the apparently all the members of what was apparently a fairly mainstream society have been put on a US watch list. Its difficult enough getting through US border control at the best of times, never mind having your name potentially put on a list of potential terror suspects! I guess things need to be kept in perspective, but it does seem a little odd.

UCL were reported to say that no details other than the student names and their email addresses had been passed on. Their student Union said the following.

The police asked the student union to provide details of members of the UCL Islamic Society and the Royal Free and UCL Medical Islamic Society between 2005 and 2008. The union provided the names and email addresses of student members only.

Another contributor to medical educator had the following thoughts…

We certainly won’t be spamming any of our customers with junk or sending out any other sort of unsolicited mail. I can’t help but wonder what sort of spam you might get from the CIA. Could be quite fun really. They are now off our list of potential sponsors for the coming year…

Read to read the whole article here from the Independent, and commented on elsewhere in British Newspapers.We’d be interested in any comments from medical students in the UK or abroad about this.

Medical Educator promises not to pass on your email addresses to other companies/ organisations or third parties, there’s no special box to tick, we just wont do it. This includes the CIA, unless they make us!

Its interesting to find many of the images and descriptions are still relevant today, although some of the descriptions are a little ‘brutal’. To the right you can see handwritten notes by a student along with an image describing the excision of a portion of a rib.

We have concluded 3 things.

1. Medical students revision notes were as illegible 00 years ago as they are today. We can’t decipher much of the revision notes shown here (answers on a postcard). There was one bit that we could read that started with Oh-Oh Oh To Touch And… We haven’t printed the rest out of common decency.
2. Writing in flowing fountain pen certainly adds to the drama of revision notes.
3. Although the 1910 book is of exceptional quality and detail, we reccomend using some of the more up to date texts available. Some of our colleagues have even suggested searching the internet, but we’re not too sure about this and prefer to stick to books!

Thanks to Ms K for the donation of the text, we hope to publish some other relevant diagrams in coming months. William Wheeler died in 1943. A telling comment from his obituary in the BMJ from the same year follows:

He was not only a brilliant operating surgeon, a clinician of much wisdom, and an authoritative writer on surgery, but
a man with a great capacity for friendship.

They look so fashionable they must be great for the modern day medical student. Right?

We here at medicaleducator.co.uk are currently checking out he use of predominantly free iPhone apps on for medical students. So what we would like are three things. Why not email us at iphone@medicaleducator.co.uk if you have a point of view on any of our points below. We’re keen to supply our users with a free iphone guide once we know what’s worth checking out. So we have a few questions….

1. Have you been refused access to any iPhone health resource because you are ‘only a student’ ? (something we’ve heard is getting more common- and is perhaps a little frustrating [we know you need the information most!]
2. Any apps that are really worth their weight in gold to budding students out there?
3. Anything you think is not worth the free download time?
4. Any recommended top apps?
5. Overall as medical students do you think an iPhone is worth the money in terms of the benefit it gives you?

We;’ll be covering a feature on a few of some of the apps that we like, and are currently using in our day to day practice. We’ll leave you with this…

I was using my iPhone to check a patients disease activity score (DAS) to check their eligibility for anti-TNF therapy- a biologic agent that is a powerful treatment for rheumatoid arthritis.  I think the patient thought I  was checking my text messages! It took a careful explanation to avoid an embarrassing incident.

A free subscription to the user who sends us in the most detailed answer to any/ all of the above. And if you can make us laugh heartily you might get one too. Check out our user guide coming soon too!

Here's the original picture from the question. Thanks for tom for pointing out that we initially uploaded a picture of the left fundus, just to confuse you! The image above is from the original question, and is the right eye!

Well now we have the answer, lets go through it step by step. Remember this is from the perspective of a general medicine/ internal medicine doctor, NOT from that of an ophthalmologist, who may have all sorts of other interesting comments to make.*

*These comments are only likely to be interesting to other ophthalmologists

First the history: There is no history! There are no particular conditions which we would link to asthma and opthalmological problems. The blood pressure and observations are all normal.

A couple of caveats:

• in medical questions when you see asthma we always have ‘could this be alpha one anti trypsin deficiency and not asthma’ in the back of our minds
• The blood pressure bits always make us recap: could this be one of the primary causes of hypertension (e.g. phaeochromocytoma, where the blood pressure can be normal?

But… hang on a bit, the history suggests nothing of the sort. So we are left with the fundoscopy. Is it normal?

Lets start:

1. Which eye:  looking from the front, the optic disc is on the nasal half of the field, so this must be the RIGHT eye!
   

   Three quarters of you got the right eye, because yes, this is the 'right eye'. For the other 11%, don't worry, x-rays of the hands confuse us too...

2. Is the optic disc normal? Colour,  yes normal (it should be pale yellow: optic atrophy is one cause of a pale optic disc, and there are multiple causes for this (such as MS, ischameia etc). Shape yes, its spherical. Margins. Distinct-the pale yellow optic disc has nice clear margins here. Blurring of these margins may represent papilloedema, which is one sign of raised intra ocular pressure. This is a key finding in cases of headache as a ‘red flag’. You can also measure the optic cup to disc ratio, and we’re not going to into this now!
3. Vessels: Follow from the disc outwards. Which ones are arteries and which ones are veins? Easy- the arteries are the thinner ones that are often paler than the veins. Now check for common signs: ‘AV nipping’- in hypertension this is when an artery crosses a vein, the vein edges are squeezed in at this point. Its one of the signs of hypertensive retinopathy, or end organ damage caused by hypertension. There is nothing like that here.
4. Anything else on the retina? What about aneurysm formation or exudates (diabetic retinopathy) or dot and blot haemorrhages? nothing of the sort here, the discs otherwise look nice and clear. remember to check the macula area. Nothing to find here suggesting any of these problems.

So, all in all from this quick check we can see nothing up! This is a normal fundoscopy. So…

35 % of you were correct: The answer is to reassure the patient that the examination is normal! No other scans or referrals are needed on the basis of this history and examination.

35% of you got this right at last check on the 21st of January!

To recap the question see below…. or click the link here. Please add any comments or questions!

A medical student is practising for her OSCE exams on the ward…

She examines a 19 year old female patient admitted with asthma on the medical assessment ward for revision purposes.

The patient has a past medical history she has the occasional migraine, and eczema.
The observations are as follows.

BP 128/70

Pulse  98 regular

Fingerprick blood glucose 8.3

Oxygen Sats 97% on Air

She performs a cardiovascular and opthalmological examination.

Cardiovascular examination: Split S2 (second heart sound) on deep inspiration.

Ophthalmology examination: Normal Eye movements. Pupils 6mm and reactive to light. Eye movements normal. Visual fields normal. No scotoma. Fundoscopy examination of one eye is shown below…

Do you get this good a view when performing fundoscopy? Of course not, this is a digital retinal photograph-remember when you are using a hand held opthalmoscope you only get to view a bit of this at a time, which is why its important you should know which eye this is!

Why not have a go at the questions below? We’ll put up the answers in a couple of days…

What is the correct course of action?

• Reassure the patient (35%)
• Request a CT Brain (24%)
• Refer opthalmology: check intra-ocular pressure (24%)
• Repeat blood pressure (12%)
• Request neurology/ clinical geneticist review (5%)

By the way, which eye is shown?

• Right eye (71%)
• Left eye (18%)

I’m not sure I get like this with x-rays of hands too… (11%)