London Student Journal of Medicine Vol. 1

lsjm 15 june 2009 volume 01
UNHEALTHY BEHAVIOUR
15 June 2009 Vol 01
Contents Page:
The nations health compass

awaits resetting by
a) Those in charge
b) Healthcare professionals or
c) Healthcare students
doi:10.4201.lsjm/ed.001
Far in the past lies the times when our governors and health advisors encouraged harmful health attitudes. Their unhealthy nature was then
yet to be realised. In 2007, smoking - as an unhealthy and antisocial habit - was finally kicked out of the nations public places. This year
sees the government and health watchdogs turn to the nations use or rather abuse of alcohol.
The change in legislature currently used to discourage unhealthy behaviours was not always the preferred employment of the law where
abusive substances are concerned. In 1563, Queen Elizabeth I ordered all land owners with 60 acres or more to grow cannabis or face
a 5 fine. Sir John Russell Reynolds, personal physician to Queen Victoria, wrote an article in the first edition of The Lancet about the
benefits of cannabis.1 Queen Victoria was at the time rumoured to have managed her menstrual pains with the drug. In the early years of
the United States one could be jailed for not growing hemp during times of shortage in Virginia between 1763 and 1767. Now in 2009, the
recent reclassification of Cannabis to a class B drug- without accordant sanctions demonstrates a new commitment by government to the
physical and mental health of current and future generations.
Sections of the LSJM

Medicine pg.8
Editors - Maham Khan and Laura Vincent
Submit to: medicine@thelsjm.co.uk
Psychiatry pg.26
Editors- Samuel Ponnuthrai and Alexander Ross
Submit to: Psychiatry@thelsjm.co.uk
The image of a physician was used in the 50s by tobacco executives to reassure the consumer that their respective brands were safe. The
somewhat prevalent use by healthcare students and professionals might send a similar message to the general public today. To echo the
words of Rene Descartes To know what people really think, pay regard to what they do, rather than what they say. It is time that our
attitudes as current and prospective healthcare professionals be aligned with the stated intention of healthcare.
Surgery pg.42
Editors- Jonathan Cheah and Milan Makwana
Submit to: Surgery@thelsjm.co.uk
The definition of unhealthy behaviours remains complex and therefore difficult to categorise. In this foundational issue of the London
Student Journal of Medicine, student articles have come together to shed light on different aspects of such behaviours, with alcohol abuse,
obesity and the attitudes of future healthcare professionals in prime focus. Along with an increase in the regulation of such behaviour by law,
now transferring to medical students by the GMC, we ask - Are such behaviours that bad? If so, why have they been tolerated for so long?
Global and Community Health pg.56

Editors- Vishal Nivani and Harpreet Sood
Submit to: gch@thelsjm.co.uk
The implications could be far reaching: future applicants to medical schools and other healthcare institutions may have to consider not only
their desire to save lives but also the lifestyle changes required to reflect healthy behaviour. Lawyers, with the responsibility of upholding
the nations legislature, will be disbarred for criminal acts. Should we follow in the same vein? Alcohol, cigarettes and fatty foods are now
so deeply intertwined with acceptable social interaction and UK culture that this could mean an infringement on individuality and human
rights. Healthcare professionals now face a battle with their inner demons for themselves and the sake of patients.
Health Law and Ethics pg.72

Editors- Tiffany Munroe-Gray and Rani
Subassandaran
Submit to: hle@thelsjm.co.uk
Nana Seiwaa Opare & Kevin Owusu-Agyemang

Editors-in-Chief
Careers pg.88
Editors- Sonia Damle and Rob McGuire
Submit to: careers@thelsjm.co.uk
1. Reynolds JR. Therapeutic uses and toxic effects of Cannabis indica. The Lancet 1890;1:639.
Kevin Owusu-Agyemang
Co-Editor-in-Chief
2
Nana Seiwaa Opare

Co-Editor-in-Chief
Jonathan Hyer
Creative Director
The London Student Journal of Medicine (LSJM) is published by the LSJM Publishing Group, an
independent non-profit organisation. The LSJM Ltd grants editorial freedom to the editors of the
LSJM. Whilst the authors and editors have taken all reasonable measures to ensure the accuracy of the
articles published and images used, they do not warrant that the information is complete, correct and
or accurate. All articles published in this journal, are views of the authors and do not reflect that of the
editors, organisation or institutions to which they are affiliated to or the LSJM unless otherwise specified
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any loss, injury or damage caused by your reliance on any article published. For further terms of use, see
www.thelsjm.co.uk. the London Student Journal of Medicine 2009.
6
44
73
Editorials
The written word
Why quality should matter to you
Unhealthy and unlawful face of medical technology: a story of india
59
Reflection
Influenza a (H1N1): echoes of spanish flu?
16
18
22
38
62
68
75
Reviews
Mitochondria more than meets the eye
The successes and failures of leptin in the fight against obesity
Rheumatoid arthritis and the anti-tnf revolution
Amphetamines
Poultry vs poverty
Is it time to put the lights out on sleeping sicknesss
Allocating organs: two bodies, one heart
13
28
30
32
34
46
48
66
70
81
86
95
96
Articles
Alcoholic peripheral neuropathy in a 24 year old
Online roleplaying games addiction
Narcissistic personality disorder: the case of jack sparrow
Time to take seasonal affective disorder seriously
Ethnicity & depression in london medical students?
The IHI open school: primum non nocere
Two-week rule in the diagnosis of colorectal cancer
Chikugunya
A short introduction to the human papilloma virus
The dangers of multiple pregnancies: the octuplets story
No consent, no defence
Graduate entry medicine
European working time directive
10
12
24
25
60
78
84
90
98
100
Perspectives
Risky business
Another pint? Go on, its not going to affect anyone....
Rheumatoid arthritis a medical students perspective
Will homo sapiens continue to evolve? If so, how?
From equasy to obesity
Promoting IVF: the (un)hidden effects of playing god
Baby shambles?
Fitness to practise
The blame game
UK foundation programme
47
Also in this issue

Profiles
Comments
Mystery object competition
3
ORACLE
Developing appropriate methodology for the study of
surgical techniques
J R Soc Med 2009: 102: 51-55
Peter McCulloch, a surgeon based at the University of Oxford, UK
describes the problems with evaluating surgical techniques using
the methodology currently in practice for the evaluation of new
drugs. He suggests that in future, evaluation should recognise these
difficulties and proposes a methodology from the first description
of a new technique through to long-term monitoring that may begin
to address these problems.
Immobilisation leads to faster recovery of function after
ankle sprain
Lancet. 2009 Feb 14;373(9663):575-81
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The benefits of membership of the MDU are all discretionary and are subject to the Memorandum and Articles of Association.
The National Co-ordinating Centre for Health Technology

Assessment funded Collaborative Ankle Support Trial Group aimed
to compare the efficacy of different methods of ankle support
on recovery following ankle sprains. In the UK-based study, 584
patients over the age of 16 were randomised to either double-layer
tubular compression bandage or an immobile support (Aircast
brace, Bledsoe boot, or a 10-day below-knee cast) and followed
up at 1, 3 and 9 months. At the primary outcome measure, which
comprised of blinded-assessment of ankle function at 3 months
using the Foot and Ankle Score, both the Aircast brace and belowknee cast showed improved function compared to compression
bandaging, whereas the Bledsoe boot did not. However, by 9
months, there were no differences in ankle function between
compression bandaging and any of the immobile supports. Adverse
events were rare but included venous thromboembolism and were
not significantly higher in any one group. The authors conclude
a short period of immobilisation is beneficial in promoting rapid
recovery from ankle sprains.
Laryngeal transplantation?
http://www.rcseng.ac.uk
A taskforce has been convened by the Royal College of Surgeons
of England to consider the complex clinical and ethical issues
surrounding the transplantation of the trachea and larynx.
Combining, Ear, Nose and Throat surgeons, transplant surgeons
and medical ethicists, the taskforce met for the first time in March
and considered issues such as patient selection and suitability, how
to appropriately gain consent and the relative benefits and harms.
Using financial incentives to achieve healthy behaviour:
BMJ 2009; 338:b1415
http://www.bmj.com/cgi/content/extract/338/apr09_2/b1415
How effective are financial incentives in trying to get a patient
to change their behaviour and their health outcome? Are these
incentives ethically and morally plausible? The article describes the
effectiveness of certain financial incentive programmes relating
to various programmes such as weight loss and smoking cessation.
Some of the outcomes show that the bigger the financial incentive,
the more effective the change of behaviour and health outcome.
We all have dilemmas regarding our health behaviour in which
what we want to do and what we do can be very different. Maybe
through these incentives we can align the two so that they are more
alike in outcome. Therefore maybe with a little bit of incentive we
would do what we want to do with regards to our health behaviour.

However, we must be cautious as financial incentives can impede
on the intrinsic motivation that an individual has to change health
behaviour, it can also take away the autonomy of a patient by
undermining informed choices and it can also encourage the
doctor-patient relationship to become more like a business
transaction. Should we pay people money to live a healthy lifestyle?
Or should health be valued as more than just a financial gain?
Medical journals and ethics: Pity the messenger
The Economist print edition Mar 26th 2009 | NEW YORK
http://www.economist.com/science/displaystory.cfm?story_
id=13361480
Every day millions of scientists and academics across the globe
dedicate their time to furthering our progress in the ever dynamic
field of medicine. Their work is usually funded by big organisations
that are able to invest a significant proportion of their money to
research and development. Research depends on some kind of
financial assistance and big pharmaceutical companies depend
on good research to maintain a cutting edge reputation. Most
publications tend to express acknowledgement towards the
institutions that have given a monetary contribution thus allowing
the research to proceed.
However, although this may seem to be a symbiotic relationship,
sometimes the balance is tipped such that research papers disguise
the actual findings, and masquerade their results in a way that
appeases the institution that has funded the work. The true extent
of these cases is unknown but their very occurrence reflects
the competitive nature of the profession. Fabricating results or
number crunching to reflect desired correlations is unacceptable
in medicine not least because evidence based medicine is our
rationale for treating the many millions of people we do.
Next time we read a paper it is important to take account of who
has funded the research and then proceed to critically appraise it.
Obesity and virtue. Is staying lean a matter of ethics?
MJA 1999; 171: 609-610
Self-control of ones own weight might be described as a form of
bioethics
http://www.mja.com.au/public/issues/171_11_061299/burry/
burry.html
Why staying lean is not a matter of ethics
MJA 1999; 171: 611-613
http://www.mja.com.au/public/issues/171_11_061299/proietto/
proietto.html
Is it unethical to be fat? With obesity putting increasing pressure
on health services, these articles discuss the potential bioethics of
being obese.
Ben Collard, Oracle Editor
MDU Services Limited is registered in England 3957086. Registered Office: 230 Blackfriars Road London SE1 8PJ.
2007 MDU Services Limited. ST/035v/0807-ls
PATRONS EDITORIAL
LETTER TO THE EDITORS
The Written Word

Joe Collier
Emeritus Professor of Medicines Policy,

St. Georges University of London
Patients Do Not Understand Doctors

Lebur Rohman
St. Georges University of London

leburrohman@doctors.org.uk
Dear Editor,
Professor Collier is former Editor

of Drug and Therapeutics Bulletin. He writes for BMJ Blogs.
A universal feature of living things is their capacity and

determination to communicate. In plants and animals, cells or
groups of cells tell other cells what to do (at its simplest the
message is divide or not divide). Through colours, shapes and
smells, it is common for plants and animals to give out messages
that serve to attract or repel other life forms. Through relatively
crude devices, such as touching, pointing, grimacing, beckoning,
humans exchange quite sophisticated messages about what
we want, how we feel, what we advise. On another plane from
these very immediate messages, we have a capacity to convey
powerful emotions and sentiments using pictures and music (the
tears shed by seeing Picassos Guernica, and the chest pain on
hearing Wagners Ring are renowned). But for me the pinnacle
of communication must be the word. It encapsulates and even
determines concepts. Moreover, when used in language, they
empower us to transmit the most complicated of facts and ideas
in the most precise of ways from one person to another and even
across generations. Such a capacity for communication occurs
whether language is presented in the spoken form emanating
directly from the mouth or through some recording, or is embodied
in a unique arrangements of characters/letters written down on
paper or screen.
Given that words are such extraordinary devices they deserve to
be treasured and revered. Indeed, those of us who are wordsmiths
(and this necessarily includes the authors and editors involved in
the production of the London Student Journal of Medicine) owe
words particular respect. To this end, here are some pointers for
journal authors and editors as they go about their business.
completeness also applies to the text generally, at least for articles

presenting original findings. Remember that enough data should
be given such that the selfsame experiment could be repeated by a
reader. Remember that sometimes clarity can be enhanced through
the careful use of grammar and punctuation. Check that the article
as a whole has consistency both within itself and within its context.
Remember that the whole text is given hollowness and its integrity
undermined if the message in an abstract strays from the data; if
the conclusion is at odds with the results; if the introduction fails
to take into account the published literature; if a reference has no
relevance to the text. Finally, it is important that the wordings used
in the text are those of the author and not of someone else.
In writing, plagiarism or false authorship are heinous sins and cannot
be tolerated.
So much for words and language. Of course it is their use that
will shape how the article is understood. They will not, however,
ultimately determine whether or not the article is published.
Here the issues are much broader and include, for example the
articles originality, topicality, timeliness or relevance, and for these
judgements, the editors are not wordsmiths but policy makers.
Needless to say, whether wordsmith or policy maker I wish all
involved in the London Student Journal of Medicine the best
of luck.
A small pilot questionnaire survey was conducted whilst on a

Geriatric placement, examining the level of understanding of
medical jargon amongst the Geriatric population, with particular
emphasis on ambiguous words. Furthermore an additional aim
of the study was to assess whether any miscommunication is
attributable to age.
There is no validated questionnaire for this study. Therefore,
the author constructed the majority of questions and some
were adapted from a previous study on terms used in cancer
consultations to the focus of this study1. The questions were
revised for content by a consultant Geriatrician. 50 patients were
interviewed (25 over 65-years, 25 under 65-years), all with an
AMTS of 8 or more. Data from the questionnaires were entered
and analyzed using SPSS v12.0.
The results demonstrate that a significant proportion of patients,

regardless of age are misunderstanding common words used by
clinicians. Furthermore, the data does not support any difference
in comprehension of words amongst the two age groups.
In every article ensure that the words used accurately express the
message(s) the authors wish to convey. Avoid wording that could
lead to misinterpretation, and with this in mind avoid words that
have ambiguous meanings, are open to misinterpretation or that
rely on the readers valued judgements ( improvement, good
results, etc). Beware of wording that is emotive, or that introduces
ideas through insinuation, innuendo or association. Be very careful
to avoid wording that might be personally hurtful or offensive.
When choosing sentences remember that the message must reflect
our shared reality there is no place for exaggeration, distortion,
fabrication, and obviously deceit (hopefully editors will sort these
out!). When developing an argument remember that the order in
which points are put can be critical. Ensure that the argument is
complete with no steps assumed and none omitted. The notion of
Doctors and students are all too aware of the impact of bad
communication and how good communication may provide
better patient care and thus constitute good medical practice. In
particular, with many patients on geriatric wards being in a state of
confusion, it seems pertinent to ascertain whether they understand
what is being communicated to them, if one is to follow the
General Medical Council (GMC) principle of encouraging patient
participation in the management of their condition. Well-known
barriers to communication include, social status, race, age, gender,
fear, embarrassment and medical jargon.
The limitations of this study include: small sample size, possible

selection bias and interviewer bias (not all interviewers read the
statements word for word from the questionnaire). Nevertheless
the results obtained are profound and of importance to all
healthcare professionals. In particular, medical students are being
molded into jargon-speaking doctors, such data should warn all
students of the importance of good communication skills
In conclusion, healthcare professionals should not assume what
patients will and will not understand, and instead follow the
recommendations of Chapman et al.1 that comprehension should
be Verified by asking them what they have understood, rather
than if they understand. Finally, this study highlights that simple/

ambiguous words, a particular type of jargon is an additional barrier
to effective communication.
References:
1. Chapman K, Abraham C, Jenkins V, Fallowfield L. Lay
Understanding of Terms Used in Cancer Consultations. Psychooncology 2003; 12 (6): 557-566
Table 1. Responses for each question in the questionnaire

QUESTION
<65 years
old (%)
>65 years
old (%)
2 test
overall
2 test between
age-groups
p<0.001
non-significant
p<0.01
non-significant
p<0.001
non-significant
p<0.01
non-significant
p<0.001
non-significant
p<0.01
non-significant
1)"Your blood test has come back POSITIVE. Do you

think this means:"
Good news
71.4
68
Bad news
21.4
7.1
28
Dont know
2)"Your blood test has come back NEGATIVE. Do you

think this means:"
Good news
35.7
20
Bad news
57.1
56
Dont know
7.1
24
3)"If you were told that your condition is
PROGRESSING, is this:"
Good news
38.8
Bad news
61.5
Dont know
0
60
36
4
4)"If your condition is in REMISSION, what do

you understand by that:"
Getting better
14.3
48
Getting worse
7.1
16
Dont know
14.3
8
Other
64.3
28
5)If you were told your condition has
RELAPSED. What does this mean?"
Getting better
0
Getting worse
28.6
Come back
64.3
Dont know
7.1
4
36
52
8
6)"If you were told your condition was BENIGN,

what does this mean?"
serious
35.7
20
not serious
50
48
dont know
14.3
24
other
0
8
EDITORIAL
A very warm welcome to the Medicine section in this landmark edition of the London Student Journal of Medicine. The Medicine section
aims to challenge the limits of current understanding, and refine clinical practice across the allied health professions. A wide and diverse
section, we select articles conveying an insightful, novel approach reflecting pertinent issues in healthcare today.
In the light of the revised GMC and Medical Schools Council guidelines released earlier this year1, defining professional values and fitness
to practise have become hot topics of discussion. Jaimie Henry explores how our actions now impact upon our practice as healthcare
professionals tomorrow. Also under the microscope are our attitudes towards our own health, we take a look at one upshot of binge
drinking in a case report on alcohol induced peripheral neuropathy.
The latest WHO estimates suggest , 1.6 billion adults are overweight worldwide with another 400 million clinically obese2; societys
expanding waistline is getting harder to tuck away. The war on BMI reached new heights as popular obesity treatment Orlistat (brand
name Alli) became available over the counter for the first time in the UK. In this issue we look at origins of obesity therapy, as Daniel
Hammersley reopens the story of Leptin. This review highlights ongoing research dedicated to further unlocking Leptins potential;
showing far from being a footnote relegated to the past, Leptin may still aid our fight against a fat future.
A fundamental aim of the medicine section is to inform without regurgitating information easily available in a textbook. With this in mind
we kick off our ongoing series into chronic conditions with an educational and engaging review of anti-TNF therapy. To complement this
review is a piece from the patients view as a student shares their experience with RA treatment. Visit our section online to read these
articles.
With the promise of potential new treatments, mitochondrial medicine is an area rapidly gaining in recognition as top clinicians and
experts worldwide compile a letter to President Barack Obama urging him to include the field amongst his top research priorities3. As we
investigate current doors being opened by mitochondrial medicine, Professors Vamsi Mootha and Richard Haas, signatories of the letter
and leading experts in the field, provide us with their thoughts on the incredible potential mitochondrial medicine offers and where it may
take us in the future.
With a bright future in view we take a fascinating look into the past in a topical tour of humankinds evolution; in a whirlwind journey
combining genetics, language and culture, Kartik Logishetty looks at the direction our species is taking, asking how will we continue to
evolve?
This is your journal, dedicated to help you in developing your ideas for publication. Whether you have an article for submission, an idea
or simply want to write, get in touch by emailing medicine@thelsjm.co.uk. We welcome your input and also encourage you to help us
improve by writing in with any comments, feedback and suggestions.
Finally, an enormous thank you to all involved in putting this issue together. From the talented authors, peer and expert reviewers to Laura
Vincent co-editor and the superb medicine panel, for their commitment, consistent hard work and continuous support.
I hope you enjoy reading this issue, as much as we have enjoyed putting it together.
Maham Khan
Section Editor of Medicine
References
1.
Illustration: Robert de Niet
2.
3.
Medical Students: Fitness to practise and behaviour guidelines document. General Medical Council [online]http://
www.medschools.ac.uk/documents/FitnesstopractiseguidanceSep2007.pdf (last accessed 21st April 2009)
The WHO media centre, 2006. Fact sheet no 311. http://www.who.int/mediacentre/factsheets/fs311/en/index.html (last accessed 21st April 2009)
Letter to President Obama, downloaded from United Mitochondrial Disease Foundation [online].http://www.
umdf.org/atf/cf/%7B28038C4C-02EE-4AD0-9DB5-D23E9D9F4D45%7D/Mitochondrial%20Research%20
Letter%20to%20the%20President-Elect%20-%20rev04%200122.pdf (Last accessed April 21st 2009)
PERSPECTIVE
NEWS
Year 2 Medicine, Imperial College

jaimie.henry07@imperial.ac.uk
It is something many healthcare students will have heard countless
times just as they are about to tuck into their family sized bucket of
deep fried chicken: Youre going to be a doctor/nurse and youre
eating that rubbish!
That scenario is usually taken in a light hearted manner and such
a rebuke is normally shrugged off and ignored. However, it does
raise a very important question: how does this type of potentially
damaging health behaviour impact upon the publics perception of
healthcare students and the profession in general?
For a long time it has been a clich of medical education and
indeed the profession in general that doctors, and in particular
student doctors, have the inalienable right to abuse their health,
often in a way that far exceeds the misdemeanours of their patients.
Studies have shown that medical students not only drink more
than their counterparts in the arts, but suffer more adverse effects,
including liver cirrhosis and alcohol-related vehicular deaths or
violence1.
This not only presents the obvious issues of poor performance at
work and the direct endangerment of patients as a result of acting
under the influence, but also presents indirect consequences:
those students who are excessive drinkers omit to routinely counsel
patients with excessive alcohol intake2. In itself, this could mean
failing to advise a patient about a potentially fatal yet manageable
condition.
Such behaviour has been shown to put at risk the inherent trust
which forms the basis of the doctor patient relationship. With the
move away from paternalism, patients no longer accept medical
advice without remark but frequently question both the advice and
the doctor. It is not surprising that evidence indicate that patients
put poor confidence in any health advice given to them by an obese
doctor.5
The overriding responsibility placed upon all healthcare professionals is to make the care of the patient your first concern. Perhaps
now the GMC should consider whether it is not simply the conduct
or health of student doctors that calls into question their fitness to
practise, but whether it is also these risky health behaviours.
Whilst there is currently little in the way of explicit or acute embarrassment of the profession as a result of binge drinking or smoking
more insidious embarrassment is becoming plain to see and could
even go so far as to jeopardise the long-term care of patients.
On the whole, the behaviour of healthcare students is substantially
underappreciated especially when one considers the effect such
behaviour has on a future health professionals ability to effectively
treat or counsel their patients. Whilst patients would generally
avoid consultation with an incompetent doctor/nurse or one with
a criminal record, the overall outcome is equally ineffective if they
disregard the advice given by a competent physician because of
their apparent medical hypocrisy.
References:
This is a problem that continues all the way through to qualified

doctors and other healthcare professionals, where as few as 13% of
all healthcare staff in one hospital (including respiratory registrars)
believed all cigarettes were harmful3. It would appear that the only
way to effectively deal with such a gaping lack of knowledge is at
a grass roots level. Unfortunately, surveys have consistently found
that teaching on smoking has not been sufficient enough to inform
students themselves about the risks; they are then unable to
effectively counsel patients in smoking cessation4.
10
1.
2.
3.
4.
5.
McCarron P, Okasha M, McEwan J, Davey Smith G.

Association between course of study at university and causespecific mortality. J R Soc Med 2003;96: pp. 384-388
Frank E, Elon L, Naimi T, Brewer R. Alcohol Consumption
and alcohol counselling behaviour among US medical
students: Cohort Study. BMJ 2008;337: a2155
Bowen EF, Rayner CFJ. Medical students knowledge
of smoking Thorax 1999;54: p.655
Richmond R. Teaching Medical Students about
Tobacco Thorax 1999;54: pp. 70-78
Hash RB, Munna RK, Vogel RL, Bason J. Does
Physician weight affect perception of health advice?
Preventative Medicine 2003;36(1): pp. 41-44
Obesity: The Next Generation
Image: Change4Life
Risky business: are fast-living

healthcare students endangering
the lives of their future patients?
Jaimie Henry
Laura Vincent
Change4Life is a government survey which was launched in January
to tackle increasing rates of obesity by promoting healthy eating
and exercise.
Based on 260,000 responders in England it showed that 72% of
children do not participate in the recommended hour of daily
activity outside school and therefore do not do enough physical
activity to keep them healthy and prevent obesity. The survey
reported that 45% of children either watched TV or played videogames before school, and only 22% did physical activity after their
evening meal.
The current exercise recommendations for children and young
people state that they should achieve at least one hour of moderate
intensity physical exercise every day. Also at least twice a week
they should include additional activities which should improve
strength, flexibility and bone health.
The survey highlights the huge challenge that the government and
the department of health face in the on-going battle with the
nations obesity crisis.
Marni Craze from World Cancer Research Fund said The survey is a
concern because it is important children get into the habit of being
regularly physically active as early as possible. This is because habit
formed as children often last into adulthood and there is convincing evidence that being physically active reduces risk of cancer and
other chronic diseases.
Change4Life has launched a new marketing campaign which aims
to motivate families to work together to improve their lifestyles.
This highlights the consequences of inactivity, including cancer,
heart disease and type-II diabetes.
www.nhs.uk/Change4Life
The LSJM is a
partner of the
Change4Life
initiative
Problems with the internet

Laura Vincent
Laura Vincent is the

associate editor of
LSJM Medicine
A recent survey conducted by GP magazine has found that at least

a quarter of doctors have treated adverse reactions caused by
medicines brought on the internet. Along with treating adverse
reactions, 85% of responders felt that online pharmacies need
tighter regulations.
Dr Sarah Jarvis from the Royal College of General Practitioners told
GP Surveys looking at many online medications suggest that the
proportion of counterfeits is enormously high and the many of them
contain very worrying ingredients.
The Royal Pharmaceutical Society of Great Britain (RPSGB) have
recently issued a warning relating to the dangers of internet
pharmacies. They are concerned that the general public are not
fully aware of the risks of purchasing medicines online, as they may
not be suitable for the patient and could lead to serious health
risks.
Although controls are in place, counterfeit drugs are still available
in large volumes. To try and combat this problem the RPSGB have
launched an Internet Pharmacy Logo, which identifies legitimate
pharmacy websites where patients can be sure they are buying safe
products.
The Medicine and Healthcare products Regulatory Agency
(MHRA) is working with the RPSGB to highlight the dangers of
counterfeit drugs and help patients become more aware of the
problems. This includes information leaflets which will be handed
out with the dispensed products from all pharmacies which will
provide advice on how to purchase medicines safely.
11
PERSPECTIVE
SHORT CASE
Another pint? Go on, its not

going to affect anyone ...
Mitul Palan
Alcoholic Peripheral
Neuropathy in a 24 Year Old
Ronit Das
Year 3 Medicine, Kings College London
ronit.das@kcl.ac.uk
doi:10.4201.lsjm/med.002
The extended abuse of alcohol leads to a myriad of health issues,
and in up to 50% of cases results in a peripheral neuropathy.1 The
corrosive effect of ethanol produces a primary axonal degeneration
that characteristically takes several years to develop and manifest as
symptoms. Sensory features often dominate the typical neuropathy,
with minor motor compromise. It is therefore unusual to see an
alcoholic neuropathy, with major motor and sensory features,
manifest in a young abuser.

Mitul.palan06@imperial.ac.uk
The first topic to surface in this discussion is undoubtedly alcohol.

A strong drinking ethic is prevalent in many medical schools, both
in the USA and UK; gallons of alcohol are shovelled down first-year
throats in the first few weeks. Is this the right mindset to impose on
budding physicians?
Recent studies in the USA 1 and in European 2 medical student
populations have highlighted this binge-drinking culture, marking
men as more likely to partake in such conduct than women. Binge
drinkers also seemed to see more positives from drinking than
others does this suggest that our viewpoint on alcohol intake is
completely wrong? Although compared to the overall population
medical students drink less on average,1 we are the role-models of
the future, and we should set an example.
Illustration: Elaine Parker
Smoking does not seem to be as prominent in medical student

population as excessive alcohol intake, but poor nutrition is very
apparent. 3, 4 Current studies show students to have a very high
saturated fat intake, and to be deficient in vegetables, fruit, dietary
fibre and vitamins.4
Perhaps we are unaware of what constitutes healthy behaviour, or

perhaps we choose to ignore it: the latter seems more plausible.
However, as a country with a rapidly increasing obese population,
renowned for a smoking and drinking culture, the future of the
nations health falls to us and before changing their health behaviour, we have to first change ours.
12
The lower limbs were the most obviously compromised.

The patellar and ankle were absent with equivocal plantar reflexes.
Power was preserved at the hip though diminished at each level
distally, such that the power of the extensor hallucis longis was
rated at MRC 1 bilaterally. The sense of light touch, vibration and
pain were absent along with proprioception, below the level of the
patella.
The distal weakening of the upper limb and the stocking distribution of lower motor neuron signs in the lower limb clearly indicated
a peripheral neuropathy. The patients report of burning and
tingling pains in the absence of pain perception was also typical
of peripheral neuropathies.
Figure 1: Findings on examination
The patient, JD, was a 24-year-old female who chronically abused

alcohol in the four years up to admission. She presented to A&E
unable to walk, complaining of a burning pain over her shins and
feet. Initial clinical suspicion was that a primary pathology was
being compounded by alcohol abuse. This diagnostically challenging case provided an atypical perspective into alcoholic neuropathy.
Miss JD presented to emergency services with numbness, pain and
weakness in the hands and legs. The symptoms arose progressively
over several weeks, prior to attendance at A&E. Tingling in the feet
and fingertips was the initial sensation the patient became aware
of. Within two weeks the slightly odd discomfort was replaced
by intense burning pain over the feet and shins, and was accompanied by an inability to walk normally. On the day of admission the
patient awoke in agony, unable to mobilize or stand.
A healthy lifestyle - something we emphasise to patients seen on

wards or in clinics. I say this whilst wolfing down my scrumptious
Indian takeaway. Have we as medical students forgotten to practise
what we preach?
Our grasp of the UK and US obesity problem has been found to

be fairly poor. Studies suggest that the hectic schedules we are
subjected to, along with the increased stress over years may be to
blame for our poor nutritional intake.5 Once again, it is a lifestyle
we must endeavour to change, both for our sakes and that of our
patients. After all, is it ethical for a clinically obese physician to
advise an obese patient on their diet?
cally light touch, was diminished distally in the hands
References
1.
2.
3.
4.
5.
Frank E, Elon L, Naimi T, Brewer R. Alcohol consumption and

alcohol counselling behaviour among US medical students: cohort
study. BMJ (Clinical research ed.) 2008 Nov 7;337: pp. a2155.
Keller S, Maddock JE, Laforge RG, Velicer WF, Basler HD.
Binge drinking and health behaviour in medical students.
Addictive Behaviors 2007 Mar;32(3): pp. 505-515.
Frank E, Carrera JS, Elon L, Hertzberg VS. Basic demographics, health
practices, and health status of U.S. medical students. American
Journal of Preventive Medicine 2006 Dec;31(6): pp. 499-505.
Skemiene L, Ustinaviciene R, Piesine L, Radisauskas R.
Peculiarities of medical students nutrition. Medicina
(Kaunas, Lithuania) 2007;43(2): pp. 145-152.
Swift JA, Sheard C, Rutherford M. Trainee health care professionals
knowledge of the health risks associated with obesity. Journal
of human nutrition and dietetics : the official journal of the
British Dietetic Association 2007 Dec;20(6): pp. 599-604.
Prior to this event, JD had been treated for depression, opiate

dependence and had a single hospital stay for a delivery at age
twenty. Heroin use was initiated at age 17, and non-intravenous
abuse continued for 3 years. JD was managed on methadone for
the duration of her pregnancy, leading to sustained heroin-abstinence.
At JDs request methadone treatment was stopped after18 months
of addiction management. Opiate withdrawal was not well tolerated and alcohol use escalated to alleviate symptoms. The patient
reported drinking 4-5 bottles of wine per day, supplemented with
other beverages daily consuming approximately 60-85 units of
alcohol. This 4-year period of binge drinking was associated with a
nutritionally limited diet.
Clinical Evaluation
On admission JD was not distressed, though in severe pain. Immediate observations of blood pressure and temperature were
normal. General inspection revealed no loss of muscle bulk or
obvious lesions.
A neurological examination found no tremors or involuntary movements in upper or lower limbs. Tone was also normal throughout.
Testing did not reveal signs of an upper motor neuron lesion.
Reflexes in the upper limb were normal. Power was bilaterally
maintained at a MRC 5 rating except at the interossei, at which it
was weakened to MRC 3 bilaterally. Similarly sensation, specifi-
Differentials & Investigations

The initial pre-investigative thinking was that JDs neuropathy
was aggravated by excessive alcohol consumption, though not
produced by it. A primary aetiology was sought.
Vasculitis was suspected following a DVT two hours into admission.
A blood test revealed normal inflammatory markers and a sedimentation rate within range. Most small or medium artery inflammation syndromes, capable of producing neuropathic change, would
distinctively affect such indicators.
Paraneoplastic syndromes could cause autonomic and peripheral
disturbances, but are rarely confined to motor and sensory deficits
in pattern distributions. Though no primary lesion suggestive of
neoplasm was found, paraneoplastic antibodies could present
anomalously and had to be excluded. The paraneoplastic antineuronal antibodies Hu and Yo were absent on CSF sampling.
Multiple myeloma, which is associated with anti-neuronal immune
activation, was also excluded with a negative urine screen for
Bence-Jones proteins.
JDs HIV status was questioned. The virus could appear as a
neural lesion reflecting a CD4 drop or opportunistic invasion.
The patients HIV status was negative.
13
SHORT CASE
EXPERT COMMENTS
Source: Wellcome Images
References
The symmetrical distribution of neurological deficits and symptoms
meanwhile strongly suggested Guillain Barre. Protein concentration in CSF samples though did not meet the diagnostic criteria of
greater than 10g/L.
1.
This meticulous process of exclusion left only alcohol-abuse as

the potential cause. A sural nerve biopsy was conducted, and the
subsequent nerve conduction study showed patterns consistent
with axonal damage characteristic of alcohol related neuropathy.
A head CT also revealed significant brain volume loss, a feature of
long-term alcohol abuse. Additionally, late into investigation, it
came to light that JDs father had abused alcohol and suffered a
peripheral neuropathy. The positive family history along with the
nerve study results strongly suggested alcoholic neuropathy.
3.
The principal treatment was alcohol cessation and dietary vitamin

supplementation. Neuropathic pain was managed on Amitryptilline, Gabapentin, Paracetamol and Ibuprofen. Muscular pain was
managed on Tramadol. Physiotherapy to rehabilitate lower limb
functionality remains on going.
Discussion
This syndrome most commonly presents after years of alcohol
abuse. How is it possible that a young person, with a relatively
short period of abuse, presented with such fulminant signs?
It is difficult to establish a reason for early onset, as the exact cause
of alcohol related neuropathy is disputed. The syndrome is clinically distinct from the thiamine deficiency etiology of Wernickes
encephalopathy and Korsakoffs syndrome; though low vitamin B
levels certainly are a factor.1 Animal models indicate that ethanol
distorts cytoskeletal elements and neuronal organelles.2 Acetaldehyde, a metabolite of ethanol, is also directly neurodegenerative.
A study by Monforte et al suggested that the severity of polyneuropathy is primarily dose dependent, implicating excessive alcohol
use.3
What is clear is that female alcohol abusers suffer higher rates of
peripheral neuropathy with a high incidence often seen amongst
women with affected family members.4 A growing body of evidence
suggests that alcoholic peripheral neuropathy is related to genetic
susceptibility to ethanol toxicity and damage. Results from a Japanese study showed a correlation between an alcohol dehydrogenase gene mutation which results in decreased ethanol metabolism
to diminished peripheral nerve conduction.5
2.
4.
5.
Koike H, Iijima M, et al. Alcoholic neuropathy is

clinicopathologically distinct from thiamine-deficiency
neuropathy. Annals of Neurology. July 2003 Vol 54: p. 19-29.
Corsetti G, Rezzani R, et al. Ultrastructural study of the alterations
in spinal ganglion cells of rats chronically fed on ethanol.
Ustructural Pathology. August 1998 Vol. 22: p.309-19.
Monforte R, Estruch R, et al. Autonomic and peripheral neuropathies
in patients with chronic alcoholism. A dose-related toxic effect of
alcohol. Archives of Neurology. January 1995 Vol. 52: p. 45-51.
Pessione F, Gerchstein JL, et al. Parental history of alcoholism:
a risk factor for alcohol-related peripheral neuropathies.
Alcohol. November 1995 Vol. 30: p. 749-54.
Masaki T, Mochizuki H, et al. Association of aldehyde
dehydrogenase-2 polymorphism with alcoholic polyneuropathy in
humans. Neuroscience Letters. June 2004 Vol. 363: p. 288-90.
How much is too much?

The most recent Government recommendations are up to 2-3
units per day for women and up to 3-4 units for men.
1 unit is equivalent to 8g of alcohol, which is approximately half a
pint of 4% beer or a 25ml measure of spirits (40%).
Statistics show over 40% of men and 33% of women drink more
than this, with over half drinking double their recommended
intake at least one day in the last week.
Young people were found to be more likely to exceed daily
guidelines and were also more likely to drink heavily, with 19% of
16-24 year old men drinking more than 8 units on a particular day
and 8% of 16-24 year old women drinking more than 6 units.
While the proportion of young women (age 16-24) drinking heavily was increasing rapidly reaching 28% in 2002, this figure has
been falling in recent years and went down to 22% in 2005.
Between 2006-2007 there were nearly 60,000 NHS admissions where the main diagnosis was related to alcohol, which is
an increase of 50% over the last decade.
Sources: NHS Information Centre, Statistics on Alcohol: England
2008, The General Household Survey 2005 and the National Statistics
Omnibus Survey 2006.
Mitochondrial medicine:
What the experts say
This is a field of growing importance as the role of mitochondria in
common diseases such as diabetes, heart disease and the neurodegenerative disorders is becoming better understood. There is
currently a NIH funded trial of Coenzyme Q10 in Parkinson disease
underway in the US and Canada recruiting 600 patients at over 50
centres a therapeutic opportunity which stems from the recognition
of the mitochondrial role in Parkinsons disease.
An estimated 1% of young diabetics have a mitochondrial DNA cause
and worldwide research on the mitochondrial role in Type 2 diabetes
is underway. There is good evidence that the study of primary
(genetic) mitochondrial diseases and their treatment provides valuable insights into mitochondrial function with important implications for more common diseases this is the focus of mitochondrial
medicine.
Richard Haas, MD
Professor of Neurosciences and Paediatrics
Director UCSD Mitochondrial Disease Laboratory
Mitochondrial medicine is an exciting new field that focuses on

human disorders that stem from inherited or acquired defects in
mitochondria. There are a large number of inborn errors that are
due to mutations in the mitochondrial genome or mtDNA - these
are often termed the primary mitochondrial disorders, and we know
with certainty that mitochondrial dysfunction causes the disease.
Whats important to remember is that for the majority of the more
common disorders [such as diabetes and obesity], it is unclear at
present whether the mitochondrial dysfunction is a cause or consequence of the disease. Human genetics studies of common disease
will help answer this question. Regardless, the important lessons we
are learning from the primary mitochondrial disorders will impact
our approach to even the common disorders.
The mitochondrion is a remarkable organelle, and scientists from a
variety of disciplines are helping to understand how it functions as
an integrated system. I think the mitochondrion will prove to be a
valuable model for systems biology - and that the lessons we learn
from mitochondrial medicine can be extended to virtually all other
human diseases.
Vamsi Mootha, MD
Associate Professor, Department of Systems Biology
Harvard Medical School
JD, fell into a surprising number of these risk categories, implying a

greater susceptibility. A cumulative effect of familial vulnerability,
poor diet, and considerable alcoholic insult lead to her presentation. Whether a genetic mutation or trait was present is speculative
although highly intriguing when considered as the root abnormality.
Such cases are unique, though no longer rare due to soaring rates
of youth alcohol misuse. Should this trend continue similar presentations could become familiar.
14
15
REVIEW
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Mitochondria
more than meets the eye
Stuart Potter
Consequences of Unregulated Apoptosis

Unregulated apoptosis, where more cells are induced to die than
can be replaced by mitosis, can exacerbate or even cause diseases.
These include neurodegenerative diseases like Alzheimers and
ischemic strokes (a result of restricted blood supply to the brain)
11,12
as well as immunodeficiency disease such as AIDS.13
Year 1 Medicine, St. Georges University of London

m0701759@sgul.ac.uk
For the full article and

references see
thelsjm.co.uk
Introduction
Mitochondria play a significant role in one of the most important
processes in the human body: aerobic (or cellular) respiration.
Mitochondria are double-membrane organelles that primarily provide energy for the cell. Utilizing the products of glycolysis in a
series of reactions called the citric acid cycle, mitochondria generate Adenosine Tri-Phosphate (ATP), the hydrolysis of which releases a substantial amount of energy. This is a very efficient process,
where as many as 36-38 molecules of ATP can be converted from a
single glucose molecule1. It is in this capacity as an energy supplier
that mitochondria are often referred to as the powerhouse of a
cell, however this is not the only function they provide.
Mitochondria also have the ability to synthesise hormones, such
as oestrogen and testosterone2, store calcium, and are associated
in the processes of cell signalling3. Another function that if not
correctly regulated could have devastating effects on the body, is
in apoptosis.
Apoptosis
Apoptosis is the controlled and regulated series of events which
results in cell death. These events can be initiated by an immune
response to stop an infection spreading or induced through extracellular (extrinsic) signals such as hormones and developmentalmediated signals. Apoptosis can also be induced when intrinsic
(intracellular) signals are produced as a result of cellular stress;
injury, oxidative stress caused by free radicals and exposure to
radiation, chemicals or a viral infection. This programmed cell
death (PCD) or cell suicide is favourable to the other form of cell
death, necrosis, which is uncontrolled and can result in potentially
serious health problems. Cell death plays a vital role in many
mechanisms and is important in the normal development of any
multi-cellular organism.
During development PCD causes superfluous tissue to disappear,
effectively sculpting the developing tissue4. An example of this is
the induction of apoptosis in inter-digital tissue, which prevents
human hands being web-like. Apoptosis can also be induced to defend an organism against unwanted or potentially dangerous cells,
such as tumour cells5 or cells infected by viruses6. This mechanism
is drastic, but also the most effective at halting viral proliferation.
PCD also serves to regulate the number of cells in an organism,
keeping the number relatively constant to maintain homeostasis7.
This is essential for the normal function of an organism, as without
16
Figure 1: Diagram showing the role of mitochondria in apoptosis

(Reproductive and Cardiovascular Research Group)
Dysfunctional or damaged mitochondria can affect the balance

between cell death and cell division (mitosis), the effect being
unregulated mitosis. Without the balance provided by apoptosis,
the cell effectively becomes immortal with its unrestrained mitosis resulting in the development of a tumour. Recent research into
the role of mitochondria in the propagation of tumours has lead to
some promising developments in combating cancer.
Conclusion
With many important functions vital for normal cell processes,
mitochondria are an essential component of a cell. The current
research into the application of mitochondrial-stimulated apoptosis
in combating cancer is particularly promising. This development,
when considered in conjunction with other mitochondria-associated functions, demonstrates that mitochondria are more than just
the cells powerhouse.
References
1.
2.
3.
Medical Application of Apoptosis

Researchers in Edmonton, Canada believe they have found a
cheap, effective and relatively safe treatment for many forms of
cancer. Dr. Evangelos Michelakis, a professor of the Department
of Medicine at the University of Alberta, has shown that the drug
dichloroacetate (DCA) attacks cancer cells while leaving surrounding healthy tissue intact. The drug has been used for years to
treat metabolic conditions due to mitochondrial disease, but when
introduced to cultures of lung, breast and brain tumours, the drug
caused regression of the cancer cells.
4.
5.
6.
7.
Researchers originally thought that cancer resulted in the irreparable damage of mitochondria; however Dr Michelakis and
his colleagues found that DCA revived cancer-affected mitochondria, showing that the cancer only suppressed their function. Dr
Michelakis believed that DCA could be selective for cancer cells
whilst leaving normal cells as it attacks a fundamental process in
cancer development that is unique to cancer cells14
8.
9.
10.
proper regulation the consequences can prove fatal. Mitochondria

contain many pro-apoptotic proteins and therefore have a very
important role in the regulation of intrinsic PCD.
The role of mitochondria in apoptosis
Apoptotic signals such as cellular damage or stress trigger
apoptosis by activating the bcl-2 family of proteins found in the
cytoplasm. Pro-apoptotic proteins, in this family such as Bax and
Bid, relocate to the surface membrane of mitochondria where they
disrupt the functioning of apoptosis inhibitors. The anti-apoptotic
protein Bcl-2, works to maintain the membrane potential of the
mitochondrion8 ; disruption of this function leads to the formation
of permeability transition (PT) pores 9which release pro-apoptotic
molecules, including cytochrome C. The release of cytochrome C
initiates a caspase (Cysteine Aspartate Specific ProteASE) cascade,
which is one of the main executors PCD.
Upon release, cytochrome C binds to Apaf-1 (apoptosis proteaseactivating factor 1), a cytosolic protein that normally exists as an
inactive monomer, this institutes a conformational change that allows it to bind with ATP 10forming apoptosome. Apoptosome then
recruits multiple pro-caspase 9 molecules, facilitating their activation to caspase 9, which in turn activate caspase 3 (the executioner
caspase) and the induction of apoptosis (Fig. 1)
It was believed that cancer cells use glycolysis because their

mitochondria were damaged, but Dr Michelakis study suggests
that these cells switch off their mitochondria as a survival mechanism. When the cells dont receive enough oxygen for their mitochondria to function properly they switch off the mitochondria so
they can produce energy through glycolysis. Incidentally, a product
of glycolysis is pyruvate, which in anaerobic conditions generates
lactic acid. It is thought that lactic acid can work to propagate
the spread of cancerous cells, spreading tumours throughout the
body.15
As the normal function of mitochondria is the apoptosis of
abnormal cells, switching it off confers immortality on the cell.
DCA reactivates mitochondria, shifting metabolism from glycolysis
to glucose oxidation16. This reduces lactic acid production and
restores the normal function of the organelle. With normal function
restored, the mitochondria initiate PCD in the abnormal cancer
cells; leaving non-cancer cells unaffected.
Side effects
Results for clinical trials using DCA to treat cancer in humans
are unavailable presently; the drug has been used to treat other
conditions with some of its side-effects known. These include pain,
fatigue, gastrointestinal distress, numbness and gait disturbance.17,
18
Dichloroacetate can also cause toxic neuropathy in certain individuals.19 Such problems would be considered minor if clinical trials
substantiate its effectiveness as an anti-cancer treatment.
Cooper, G. M. Metabolic energy. [Internet]. The Cell: A Molecular

Approach 2000. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?indexed
=google&rid=cooper.section.294 [Accessed October 25th 2007]
Widmaier, Eric P., Raff, Hershel and Strang, Kevin T. Vanders
Human Physiology.10th edition 2006 New York: McGraw-Hill
Smaili, S. S. Mitochondria in Ca2+ signaling and apoptosis.
2000 Caspases.org. <http://www.caspases.org/showinfo.
php?pmid=11768760>[Accessed October 15th 2007]
Clarke, P. G. & Clarke, S. Nineteenth century research on
naturally occuring cell death and related phenomena. 1996 Anat.
Embryol. [Internet]. (193). 81-99. In:Mignotte, B. V. (1998).
Mitochondria and Apoptosis. Eur. J. Biochem. 252. 1-15. <http://
www.blackwell-synergy.com/> [Accessed 25th October 2007]
Williams, G. T. Programmed cell Death: apoptosis and oncogenesis.
1991 Cell [Internet]. (65). In: Mignotte, B. V. (1998). Mitochondria and
Apoptosis. Eur. J. Biochem. 252. 1-15. <http://www.blackwell-synergy.com/>
Vaux, D. L.. An evolutionary perspective on apoptosis 1994 Cell
[Internet]. (76). In: Mignotte, B. V. (1998). Mitochondria and Apoptosis.
Eur. J. Biochem. 252. 1-15. <http://www.blackwell-synergy.com/>
Raff, M. Social control on cell survival and cell death 1996 Nature
[Internet]. (356). In: Mignotte, B. V. (1998). Mitochondria and Apoptosis.
Eur. J. Biochem. 252. 1-15. <http://www.blackwell-synergy.com/>
Zamzami, N. S.-M. Mitochondrial control of nuclear apoptosis. 1996J.
Exp. Med. [Internet]. (183). In: Mignotte, B. V. (1998). Mitochondria and
Apoptosis. Eur. J. Biochem. 252. 1-15. <http://www.blackwell-synergy.com/>
Antonsson, B. C.. Inhibition of Bax channel-forming activity by
Bcl-2. Science 1997 [Internet]. (277), 370-372. In: Mignotte,
B. V. (1998). Mitochondria and Apoptosis. Eur. J. Biochem.
252. 1-15. <http://www.blackwell-synergy.com/>
Wang, X. The expanding role of mitochondria in apoptosis. Genes and
Development 2001 [Internet]. 15 (22), 2922-2933. <http://www.
genesdev.org/cgi/reprint/15/22/2922.pdf> [Accessed October 2007]
Mitochondrial Medicine
Research in the UK has demonstrated that mitochondrial diseases are not rare. A
study carried out at Newcastle University shows that 1 in every 200 people have a DNA
mutation that could potentially cause a mitochondrial disease.1
Symptoms of Mitochondrial Disease
Mitochondrial diseases are extremely complex. The affected individual may present
with the following symptoms:
Seizures
Muscle weakness
Severe vomiting and diarrhoea/constipation
Feeding problems
Poor immune system
Failure to thrive
Delayed achievement of key milestones
Heat/cold intolerance
Diabetes and lactic acidosis
A red flag would be where a patient has more than three systems affected, or when
a disease exhibits atypical signs and symptoms.
Further Reading
http://www.ncl.ac.uk/biomedicine/research/groups/mitochondrial.htm
References
1. Turnbull, D and Chinnery, P. How Common are Mitochondrial Disorders? s.l. : United Mitochondrial Disease Foundation, 2001.
17
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The successes and failures of

Leptin in the fight against obesity
Daniel Hammersley BA Hons(Oxon)
djhammersley@googlemail.com
the regulation of energy balance and body weight. 7 The concept

of a peripheral factor responsible for relaying energy status to the
hypothalamus was later introduced. 8 It was suggested that this
factor was responsible for matching changes in body energy status
with compensatory changes in food intake and energy expenditure,
so as to maintain energy stores. Evidence for this being a bloodborne factor came from Herveys parabiosis experiments. 9 Hervey
showed that parabiosis between a rat that was obese due to a
lesion of the ventromedial hypothalamus (VMH) and wild-type rat,
caused profound weight loss in the latter; this was assumed to be a
result of an unidentified circulating factor produced in the lesioned
rat acting on the wild-type rat. It was not until 1994 that Friedmans
group identified the ob gene by positional cloning, identifying also
its gene product Leptin.3 This discovery was soon followed by the
identification of the Leptin receptor.10 Such high hopes were held
for Leptin, that the commercial rights to the hormone were bought
by Amgen for US$20 million in 1995. 11
Knowledge acquired from the discovery of Leptin

The discovery of Leptin has opened up an entirely novel area of
research which has given energy homeostasis a biological context,
whilst offering a new perspective from which to consider obesity.21
Human understanding of the biology of energy homeostasis has
increased exponentially since its discovery, and this knowledge is
crucial in understanding how this system may malfunction in obesity. It is through understanding the pathophysiology of obesity that
effective novel therapies will be developed.
The discovery of Leptin has facilitated the precise unravelling of
many molecular pathways and the hypothalamic neurocircuitry involved in energy homeostasis, and in particular in appetite control.
Crucial to this, is the ability of Leptin to manipulate anorexigenic
(inhibiting appetite) and orexigenic (stimulating appetite) neuropeptides in the hypothalamus. This is illustrated in Figure 1.
Hy pothalam us
Early work following the discovery of Leptin

If we consider the early experiments published following the
discovery of Leptin, one can begin to understand the scale of
the initial scientific hype that surrounded its discovery. Early
experiments involved the morbidly obese ob/ob mouse, which is
homozygous for mutation of the ob gene. Following administration
of recombinant Leptin, the ob/ob mouse showed marked weight
loss characterized by a reduction in the percentage body fat. 12
This finding lead to hopes that the pathophysiology of common
human obesity related to low levels of Leptin, and therefore that
recombinant Leptin therapy could act as a novel and revolutionary treatment. However, only in a very small number of cases has
recombinant Leptin therapy proved effective; 13 this is limited to
individuals with absolute congenital Leptin deficiency caused by
homozygous mutation of the human ob gene. 14

references see
thelsjm.co.uk
18
The world obesity problem is now reaching pandemic proportions.

Using criteria drawn up by the World Health Organisation (WHO)
defining overweight as a Body Mass Index (BMI) of over 25 and
obese as a BMI of over 30, worldwide estimates in 2005 were of
the order of 1.6 billion overweight and 400 million obese.
The WHO predicts that by 2015, an estimated 2.3 billion will be
overweight and more than 700 million obese.1 The considerable
morbidity and mortality associated with obesity mean that the
condition now presents one of the leading world health burdens.
Despite the overwhelming proportions of the obesity problem,
obesity is a poorly understood condition for which therapeutic
intervention and clinical management strategies are clearly inadequate. In 1994, the discovery of the hormone Leptin3 was heralded
as a major breakthrough in the field of appetite control and obesity.
Initial hopes that the hormone would yield a magic bullet treatment for obesity were met with disappointment; however the implications of the discovery of Leptin reach far beyond these initial
hopes. The discovery of Leptin has opened up a whole new area of
biology relating to appetite and energy homeostasis and provided a
scientific framework for approaching obesity and developing novel
therapeutic approaches.
Historical background
Congenital Leptin deficiency is exceedingly rare, and in the years

following the discovery of Leptin, evidence accumulated to suggest that the direct use of recombinant Leptin alone was of little
therapeutic value to the vast majority of obese patients. The initial
evidence for this came from the observation that subjects suffering
from common obesity had raised plasma Leptin concentrations.15
This inferred that in common obesity there is a state of Leptin
resistance. Subsequent evidence from a number of clinical trials
showed that subcutaneous recombinant Leptin administration
did not induce a significant reduction in body weight in obese patients.16, 17 These findings accompanied a shift in opinion concerning the major physiological role of Leptin from a prevailing view
that it acted as an anti-obesity hormone to a belief that Leptin was
in fact more important as an anti-starvation hormone, and that in
low concentrations, Leptin signalling initiates some of the adaptive
physiological responses to starvation.18
Understanding the physiological control of appetite and energy

homeostasis has long been an elusive goal for scientists. Fundamental to the understanding of energy homeostasis was an initial
appreciation that humans obey the first law of thermodynamics; meaning that in order to maintain body weight, energy input
must balance energy expenditure. 6 Such is the stability of body
weight that it was assumed that this balance was maintained by
extensive regulatory mechanisms; the identification of which
remained unknown to scientists for many years. 6 Hypothalamic
lesion studies indicated that the hypothalamus plays a key role in
Why was the discovery of Leptin a major scientific breakthrough?

The failure of Leptin to provide a therapy for obesity coupled with
its suggested primary role in signalling during starvation, initially
lead some to question whether Leptin has lived up to its early
promise as a major breakthrough in the field of obesity and appetite
control. However, the significance of its discovery is justified by
first considering the scientific knowledge that has been acquired
as a result, and second by considering the future implications of its
discovery.
Leptin and its role in energy homeostasis

Leptin is a single-chain protein hormone with a molecular mass of
16kDa .4 Leptin is the cleaved transcript of the ob gene, produced
predominantly by adipocytes in white adipose tissue.5 It functions
as an afferent signalling molecule responsible for feeding back the
bodys energy status from peripheral adipose tissue to the hypothalamus. Leptin signalling results in the modulation of feeding
and energy expenditure, and thus is involved in energy homeostasis
and weight maintenance. Circulating basal Leptin levels reflect the
total fat stored in adipose tissue. Fluctuations from this level occur
during times of energy imbalance, especially during times of energy
deficiency, when circulating Leptin levels are rapidly reduced.6
ARC
W hit e A di pose
T issue
L epti n
NPY
A gR P
PO M C
CA R T
L HA
F ood
int ak e
En er gy
expendi t
ure
PVN
BBB
Figure 1: Simplified schematic diagram illustrating the major effects of Leptin on hypothalamic neurocircuitry. Leptin is transported across the bloodbrain barrier (BBB). Leptin binding in the hypothalamic arcuate nucleus
(ARC) results in the inhibition of orexigenic neuropeptide Y (NPY) and
agouti-related protein (AgRP) neurons and the stimulation of anorexigenic
pro-opiomelanocortin (POMC) and cocaine- and amphetamine- related
transcript (CART) neurons. AgRP is an endogenous antagonist of receptors
downstream of the POMC neurons (melanocortin 3 and 4 receptors
[MC-3R, MC-4R]). First-order neurons project primarily to the lateral
hypothalamus (LHA) and the paraventricular nucleus (PVN). The action of
Leptin on the hypothalamic neurocircuitry results in reduced food intake
and increased energy expenditure. Conversely, low levels of Leptin, as
occurs during starvation, stimulates NYP and AgRP and inhibits POMC and
CART.
Leptin signalling undoubtedly affects a number of other neuropeptides such as corticotrophin-releasing hormone (CRH), orexin,
galanin and neurotensin, also involved in energy homeostasis signalling.23 Leptin is therefore important in integrating the many different hypothalamic neuropeptides involved in energy homeostasis.
A further integrative role for Leptin

As well as integrating hypothalamic neuropeptides, Leptin signalling is known to mediate some of its effects on energy balance via
the regulation of other parallel systems involved with communicating peripheral energy status to the CNS. Leptin is known to regulate the responsiveness of the Nucleus of the Solitary Tract (NTS)
to short-acting gut-derived satiety signals such as cholecystokinin.24
Leptin has also been found to directly modulate reward pathways
associated with feeding. 25 Beyond the homeostatic control imposed by the hypothalamus, feeding is known to also be influenced
by the reward value and pleasure associated with particular food,
19
REVIEW
mediated via the mesolimbic pathway.26 Leptin receptors are
expressed on dopaminergic neurons in the ventral tegmental area
and Leptin binding has an inhibitory effect on this circuit, reducing
the reward value of food.27 Conversely, decreased Leptin signalling
increases the reward value of food, accounting for the increased
palatability of food during starvation.25 Therefore, there is increasing evidence for Leptin being a kingpin hormone with a number of
integrative roles linking different systems that influence food intake
and energy balance.
The future implications of the discovery of Leptin
Much research is ongoing in the field of Leptin resistance. Leptin
is undoubtedly an effective signalling molecule in low concentrations; however what remains to be seen is whether overcoming
Leptin resistance will result in Leptin acting at higher concentrations to reduce body weight. It is likely that Leptin resistance is a
remnant from our evolutionary past which once conferred a selective advantage.18 This probably evolved in response to feast-famine
feeding habits, when the Leptin resistance allowed the development of latent obesity during times of plenty, and that this storage
of excess fat was advantageous during subsequent times of food
scarcity. 6 Thus Leptin resistance may have been a component of
the so-called thrifty genotype. However, in modern society where
food is generally unlimited and a sedentary lifestyle the norm, the
existence of such thrifty genes is associated with the widespread
development of obesity. If Leptin resistance is indeed involved in
the pathophysiology of obesity then understanding and overcoming
this resistance could provide the key to novel therapies.
Two main hypotheses have been put forward to explain Leptin
resistance; the first relates to a failure in the BBB Leptin transport
system and the second to impairment of Leptin signal transduction
pathways. Considering the former, rodent studies revealed that
the transport system responsible for transporting Leptin across the
BBB is saturable28 and that diet-induced obesity is associated with
a reduction in the ability to transport Leptin across the BBB,29 this
proposed mechanism is termed peripheral resistance. The second
hypothesis, relates to the finding that Leptin signal transduction is
inhibited by regulatory molecules such as suppressor of cytokine
signalling 3 (SOCS3). The activity of such molecules has been
shown to be increased in obese rats compared with wild-type,30
termed central resistance.
Although presently the manipulation of downstream Leptin
pathways has not yielded novel therapies for obesity, it is hoped
that given the current level of research this approach will soon
result in a breakthrough. That said, critics question the existence
of Leptin resistance, believing that the hormone only functions at
low concentrations and that high Leptin levels in obesity are purely
a consequence of the increased adipocyte fat mass, rather than a
cause of the condition.35 Further research will reveal whether this
theory holds true.
life-style alterations. Consistent with this hypothesis, it was found

that weight loss caused by Sibutramine (a centrally-acting appetite
suppressant that can be prescribed to promote weight loss in obese
patients) was enhanced by the serendipitous administrations of low
doses of Leptin in rats.2
Summary
The discovery of Leptin has greatly expanded human understanding of appetite control and energy homeostasis and it is for this
reason that this discovery has been a scientific advance of major
significance. Leptin itself has not provided an instantaneous cure
for obesity, but its discovery has unveiled a whole new area of biology which has opened up a Pandoras box of possible therapeutic
targets for the future. One cannot expect to find an effective
treatment for obesity without first having a sound understanding
of the physiology of energy homeostasis and the pathogenesis of
obesity. The discovery of Leptin has resulted in major advances
human understanding of both these areas. An understanding of
Leptin biology is likely to underpin future developments in appetite
control and obesity.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
WHO media centre. WHO Fact Sheet No. 311. 2006.

Available from http://www.who.int/mediacentre/
factsheets/fs311/en/, accessed on 05/03/09.
Boozer CN, Leibel RL, Love RJ, Cha MC, Aronne LJ. Synergy
of sibutramine and low-dose Leptin in treatment of dietinduced obesity in rats. Metabolism. 2001; 50:889-93.
Zhang Y, Proenca R, Maffei M, Barone M, Leopold L,
Friedman JM. Positional cloning of the mouse obese gene
and its human homologue. Nature. 1994; 372:425-32.
Meier U & Gressner AM. Endocrine regulation of
energy metabolism: review of pathobiochemical and
clinical chemical aspects of Leptin, ghrelin, adiponectin,
and resistin. Clin Chem. 2004; 50:1511-25.
Trayhurn P & Bing C. Appetite and energy balance signals from
adipocytes. Philos Trans R Soc Lond B Biol Sci. 2006; 361:1237-49.
Friedman JM. Modern science versus the stigma
of obesity. Nat Med. 2004; 10:563-9.
Anand BK & Brobeck JR. Hypothalamic control of food
intake in rats and cats. Yale J Biol Med. 1951; 24:123-40.
Kennedy GC. The role of depot fat in the hypothalamic control of
food intake in the rat. Proc R Soc Lond B Biol Sci. 1953; 140:578-96.
Hervey GR. The effects of lesions in the hypothalamus
in parabiotic rats. J Physiol. 1959; 145:336-52.
Tartaglia LA, Dembski M, Weng X, Deng N, Culpepper J,
Devos R, Richards GJ, Campfield LA, Clark FT, Deeds J, Muir
C, Sanker S, Moriarty A, Moore KJ, Smutko JS, Mays GG, Wool
EA, Monroe CA, Tepper RI. Identification and expression
cloning of a Leptin receptor, OB-R. Cell. 1995; 83:1263-71.
Another potential future role for Leptin is to prevent the re-gaining

of weight following weight loss. The reduction in Leptin levels
following weight loss and the physiological response to this is
thought to be a major contributing factor to the subsequent re-gain
of weight. Therefore it has been hypothesized that exogenous
Leptin therapy, in order to maintain high Leptin levels, may help
to maintain weight loss. Leptin therapy could be used in this way
in combination with other anti-obesity therapies or simply with
20
PERSPECTIVE
REVIEW
Rheumatoid arthritis and the

anti-TNF revolution
Bernard Freudenthal BA (Hons)
Year 5 Medicine, University College London

bfreud@gmail.com
references see
thelsjm.co.uk
Introduction
Advances in biotechnology have given rise to biotherapeutics
synthetic proteins that mimic antibodies or large-molecule
inhibitors to directly modulate specific disease pathways. The
development of anti-TNF cytokine inhibition in rheumatoid arthritis
(RA) is a great success story of recent medical science.
Background
RA is a systemic inflammatory disease marked by a symmetrical
peripheral polyarthritis 1. It affects approximately 1% of people
worldwide, with a highly variable clinical course. Features include
joint swelling, pain, stiffness, fatigue and fever. RA can be highly
debilitating with significant morbidity, loss of productivity and
shortened life expectancy.
Articular involvement is characterised by erythema, effusion
and synovitis that can lead to progressive joint destruction and
deformity especially of the proximal interphalangeal, metacarpaland metatarsal-phalangeal joints, and of the wrist and ankle.
Common extra-articular manifestations include subcutaneous
rheumatoid nodules, anaemia, pulmonary fibrosis, and Sjgrens
syndrome .2
Before recombinant biotherapeutics, treatment was restricted
to non-steroidal anti-inflammatory drugs (NSAIDs), smallmolecule disease-modifying anti-rheumatic drugs (DMARDs), and
corticosteroids. Though DMARDs such as methotrexate can allow
sparing of corticosteroids, they often have toxicity and limited
efficacy .3
Cytokines in RA
RA is commonly regarded as an autoimmune disease with 80%
of patients having serum rheumatoid factor (RF) (anti-IgG
autoantibodies). Deranged antigen presentation or T-cell
recognition have also been implicated, given RAs correlation with
HLA-DR4/DR1 alleles (MHC class II) and since T-cells are found
in the synovial infiltrate.1 With increasing knowledge of the role
of cytokines in inflammation, RA disease mechanisms are better
understood, though what triggers its onset remains unclear.
Cytokines are extracellular short-range paracrine or autocrine
signalling proteins that regulate inflammation, tissue repair,
immunity, and cell division . 4 There are over 100 known cytokines,
22
which function via complex network-like interactions. Though they

must also drive pathogenic inflammatory processes, it is difficult
to demonstrate an aetiological role for specific cytokines in a given
disease .5
For a given cytokine to become a potential therapeutic target, it
must be shown to have a key rate-controlling function. Qualified
deductions can be made from animal models by cytokine over
expression or total abrogation in transgenic mice, or by infusion
of neutralising antibodies5. Alternatively, human in vitro models
using cultures or explants can be used. However, transient and
variable cytokine expression, and synergy and antagonism between
cytokines and physiological inhibitors, can frequently cause
negative results .6
To discover which of the many cytokines identified are upstream
and rate-limiting, anti-TNF antibodies were added to rheumatoid
synovial cell cultures, which caused a decrease in IL-1 production.11
Furthermore, TNF induced the synthesis of IL-1 in endothelial
cell cultures12, while an IL-1 receptor antagonist did not reduce
TNF expression in rheumatoid synovial cell cultures.13 IL-1 was
already known to be a crucial stimulator of fibroblast proliferation
and prostaglandin synthesis in cell cultures, bone resorption and
proteolysis in tissue explants, and release of systemic acute phase
proteins.10,14
TNF - the key RA cytokine?
Tumour necrosis factor (TNF) was first identified in 1975 as a
serum extract from mice inoculated with bacterial endotoxin,
which induced haemorrhagic necrosis of tumours .15 By 1985, the
molecular identity of human TNF was characterised and cDNA
clones were synthesised .16 A structurally homologous cytotoxic
factor was named TNF to differentiate from the original
TNF.17 TNF was subsequently renamed lymphotoxin and is
mainly produced by stimulated T-cells. TNF is synonymous with
TNF, and is produced in disease by macrophages. Physiological
functions of TNF include protection against bacterial infection, and
also modulation of cell growth, viral replication, tumour genesis
and immune regulation.17
Animal models further demonstrated TNFs role in RA. Collageninduced arthritis (CIA) arises in genetically susceptible mice
injected with collagen type-II and an adjuvant, and has many
similarities with RA. Administration of anti-TNF antibodies in CIA
mice reduced both active inflammation and joint damage.18 In
addition, over expression of TNF in transgenic mice caused an
erosive polyarthritis, which anti-TNF antibodies could prevent.19
Therapeutic anti-TNF
Sufficient evidence had been accumulated to move onto clinical
trial of TNF blockade in RA. Fortuitously, anti-TNF antibodies
and TNF-receptor (TNFR)-IgG-Fc fusion proteins were already in
development as experimental treatment of TNF-mediated sepsis.18
The first anti-TNF agent tested was a chimeric antibody, later
named infliximab, with a mouse variable region grafted to a human
constant region. In 1992, an open trial was performed at Charing
Cross Hospital, London. Infliximab infusion was given to twenty
longstanding RA patients who were unresponsive to DMARDs.20
All the patients responded, many with dramatic symptomatic
improvement, and at 6 weeks there was a 70% reduction of
swollen joints. By 26 weeks, all the patients had relapsed, showing
that TNF blockade only brings temporary relief, but the therapy
appeared efficacious and safe, warranting further trials. A phase-2
double-blind randomised placebo-controlled trial was performed
in 1993 with two doses to demonstrate dose response, with 79%
response to the high dose.18
Many questions remained concerning the feasibility of long-term
TNF blockade. Might the infused antibodies, even if completely
humanised, still prove to be immunogenic on the long-term and
so elicit a neutralising host antibody response? Even if TNF could
be successively inhibited, might another cytokine replace TNFs
function, given the dynamic cross-communication of cytokine
pathways? An additional concern was that permanent disruption
of TNFs physiological functions might increase susceptibility to
infection and malignancy.18
including ankylosing spondylitis, psoriasis and Crohns disease.17

However, results have been more mixed in other diseases such as
systemic lupus erythematosus and multiple sclerosis, and anti-TNF
proved to be ineffective in treating septic shock, for which it was
first developed.25
Even in RA, anti-TNF treatment is not without its problems, with
concerns that anti-TNF could cause infection and malignancy.
UK National Institute for Clinical Excellence (NICE) guidelines
require all patients to be enrolled in the Biologics Registry of the
British Society of Rheumatology to monitor the long-term safety
of anti-TNF. Rates of serious infection are so far unchanged,
though there is an increase in skin and soft tissue infections, in
particular with intracellular pathogens such as salmonella, listeria
and legionella, and as of March 2005, there were 11 cases of
tuberculosis.26 A recent meta-analysis of adverse effects in antiTNF trials (excluding soluble TNFR) showed a dose-dependent
increase in malignancies and serious infections, suggesting that a
minimum required dose should be used, and that patients should
be screened for subclinical malignancies before initiating anti-TNF
therapy.27
Conclusion
Anti-TNF is a remarkable clinical success and continues to be the
predominant biological therapy for RA over a decade after being
licensed. It has transformed the lives of many thousands of sufferers
of a severely debilitating progressive illness. However, the use of
biotherapeutics will always be affected by their prohibitive expense
a years treatment of infliximab costs nearly 10,000. Treatment
by cytokine inhibition requires that continuous blockade will always
be required, and the requirement for parenteral administration is an
important practical consideration. With advancing understanding
of disease mechanisms, future goals for biological treatment of RA
should be to induce long-term remission by targeting the underlying
pathogenic causes.
References
A subsequent study with five doses over three months showed that
immunogenicity could be managed either by using larger doses
or by co-administering methotrexate, which is known to deplete
T-cells.18 This suggests a synergistic effect similar to the successful
co-administration of anti-CD4 (a T-cell marker) and anti-TNF
antibodies in the CIA model.21 A two-year phase-3 study with six
months treatment showed that cartilage and bone damage was
arrested, with sustained benefit in over half the patients.22 In some
patients there was even evidence of repair to damaged joints.
Trials of a TNFR fusion protein, etanercept, followed soon after,
and both drugs were subsequently licensed for use in RA. Current
UK guidelines advocate their use in patients who have failed to
respond to at least two DMARDs including methotrexate.23
With response rates of 60-80% in trial subjects who were resistant
to all other treatments, anti-TNF was a huge success.18 Nonresponders might have raised a neutralising human anti-chimeric
antibody (HACA) response, they might have TNF or other cytokine
polymorphisms, or they could require higher dosing. Synovial
biopsy has shown that patients with low TNF in their synovial fluid
are less likely to respond,24 suggesting heterogeneous pathogenic
mechanisms.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Lee DM, Weinblatt ME. Rheumatoid arthritis.

Lancet. 2001; 358(9285):903-11.
Young A, Koduri G. Extra-articular manifestations and complications of
rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2007; 21(5):907
Smolen JS, Steiner G. Therapeutic strategies for rheumatoid
arthritis. Nat Rev Drug Discov. 2003; 2(6):473-88.
Oppenheim JJ, Feldman M. Introduction to the Role of Cytokines
in Innate Host Defense and Adaptive Immunity, In: Cytokine
Reference, Vol 1: Ligands. London: Academic Press, 2001.
Feldmann M, Brennan FM. Cytokines and Disease, In: Cytokine
Feldmann M, Saklatvala J. Proinflammatory cytokines, In: Cytokine
Brennan FM, Chantry D, Jackson A, et al. Inhibitory effect of
TNF alpha antibodies on synovial cell interleukin-1 production
in rheumatoid arthritis. Lancet. 1989; 2(8657):244-7.
Nawroth PP, Bank I, Handley D, et al. Tumor necrosis factor/
cachectin interacts with endothelial cell receptors to induce
release of interleukin 1. J Exp Med. 1986; 163(6):1363-75.
Butler DM, Maini RN, Feldmann M, et al. Modulation of proinflammatory
cytokine release in rheumatoid synovial membrane cell cultures.
Comparison of monoclonal anti TNF-alpha antibody with the interleukin-1
receptor antagonist. Eur Cytokine Netw. 1995; 6(4):225-30.
Saklatvala J, Sarsfield SJ, Townsend Y. Pig interleukin 1. Purification of two
immunologically different leukocyte proteins that cause cartilage resorption,
lymphocyte activation, and fever. J Exp Med. 1985; 162(4):1208-22.
Anti-TNF treatment has since been successfully tested and

licensed for use in other autoimmune inflammatory diseases
23
PERSPECTIVE
PERSPECTIVE
Rheumatoid Arthritis A
Medical Students Perspective
Sarah Hewett
Sarah.hewett06@imperial.ac.uk
Ironically, I was sitting in a rheumatology lecture when I first
realised that I had arthritis. I had had a few random joint pains for
a month or so, but assumed Id just bumped my hand, or twisted
my ankle. I was probably in denial for a while - four or five years
previously, I got a virus, which lead to arthritis, and I did not want
to admit that it was back. Eventually though, the arthritis was
interfering with daily activities like walking and writing, so I knew I
had to get some help.
At the beginning of the summer 2008, I went to see the GP.
Unfortunately, he could see no signs of active inflammation and
so, despite the pain I was in, he was unable to give me a referral.
Shortly afterwards, I had the first of many flare ups. My left hip was
excruciatingly painful on any movement and to the touch. I went
to my local A&E, and was given co-codamol, which helped hugely,
and a referral to an excellent rheumatologist in London.
My rheumatologist has been wonderful. He suspected rheumatoid
arthritis from the start, and ordered bloods (including rheumatoid
factor and anti-CCP antibody, both of which were positive). He
also gave me an IM injection of depo-medrone, a corticosteroid,
which calmed the arthritis for about a month, and allowed me to
enjoy the rest of the summer. I was formally diagnosed at the next
appointment in September 2008.
I do not have the typical symmetrical rheumatoid arthritis.
Different joints are involved at different times. My shoulders,
elbows, wrists, hands, hips, knees, ankles and feet have all been
affected. The arthritis jumps at random between the joints,
affecting varying numbers of joints at any one time.
I was started on a low dose of methotrexate (7.5mg once
weekly). Methotrexate is a disease modifying anti-rheumatic drug
(DMARD). The dose was slowly increased as I didnt seem to have
any benefit from the methotrexate, up to the maximum dose for
rheumatoid arthritis (20 mg once weekly). Luckily, I didnt have
any side effects either! However, the methotrexate didnt seem to
do the trick so, a few months later, hydroxychloroquine (another
DMARD) was added, along with a regular NSAID (diclofenac).
The next step in the treatment of rheumatoid arthritis is anti-TNF.
Anti-TNF is currently the best treatment for rheumatoid arthritis,
but patients have to jump through many hoops to get it. Current
NICE guidelines state that a patient has to have tried at least two
DMARDs for six months each, partly because anti-TNF is a very
expensive medication. Of course, this means up to twelve months
of failed therapy before getting the medication which works, which
can cause unnecessary suffering and irreversible joint damage.
The addition of hydroxychloroquine was done with future anti-TNF
treatment in mind, so that I would meet these criteria as soon as
possible. I was hugely lucky, because my rheumatologist and the
rheumatology specialist nurse did so much to help me. One month
ago, I started taking Etanercept 50mg once weekly.
24
The first hurdle there was learning how to inject myself. The first
time was terrifying, and it took about ten minutes before I worked
up the courage to do it! But after that, it became much easier. The
benefit of being on the anti-TNF quickly became apparent, so that
gave me some incentive.
Of course, anti-TNF disrupts the immune system, making me
more prone to infections. I developed a chest infection a couple
of weeks ago, so had to miss my dose of anti-TNF to give myself a
chance to recover, and wound up having two flare ups in as many
weeks. Back on the anti-TNF now, Im feeling a hundred times
better again.
The flare ups, when I have them, are really tough. The pain is often
excruciating, and can be in just a few joints or all over. Pain killers
dont do much for the pain on the first day of the flare up, but do
help after that. Flare ups usually last for a few days. Since being
on the anti-TNF, I have found that the flare ups I have dont seem
to last as long as they did before I started treatment, which is a
definite bonus.
One of the hardest things to cope with has been the tiredness.
The arthritis means that everything is a huge effort, so Im always
exhausted by the end of the day, and I usually dont sleep very well
because of discomfort. But, by going to bed very early, and giving
up my extra-curricular activities, I have been able to continue with
my studies.
Something else that has been quite difficult is the fact that
physically I look quite well. This means that the people around me,
who do not know about my condition dont understand why, for
example, it takes me a few moments to get off the bus, or longer
to walk up the stairs. I often get unpleasant looks from people who
simply dont realise what is wrong with me.
I have been extremely lucky with the support that I have been
given. My rheumatologist and the rheumatology specialist nurse
are always happy to talk to me, and I am extremely grateful for
this, as there have been times when I have needed advice quickly
on how to manage pain during flare ups, or information about my
medication.
My mum lives fairly close to me, and has always been there to drop
everything and take me home whenever I need her. She has made
it possible for me to continue studying medicine and I owe her so
much. My wonderful boyfriend puts up with my whinging, and is
always there for me when I need him. My friends have all stuck by
me, giving me both moral support and helping me to complete
tasks that I physically cant do, like changing my sheets, or brushing
my hair. All of these people have made this so much easier for me,
and I am eternally grateful to them all.
I am now in the middle of a ten week clinical attachment,
and, despite everything, really enjoying it. My team are really
understanding of my condition, and do everything they can to help
me. Medicine is what Ive always wanted to do, and, although I
do have times when I feel down, usually I can look to the future,
when the arthritis should be under much better control, with great
enthusiasm.
Will Homo sapiens Continue to

Evolve? If so, how?
Kartik Logishetty BSc (Hons)
karlog43@googlemail.com
In the shadow of the 200th anniversary of the birth of Charles
Darwin, biologists continue to furiously debate the continuation or,
indeed, the end of human evolution.
The increased average life-span of the homo sapien means that a
greater proportion of the population reach reproductive potential
than ever before, leading to decreased deletions of unique genes.1
Simultaneously, the inter-breeding of ever more distant and distinct
populations has produced a colourful blending of genes.
In the Western world, the unchallenging availability of food,
provision of healthcare and dominance of hygiene, has dampened
the environmental conditions that Darwin, Mendel, Huxley and
their contemporaries deemed necessarily for evolution through
natural selection.
Most humans, especially the male of the species whose
reproductive potential is not limited by child-bearing mechanics
or timing, are able to propagate their genotype to the next
offspring, irrespective of the extent of their adaptability to the
prevailing environment. More so, with fewer older fathers there
are fewer spermline mutations potentially passed on, and therefore
decreased individual variation.
This homogeneity suggests that evolution has ground to a standstill,
and that without a sensational change in climate or an epidemic
proliferation of cloning and gene therapy, the future is as we see it
today.
Inversely, a large body of scientists argue that evolution is as
unstoppable as it is unpredictable, particularly in the developing
world. The slow phenotypic changes, produced by todays larger
gene pools, serve to mask the unremitting dialogue between the
species and environment.
The capricious advent of new diseases will force natural selection
of Homo sapiens for example, incidence of haemoglobin C,
which confers a resistance to malaria without anaemia, is increasing
exponentially in West African populations. Some even predict
the emergence of an AIDS-resistant population in areas currently
epidemically ravaged by HIV.
The clash of these two opposing perspectives could in fact exist
concurrently. It may well be that evolution has stopped in certain
populations, and is continuing in others. However, a new conflict
arises when one attempts to define evolution, and whether in a
more fluid sense, it continues as strongly and ubiquitously as ever.
Evolution, in its most literal sense, means change over
time changing species, changing populations, or changing
characteristics. Evolution is not only a genetic mechanism, and
perhaps natural selection and culture are the motors of change.2
The continuing development of the human race, spurred by
technology, creativity, and money, itself engenders competition
the foundation of natural selection.
Homo sapiens are considered uniquely capable of representational

communication. Language is one of our greatest commodities and
has developed in tandem with another almost exclusively human
trait: culture. Language allows for productivity i.e. the capacity
to say things that have never been said or heard before, yet still
be understood, and cultural transmission i.e. our genes have a
strong capacity to acquire language, which can be transmitted
extragenetically by learning and teaching. Darwin claimed that the
human brain is selected for sociability, which would explain the
origin and strength of culture, as well as its variability.3
As argued by Pinker, 1990, human language is the product
of Darwinian natural selection, arising from the reproductive
advantages that linguistic compositionality affords. Furthermore,
cultural transmission (e.g. seen in the recent proliferation of the
SMS language) combined with biological transmission, influence
the evolution of language, and indirectly, the evolution of homo
sapiens.4
As well as the transmission of language, culture has spawned
materialism. The evolution of human behaviour is seen in three
dynamic processes termed first nature (matter originating from
the Big Bang), second nature (the evolution of life forms, from
bacteria), and third nature (the dawn of ideology, symbolic
thought, and agrarianism).
Third nature has infused the human mind with the idea of
progress, which has itself fueled the evolution of complex
institutional order and technology, and their unfortunate symbiosis
with war and environmental degradation.5
A concerted effort by neuroscientists and archeologists has
demonstrated that the rapid encephalization seen in early homo
sapiens was intimately related to social relationships, later
extended by an increasing engagement with material culture.
The ability today to manipulate social networks using a variety of
material resources continues to reflect the evolution of culture.6
The craft with which homo sapiens can now apply material devices
is under the constant scrutiny of morals and ethics. The recent
manifestation of international and local standards of ethical
acceptability has demonstrated a new form of evolution in
culture.7
The argument on the prevalence of evolution can therefore only
be settled based on the fluidity of its definition. Using the broader
brush, it is clear that our species is still evolving on a genetic,
linguistic, and cultural plane, albeit in more subtle ways. The future
will almost inevitably be one of a uniform brown skin phenotype,
but where our verbal, social, and moral compasses direct us is
altogether unknown.
References
1.
2.
3.
4.
5.
6.
7.
Hockett, C. F. (1960). The origin of speech. Sci Am 203: 89-96.

Aoki, K. (2001). Theoretical and empirical aspects of geneculture coevolution. Theor Popul Biol 59(4): 253-61.
Hayflick, L. (2000). The future of ageing. Nature 408(6809): 267-9.
Johnston, W. A. (2005). Third nature: the co-evolution of human behavior,
culture, and technology. Nonlinear Dynamics Psychol Life Sci 9(3): 235-80.
Kirby, S., M. Dowman, et al. (2007). Innateness and culture in the
evolution of language. Proc Natl Acad Sci U S A 104(12): 5241-5.
Phillips, C. S. (2001). Culture, social minds, and governance
in evolution. Politics Life Sci 20(2): 189-202.
Mesoudi, A. and P. Danielson (2008). Ethics, evolution
and culture. Theory Biosci 127(3): 229-40.
25
EDITORIAL
Recreational drugs are a significant starting point in psychiatric research. Firstly they are interesting in that they might contribute to the
aetiology of some mental illnesses (the ongoing debate of cannabis and schizophrenia for example)1. Secondly, in understanding them
as part of the pathology of a mental illness, we indirectly learn more about what might be going on in the brains and hence the minds
of patients.
Even if there is no immediate application of knowing the neurochemical changes that occur in an illness, appreciating these as well as
the social and psychological factors contribute to the psychiatrists understanding of how to treat a patient. The explanation of a drug as
a cause or treatment of a mental illness cannot alone answer the question of why someone has a particular mental illness. As the mind
emerges not only from its physical and chemical make-up but also from the experiences that have moulded it, so does mental illness.
Physiological but also psycho-social factors must all contribute to an illness, as exemplified by Schildermans review of amphetamine
abuse and self harm.
Despite this, there is much hope in recent literature that neuropsychiatry will bring psychiatry forward as a discipline. It will hopefully
provide us with new ways of approaching treatment for mental illness as Craddock et al2, and more recently Bullmore et al3 have argued
in The British Journal of Psychiatry. For example, it has been suggested that depressive illness in adolescents may alone be a cause of
substance use in adolescents. However it has been shown recently that by testing for stress (measuring cortisol levels) it now seems
possible that we were missing stress as a key link.
However, the greatest hope from this perspective is that it will provide better targeted treatments. For example, last month Ross and
Margolis argued that the basis of the major psychiatric illnesses schizophrenia, bipolar disorder and depression - may all stem from
alterations in the cell signalling systems of neurons altered during neuronal development.5 Targeting these pathways with more effective
treatments and fewer side effects may therefore become possible.
It is important to remember however, that not only are such innovations a long way off but also research into them should not come at the
expense of research into the other contributing factors of mental illness the sociological and psychological elements. In fact, where
possible, neuropsychiatric research should try to integrate the existing aetiological models that are based on these factors.4
It is in this context that our section hopes to publish new student writing in psychiatry. It is the fact that psychiatry meets at the crossroads
of all of these disciplines that makes it so interesting. We want to publish work that focuses on sociological factors - like Baigel et als
paper on the impact of ethnicity upon the reporting of depression in London medical students - as well as papers on psychological and
even neuropsychiatric factors. This includes work in the form of research but also as literature reviews, news articles and case studies from
students of any of the health sciences.
Samuel Ponnathurai
Section Editor Psychiatry
References
Illustration: Robert Hare
26
1.
2.
3.
4.
5.
Arsenault, L. et al The British Journal. of Psychiatry, Vol 184, (2004), 110-117

Craddock N, Antebi D, Attenburrow M-J, Bailey A, Carson A, Cowen P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6 9
Ed Bullmore and Peter Jones. Why psychiatry cant afford to be neurophobic. The British Journal of Psychiatry (2009) 194: 293-295.
Rao et al . Mechanisms underlying the comorbidity between depressive and addictive disorders in adolescents:
interactions between stress and HPA activity. Am J Psychiatry. 2009 Mar;166(3):361-9. Epub 2009 Feb 17.
Christopher A. Ross1 & Russell L. Margolis. Schizophrenia: A point of disruption. Nature 458, 976-977 (23 April 2009)
27
RESEARCH REPORT
RESEARCH REPORT
Massively Multiplayer Online

Roleplaying Games
(MMORPGs) addiction
Amin Golmohamad BSc(Hons)
m0400037@sgul.ac.uk
doi:10.4201.lsjm/psy.002
Screenshot from the online game EVE

references see
thelsjm.co.uk.
Conflicts of interest: Amin
is a panellist for LSJM
Psychiatry.
28
In the electronic age, computers and the internet continue to

be further integrated into day-to-day activities. Facilities such as
email, social networking sites and online games are ubiquitous and
a norm.
The available literature on the subject of computer-related
disorders has grown exponentially over the last decade, resulting
in coined terms such as internet addiction, problematic internet
use and pathological internet use. 4, 5, 6 However it is not the
internet itself that is addictive, rather that it is the interactive
applications that seem to play the prime role in the development of
problematic use.7 One such interactive application of particularly
addictive potential currently in ascendance is the genre of online
game, the Massively Multiplayer Online Roleplaying Game.
These computer games, also referred under the acronym

MMORPG, represent a new paradigm in computer gaming that
now immerses tens of millions of players worldwide. A typical
MMORPG consists of a complex, persistent virtual environment
that facilitates real-time interaction between large numbers of
players in geographically different locations. They are a relatively
new phenomenon, having only been in existence in their current
form for just over a decade. Examples of such games include titles
such as World of Warcraft, Eve Online, Guild Wars and
Everquest. Their unique formula combines the allure of
traditional stand-alone video games with that of the social networking capacity afforded by ever more accessible high speed internet
connectivity. Their appeal is reflected in the near exponential rise
in subscription numbers, with the growth rate reported to be
several-fold faster when compared to that of traditional electronic game genres such as arcade, PC and console video games. 8,9
A strong multi-faceted appeal
How can their appeal be explained? The extensive work of Yee10
concluded, MMORPGs have a strong multi-faceted appeal to a
diverse demographic, motivating individual users in very different
ways. While some traditional stereotypes may associate affiliation
with computer games with people of teenage years, Yee also
demonstrated in a study of 30,000 MMORPG users that the age
ranged from 11 to 68 years, with the average lying between 25-27
years, underscoring their broad appeal and weakening the cogency
of such views. Upon exploratory factor analysis, Yee identified a
five factor model of user motivations: achievement, relationship,
immersion, escapism and manipulation - motivations that typically
carried different import to players of a different demographic.
According to this model, the motivating factors external to the
game define the degree to which inherent attractive factors
offered by a MMORPG act as an outlet.
MMORPG users can immerse themselves into worlds that are rich,
varied and detailed; detail that can provide fulfilling game-play
experiences varied playstyle preferences; that may vary from casual
socialising to combat, strategy, commerce and fantasy role-play.
The goals are only limited by player ambition, with instant and
measurable rewards available at progressively lengthening cycles.
The perceived ability to supersede limitations present in the real
world by using the adapted identity in the virtual world can be
appealing where life cannot offer these options.
Social activity derived from an MMORPG is another dominant
motivating factor. Characterised by anonymity, users can avoid real
world prejudices of colour, gender, age and physical attractiveness.
These prejudices are partially replaced by an order of meritocracy
based on gaming aptitude and behaviour. This can be an added
attraction for people who face difficulty in the real world on
account of these factors. Furthermore, a player can discard their
identity and assume a new one by creating another avatar, should
their relationships or online reputation not be to their liking.
Social interactions can be controlled, taking place in structures
similar to chat rooms, online forums and 3rd party voice communication. As the relationships accrue over time, increasing obligations to them emerge. Social contact has also been postulated to
be used as self-medication to compensate for the lack of family or
social support in a players real life11.
Negative sequelae and comorbidities
To play MMORPGs requires lots of time investment; they are
not games that one can play for a short period of time.12 In-game
advancement encourages increased use, which can be excessive.13
Chronic MMORPG addiction can lead to self-maintaining factors.12
For instance, where playing an MMORPG is used to escape a difficult situation in the real world, it acts only as a temporary
nepenthe. When the player logs out of the game, problems may
have been further compounded due to resultant neglect. Chronic
usage can also lead to isolation, loss of friends and contacts.
Mental and physical health co-morbidities have been postulated.5
Can it qualify as an addiction?

While research into the concept of MMORPG addiction
continues to proliferate, there remain no agreed diagnostic criteria
or treatments, with recognition of the disorder pending. In July
2007 the American Psychiatric Association released a statement
stipulating that they did not recognise any type of video game
addiction as a mental disorder.14 The DSM IV criteria for addiction
require three or more of the following:
Tolerance
Withdrawal
Large amounts over a long period
Unsuccessful efforts to cut down
Time spent in obtaining the substance replaces social,
occupational or recreational activities
Continued use despite adverse consequences
The term addiction does not require a substance of abuse, it can
include non-physical, behavioural addictions. Examples include
pathological gambling, eating disorders and sex addiction.15, 16, 17
Studies have identified self-reported usage despite adverse
consequences, withdrawal, tolerance and that it is difficult to quit
playing even with intent to do so. The frequency of these findings
was found to be proportional to the number of hours spent playing
per week.
It would be a misconception to consider these games as a niche,
for they represent a rapidly growing problem. It could be labelled as
a silent addiction, only presenting in extremis. An ideal addiction
in a time of a poor economic climate in that it is rewarding,
constantly available, legal and requires relatively low investment.
As successful treatment is predicated upon the medical professional
being aware of the nature of this 21st century problem, it is important
that research into this area continues to help provide answers for the
lack of widely agreed methods for screening, diagnostic criteria or
treatment approaches.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
BBC news article (2005), S Korean dies after games

session, Retrieved from http://news.bbc.co.uk/1/
hi/technology/4137782.stm, on 28/4/2009
Gamespot.com article, Couples online gaming causes
infants death, Retrieved from http://uk.gamespot.com/
news/2005/06/20/news_6127866.html, on 28/4/2009
BBC news article, (2005), Game theft led to fatal
attack, Retrieved from http://news.bbc.co.uk/1/
low/technology/4397159.stm, on 28/4/2009
Freeman C.B., (2008), Internet Gaming Addiction, The
Journal for Nurse Practitioners, vol.4, no.1, pp42-47
Yen J.Y., Ko C.H., Yen C.F., Wu H.Y., Yang M.J., (2007), The Cormorbid
Psychiatric Symptoms of Internet Addiction: Attention Deficit and
Hyperactivity Disorder (ADHD), Depression, Social Phobia and
Hostility, Journal of Adolescent Health, Vol.41, no.1, pp93-98
Shapira N.A., Lessig M.C., Goldsmith T.D., Szabo S.T.,
Lazoritz M., Gold M.S. Stein D.J., (2003), Problematic
Internet use: proposed classification and diagnostic
criteria, Depression and Anxiety, vol.17, pp207-216
Young K.S., (1998), Internet addiction: The emergence of a new
clinical disorder, CyberPsychology & Behavior, vol.3, pp237-244
Woodcock, B.S. (2008), An Analysis of MMOG Subscription
Growth, MMOGCHART.COM 22.0, retrieved from
http://www.mmogchart.com on 27/4/2009
Harding-Rolls P., (2007), Western World MMOG Market:
2006 Review and Forecasts to 2011, Screen Digest
Yee, N., (2006), The Demographics, Motivations
and Derived Experiences of Users of MassivelyMultiuser Online Graphical Environments, PRESENCE:
Teleoperators and Virtual Environments, 15, 309-329.
29
SHORT CASE
SHORT CASE
Narcissistic Personality
Disorder
Jeremy Hoffman BSc (Hons)*, Adiele Hughes BSc (Hons),

Andrew Allard BA (Cantab), Sarah Greenough BSc (Hons)
Image: Actor Johnny Depp as
Captain Jack Sparrow in Pirates of
the Caribbean
All Year 4 Medicine, University College London

j.hoffman@ucl.ac.uk
Introduction
Captain Jack Sparrow displays numerous attributes of Narcissistic
Personality Disorder (NPD), which affects approximately 1% of the
population.
Captain Jack Sparrow is a 33-year-old male pirate with no previous
contact with psychiatric services. He presented with a multitude
of symptoms including visual and auditory hallucinations, alcohol
intoxication and grandiose delusions.
He was found by colleagues wandering alone on an island
responding to visual and auditory autoscopic hallucinations (see
Table 1), talking to several versions of himself. Little is known about
the events leading up to this episode however, it is thought from
collateral history that this is not the first hallucinatory episode and
his colleagues regularly hear him talking, apparently, to himself.
There is no significant psychiatric family history, however he has
never been close to his father who is also a pirate in his mid-sixties
and carries around the shrunken head of his deceased mother.
JS is not currently taking any medication. His alcohol use is
bordering on dependence with stereotyped drinking of only rum.
He is known to drink when in stressful situations such as when under
attack, shows binge drinking behaviour and drinks first thing in the
morning. He also craves alcohol and shows agitation when rum is
not available. He is a non-smoker and denies other recreational
drug use.
Autoscopic hallucinations
Ego-syntonic
These are a blend of visual and proprioceptive hallucinations.

In these cases, the vision is of ones double, like in a mirror,
sometimes repeating ones gestures, and on occasions busy with
other activities.
A term referring to behaviours, values, feelings, which are in
harmony with or acceptable to the needs and goals of the ego, or
consistent with ones ideal self-image.
Lilliputian hallucinations
Hallucinations in which the patients see imaginary people of a

small size.
Pressured speech
The patient keeps talking, with no interruption between thoughts

or sentences. The speech may be loud and rapid, with creative,
amusing, or trivial and irrelevant content.
Circumstantiality
In conversation, the use of excessive and irrelevant detail in

describing simple events, the speaker eventually reaches his goal
only after many digressions.
Table 1: Definitions of psychiatric terms referred to in text
30
He has been a pirate all his working life, however, little is known
about his birth, childhood and education history. A significant
life-event occurred 10 years ago in which the crew of his ship
mutinied and left him on an island. At this point he showed low
risk suicidal ideation as he was left a gun with just one bullet,
which he considered using but was protected by a revenge motive.
Following this event he became very fixated on revenge and there is
concern over risk of harm to others, however he does not appear to
deliberately self harm or have any current suicidal ideation.
One previous long-term relationship is confirmed, although he
is known to have had many other sexual partners, most of which
ended badly.
His forensic history is extensive and includes mugging, wilful crimes
against the crown, impersonating a cleric of the Church of England
and a member of the Royal Navy, arson, kidnapping, pilfering,
depravity and before absconding, he was sentenced to be hung by
the neck until dead.
On presentation he appeared to be a scruffy Caucasian pirate in his
mid-30s with questionable personal hygiene. He was unshaven,
with dread-locked hair and clearly had not changed his clothes
for many days. He was dressed in grand 18th century pirate attire,
congruent to that expected. Although appropriate his attire was
eccentric, slightly outside boundaries of normality with added
femininity including make-up, beads in his hair and many rings on
his fingers.
His behaviour was markedly socially and sexually disinhibited with
invasion of personal space and inappropriate and lewd comments
such as You need to get a girlfriend and Are you a eunuch?
He made good, often intense eye contact. He also had an ataxic
gait, explainable by alcohol consumption but no psychomotor
abnormalities
His speech was pressured, suggested by quotes such as Me?
Im dishonest. And a dishonest man you can always trust to be
dishonest. Honestly, its the honest ones you want to watch out
for, because you can never predict when theyre going to do
something incredibly... stupid. It was also at times over-inclusive
with circumstantiality, for example No! If we dont have the key,
we cant open whatever it is we dont have that it unlocks. So what
purpose would be served in finding whatever need be unlocked,
which we dont have, without first having found the key what
unlocks it? It was of normal volume and tone.
His mood was, objectively, persistently elevated with situational
incongruence, for example inappropriate laughter when his life was
in serious danger. He was reactive to his surroundings.

He clearly had a grandiose sense of self-importance, believing
himself to be special as the greatest of all pirates and requiring
excessive admiration, insisting on being called captain although
he did not technically have his own ship. He is selfish and lacks
empathy towards others, always thinking about saving himself
with no consideration for others, using friends for his own gain
for example holding them at gunpoint. He is also constantly
preoccupied with ideas of questionable success and power
regarding treasure and The Black Pearl ship. He embellished stories
about himself, making himself sound grander or more daring than
in reality.
His perceptions were disordered as he described many episodes of
ego-syntonic hallucinations. One described involved a Lilliputian
hallucination of small versions of himself and another episode of
multiple autoscopic hallucinations. These could potentially be
related to alcohol withdrawal. Collateral history suggests many
other episodes of him having conversations with himself.
He was orientated in time, place and person, however had limited
insight into his hallucinations, unsure as to what was real and what a
hallucination was.
Our impression is that JS is suffering from NPD, possibly with
hypomania and/or alcohol withdrawal.
Discussion
Captain Jack Sparrow is arrogant to the extreme of grandiosity
he believes he is far more superior than he actually is. He makes
constant reference to being called Captain Jack Sparrow and
does not let people forget that he can out-think others: Today will
be the day that you will always remember that you almost caught
Captain Jack Sparrow. He sees himself as special or unique, and
constantly requires admiration from others around him. He exploits
others to his own personal benefit and is constantly preoccupied
on his quest for success. These personality traits interfere with
Jacks life and constantly lead him astray, developing a significant
forensic history in the process; he only just managed to escape the
hangmans noose. As a result of this, we believe it is possible to
diagnose him with NPD.
The term narcissism comes from the Ancient Greek mythological
story of Narcissus.1 Narcissus, a Greek hero from Thespiae, was
famous for his beauty. After rebuking the nymph Echo who tried
to embrace him, he fell in love with his own reflection in a pool
and killed himself when he realised that he could not act upon
his love. Freud, who often used mythology to aid his theories of
psychopathology, formally introduced the term narcissism into
the psychiatric literature in his 1914 paper On Narcissism.2 Since
then, NPD has become a formal psychiatric diagnosis as defined
by the American Psychiatric Association in the fourth edition of the
Diagnostic and Statistical Manual of Mental Disorders: DSM-IV,
which outlines the diagnostic criteria.3 To receive the diagnosis of a
NPD, a person must meet these diagnostic criteria (Table 2).
It is evident that Jack meets at least five and arguably all nine of
these criteria. It should be noted that that the ICD-10 does not
specifically code for NPD, but instead categorises it in Other
specific personality disorders.4
Other authors suggest various dominant features of NPD.5
These include Pathology of the self; pathology of the relationship
with others; pathology of the superego; and a chronic sense of

emptiness and boredom, resulting in stimulus hunger and a wish
for artificial stimulation of affective response by means of drugs or
alcohol that predisposes to substance abuse and dependency.
Patients typically present with the complications of their disorder
as opposed to their primary symptoms. This includes drug
dependence and alcoholism, sexual promiscuity or disinhibition,
suicidal ideation, and when under extreme stress, brief psychotic
symptoms.
Image: Caravaggios Narcissus
The prevalence of NPD is approximately 1%, rising to between 2

and 16% in clinical situations, with up to 75% of those diagnosed
being male. The aetiology of the disorder is largely unknown
but various risk factors have been identified. These are mainly
childhood parenting and developmental factors such as parental
overindulgence or overvaluation, excessive admiration, learned
manipulative behaviour and early severe emotional abuse. 6
Medication and hospitalisation are indicated in NPD only for
co-morbid conditions such as anxiety or affective disorders.
The management therefore largely involves a multi-disciplinary
approach with psychosocial interventions such as supportive
psychotherapy, cognitive behavioural therapy and social skills
training.7
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of
empathy, beginning by early adulthood and present in a variety of contexts, as indicated by
five (or more) of the following:
1
Has a grandiose sense of self-importance (e.g., exaggerates achievements and

talents, expects to be recognized as superior without commensurate achievements)
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal

love
Believes that he or she is special and unique and can only be understood by, or
should associate with, other special or high-status people (or institutions)
Requires excessive admiration
Has a sense of entitlement, i.e., unreasonable expectations of especially favourable

treatment or automatic compliance with his or her expectations
Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her

own ends
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of
others
Is often envious of others or believes that others are envious of him or her
Shows arrogant, haughty behaviours or attitudes
Table 2: DSM-IV criteria for Narcissistic Personality Disorder
References
1.
2.
3.
4.
5.
6.
7.
Ovid, AD 8, Metamorphoses III. 340 - 350, 415 510.

Freud S. On narcissism: An introduction. SE, 14: 67-102. 1914
American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders: DSM-IV-TR. 4th Edition, revised.
American Psychiatric Association, Washington, 2000.
World Health Organisation. ICD-10 : The ICD-10 Classification
of Mental and Behavioural Disorders : Clinical Descriptions and
Diagnostic Guidelines. World Health Organisation, Geneva. 2007
Kernberg O, Pathological narcissism and narcisstic personality
disorders; Theoretical background and diagnostic classification
in Disorders of Narcissism; Diagnostic, Clinical, and
Empirical implications, ed. E. F. Ronningstam. Washington,
DC: American Psychiatric Press, pp. 29-51. 1997
Groopman L and Cooper A. Narcissistic Personality Disorder.
Personality Disorders - Narcissistic Personality Disorder.
Armenian Medical Network. 2006. http://www.health.am/psy/
narcissistic-personality-disorder/. Retrieved on 8/03/2009.
Davison S E. Principles of managing patients with personality
disorders. Advances in psychiatric treatment 2002 8:1-9
31
ARTICLE
ARTICLE
Time to take Seasonal Affective

Disorder seriously
Neil Graham1, Prof Anne Farmer2
Medical Student, University College London
2
Institute of Psychiatry, Kings College London
Conflicts of interest:
None declared.
When we labour through the short days and long nights of the
British winter, the perennial column-filler, Seasonal Affective
Disorder (SAD - which lends itself to puns like few other
illnesses), is never far from headline-hungry newspaper pages.
Skepticism is a key facet of modern, evidenced-based practice, but
is the prolific cynicism about SAD (the winter blues, or seasonal
depression) justified? And is there any mileage in the debate over
whether this is a true illness?
What is seasonal affective disorder?
The American Psychiatric Associations Diagnostic and Statitistical
Manual of Mental Disorders (DSM-IV) characterises SAD as a
specifier: a cohort of features which can occur within major
depressive or bipolar disorders, emphasising seasonality and
prominence over non-seasonal depressive episodes, for at least
two years.
Symptoms occur in autumn and winter, accompanied by full
remission, mania or hypomanias in summer. Depressed mood,
diminished interest, psychomotor agitation, loss of energy, feelings
of worthlessness, guilt, and thoughts of death may be experienced
in addition to what appear to be SAD specific features increased
appetite with associated weight gain, tiredness and over-sleeping.1
Critics who argue that aspects of SAD are likely to be experienced
by most people at this time, and disagree with the concept in the
most general terms, fail to appreciate a key feature of this, and
many other psychiatric ailments: for diagnosis and treatment to be
indicated, symptoms must be of a given severity, quantity, duration
and pattern.
One could read entire books about the medicalisation of benign
phenomena, and there is a place for this debate. In respect of
seasonal depression, however, it seems that many have been too
quick to apply labels obviously not everyone who is miserable in
winter has an illness, and nobody is claiming that they do.
Epidemiology and the nature of the disorder
The population prevalence of the disorder is highly variable and has
been shown to increase with latitude. Landmark research by Rosen
32
et al. in the USA found incidence of 1.4% in Florida increasing to

9.7% in New Hampshire.2 This may be compared with estimates at
non-seasonal mood disorder prevalence of between 8% and 20%.3
Genetic factors are implicated in the aetiology of winter
depression, and concordance studies found correlations
in dizygotic twins to be fewer than half those observed in
monozygotic twins.4 Identification of specific mutations
associated with the disease has generally been unfruitful though
an association has been established with serotonin transporter
polymorphisms.5
Management
While evidence fails to support light therapy for unipolar
depression, other than as an adjunct to classical therapies,6 over
seventy therapeutic trials, and two meta-analyses have found light
therapy to be effective in the treatment of seasonal depression,
with a dose-response relationship observed in the control of some
symptoms.7,8
Best outcomes are achieved with light of sufficient brightness
(10,000 lux) and duration (15-90 min per day), which is timed
appropriately: morning exposure is usually most effective.9
Treatment may produce a range of transient side effects (headache,
eye strain) but appears to be safe in patients without ocular
abnormalities.10
Evidence to support the use of traditional antidepressants is weak,
though the selective serotonin reuptake inhibitor drugs appear
to help in established episodes. Recently, the FDA licensed
bupropion hydrochloride (a noradrenaline-dopamine reuptake
inhibitor), specifically for prevention of winter depression, after
convincing results in three placebo controlled trials.11
Pathophysiology
Finding an inactive placebo treatment in trials of phototherapy has
contributed to the uncertainty about winter depression, and the
mechanism of action of many therapies is not entirely clear.

Diverse pathophysiological explanations exist, but irrespective
of their ingenuity and logical appeal, little evidence exists to
conclusively support any one over another. Rosenthal et al
originally proposed the melatonin hypothesis, which argues that
an abnormal secretion or sensitivity underlies the phenomenon.
Winter depression has often been portrayed as a disorder of
delayed circadian rhythms; and more recently, as a product of
dopaminergic system dysfunction.12
That a clear mechanism of action is yet to be elucidated ought
not to empower doubters to ignore this phenomenon. Indeed,
squabbling over whether seasonal depression merits the label
illness is quite unnecessary.
Life after semantics
The facts are that this experience affects the quality of life of
a significant number of individuals, in a stereotyped, recurrent
manner. Safe, low cost, effective treatments exist which can
ameliorate these symptoms. Withholding these for the sake of
word-play is hardly the enlightenment thinking that detractors
imagine it represents. The time has come for us to update their
practice to keep pace with the research in this field.
4.
5.
6.
7.
8.
9.
10.
11.
References
1.
2.
3.
American Psychiatric Association. Diagnostic and statistical

manual of mental disorders. 4th ed. Washington, D.C.:
American Psychiatric Association, 1994:317-91.
Rosen LN, Targum SD, Terman M, Bryant MJ, Hoffman H, Kasper SF,
12.
Hamovit JR, Docherty JP, Welch B, Rosenthal NE. Prevalence of seasonal

affective disorder at four latitudes. Psychiatry Res. 1990 Feb;31(2):131144.
Blazer D. Mood disorders: epidemiology. In: Kaplan,
H.I., Sadock, B.J. (Eds.), Comprehensive Textbook of
Psychiatry, 6th ed. 1995. Vol. 1, pp. 10791089.
Madden PAF,Heath AC, Rosenthal NE,Martin NG. Seasonal
changes in mood and behavior. The role of genetic factors.
Arch. Gen. Psychiatry. 1996. 53, pp. 4755
Rosenthal, N.E., Mazzanti, C.M., Barnett, R.L., Hardin, T.A., Turner,
E.H., Lam, G.K., Ozaki, N. and Goldman, D. Role of serotonin transporter
promoter repeat length polymorphism (5-HTTLPR) in seasonality
and seasonal affective disorder. Mol. Psychiatry 3, pp. 175177
Even C, Schrder CM, Friedman S, Rouillon F. Efficacy of light
therapy in nonseasonal depression: a systematic review.. J Affect
Disord. 2008 May;108(1-2):11-23. Epub 2007 Oct 22.
Terman, J.S. Terman, F.M. Quitkin, P.J. McGrath, J.W. Stewart and
B. Rafferty, Light therapy for seasonal affective disorder. A review
of efficacy, Neuropsychopharmacology 2 (1989), pp. 122.
Lee and Chan, 1999 T.M. Lee and C.C. Chan, Doseresponse
relationship of phototherapy for seasonal affective disorder: a
meta-analysis, Acta Psychiatr. Scand. 99 (1999), pp. 315323.
Thompson et al 1999 C. Thompson, I. Rodin and J. Birtwhistle, Light therapy
for seasonal and non-seasonal affective disorder: A Cochrane meta-analysis,
Society for Light Treatment and Biological Rhythms Abstracts (1999), p. 11.
Gallin et al., 1995 P.F. Gallin, M. Terman, C.E. Reme, B. Rafferty,
J.S. Terman and R.M. Burde, Ophthalmologic examination of
patients with seasonal affective disorder, before and after bright
light therapy, Am. J. Ophthalmol. 119 (1995), pp. 202210.
Modell JG, Rosenthal NE, Harriett AE, Krishen A, Asgharian A,
Foster VJ, Metz A, Rockett CB, Wightman DS (2005). Seasonal
affective disorder and its prevention by anticipatory treatment
with bupropion XL. Biol Psychiatry 58 (8): 65867
Lee TM, Blashko CA, Janzen HL, Paterson JG, Chan
CC. Pathophysiological mechanism of seasonal affective
disorder. J Affect Disord. 1997 Oct;46(1):25-38.
33
RESEARCH
RESEARCH
Does ethnicity impact upon

reporting of depression in
London medical students?
Rachel Baigel*, Robert Freudenthal, Deborah Ragol Levy,

Daniel McNaughton, Sara Taha
All Year 4 Medicine, University College London
rachel.burns@ucl.ac.uk
For the full article
and references see
thelsjm.co.uk.
Conflicts of interest:
Rachel is a panellist for
LSJM Psychiatry.
Abstract
An online questionnaire was distributed to preclinical medical
students in UCL, Kings college London and Barts and the London
Medical School and students were asked to respond to four case
vignettes. These were constructed based on the ICD-10 criteria
for mild, moderate and severe depression and one vignette that
acted as a control group presenting with subclinical symptoms
of depression. Students were asked how likely they were to seek
help from several different services and the reasons that would
prevent them from going to these services. Statistical analysis
was performed using chi squared tests. With regard to ethnicity,
we found that African students were less likely to seek help
from friends for either subclinical (p=0.032) or mild depression
(p=0.043) and less likely to seek help from relatives in subclinical
depression (p=0.047) that other ethnicities. South East Asians
were more likely to seek help from a counsellor in mild depression
(p=0.025) and from a university tutor in subclinical depression
(p=0.04) than students of other ethnicities. When students were
asked about the factors deterring them from seeking help for
depression 31% said they definitely would not seek help because
they believed their grades would suffer as a result, 35% said the
same because they would not want the label of depression, and
33% said the same because they believe that seeking help for
depression could affect their medical career. We believe that these
are significant and that greater effort should be made elucidate at
the start of medical school.
Introduction
Mental illness, particularly depression, is responsible for a
significant proportion of the worlds health burden. The World
Development Report 1993 states that depression ranks fifth
amongst women and seventh amongst men as a cause of morbidity,
whilst the World Health Organization has predicted that by
2020 depression will be the most common cause for disability
worldwide, second only to ischaemic heart disease.1 Depression
is massively under-diagnosed with an estimated 56% of people
worldwide exhibiting clear-cut features of clinical depression but
receiving no treatment and an estimated 74% of Europeans are
affected by mental illness but remain untreated.2
34
Prevalence of depression varies across different socio-economic

and occupational groups. There is evidence that young people
have the highest population prevalence rates for mental health
problems and substance abuse, however, their use of primary
care and specialist services tends to be low when compared to
other population age groups.3 This remains true amongst university
students, where the high prevalence of anxiety and depression is
thought to be related to social and academic factors indeed, one
study of Oxford University students reported higher rates of suicide
than in the general population. Half of these students had clinical
depressio students, particularly in London, are a heterogeneous
group with a large proportion from ethnic minority backgrounds.
It has been shown that presentations of depression are culturally
dependent with somatic complaints dominating over psychological
symptoms amongst non-Western cultures.5 Within the UK it is
unclear if the prevalence of Depression is higher amongst ethnic
minorities, with one study showing that whilst London Punjabi
populations have a lower rate of diagnosis, they do experience
more depressive thoughts than their white counterparts.6
The interaction between ethnicity, culture, clinical depression
and its symptomatology amongst London students is complex
however this study aims to ascertain how this interaction impacts
on the likelihood of self-presentation to healthcare services when
experiencing features of clinical depression.
As discussed above, previous studies have shown that Depression
is prevalent in both student groups and ethnic groups in the UK. In
this study London medical students will be used as subjects, as this
group is a culturally diverse high risk group.
Methods
To study the impact of ethnicity upon an individuals likelihood
in seeking help for symptoms of depression, four vignettes were
prepared (Appendix 1). One vignette describes a person with no
symptoms of depression with another three representing scenarios
of mild, moderate and severe degrees of depression according to
the ICD-10 classification of depression. In relation to each vignette
presented, participants were asked to rate how likely they were to
use any one of a range of services and were asked to score them
regarding the likelihood of their using each service for that vignette
(box 1). Participants were asked about different factors affecting
their decision to attend these services and asked to score these

factors (box 2).
This questionnaire was distributed to preclinical medical students
at University College London Medical School, Kings College
Medical School and Barts and The London School of Medicine.
The questionnaire was hosted online at http://www.surveymonkey.
com and a link to the questionnaire was provided in an e-mail to
students. The survey was left open to access for a period of three
weeks. An incentive of 20 was made available to encourage
responses.
On entering the online domain, participants were presented
with contact details of the counselling services of the respective
institutions and were given the chance to opt out of the study
at any point. Ethical approval, data protection and research
governance for this study was granted by University College
London.
Ethnicities were grouped together under 6 categories and chi
squared tests were performed to analyse if there was significant
differences between the attitudes of people of different ethnicities
to seeking help for sub-clinical, mild, moderate and severe
depression from internet/books, friends, relatives, their GP,
university counsellor, other counsellor or university tutor. Chi
squared tests were also used to identify statistical differences
between ethnicities regarding factors that would affect them
seeking help for depression.
Results
This questionnaire was sent to 1760 students. 311
(18% of the study population) completed it.

Approximately 56% were second year students and
44% first year students. 10% of the students had
suffered from clinical depression beforehand.

Of the students who had suffered depression:
31% mild, 25% moderate 9% severe (75% White,
9% Chinese, 6% African, 6% Asian, 3% South East
Asian). See figure 1 for more demographics.

Of the students who completed the
questionnaire: 58% female, 41% male and all
were aged 18-30 with 64% aged 19-20.

The representation of ethnicities in the study
was: White 62% Asian 16% Chinese 8% Mixed
Race 5% South East Asian 5% African 3%

Statistical significance of the results was
calculated at the 5% significance level.
and the ICD-10 criteria (either unaffected by clinical depression or

mild, moderate or severe Depression) and whose help would be
sought. Four bars are displayed for each ethnic group representing
the percentage of that group who selected each response (seek
key). The degree of significance is indicated in the title of each
graph.
Reasons for students experiencing symptoms of depression for
presenting to welfare or healthcare services are complex. This
study attempted to ascertain what factors lead to some students
presenting earlier than others, and to identify any correlations
between the ethnicity of the students and their presentation.
The results for the students responding to the vignettes
representing moderate and severe Depression did not show
significant differences between the ethnic groups in their likelihood
of presenting to different welfare or healthcare services with
symptoms of depression. However there were some significant
differences between the attitudes of different ethnic groups in the
mild depression group and the control group. When asked about
seeking help from friends, people of African origin were far less
likely to seek help than people of other ethnicities in both of the
above groups (control p=0.032, mild Depression p=0.047). In
mild depression, Asian, South East Asian and Chinese participants
were significantly more likely to seek help from friends.
When unaffected by clinical depression, it seems that students
would consider turning to their relatives for help, but the African
students were significantly resistant to this avenue p=0.047.
Consulting University tutors and counsellors was universally an

unpopular service to access for depression. However, students of
White, South East Asian and Asian origin were more inclined to
consult a university tutor for subclinical symptoms of depression.
A similar pattern was seen for consulting a counsellor in mild
depression.
In this study, the African students seemed more reluctant to seek
help from any cause. However, our study population of African
students was small and therefore may not be representative of
the African population as a whole. If it were to be confirmed
that Africans were less likely to seek help for depression, then
steps should be taken to increase African awareness of services at
university of a confidential nature in order to increase help seeking
in this ethnic group.
The graphs 1-5 illustrate the statistically results that were significant
at the 5% significance level. There were 5 instances where
there were significant differences between ethnic populations
concerning the degree of depression as established by the vignette
The study found that despite the diversity of the respondents to the
questionnaire there were some unifying factors across all groups
that prevented presentation of the depressive symptoms. Seeking
help from friends and family was always more popular than seeking
help from tutors or counselors:63% of respondents had concerns
Type of depression within each ethnic group (%)

Ethnicity
Percentage of each ethnicity

who had been depressed
Unknown
Mild
Moderate
Severe
African
25
50
50
Chinese
12
33
67
Indoasian
50
50
South East Asian
100
White
11
29
29
29
13
Mixed
50
50
Figure 1: This tabulates the demographics of our findings. Overall, the South
East Asian population suffered the highest morbidity with all of the subjects who
partook claiming to have experienced moderate depression. The only cases of
severe depression were found in the White population. In the African, Chinese,
IndoAsian and Mixed populations, all participants classified their depression as
either mild or unknown.
35
RESEARCH
RESEARCH
Graph 1: Unaffected - seeking help from a friend p = 0.032
that seeking help for depressive symptoms would affect their

medical career whilst 69% of students were concerned that seeking
help would result in an unwanted label of depression.
Keys for graphs 1-5:
Graph 1 & 2: these graphs show that

the majority of students of african
origin would not seek help from a
friend if they experience symptoms
of sub-clinical depression or mild
depression. In contrast, chinese,
south east asian and mixed race
students are more likely to seek
help from a friend in the case
of sub-clinical depression, but
this likelihood is slightly reduced
amongst white students. Graph 2
shows that all students, with the
exception of africans, are inclined
to seek help from a friend if they
experience mild depression
Graph 2: Mild depression - seeking help from a friend p = 0.043
Graph 3: This bar chart shows that

the majority of students would
consider hep from a relative if they
experience sub-clinical depression.
This affirmation is higher among
Chinese and Asians. Africans were
particularly unlikely to seek help
from relatives when experiencing
sub-clinical
effects
of depression.
Graph 3: Unaffected - seeking help from a relative p = 0.047
Graph 4: Help seeking for

subclinical depression from a
university tutor appears universally
unpopular. However students of
White, Chinese, Asianand South
east Asian origin were more likely
to present than those of African or
mixed race.
Graph 4: Unaffected - seeking help from a university tutor p = 0.04
Graph 5: Mild depression - seeking help from a counselor p = 0.025
Graph 5: Seeking help from a

conselor in this instance seems to
be universally unpopular. However,
students of Chinese, White, South
East Asian and Asian origin were
morel ikely to present than those of
mixed or of African origin.
36
Previous research into students attitudes to Depression showed

a lack of knowledge about the illness and the implications that a
diagnosis and its subsequent treatment may (or may not) have.7
These statistics are concerning as they highlight the stigma
that exists within the medical world and implications for the
presentation of depression in students. This carries a significant
risk of under-diagnosing the condition in this group and subsequent
poor management.
There are some confounding factors that mean that these results
cannot be extrapolated to the remainder of the London student
population. In using medical students as a study population, we
surveyed a highly educated, medically interested subsection
of society, who have all been trained in the importance of
confidentiality in a professional setting. We would expect that this
group would have greater immunity
to societys stigmatisation of
depression than other social groups. Therefore, our results showing

such a high tendency to question seeking help due to stigmatisation
of depression on the grounds that it could affect their careers
are worrying. We would suggest that action should be taken in
medical schools to promote a better understanding of the issues
on confidentiality. This would impact both on the care of future
patients and the unwillingness of medical students to seek help
in the knowledge that their disclosure would remain completely
confidential.
Further research needs to be done as to why these attitudes persist
amongst the London medical student population.
Improvements/Further Work
Study Design:
1. 18% of the students who received our e-mail completed the
questionnaire. Whilst this response was good, it could have been
improved by going into lecture theatres and asking all present to fill
out a handwritten form.
2. Feedback from students made us aware that students responded
to the cases set out in the vignette in different ways. Students
did not always base their answers on the symptoms of depression
laid out in the vignette, but responded on the significance of the
trigger eg. Grandparent dying versus breaking up with a boyfriend.
For this reason it would be particularly important to analyse the data
with respect to history and family history of depression.
students seeking help for depression. The majority of the students

we assessed claimed to have had no history of depression and
therefore the study largely surveyed the attitudes of healthy
students as to whom they would go to for help. To accurately
address the question of how likely students are to present for help
with depression, it would be important to interview and identify
students who were depressed, classify their depression according
to ICD-10 criteria and then ask them how likely they would be to
present to each service. These results would be far more accurate
than the results obtained in our study, but would require a larger
study population and large amounts of time as each student would
need to be interviewed to assess their mental state.
Conclusion
Having achieved these results, we feel that it is important to
address the negative attitudes of medical students to seeking help
for depression, We propose a further study where information is
provided to students about confidentiality in the services available
to help people suffering from depression and to assess if this
information could improve the attitudes of students to seeking
help.
If you believe your

experiences can
help others in a
similar situation
please write to
the editor with a
short 350 word
response.
References
Box 1: For each vignette students were presented with the
following statement:
2.
If you were experiencing these problems how likely would you

be to see help from: please fill in 1-4 where 1 = wouldnt go, 2 =
might go, 3 = would probably go, 4 = would definitely go)
3.
a) Internet/books
b) A friend
c) A relative
d) GP
e) University counsellor
f) Other counsellor
g) University tutor
h) Someone else not on this list, please specify ________
4.
3. For some of the chi squared tests, the expected values were
under 5. This has been said to reduce the validity of this statistical
method and in future we would either try and increase the number
of respondents to the questionnaire or group several ethnicities
together to achieve higher expected values. 9
Ideal Study Design
Our study asked theoretical questions about the likelihood of
Vignette 3 Unaffected by clinical Depression

You have noticed that a few things have changed in the last couple
Vignette 4 Moderate depression

Since your boyfriend/girlfriend broke up with you over a month ago,
youve started to notice some changes. Your appetite has gone and
you notice that your clothes are starting to look increasingly baggy.
You feel tired a lot of the time, but still wake most mornings at
about 5am. Things take you a lot longer than they used to, so often
you just stay in your room. You begin to feel guilty about this and
think that you dont deserve anything better anyway. Your friends
have been out partying and normally you would have loved to join
them, but just dont seem to enjoy the things you used to anymore.
1.
Appendix 1 Case Vignettes

Vignette 1 Severe depression
Since your grandma passed away three months ago, you have
noticed some changes in your daily routine. You wake at 5am
despite feeling tired all the time. You have little energy and rarely
cook for yourself. You are feeling down and have little interest
in your university course. You remember an incident from the
beginning of the summer when you left a shop with an apple and
forgot to pay for it. You feel very guilty about this and feel that you
have brought shame on your family. Sometimes you hear voices
talking about you and to you saying that you are worthless and you
should turn yourself in to the police for stealing the apple.
Vignette 2 Mild depression
Since starting university over three weeks ago you have been feeling
quite low. You are struggling to make it in for your 9am lecture,
despite getting a reasonable night of sleep and you find that you
are eating less and rarely make your own food. You find that you are
going out a bit less in the evenings, but are finding it harder than
usual to concentrate in lectures, and you no longer enjoy some of
the things that you used to.
Statistical analysis:
1. 34 chi squared tests is a large number of tests to run and it is
possible that running this number of statistical tests, will by chance,
procure some statistically valid results. Therefore better planning
should have taken place in order to minimise the number of tests
performed and the amount of data collected.
of weeks running up to your first big set of exams. You wake earlier
in the morning in order to make it to lectures, but oversleep a
couple of days a week. Your eating habits have changed you
havent had much time to cook for yourself and find yourself
skipping breakfast due to the morning rush and consequently eat
more during the day. Sometimes, especially towards the end of
the day, you find it hard to concentrate in lectures. One evening in
the last week you felt a bit down, and so you decided to go to the
cinema and watch an upbeat film.
5.
6.
7.
8.
9.
Bhugra et al. Globalisation and mental disorders. Overview

with relation to depression. The British journal of psychiatry
: the journal of mental science (2004) vol. 184 pp. 10-20
Thornicroft. Most people with mental illness are not
treated. Lancet (2007) vol. 370 (9590) pp. 807-8
National Mental Health Report 1996, Fourth Annual
Report. Changes in Australias Mental Health Services
Under the National Health Strategy 199596. 1998
Canberra : Dept. of Health and Family Services, 1998.
Hawton et al. Suicide in Oxford University students,
1976-1990. The British journal of psychiatry : the journal
of mental science (1995) vol. 166 (1) pp. 44-50
Minhas FA, Nizami AT. Somatoform disorders: Perspectives from
Pakistan. Feb 2006; International Review of Psychiatry. 18(1) (55-60)
Bhugra D, Mastrogianni A. Globalisation and mental
disorders. Overview with relation to depression. 2004
Jan, British Journal of Psychiatry. 184:10-20
Merritt RK; Price JR; Mollison, J, et al. A cluster
randomized controlled trial to assess the effectiveness
of an intervention to educate students about depression.
Psychological medicine (2007) vol. 37 (3) pp. 363-72
Roness A, Mykletun A, Dahl AA. Help-seeking behaviour
in patients with anxiety disorder and depression.
Acta Psychiatr Scand. 2005 Jan;111(1):51-8.
Armitage P, Berry G and Matthews JNS. Statistical
Methods in Medical Research, Wiley-Blackwell 2001
Box 2: at the end of the questionnaire the participants were asked:

How likely would it be that the following factors prevented you from
seeking help from the list above? 1-3 where: 1 = wouldnt prevent me at
all, 2 = might prevent me 3 = would definitely prevent me
a) They would think less of me.
b) I wouldnt want other people interfering with my business.
c) Wouldnt want to waste their time.
d) This could affect my career as a doctor.
e) This could affect my grades or go on my university record.
f) Wouldnt want to have a label of depression.
g) The opening hours wouldnt suit me/I wouldnt have time.
h) The service is too far away.
i) Another reason ___________
37
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REVIEW
Amphetamines
behaviour including substance abuse.19 Experiential avoidance

such as self-harm is a form of negative reinforcement via distancing
the self from unpleasant emotional responses to stimuli; and may
therefore also be associated with greater degrees of BAS; with the
impulsivity and novelty-seeking aspects of a BAS trait personality
likewise linked to such avoidance.20,21
Marcela Schilderman BSc (Hons)

m0401306@sgul.ac.uk

and references see
thelsjm.co.uk.
Abstract
A relationship between amphetamine misuse and deliberate
self-harm has been cited1, yet few epidemiological or research
studies have been carried out to verify or nullify this link. The
author explores the relationship between these behaviours through
examination of the neurobiological, sociological and psychological
similarities in their effects and occurrence, with a view to
suggesting why the two might co-exist in the same patient and the
implications of this relationship.
Introduction
The term amphetamine misuse is used here to refer to any nonprescribed (and therefore illicit) amphetamine administration from
single use to complete dependence; whilst self-harm and self-injury
are used interchangeably to denote deliberate infliction of injury
(most commonly poisoning or skin laceration)2, to an individuals
own body in the absence of the intention to die from the damage
caused.
Epidemiology
Amphetamine misuse and self-harm are significant problems in their
own rights. 16% of the 4713 11-35 year olds interviewed in the 1996
UK National Drugs Campaign Survey had used amphetamines.11
Amphetamines are the second most popular illicit substance
after cannabis in the UK and Australia, and fourth most popular.3,11
Self-harm is estimated at between 400 and 1400 per 100,000
population per year. 4
In conjunction, drug misusers have a greater incidence of suicide
and self-harm than the rest of the population.5 But amphetamines
have especially been related to severe self-harm such as self
enucleation and removal of the hands,6 with three documented
cases of repetitive genital self-injury.7 The Department of
Psychiatry belonging to the University of California reports
encountering serious self-harm with amphetamine induced
psychosis, and recommends screening for amphetamine use in
cases of unusual or serious self-harm.6
38
Amphetamines are sympathomimetic. 22 They function as

indirect agonists by acting on intracellular vesicles, instigating
the reversal of catecholamine transporters at the vesicle and the
release of noradrenaline and dopamine.23,24,25 Amphetamines
also inhibit the re-uptake of dopamine released in the Nucleus
Accumbens (NAcc.). Both of these mechanisms thus lead to a rise
in the amount of this neurotransmitter acting on its postsynaptic
receptors in the NAcc, an occurrence deemed essential to the
reward sensation in the dopamine reward hypothesis of drug
addiction.26
Demographic factors
Gender
Self-harm is an estimated four times more frequently reported
in females than males, though self-poisoning (and therefore the
use of drugs to procure injury) is greater in women.8 Contrarily,
surveys place amphetamine use as 1.25 to 2 times greater in males
than in females, both in the preceding year to the surveys and
over the participants lifetime. 9,44 The latter could be explained
by the recent discovery that men release more dopamine in the
ventral striatum (including the reward-associated NAcc [nucleus
accumbens]) and report a significantly more positive experience on
amphetamine administration than females. 10
Age
The greatest percentage of amphetamine misusers are aged 16 to
24 based on their amphetamine consumption in the preceding
month (4% of a total 4647 respondents of a general drug survey),
three months (7%), year (13-14%) and entire lifetime (22-26%).11
Similarly, self-harm is more frequently reported in the younger
population, those aged 12 to 30, with figures as large as 61%
ascribed to adolescents.12,13
Ethnicity
Surveys in the USA have shown the prevalence of self-harm,
stimulants, and particularly methamphetamine use to be amongst
the greatest in Hispanic and white groups, and the lowest in the
black subpopulation. 14,15,44
Biological Factors: Biochemistry and Neurophysiology
Higher doses of amphetamines elicit stereotypical self-mutilatory
behaviour in rats (such as biting and gnawing)16 dogs 17 and horses.18
This would suggest a biochemical theory of causation.
Dopamine
Differences in transmission of dopamine are thought to underlie
variance in the Behavioural Approach System (BAS) within the
population. BAS is stimulated in positive or negative appetitive
reinforcement, and those with high BAS are thus considered more
likely to enter into, and respond positively to, reward- related
An addiction to self-harm hypothesis, has been put forward

suggesting that the release of endogenous opiates onto
receptors ( endorphin in particular) in response to pain, results in
pleasure.27 Opioids active at the receptors block the action of
GABA interneurones on neurones of the Ventral Tegmental Area
(VTA). The disinhibition of VTA neurones causes them to increase
their firing rate, and thus increase dopamine function in the NAcc
upon which they synapse.28,30 Furthermore, a defective dopamine
mechanism has been recorded in half of self-harming patients with
Tourettes syndrome.22,29
with OFC lesions.40 This is likewise true for patients with borderline
personality disorder patients and history of violent behaviour
inclusive of self-injury. 48
Further research is required to determine whether or not
amphetamine induced 5-HT depletion, particularly in the
orbitofrontal region, leading to the typical decision-making
abnormalities (a tendency to make delayed, ineffective choices) of
an OFC lesion, may result in self-harming behaviour, or at the least
aggression and a propensity towards it.
Caudate
As well as the NAcc; self-harm and amphetamine use may share
the caudate in their instigation. Lesion of the caudate using
6-hydroxydopamine terminated the stereotypical amphetamineinduced gnawing and biting in rats.26 Whilst Yaryura J.A. et al
proposed a possible neuronal circuit responsible for self-harming
behaviour wherein the caudate and other basal ganglia, in addition
to the thalamus, are involved with mediations between rageregulation of the amygdala, fear and appetite regulation of the
hypothalamus, and the activity of the frontal lobe. 22,39
Sleep deprivation
Sleep-related problems were reported in 93.4% of
methamphetamine users in one survey.40 A quantity of research
exists to suggest that self harm in amphetamine abusers may be a
result of the lack of REM sleep obtained by some misusers of the
drug.1
Serotonin
Serotonin may also be a mediator. Several reports associate
p-chloro-N-methylamphetamine abuse with a significant
depletion in serotonin levels. 20,31,32 Conditioned preference for
amphetamine-associated places by rats was inhibited with the
administration of the 5-HT transmission amplifier zimelidine,
but increased with the administration of the serotonin antagonist
ritanserin.33 Sekine et al. found density of 5-hydroxytryptamine
(5-HT) transporters decreased inversely with length of
methamphetamine abuse in universal areas of the brain; and that
their density in the anterior cingulate, orbitofrontal, and temporal
regions was highly connected with the raised levels of aggression
they documented in methamphetamine abusers. 34
Genetics
Incidence of substance misuse was shown to be greater
in monozygotic than dizygotic twins, indicating a genetic
component.41 Whilst the A779 allele for tryptophan hydroxylase
was more frequently encountered in deliberate self-harmers than
controls in one survey, which supports a serotonin hypothesis for
the disorder, as well as suggesting a genetic basis for it.42 It may
therefore be that some amphetamine users who self-harm have a
genetic predisposition towards it.
Aggression has been listed as one causative factor in self-harm; and

self-injury may frequently be the major presenting symptom of an
aggressive disorder. Studies in humans and animals have shown a
link between self-harm and problems in 5-HT regulation. 22,35 The
efficacy of selective-serotonin reuptake inhibitors in the treatment
of self-harming and aggressive behaviour supports 5HTs role in
their genesis.22
Borderline Personality Disorder

The DSM-IV requires a minimum of five out of the nine criteria
listed for a diagnosis of Borderline Personality Disorder (BPD).
Criterion 5 refers to recurring self-harm or threats of it, (occurs in
an estimated 48-79% of sufferers 43,44,45) and criterion 4 refers to
two or more other impulsive and possibly self-injuring acts such as
substance misuse (57.4% of BPD patients also have a substance use
disorder).46,47 Thus amphetamine misuse and self-harm can easily
co-exist in a BPD individual, since they are common to, and relate
to, fundamental aspects of the psychiatric disorder.48
Serotonin and Decision Making

Serotonin appears to have a role in decision-making ability.
Experimentally reduced serotonin function resulted in slow,
maladaptive deliberation in subjects akin to that displayed in
patients with orbitofrontal cortical (OFC) lesions. 36
Evidence has indicated that abnormal decision making is central to
substance abuse. 37 Recent research shows that the problems in
decision-making exhibited in chronic amphetamine abusers are also
very similar to the decision-making problems seen in individuals
Psychiatric factors
There is an increased prevalence of both self-harm and substance
abuse in certain psychiatric disorders.
Conduct Disorder
Those with conduct disorder are at increased risk of self-harm
(12.6% prevalence)49 and substance misuse.50 A study of
delinquent adolescent boys concluded that they all achieved
modified criteria for conduct disorder, and found a significant
association between the number of conduct disorder symptoms
and self-harming history. 51
39
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REVIEW
Children suffering from conduct disorder have a greater probability
of discord with their contemporaries,52 of association with
delinquent and rejection by non-delinquent contemporaries. It
could be that the psychological impact of rejection and conflict,
and deviant peer influence guide a person with conduct disorder
towards self-harm and amphetamine use.
Post Traumatic Stress Disorder (PTSD)
PTSD has been linked to an increased probability of both substance
abuse and self-harm.1, 10 Jacobson et al comment on the large
amount of data supporting a pattern where substance misuse
occurs secondary to PTSD as a means of altering the symptoms
of PTSD (the self-medication hypothesis); they propose that the
high level of comorbidity in this area is indicative of a functional
similarity between the two disorders.53 Prospective and analytical
studies by Chilcoat H.D. and Breslau N. are in favour of this
hypothesis over the two alternatives: namely, that substance abuse
occurs prior to PTSD and is causative of it, either through placing
the individual at increased risk of exposure to traumatic events,
or through increasing their susceptibility to PTSD on exposure to
trauma .54
In terms of more general stress, chronic stress caused development
of sensitisation to the stimulatory behavioural effects of
amphetamines in mice of particular strains (DBA/2 but not
C57BL/6) , 55 thus suggesting a plausible hypothesis that individuals
of some genotypes are susceptible to amphetamine sensitisation
on prolonged or repeated exposure to stressors
Self harm as a means of feeling some sensation to overcome
numbness (automatic positive reinforcement), was found to be
associated with PTSD.89
Study findings have shown that serotonin (SERT) gene knockout
mice have greater vulnerability to predator stress,56 and that
persons with low-functioning forms of this gene are more
susceptible to depression and anxiety (and thus, symptoms of
PTSD) following traumatic incidents.57,58,59 Inactivation of the
serotonin SERT gene, although leading to increased 5HT2A
receptor binding density in the amygdala,60 leads to a decrease
in 5HT1A receptor binding density in numerous areas of the
brain as well as the amygdala.61 Decreased binding density
might suggest decreased response to serotonin. In light of the
aforementioned associations between self-harm, amphetamine
use and 5HT, it could be postulated that an underlying SERT gene
malfunction affecting 5HT receptors, exacerbated by the effects of
amphetamine use, may make some individuals vulnerable to anxiety
and depression in response to stressful life events, and therefore
PTSD and/or self-harm.
Eating Disorders
Amphetamines, being appetite suppressants, are open to common
abuse amongst individuals with bulimia nervosa.62 The level of
severity that those with an eating disorder limit their calorie intake
has been shown to correlate with their likelihood of amphetamine
use. 63
An association between self-harm and eating disorders has likewise
been noted, with epidemiological research placing self-injury at a
25% for inpatient and outpatient bulimics, and 23% for outpatient
anorexics.64,65
40
It may be that the lack of esteem in the self, particularly the body,
which can direct an individual towards taking amphetamines in the
propagation of an eating disorder, may also direct them towards
self-harm (see later, under self-esteem.)
Depression
Depression has been associated with amphetamine misuse and
very much so with self-harm .66,67 Major depressive disorder was
diagnosed in 67% of self-poisoners in a study by Kerfoot et al.68
The vast majority of deliberate self-harmers in another survey
achieved scores on the Beck Depression Inventory indicating
moderate to severe depression. 73
There was a significant decrease in the 5HT binding capacity in the
individuals of one study who had self-harmed, which would suggest
a reduced response to 5HT in these patients. 69 Evidence, including
lower concentrations of serotonin metabolites in the cerebrospinal
fluid and serotonin in post-mortem brain tissue, reduced numbers
if serotonin transporters in such tissue and the efficacy of selective
serotonin reuptake inhibitors in depressed individuals all suggest
that depression is likewise affiliated with impaired 5HT function. 70
Self-medication with amphetamines in order to combat depression
occurs commonly; typically one user in a qualitative study
recounted being so low in morale that she was drawn into the
habit to resolve this. 71,72 In another such survey, those respondents
who were also administering the drug for this purpose did report
the desired elevation of affect on initial use; however, over 66% of
the overall 450 questioned described depression as a serious result
of chronic use. 73
It is not clear where precisely causality might lie. Whilst it appears
pre-addiction depression might instigate either behaviour, and
thus possibly both in the same individual, either simultaneously,
or sequentially; it is also plausible that dysphoria produced by
amphetamine withdrawal 50 or the effect on neurotransmitters
of its chronic use, or the impact of sociological factors (such
as unemployment) resulting from its misuse, may produce a
depression that leads to self-harming behaviour.
Sociological Factors
There are several cofactors in substance misuse and self-harm in
young people, including those following.
Peer Influence
Peer pressure is viewed as a possible reason for commencement of
self-injury, and the negative influence of self-harming individuals
among peer groups has been noted.74,75 Amphetamine use
by peers significantly raised the likelihood of amphetamine use
reported in a large sample of adolescents in America.76
Childhood Abuse
Review of both retrospective and prospective research suggests
most of the research indicates that childhood physical and sexual
abuse is a risk factor for substance abuse, often through generation
of depression and anxiety which put the victim at greater risk of
such behaviour. 77
In one survey of self-harmers, 25% reported childhood physical
abuse, and 49% childhood sexual abuse, as factors in the distress
that caused them to self-harm. 78
Family problems
Single parent status and one third of divorces have been linked to
substance abuse , whilst over 50% of those self-harming under the
age of 16 have divorced or separated parents.79,80,81
American research has categorised victims of emotional abuse as
being at risk of substance use;82 and emotional abuse was cited in
43% respondents in one survey as a factor for their self-harm.109
Lack of warmth has been associated with both self-harm and
advancement from experimental to more frequent substance
use.83,84
Connections have been made between family disruption and
dissension, and both self injury and substance misuse.85,110,114
The object relations theory hypothesises that people, objects
and fantasies in the environment of a child will form the basis
from which the child acquires their sense of self. In cases of
childhood abuse and family turmoil and lack of warmth, the childs
environment is unstable, love is conditional, and trust may be
abused.86 Van der Kolk proposes that this may cause the child to
envision themselves as lacking in trustworthiness and unable to be
loved unconditionally leading to self-injury as a form of punishment
or a need to re-enact the trauma.87,88 The childs emotional
system may also be sensitised to future traumas by these earlier
experiences, making them more difficult to withstand, and perhaps
therefore necessitating self-injury and amphetamine use as coping
strategies for the emotions (experiential avoidance).
Conclusion
Both self-harm and amphetamine misuse are significant medical
issues in their own rights in terms of their high popularity and
negative effect on multiple aspects of quality of life. It is clear that
there is a paucity of research into the exact relationship between
amphetamine misuse and self-harm in humans. Currently, only
animal studies have provided firm evidence of a link between
amphetamines and self-mutilatory behaviour though many possible
explanations for a human association are plausible. There is a need
for further research in this area to establish causality, which will be
beneficial in establishing the extent of comorbidity or sequential
morbidity with these disorders, and vital in planning the treatment
approach; for example, an underlying neurobiological problem
would favour pharmacological treatment, a psychiatric problem
might favour a problem-solving emendation approach. Unified
nomenclature would help make research studies comparable with
each other.
It is likely that not just biological but also psychosocial factors

mediate. From the factors involved in relation to self-harm and
amphetamine misuse, it is clear that there is scope for further
research studies into combined treatment involving
1. Raising of self-esteem.
2. Family therapy to resolve conflict and care issues.
3. Amendment of poor problem-solving abilities
4. Amendment of poor decision-making capabilities
5. Alternative medicine
The high physical, psychological, financial and social health costs
of amphetamine use and self-harm, and its popularity in an age
group of individuals expected to be at the peak of their health,
and at critical junctures of their educational or working lives, make
research into the incidence and co treatment of it prudent.
Routine screening for amphetamine use in self-harmers and vice
versa may also be worthwhile given the apparent relationship
between them.
Where there is a diagnosable underlying medical condition,
such as PTSD, then recommendation is made to treat the cause.
Cotreatment of amphetamine use is considered advisable, to
ensure amphetamines do not mask an underlying psychiatric
condition, and so that physical harm is limited.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Much of the research into amphetamine and self-harm focuses on

the adolescent to 30 year old age group since this is the one with
the highest prevalence of both disorders. This is inadequate for
a full understanding of the populations with these disorders and
ought to be addressed in future studies, particularly as possible
contributing psychosocial factors such as life events and education
status tend to show variance with age.
Lara-Lemus A., Perez de la Mora M., et al.,(1997) Effects

of REM sleep deprivation on the d-amphetamine induced
self-mutilating behaviour, Brain Research, 770;60-4
Patton G.C., Harris R., et al.,(1997) Adolescent suicidal behaviours:
a population-based study of risk, Psychol. Medicine, 27(3);715-24
Yoshida T., Use and misuse of amphetamines: An
international overview. In: Klee H, ed. Amphetamine
Misuse, International Perspective on Current Trends, The
Netherlands: Harwood Academic Publishers, 1997;43-59
Favazza A.R., Rosenthal R.J., (1993) Diagnostic issues in selfmutilation, Hospital and Community Psychiatry, 44(2);134-40
Hasin D., Grant B., Endicott J.,(1988) Treated and
untreated suicide attempts in substance abuse patients,
Journal of Nervous and Mental Disease, 176;289-94
Kratofil P.H., Baberg H.T., Dimsdale J.E. (1996) Self-mutilation
and severe self-injurious behaviour associated with amphetamine
psychosis, General Hospital Psychiatry, 18;117-20
Israel J.A., Lee K.,(2002) Case Report: Amphetamine
usage and self-mutilation, Addiction, 97(9);1215-18
McAllister M.,(2003) Multiple meanings of self harm: a critical
review, International Journal of Mental Health Nursing, 12;177
Grahame-Smith D., Barlow J., et al., Drug Misuse and the
Environment, A Report by the Advisory Council on the Misuse
of Drugs, Norwich: Her Majestys Stationery Office, 1998;15-6
Munro C.A., McCaul M.E., et al.(2006) Sex differences
in striatal dopamine release in healthy adults, Biological
Psychiatry, Article in press, corrected proof accessed via
www.sciencedirect.com at 23:14 hrs on 21/04/06
Evidence is strongest for a neurobiochemical link between

behaviours, specifically serotonin depletition and dopamine
mediated reward. It could be that in the future, there may be the
opportunity of development of one pharmaceutical therapy to treat
both conditions.
41
EDITORIAL
Welcome to the Surgery Section of the London Student Journal of Medicine. We aim to inform all healthcare disciplines through historical
pieces, reviews of fundamental topics and cutting edge research. By understanding the basis of past and current surgical science, current
practice can be challenged and future practices shaped. The Surgery Section encompasses all surgical specialties, Obstetrics and
Gynaecology, Anaesthetics as well as aspects of Clinical Oncology and Clinical Radiology.
This first issue of the journal concerns itself with the topic of unhealthy behaviours. The Surgery Section includes a discussion around the
area of patient safety and the consequences of errors in healthcare. The impact of events that have an adverse effect on patients while under the care of healthcare professionals is substantial and has been known for a very long time. The UKs Department of Health, in 2000,
released the report An Organisation with a Memory which revealed that adverse events affected 10% of hospital inpatients, translating to
approximately 850,000 individuals.1 Furthermore, the report highlighted the fact that many of these adverse events were happening time
and time again as lessons were not being learned. In 2004, the UKs Chief Medical Officer spoke at the launch of the World Alliance for
Patient Safety and said, To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.2 This is an unhealthy behaviour
within healthcare that we must eradicate to ensure that we are not adding to the burden of illness.
So how can we as healthcare professionals improve upon our unhealthy behaviours? Sebastian Yuen in his Expert Comment covers a range
of strategies. What is needed first and foremost is an awareness of these issues. Speaking from our perspectives as medical students, we
admit to having little exposure to patient safety, and perhaps this needs to be the first issue to be addressed. We would like to know of your
experiences of patient safety as a student in a healthcare discipline around the world as well as your suggestions on how to improve patient
safety. The use of the World Health Organisation Surgical Safety Checklist (see our Ask the Expert feature) is a strategy being implemented
in the area of surgery to address this issue.
This issue also features a review of Primary Care referral guidelines for patients with suspected colorectal cancer. Over the coming months
the surgery section hopes to share with you the opinions of experts currently shaping the landscape of surgical practice. Alongside original
contributions, the section includes articles of general interest and hopes to impact on student life with our perspective pieces. Making the
most of a surgical placement, profiles of eminent individuals and a Mystery Object competition are a few such articles which we hope will
do just this.
We are always on the lookout for potential ideas and articles that can be turned into published pieces in the LSJM. To discuss an idea or
submit a manuscript to the Surgery section, please e-mail us at surgery@thelsjm.co.uk. If you have an individual in mind to profile, please
contact us first as there are certain questions we want all our profiles to include to create a quick and interesting comparison between
them. Looking forward to subsequent issues, we hope to build an issue specifically around peri-operative care and would welcome any
submissions in this area from students of all healthcare disciplines.
As with any publication, feedback is essential both for reflection and improvement. We welcome your views and suggestions that our
readers may have and encourage you to write to us with Letter to the Editors as the subject line of your email.
Our thanks go to everybody who has contributed to this issue including the authors, peer and expert-reviewers. They have provided insightful and pertinent comments, which have thus improved the quality of submissions. However, most thanks must go to our group of panellists for all their hard work, dedication and support.
We sincerely hope you enjoy this inaugural issue of the journal, consider it as a place to publish your work and begin to make it part of your
regular reading.
Jonathan Cheah & Milan Makwana
Section Editors of Surgery
References
42
1.
2.
Department of Health. An organisation with a memory: Report of an expert group on learning from adverse events
in the NHS chaired by the Chief Medical Officer. Crownright. Department of Health. HMSO. 2000.
WHO World Alliance for Patient Safety. World Health Organisation [online]. 2009. http://
www.who.int/patientsafety/en/ [Last Accessed 11 April 2009]
43
EXPERT COMMENT
EXPERT COMMENT
Why Quality Should Matter

To You
Sebastian Yuen MBBS DCH MRCPCH FHEA
Consultant Paediatrician, Royal Free Hospital, London

Fellow, NHS Institute for Innovation and Improvement
sebastian.yuen@institute.nhs.uk
Sebastian Yuen is leader

of the Royal Free Hospital
IHI Open School Chapter
In 2004 in the UK, 2180 patients died as a result of mistakes; this is

not acceptable. Medicine is changing rapidly. Once, it was enough
to acquire knowledge, clinical skills and expertise in a specialty.
Now, however, there is increasing recognition that high quality
healthcare also depends on creating reliable and effective systems
and processes. Lord Darzis High Quality Care for All defines
quality care as being safe, effective and patient-centred.1 Many
patients are actually harmed by the care they receive, resulting in
injury and even death. In 2004/5, 2180 deaths occurred in the
UK due to error.2 Of the 16 million admissions to hospital each
year in the UK, one million experience harm and half of this is
preventable. The US Institute for Healthcare Improvement (IHI)
is working towards a vision they call the No Needless List: No
needless death, no needless pain or suffering, no helplessness in
those served or serving, no unwanted waiting, no waste and no one
left out. Healthcare students have a key role to play in making this
vision a reality. The following discussion will signpost a number of
organisations and resources that will help you learn to see things
differently.
will beings
always carry
risks; human beings are fallible.
Healthcare will always carry Healthcare
risks; human
are fallible.
However,
harm
to
patients
should
not be viewed as an acceptable
However, harm to patients should not be viewed as an acceptable
part of modern healthcare. Liam Donaldson, UK Chief Medical
part of modern healthcare.
Officer
Liam Donaldson, UK Chief Medical Officer
Patient safety curricula have been developed by the World

Health Organisation and Medical Royal Colleges
Adverse events occur, not because people intentionally hurt
patients, but because of the complexity of the system of medical
practice. Other high risk industries, such as aviation, have
embraced the science of safety and transformed the way they
operate. The Academy of Medical Royal Colleges has developed
the Medical Leadership Competency Framework.3 This describes
the competencies that all doctors need to know about planning
and delivering services. The five domains are: personal qualities,
working with others, managing others, improving services and
setting direction. The competencies are outlined for students,
trainees and consultants. The WHO is currently piloting its Patient
Safety Curriculum Guide for Medical Schools.4 The future of
healthcare will depend on a workforce that is skilled in methods
of quality improvement and which can work collaboratively with
44
other professions. But who is teaching this? The challenge faced

by most medical schools is of squeezing ever more into a crowded
curriculum.
The NHS Institute pre-registration training: Improvement for
better, safer health and social care
The NHS Institute for Innovation and Improvement aims to
transform healthcare by rapidly developing and spreading new ways
of working, new technology and world-class leadership. In 2006
it worked with three universities to incorporate improvement
methodology training into their pre-registration programmes
for healthcare professionals.5 There are currently 32 universities
involved. Core principles of the training include an introduction
to systems-thinking, understanding the patients perspective
and sustainable ways to improve the service. In addition to the
theory, students are encouraged to work as inter-professional
teams and practise using one of the improvement tools. The
programme enables them to understand that quality improvement
is an everyday task, not one carried out on us by managers. 88% of
participating students felt that service improvement was important
or very important to their professional development. 85% agreed
that knowledge of service improvement would enhance their job
prospects. The NHS Institute continues to promote this training
and aims for it to become compulsory in all universities.
We all have two jobs, one is to do the job were trained to do;
We all
have two
one is to doimprove
the job were
trained
do; the second
the
second
one jobs,
is to constantly
the job
weretodoing.
one
is
to
constantly
improve
the
job
were
doing.
Healthcare student
Healthcare student
The NPSA has created Safe Foundations, a training package

for junior doctors
The NHS National Patient Safety Agency (NPSA) has also
produced a programme for teaching junior doctors.6 Entitled Safe
Foundations and available free online, it consists of four workshops
with UK examples of patient stories and videos. The first focuses
on human error, which it describes as inevitable. It emphasises that
you are most likely to make errors when you start as a junior doctor.
The series continues by contrasting the individuals actions with
the impact of the system. Whilst error will never be eradicated,
harm to patients is not inevitable and can be avoided. To achieve
this, clinicians and institutions must learn from past errors and
learn how to prevent future errors. Root cause analysis of critical
incidents is normal in other complex industries such as aviation.

Systematic investigation of adverse incidents exposes system
failures that often can then be minimised or eliminated.
approximately one hour each to complete. Students are able to

explore the extensive IHI literature that experts and professionals
around the world read and refer to.
Doctors and other frontline staff are harm absorbers, the last
line of defence in the healthcare system. Through a better
understanding of human factors and systems, you will be able to
recognise when things are going wrong. As an emerging clinical
leader, you will be able to prevent that situation from spiralling into
a patient safety incident.
Open School Chapters in the UK allow face-to-face discussion

and learning
The web-based resources are complimented by chapters where
students from a variety of professions meet face-to-face. There is
one chapter in London, based in the Royal Free Hospital. There
are seven others in England, six in Wales and three in Scotland.
Worldwide, the total has reached 122 chapters in 12 countries.
Each has a chapter leader, usually a student, and a faculty advisor
who will have experience of leading quality improvement. The
membership and frequency of meetings will vary, but their purpose
is to engage, enthuse, challenge and stimulate learning and action.
The leaders have monthly calls with IHI to share experiences and
ideas for activities. There are regional clusters which develop
their own support networks. The UK hosted its first UK Chapter
Congress in Stirling, Scotland, on 28th April 2009. As members
of Open School, students are invited to attend the inspirational
IHI national forum (6-9.12.2009, Florida) and International Forum
(20-23.04.2010, Nice, France) with free registration.
Great doctors are not the ones that never make errors. Rather, they
are the people who expect errors to happen and who have strategies
in place to cope with them, before these adverse events could cause
harm to a patient. Professor James Reason
BAMMbino is developing resources for students to complement
the BAMM Fit To Lead programme for consultants. BAMMbino
is the junior doctor division of the British Association of Medical
Managers (BAMM).7 They are supported by the senior leadership
of the NHS and are currently developing resources for medical
students and trainees. These will complement the BAMM Fit To
Lead programme for consultants. Learn To Lead will involve two
years of active participation for doctors and lead to a certificate
in medical management. It will follow the Medical Leadership
Competency Framework and combine courses, project work and
coaching. The student development programme will target medical
students in their clinical years. The format will include facilitated
small group teaching, a management project and individual
mentoring.
The doctors frequent role as head of the healthcare team and
commander of considerable clinical resource requires that greater
attention is paid to management and leadership skills regardless of
specialism. Professor John Tooke
A final thought
Improving quality (safety, effectiveness and patient experience) is
now the number one priority in the NHS. In a recession, with the
NHS budget contracting after 2011, improving the quality and safety
of systems will be essential. Those with experience of effectively
implementing innovations and processes (however small) will
be very attractive to employers. Take advantage of the above
opportunities now, learn to see differently and help provide the
best care for your patients.
Wekind
cant
problems
by using the same kind of
We cant solve problems by using the same
of solve
thinking
we
thinking we used when we created them.
used when we created them. Albert Einstein
Albert Einstein
References
The IHI Open School is a free international interactive

resource for healthcare students
The IHI is an independent not-for-profit organisation helping to
lead the improvement of healthcare throughout the world. During
an 18 month period in 2004-6, they organised the ambitious
100,000 Lives Campaign.8 They enrolled 3,000 hospitals and
introduced six interventions including rapid response teams,
better medication management, and care bundles for acute
myocardial infarction, ventilator-associated pneumonia and central
line infections. The impact was dramatic and saved an estimated
123,000 lives. Similar techniques have spread to many countries
across the world. In the UK, the IHI worked with The Health
Foundation and 24 hospitals on the Safer Patient Initiative (20048). This has evolved into the Patient Safety First Campaign covering
England9 and equivalent programmes in Ireland, Scotland & Wales.
1.
IHI launched the Open School for Health Professions in 2008 to

transform thinking about how healthcare should be delivered10. It
is free and makes full use of Web 2.0 applications to engage its
worldwide audience as fully as possible. Examples of 21st Century
media used include Google Groups, WebEx, Facebook, Blogger,
Twitter, Podcasts and YouTube. The curriculum covers core fields
such as the science of patient safety, systems thinking, quality
improvement, teamwork and communication. This is contained
within six online courses, each comprising four lessons which take
7.
2.
3.
4.
5.
6.
8.
9.
10.
1. Darzi A. High Quality Care for All: NHS next stage review final
report. Crownright. Department of Health. HMSO. 2008.
2. Department of Health. Safety first: a report
for patients, clinicians and healthcare managers.
Crownright. Department of Health. HMSO. 2006.
3. Medical Leadership Competency Framework. NHS Institute
for Innovation and Improvement [online]. 2009. http://www.
institute.nhs.uk/mlcf [Last Accessed 27 April 2009].
4. WHO Patient Safety Curriculum Guide for Medical Schools.
World Health Organisation [online]. 2009. http://www.who.
int/patientsafety/activities/technical/medical_curriculum/
en/index.html [Last Accessed 27 April 2009].
5. Building improvement capability into pre-registration training.
NHS Institute for Innovation and Improvement [online]. 2009.
http://www.institute.nhs.uk/building_capability/building_
improvement_capability/building_improvement_capability_into_
pre-registration_training.html [Last Accessed 27 April 2009].
6. Safe foundations. National Patient Safety Agency [online]. 2008.
http://www.npsa.nhs.uk/nrls/improvingpatientsafety/learningmaterials/safe-foundations/ [Last Accessed 27 April 2009].
7. BAMMbino. The British Association of Medical Managers [online].
2009. www.bamm.co.uk/Services/Support_&_Development/
BAMMbino_2007072440 [Last Accessed 27 April 2009].
8. The First Campaign Initiative. Institute for Healthcare
Improvement [online]. 2009. http://www.ihi.org/IHI/
Programs/Campaign/Campaign.htm?TabId=6#TheFirst
CampaignInitiative [Last Accessed 27 April 2007].
9. Home. Patient Safety First Campaign [online]. 2009. http://
www.patientsafetyfirst.nhs.uk/ [Last Accessed 27 April 2009].
10. IHI Open School. Institute for Healthcare Improvement [online].
2009. http://www.ihi.org/OpenSchool [Last Accessed 27 April 2009].
45
ARTICLE
COMPETITION
The IHI Open School:

Primum non nocere
Andrew Carson-Stevens BSc (Hons)
Intercalated MPhil Medical Student, Cardiff University

carson-stevens@doctors.net.uk
doi:10.4201.lsjm/surg.002
Students, with eyes fresh to the healthcare system, are uniquely

positioned to spot opportunities for improvement. Think about it.
From your experience of the system - as a healthcare student on a
clinical placement, as a patient, as a relative of a loved one - how
often have you thought this could be done so much better?
The Wales Chapter for Healthcare Improvement1 is part of a global

movement, initiated by the Institute of Healthcare Improvements
(IHI) Open School,2 to advance healthcare quality improvement
and patient safety competencies in the next generation of health
professionals worldwide. The Wales Chapter was launched on
April 24th 2009 on the 1st Anniversary of the Wales 1000 Lives
Campaign.
A new generation of healthcare professional

The IHI Open Schools free and certified courses aim to provide
students with the opportunities to learn how to improve the
healthcare systems in which they will work as professionals. Course
content raises awareness of healthcare quality and patient safety
issues, and also equips learners with the skill base to implement
change which can lead to improvement.
The 1000 Lives Campaign recognises the tireless efforts of

frontline NHS professionals and aims to save an additional 1000
patient lives and prevent up to 50,000 episodes of harm over
two years.3 Early figures indicate that in the first six months, 410
patient lives have been saved.4 The combined and unceasing
efforts of frontline NHS healthcare professionals to deliver simple,
evidence-based checks and changes in practice, have contributed
to this success. The Wales Chapter believes that students can assist
identify areas for improvement and save even more lives.
The Open School encourage the set up of a chapter, which is the

UK equivalent of society, and the courses serve as a sound starting
point for generating initial buy-in from colleagues. However, once
students are signed up to the chapter, what next? The Open School
has generated and collected a plethora of learning resources that
promote the sharing of experiences and understanding of roles
between the healthcare professions. Such activities go a long
way towards encouraging a student-led interprofessional learning
environment.
Every system is perfectly designed to achieve exactly the

results it gets
The IHI is working to change the way in which medical error is
understood and managed. IHI advocate that when a medical error
occurs, it is important to acknowledge that the system within which
it happened was perfectly designed for that error to occur.5 The
same could be said for medical education. In fact, it is possible that
as young professionals entering the workplace, we could actually
do more harm than good, despite the very best of our intentions.
A few examples of Chapter activities: video case studies of patient

experiences or interviews with experts in patient safety prompt
discussion and reflection from practice; journal articles can initiate
debate about current and future implications for practice; monthly
audio calls given by world renowned experts in improvement can
help keep momentum, generate new ideas for testing improvement
locally and maintain enthusiasm amongst the group.
A student-led improvement project conducted by the Wales

Chapter involves collecting data to encourage the implementation
of the WHO Surgical Checklist.6 Analogous with pre-flight checks
carried out by an aeroplane pilot prior to take off, the surgical
checklist involves a series of checks prior to, just before and
following surgery. The checklist was implemented at eight sites
across the world, in developed and developing countries, and
resulted in a rate of major complication decrease by one-third and a
40% reduction in patient death.7
We want the Surgical Safety Checklist to be used in every hospital,
for every surgical procedure, by every surgical team, in Wales by
2010. Students observe procedures in operating theatres on a
daily basis. We have asked our medical students to record a series
of observations (e.g. Yes/No) against five key processes that are
already considered standard procedure (e.g. correct site marked
prior to surgery and antibiotics given within the correct time
interval). In collaboration with the 1000 Lives Campaign Surgical
Complications team, this baseline data will be used to encourage
uptake and implementation of the Surgical Checklist in Wales.
The Wales Chapter is working with colleagues at Harvard University,
to establish a global drive to engage students in encouraging
the spread and implementation of the WHO Surgical Checklist,
through the international network of over 100 IHI Open School
Chapters.
A sobering thought ...
By being part of an IHI Open School Chapter and completing
the online courses, students can make a big difference to patient
care. Changes made to create an improvement are very often the
simplest ideas, and IHI Vice-President Joe McCannon reminds us,
If we can improve care for one patient, then we can do it for ten.
If we can do it for ten, then we can do it for 100. And if we can do it
for 100, we can do it for 1,000.
1.
2.
4.
5.
6.
If so, the Surgery Section has a signed copy of The Knife Man:
Blood, Body-Snatching and the Birth of Modern Surgery, a
biography of John Hunter, eighteenth-century surgeon by Wendy
Moore, to give away. The prize has been kindly supplied by the
Hunterian Museum.
To enter, e-mail your answer to surgery@thelsjm.co.uk with
Mystery Object Competition as the subject line along with your
name, course and year/place of study by 30 July. The winner will be
the first randomly selected from all the correct entries.
References:
3.
Setting global challenges

Monthly Chapter Leader calls provide direction through sharing
and discussing successes and challenges. The IHI Open School has
Can you identify this object from the Hunterian Museum, based at
the Royal College of Surgeons of England?
The Royal College of Surgeons of England
46
Simple interventions can save lives

Lives are being saved everyday in the National Health Service
(NHS) but thousands more preventable deaths and incidents of
harm could be avoided. Lasting cultural change within the NHS is
required to ensure this. Healthcare students, as the workforce of
the future, are vital to this process.
Chapter members are encouraged to use their newly identified

skills in practice by getting involved in projects through established
safety campaigns, or even initiating their own improvement projects
to test their individual ideas for change.
Mystery Object Competition
The Royal College of Surgeons of England
Andrew Carson is the leader

for the Wales Chapter for
Healthcare Improvement
created a network of global partnership and friendship between

groups of enthusiastic and dedicated students that share similar
values, visions and goals, successes and challenges, across the
globe.
7.
The Wales Chapter for Healthcare Improvement [online]. 2009. http://

www.waleschapter.wales.nhs.uk [Last Accessed April 29th 2009].
IHI Open School. Institute for Healthcare Improvement [online]. 2009.
http://www.ihi.org/OpenSchool [Last Accessed April 29th 2009].
1000 Lives Campaign [online]. 2009 http://www.1000LivesCampaign.
wales.nhs.uk [Last Accessed April 29th 2009].
Over 400 lives saved in first six months of Campaign. 1000 Lives
Campaign [online]. 2009. http://www.wales.nhs.uk/sites3/news.
cfm?orgid=781&contentid=11897 [Last Accessed April 29th 2009].
Improvement Tip: Want a New Level of Performance? Get a New System.
Institute for Healthcare Improvement [online]. 2009. http://www.ihi.org/
IHI/Topics/Improvement/ImprovementMethods/ImprovementStories/
rovementTipWantaNewLevelofPerformanceGetaNewSystem.
htm [Last Accessed April 29th 2009]
Safe Surgery Saves Lives. World Health Organization [online]. 2009. http://
www.who.int/patientsafety/safesurgery/en/ [Last Accessed April 29th 2009]
Haynes, A.B., Weiser, T.G., et al. 2009. A Surgical Safety Checklist
to Reduce Morbidity and Mortality in a Global Population. N
Engl J Med. 2009 Jan 29;360(5):491-9. Epub 2009 Jan 14.
47
ARTICLE
ARTICLE
A Retrospective Analysis of the

Two-Week Rule in the Diagnosis
of Colorectal Cancer
Theo Walcott
Attack the disease
Michael Carrick
Pass the message on
David James
Saving lives
Rio Ferdinand
Defend your body
Micah Richards
Defend your body
that the poor yields may be due to the guidelines poor sensitivity
and specificity.7
All ages
However, it has also been suggested that these findings reflect the
inappropriate use of the guidelines by GPs. It has been suggested
that the high numbers of nonconforming referrals made are as
a result of some GPs using the TWR referral system as a quick
disposal route for all patients presenting with rectal bleeding.8
Some authors have shown that approximately 60% of all CRCs
identified when analysed retrospectively appeared to fit the
guidelines, therefore suggesting that the guidelines, if accurately
implemented, might prove useful.9
Shaun Wright-Phillips
Pass the message on
Mostafa Albayati
Registered Charity No. 1089464
mostafa.albayati@kcl.ac.uk
Intercalating BSc Medical Student, Kings College London
doi:10.4201.lsjm/surg.003
Michael Carrick
Pass the message on
Rio Ferdinand
Defend your body
Micah Richards
Defend your body
44 people die from bowel

cancer every day in the UK
Shaun Wright-Phillips
Pass the message on
Registered Charity No. 1089464
There is Moore to know

and references see
thelsjm.co.uk. For further
reading please see NICE
guidelines on CRC/ TWR.
44 people die from bowel

cancer every day in the UK
Abstract
Objective: Colorectal cancer (CRC) is the third most common
cancer in the UK. CRC patients in the UK are known to have
poorer survival rates compared to other European countries, with
a three-year survival rate of approximately 44%. In 2000, the
Department of Health (DoH) introduced the Two-Week Rule
(TWR) for fast tracking all urgent cancer referrals, with the aim
of identifying 90% of bowel cancer cases. We aimed to assess
Thereof istheMoore
to know
the efficacy
TWR for suspected
CRC in a large university
Visit
www.bobbymoorefund.org
teaching hospital.
www.teamenglandfootballerscharity.com
Photography by John Davis @ Soho Management; anatomical layers generated by www.TheVisualMD.com and scans by Philips Medical
Ref ED078B.April2009
Methods
A retrospective study of all patients referred to the colorectal unit
during a six-month period was conducted, documenting various
outcomes. Parameters in the study included source of referral,
CRC diagnosis and GP compliance with referral guidelines.
Results
A total of 75 referrals were made to the fast-track clinic during
the study period. 68 of these were made via the TWR, of which 3
(4.4%) were diagnosed with CRC. 7 patients with CRC presented
to the colorectal unit in the same study period through other
means. 38 (56%) referrals complied with the DoH guidelines
for appropriate TWR referral and 66 (97%) complied with the 14
working days target.
Conclusion
The detection rate for TWR-referred CRC was low and accounts for
only approximately a third of all CRC cases diagnosed during this
study period. This low yield suggests that the referral guidelines are
not as effective as the DoH target. Reasons for this may include
48
Visit www.bobbymoorefund.org
www.teamenglandfootballerscharity.com
Photography by John Davis @ Soho Management; anatomical layers generated by www.TheVisualMD.com and scans by Philips Medical
Ref ED078B.April2009
poor compliance with the guidelines by GPs and poor specificity of

the guidelines.
Introduction
Colorectal cancer (CRC) is the third most common cancer in the
United Kingdom, with 32,300 new cases diagnosed and 14,000
deaths annually in England and Wales alone. In addition, patients
presenting with CRC in the UK have been shown to have poorer
survival rates compared to other European countries, with a
three-year survival rate of approximately 44% compared to 67% in
Italy.1,2 The reasons for this are unclear. CRC implies major health
costs to the National Health Service (NHS) (annual expenditure
of more than 300 million) and is important to overall public
health strategy because it is common and frequently fatal. In
order to improve cancer survival rates, the UKs Department of
Health (DoH) issued the NHS Cancer Plan in 2000, with the
introduction of the Two-Week Rule (TWR) for fast tracking all
urgent cancer referrals from primary to secondary care.3 The DoH
also published guidelines for General Practitioners defining those
patients with high risk symptoms that required specialist assessment
within the two week time frame (Table 1), with the aim to identify
up to 90 per cent of patients with bowel cancer.4
Previous studies have commented on the impact of the TWR on the
detection rate of CRC. Chohan et al. revealed that, while the TWR
was successful in speeding up patients access to clinic, only 27% of
referrals had a confirmed diagnosis of CRC.5 Similarly, a systematic
literature review by Thorne et al. in 2006 indicated that only 10.3%
of patients referred by the TWR were eventually diagnosed with
CRC.6 Several other studies have cited pitfalls and have suggested
Courtesy of Cancer Research UK & Bobby Moore Fund
Theo Walcott
Attack the disease
David James
Saving lives
Table 1: Department of Health high risk criteria for suspected colorectal

cancer.
The principal objective of this study was to assess the CRC

detection rate to determine whether the TWR is effective in
identifying suspected CRC patients, and whether findings from our
unit agree with those from other studies published.
Methods
All TWR referrals to the colorectal unit at Bassetlaw Hospital,
Nottinghamshire were audited over a six month period between
April 2006 and September 2006. Referrals were identified from
both faxed TWR proformas and standard GP referral letters. Data
collected from the referral letters included age, sex, and symptoms
for referral. In addition, other outcomes were noted, including
GP compliance with the TWR guidelines (patients fulfilling one
or more of the six high-risk criteria), other routes of referral,
investigations undertaken, the number of cancers diagnosed,
timescale from referral to investigation, and the waiting time from
referral to diagnosis. Diagnosis of all malignancies was confirmed
histologically and graded using Dukes classification.
Results
In total, there were 75 referrals made to the colorectal unit
during the six month study period, all of which were new referrals.
Seven referrals were from outside of the TWR referral system and
were subsequently not included in the main study. The ratio of
male:female patients was 28:40 (41%:59%). Of the 68 patients
seen in the fast-track clinic, only three (4.4%) were subsequently
diagnosed with CRC (Table 2). A further seven patients with
CRC presented to the department in the same time period via
other routes; three were internal consultant referrals from other
departments, two were GP urgent referrals, and two were GP
routine referrals. The final diagnosis of CRC was greater from
referrals outside of the TWR referral system (70% (7/10) versus
30% (3/10), respectively). Furthermore, of the three malignancies
diagnosed through the TWR referral system, one was Dukes stage
B and the remaining two were Dukes stage D.
Compliance with the published guidelines for appropriate TWR
referral by GPs was generally poor, with only 38 (56%) of the 68
referrals complying with the guidelines. The remaining 44% of
patients referred did not fulfil at least one of the six referral criteria
(Table 1). Table 3 documents the symptoms for referral to the fasttrack colorectal clinic. The majority of patients presented with a
change in bowel habit, which was documented 47 times, followed
by rectal bleeding (documented ten times). Rectal bleeding with
a change in bowel habit was noted six times. Unexplained iron
deficiency anaemia was noted five times, and a palpable right sided
abdominal mass was noted once. Abdominal pain and weight
Rectal bleeding with a change in bowel habit to looser stools

Increased frequency of defecation persistent for 6 weeks
A definite palpable right-sided abdominal mass
A definitive palpable rectal mass (not pelvis)
Unexplained iron deficiency anaemia (Hb < 11 g/dl in
men or < 10 g/dl in postmenopausal women)
Over 60 years

Change in bowel habit as above without rectal

bleeding and persistent for 6 weeks
Rectal bleeding persistently without anal symptoms
Table 2: Number of colorectal cancers diagnosed

Number of patients
N TWR referrals received
N CRC cases identified from TWR
referrals (%)
Total number of CRC cases
diagnosed
68
3 (4.4%)
10
Table 3: Symptoms for referral to fast-track colorectal clinic.

Symptoms
Incidence in
patients
Rectal bleeding in patients >55 years
10
Change in bowel habit: looser/increased frequency
47
Rectal bleeding and change in bowel habit
Unexplained iron deficiency anaemia
Right-sided abdominal mass
Abdominal pain
10
Weight loss
loss were also documented as presenting symptoms (ten and four

times, respectively).
The proposed Government target of 14 working days from referral
to outpatient appointment was met in 66/68 (97%) of the TWR
referrals.
Figure 1 shows that the majority of patients underwent colonoscopy
during the course of their investigation, followed by barium enema.
Other investigations included abdominal ultrasonography, flexible
sigmoidoscopy and abdominal CT. The overall median time from
referral to investigation was 3 weeks (range 1-6 weeks) and the
overall median time from referral to diagnosis was 9 weeks (range
2-12 weeks). The most common final outcome of the fast-track
patients was diverticular disease (24/68).
Discussion
The current DoH guidelines for suspected CRC were put in place
to be used by GPs in primary care as a guideline to prioritise
referral.7 Despite original targets, more than two thirds of the
CRC patients in this audit were referred via routes other than the
TWR referral system. The low number of CRC patients identified
following a TWR referral in this study, suggests that the guidelines
are not as effective in identifying CRC patients at first presentation
to their GP as was hoped.
Poor compliance with the guidelines has been documented at many
centres as one of the major reasons for this poor CRC detection
49
ASK THE EXPERT
ARTICLE
rate. The results from our study demonstrated that only 56% of
referrals complied with the guidelines, reflecting many previous
audits. Rai et al., in a recent review of all audits on the TWR
referral system published in mainstream peer-reviewed journals,
found that compliance with the published guidelines by GPs at
primary care level is poor in the majority of centres.10 Possible
reasons for this poor compliance may be due to a lack of time in
the general practice consultation, poor experience with taking
colorectal histories, or exaggeration of the symptoms by the
patient or GP in order to speed up their hospital appointment.
The Advisory Group formulating the guidelines for the TWR
referral system did, however, emphasise the importance of close
adherence and implementation at the time of the guidelines
publication.11 Ideas on improving compliance in the future include
a personalised feedback system from the hospital clinician to the
GP which may help to emphasise the importance of not referring
patients with transient symptoms or symptoms over 18 months
duration to the fast-track clinic.11,12
However, increased compliance with the TWR referral guidelines
reported in some centres has not necessarily improved the
diagnostic yield of CRC in the fast-tracked population. For
instance, Barwick et al. reported only a 10% yield in CRC despite
a 96% compliance rate with the TWR referral.13 This suggests a
problem with the specificity of the guidelines.
Furthermore, CRC is notoriously difficult to diagnose due to its very
non-specific symptoms, dependent on the anatomical location of
tumours. Patients with proximal cancers are more likely to present
with anaemia and therefore be referred to medical outpatients,
whereas those with more distal tumours, producing rectal bleeding,
will be referred to surgical outpatients.14 This suggests that it may
not just be poor GP compliance or poor guidelines that makes the
detection rate using the TWR system hit-and-miss but rather due to
the nature of the disease itself.
More worryingly, the sharp increase in the total number of TWR
referrals in England (60% increase from 13,410 referrals in 20012002 to 21,234 referrals in 2004),15 is overwhelming the system
and a significant number of patients referred routinely are now
being disadvantaged by longer clinic waits and delays in diagnosis,
suggesting that a change is urgently needed.
screening programme for CRC. Faecal occult blood testing

(FOBt) has been suggested as a possible screening tool and
can detect CRC at an early and more treatable stage. It also
provides an opportunity to identify precursors to invasive disease
and polyps.19 However, recent results from the NHS Bowel
Cancer Screening Pilot demonstrate that, despite the feasibility of
population-based FOBt screening, this method of screening has a
sensitivity of 57.7% and a positive predictive value of 5.3% for CRC.
This low positive predictive value means that it has the potential to
produce many false-positive results, and therefore the associated
cost, risk and anxiety of colonoscopy.20 There is a need to improve
the screening tool in order to produce an effective, safe, and
relatively inexpensive screening method with a high positive
predictive value that will function as a good addition to the TWR
referral system.
Our study has shown that CRC is most often detected using the
TWR system in patients presenting with later stage (Dukes stage
C and D) disease. Similarly, Debnath et al. reported an early
cancer detection rate of only 4.6%.17 These findings suggest that
the referral system is ineffective in identifying early stage CRC and
raises a question of whether it translates into any apparent future
survival benefit. Earlier presentation of CRC is very non-specific,
and if the TWR system is to detect these earlier malignancies,
its criteria would need to be even more non-specific than it
currently is.
A solution to this problem would be to introduce a national
50
Sebastian Yuen MBBS DCH MRCPCH FHEA
sebastian.yuen@institute.nhs.uk
Consultant Paediatrician, Royal Free Hospital, London
Fellow, NHS Institute for Innovation and Improvement
Conclusion
Ultimately, the objective of any fast-track referral system is to
diagnose and treat suspected cancer at an earlier stage in order to
improve survival. The evidence presented in this paper indicates
that the detection rate for TWR referred CRC was low and
accounts for only approximately a third of all CRC cases diagnosed.
This may be reflected by the fact that many patients referred to the
fast-track clinic did not comply with the guidelines.
Although the TWR remains a valuable service to GPs and their
patients and that its low CRC yield may be partly due to the nonspecific nature of the disease, the results from this study and many
similar audits suggest that the system is in need of independent
evaluation and improvement. The effectiveness and efficiency of
any future system in detecting CRC will depend on the sensitivity
and specificity of the referral criteria, the ease with which GPs
could identify the criteria, and the extent to which they choose
to use the new service. This will require well funded programmes
with increased support and feedback to GPs to encourage the
appropriate use of guidelines in the decision to seek referral.
Acknowledgement
Advice regarding the submission was sought from Mr. Kamal
Nagpal, Upper GI Research Fellow, St Marys Hospital, London
References:
1.
Interestingly, similar outcomes in the cancer detection rate using

the TWR referral system have been reported for other cancers.
There has been a decline in the breast cancer detection rate since
the introduction of the TWR, despite an increase in the number of
fast-track referrals.16
What is the WHO Surgical Safety

Checklist?
2.
3.
4.
5.
6.
7.
8.
9.
Gatta G, Capocaccia R, Sant M et al. Understanding

variations in survival for colorectal cancer in Europe: a
EUROCARE high resolution study. Gut 2000;47:533-8.
Ciccolallo L, Capocaccia R, Coleman MP et al. Survival differences
between European and US patients with colorectal cancer: role
of stage at diagnosis and surgery. Gut 2005;54(2):268-73.
Department of Health: NHS Cancer Plan. London; 2000.
Department of Health: Referral Guidelines
for Bowel Cancer. London; 2000.
Chohan DPK, Goodwin K, Wilkinson S, Miller R, Hall NR.
How has the two-week wait rule affected the presentation
of colorectal cancer? Colorectal Dis 2005;7(5):480-5.
Thorne K, Hutchings H, Elwyn G. The effects of the TwoWeek Rule on NHS colorectal cancer diagnostic services: A
systematic literature review. BMC Health Serv Res 2006;6:43.
John SKP, Jones OM, Horseman N et al. Inter general
practice variability in use of referral guidelines for
colorectal cancer. Colorectal Dis 2006;9(8):731-5.
Smith RA, Oshin O, McCallum J et al. Outcomes
in 2748 patients referred to a colorectal two-week
rule clinic. Colorectal Dis 2006;9:340-3.
Eccersley JA, Wilson EM, Makris A, Novell JR.
Referral guidelines for colorectal cancer do they
work? Ann R Coll Surg Engl 2003;85:107-10.
In 2000, in Llanelli, South Wales, two experienced surgeons

removed the wrong kidney, leaving the patient in complete renal
failure. A medical student had realised the error prior to surgery and
alerted the surgeons.1 She was unable to persuade them to stop and
the patient died five weeks later. The root cause was the clerking,
which identified the wrong side for surgery and led to the operating
list being booked incorrectly. In theatre the scans were displayed
back to front. Catastrophic events are seldom the result of a single
error, but more commonly result from the accumulation of multiple
minor errors.
The World Health Organization (WHO) created the Surgical Safety
Checklist as part of the Safe Surgery Saves Lives programme.2 A
world-wide study with nearly 8000 consecutive patients compared
complication and mortality rates before and after the introduction
of the checklist.3 The results demonstrated a reduction in mortality
from 1.5% to 0.8% (P = 0.003) and complications from 11.0% to
7.0% (P<0.001) when the checklist was used. The impact was
greater in developing countries than high-income centres, but
there were improvements in all eight sites.
In January 2009, the United Kingdoms National Patient Safety
Agency released an alert requiring all hospitals to implement the
checklist for every patient having surgery.4 25 items are divided
into three sections, each to be read out loud. Sign In occurs
pre-anaesthesia and confirms the patients identity, allergies,
procedure, site (including mark) and consent. Other important
checks include anticipated airway problems and risk of significant
bleeding. Time Out occurs prior to skin incision. All team
members introduce themselves by name and role. During the

surgical pause, the surgeon and anaesthetist verbally repeat the
patient, site, procedure and predictable complications. The Sign
Out requires a written plan of management, instrument count and
ensures specimens are labelled correctly.
The aim is to ensure that key safety checks are made reliably for
every patient, instead of relying on memory. It is important to
remember that the checklist is simply a tool. Its effectiveness will
depend on how it is implemented and the value placed on safety
within the culture of the department.
As students observing procedures in theatre, you have a duty to
speak up if you have any concerns. As a result of the introduction
of the checklist, the team should now respect and listen to you.
The WHO website has videos of Atul Gawande using the WHO
checklist.2
References
1.
2.
3.
4.
Dyer O. Surgeon is struck off for failing to

mention disciplinary action. BMJ 2005;330:274 (5
February) doi:10.1136/bmj.330.7486.274-a
WHO Safe Surgery Saves Lives. World Health Organisation [online].
2009. www.who.int/safesurgery [Last Accessed 11 April 2009]
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH,
Dellinger EP, et al. A surgical safety checklist to reduce
morbidity and mortality in a global population. N Engl J
Med 2009;360:491-9 doi:10.1056/NEJMsa0810119
WHO Surgical Safety Checklist. National Patient Safety Agency
[online]. 26 January 2009. http://www.npsa.nhs.uk/nrls/alerts-anddirectives/alerts/safer-surgery-alert [Last Accessed 11 April 2009]
51
STUDENT COMMENTS
STUDENT COMMENTS
Maximising your Surgical Placement

Anish Amlani BSc (Hons), Amin Elmubarak BSc (Hons)
Year 5 Medicine, Imperial College London

anish.amlani@imperial.ac.uk, amin.elmubarak@imperial.ac.uk
important both for exams and your first few years as a junior doctor.
Also, if you are looking for interesting or co-operative patients to
examine or clerk, the nurses will always be able to point you in the
right direction.
Try to clerk, and if possible examine all the patients that are in the
care of your firm and present to any member of the team that has
time for you. Read up on as many patients conditions as possible
including: signs, symptoms, management (surgical and medical)
and prognosis. You will definitely be quizzed when presenting your
history.
Be useful
House Officers are very busy and Surgical House Officers are
very, very busy. So if you want teaching offer to do their bloods or
take the histories of patients that they need to see. If the House
Officers finish early with your help, they may be free to give you
some teaching.
Clinics
Though it may sound boring in your first few visits, you will quickly
learn that with the advancements in both surgical and non-surgical
management, a vast majority of the modern surgeons time is
spent in the clinic. Remember the old motto: proper preparation
prevents poor performance. If you know what the clinic is about
then make use of your journey by reading up on the subject and
never be afraid to ask questions if things are unclear.
Beyond that, the same principles apply: push yourself forward.
Before you know it, the staff nurse will be giving you your own
room, you will be clerking patients and coming up with your own
differential diagnoses and treatment plans. Dont be afraid of
making mistakes as long as you learn from them.
Medical students can often take some time to find their feet when
AA and AE are joint co-authors
on surgical placements. Upon reflection, the early weeks are
Competing Interests: None
often unproductive and disorganised, until familiarity, etiquette
Declared
and routine are eventually established. This article aims to provide
anecdotal advice from two medical students who have been
through this cycle too many times, and have learnt from their
mistakes.
Surgical placements are NOT just for future surgeons theres
a lot to be learnt by every medical student. The surgical rotation
is often as equally revered as it is anticipated. But with the right
preparation and attitude, you can not only sail through your surgical
exam but also get an accurate taste of a life in surgery. Hopefully,
this guide will help you get the most experience out of your
placement.
Keenness is the KEY
There is a lot to be gained from a surgery firm, whether you want
to become a surgeon or not. Surgical firms allow you to get into
theatre and see anatomy first hand. You will get a chance to see all
those signs and symptoms that you can recite but have yet to see.
This will aid you in retaining and understanding knowledge better
than any textbook can. As you will also get to see and possibly
(if you play your cards right, see later) feel real abnormalities.
Following a case from admission to discharge can be extremely
interesting and in some cases fascinating.
52
Assisting
Surgery like all aspects of medicine is about teamwork and a
surgeon cannot perform an operation by himself or herself. Even if
you are just holding a retractor, as an assistant you are performing
an essential role.
Is it worth it?
Definitely whilst assisting, you will be able to observe the
operation from the best seat in the house.
Finally
Never be afraid to ask to be excused if you are feeling faint. It
would be a lot worse to faint mid-surgery and land face first in an
open surgical field (it has happened).
Surgical firms offer incredible and rapid learning opportunities for
medical students. However, they are often not exploited for the
wealth of experiences available. So turn up early, make yourself a
regular and get stuck in.
Box 1 : Top 10 tips for theatre

1.
2.
3.
4.
5.
Surgical firms provide an invaluable opportunity to gain proficiency

in basic examination
Practising examinations with other students is great, especially for
exams earlier on in medical school, but at the end of the day we
are in medical school to become doctors (something often lost
sight of). You will be a much more confident and better prepared
Foundation Year 1 (FY1) doctor if you have examined real patients
throughout your medical school training and found abnormal
signs yourself. Also, more importantly how can you identify
organomegaly if you have never felt it?
The early bird
Get there as early as possible if handover starts at 7:30, make sure
youre there 10 minutes before. At the very least it will give you a
chance to skim through the handover sheet and read up on any of
the conditions that the patients have.
Be part of your team
Talk to your team, from House Officer to Registrar and try to gauge
how things are done in the firm; every firm differs from hospital to
hospital, speciality to speciality and Consultant to Consultant.
Do not forget that an integral part of the team are the nurses and
ward clerks ensure that you introduce yourself to them from the
start as they are on the wards for a lot longer than anyone else and
are an invaluable resource for doctors and medical students alike.
They are great for teaching you those basic clinical skills that are
From practising how to ask sensitive questions, to taking histories

and practising those all-important examinations, clinics are a great
time to learn. If you know what your weaknesses are you may be
able to get some guidance in real relevant clinical situations and
you may also be lucky enough to receive one-on-one tuition from
the Registrar or Consultant depending on how busy the clinic is.
The fun bit Theatre!
Whether you are going into theatre to hone your anatomy, see
some abnormalities or because you know that surgery is for you, its
important to know what to expect and to observe the etiquette of
theatre to maximise your experience.
Theatres can be surprisingly small and medical students are not
usually in there to contribute anything, so if you get in the way it
will not go down well. So follow our ten handy hints (see Box 1):
Scrubbing up
This is an essential skill in theatre and one that is easily learnt. If you
do not demonstrate the competence to scrub in proficiently and
quickly, surgeons are never going to let you near an open surgery.
Queens University Belfast provide easy to follow instructions (see
Further Reading) read this before your first day in theatre and
never be afraid to arrange time with a scrub nurse to teach you if
you are still not sure.
6.
7.
8.
9.
10.
Try to eat and have something to drink prior to going into theatre,
fainting isnt fun and can be pretty embarrassing.
Find the changing rooms. It is easy to get lost.
Find some clogs that fit well because you could be standing for a while. N.B. Wearing
your Consultants/Registrars clogs will NOT go down well. It is not normally
worth buying your own clogs as an undergraduate but for those of you who do not
want the hassle of continuously looking for clogs, go to http://www.crocs.eu/.
Turn your mobile phone OFF, no one likes the medical student who leaves it on silent and
then everyone hears the vibrating or worse still, tries to stop it ringing whilst scrubbed up.
Prior to entering the scrub room or theatre, ensure you are wearing a scrub cap to cover
your hair. (Girls tie your hair up and then put on the cap. For students that wear religious
headscarves of turbans, the larger theatre caps will normally go over these. Always ask
your specific consultant for advice, however, if you are unsure as to what to do.)
Introduce yourself to the scrub nurse.
(Re) Introduce yourself to the patient prior to them being anaesthetised.
If you have not managed to clerk and examine the patients on the list, at least ask
the scrub nurse or your FY1 which procedures are being performed that day.
When instruments and the patient are being wheeled in, do not stand in
front of anything, especially doorways you will only be in the way.
Always ask to scrub in and do not be afraid to assist.
Further Reading
http://www.qub.ac.uk/cm/sur/teaching/year3/introductorycourse.pdf Queens University Belfast Guide to Scrubbing
The authors of this published article do not claim to be experts. If you would like to
act on any advice provided, you are strongly advised to seek expert opinion in the
field. Any mention of specific companies or of certain manufacturers products does
not imply that they are endorsed or recommended by the authors, editors or the
London Student Journal of Medicine.
53
LSJM PROFILE
BOOK REVIEW
Mr Niall Kirkpatrick
Principles of Surgery
Principles of Surgery: Everything you need to know but were frightened to ask!
Sam Andrews and Luke Cascarini
Publisher: TFM Publishing Ltd
ISBN: 1903378575
United Kingdom Recommended Retail Price: 25
Current post
Consultant Craniofacial Plastic Surgeon
Lead clinician for the Craniofacial Unit, Chelsea & Westminster
Hospital, London
Member of the Head & Neck Unit, Charing Cross Hospital,
London
Imagine the morning ward round on your first surgical attachment.

The registrar has just asked you a seemingly simple question, Why
was this patient shivering when she woke up after her operation?
You find yourself searching for a coherent answer, fully aware that
the longer you keep the registrar waiting, the better the answer he
expects. They might have been cold? you reply sheepishly, hoping they ignore your patent answer but they push on, and?
demanding you to delve deeper into this conundrum.
Medical School/Undergraduate Studies

BDS Guys Hospital Dental School, London 1984
MBBS Guys Hospital Medical School, London 1990
Postgraduate
MD University of London 1996
FRCS (Eng) 1996, FRCS (Plast) 2001
Principles of Surgery intends to sum up everything you need to

know but were frightened to ask about the field of surgery. This
is a tall order for such a short text but as you read, you will quickly
realise that the authors, Messrs. Andrews and Cascarini, fully appreciate the classical medical student dilemma of trying to work
out what we need to know whilst still trying to learn for the career
ahead. The authors - a Consultant General and Vascular surgeon
and a Specialist Registrar in Maxillofacial surgery respectively - have
a combined experience of fifteen years of being a student.
Through an effective question and answer format, they cover
the key issues that any health professional should know about
peri-operative medicine. For each question posed, there is a
comprehensive answer, explaining the reasons for routine tests and
pertinent Red-Flag signs and symptoms, for example: what factors predispose to wound dehiscence? and how do you recognise
and treat postoperative pneumothorax?
The book is targeted at students of any healthcare profession that
have contact with surgical patients. Principles of Surgery is more
than a surgical dictionary but a well-structured discussion of the
medical care of a surgical patient. In this way, it can be compared
to popular surgical texts such as Surgical Talk. However, this book
does not describe favourite OSCE examinations: It instead fills
in the gaps in a students knowledge that these other texts fail to
cover.
Written in an informal yet didactic style, the book is easily digested
and allows for quick referencing with a comprehensive index and
division into three sections focusing on pre-operative care, operating theatre environment and post-operative care and complications. It is all too easy on a surgical ward round to miss the opportunity to ask about a patients individual management. For example,
students have to try and collate information from many sources
to deduce why some patients are sent to ITU and others can be
treated as day cases. The answers are clearly described in this book.
Principles of Surgery has an excellent chapter discussing concomitant conditions and the resulting differences in the management of
the elderly, emergency patients and those with co-morbidities. The
authors also explain the basic principles of anaesthesia and describe
the functions of basic operating equipment. It even lists commonly
used drugs with the trade names printed alongside to give students
a fighting chance on a lightning-fast ward round.
54
What do you do?

Reconstruction of congenital paediatric & adult craniofacial deformities. Acute facial trauma and reconstruction following Head and
Neck cancer ablative surgery. I work within a large multidisciplinary
team consisting of a number of head/neck surgical specialists
including ENT, Neurosurgeons, Oculoplastic and Maxillofacial
Surgeons. I also participate in joint clinics with Dermatologists in
the treatment of complex facial skin malignancies.
The pre-operative section of Principles of Surgery focuses on the

clerking jobs carried out by house officers and in this respect is not
directly relevant to medical students but does explain the reasoning
for pre-operative haematology and biochemistry. The section about
the operating theatre environment does state the obvious in places
and you could be forgiven for thinking that it is written for students
and junior doctors that never bothered to scrub in when at medical
school.
All of the information offered is extremely useful when on the
wards, in theatre and when presented with a surgical patient with
multiple pathologies, but will this help you in exams? The book
gives students a framework on which to hang information gleaned
from bedside teaching and other sources. I personally found the
post-operative sections the most useful and elements of this
included potentially examinable material especially for critical care
OSCE stations.
In conclusion, Principles of Surgery would be an excellent candidate for a companion read to other surgical, pathology and clinical
examination textbooks and would certainly be of benefit whilst on
the wards or just to read up before presenting a surgical case. It
is surprising how much useful information is contained within this
book and perhaps a more appropriate subtitle should be, everything you hope you never get asked in surgery (but really should
know!)
Conrad von Stempel
Year 1 Clinical Medicine, UCL Medical School
vonstempel@gmail.com
Why did you get involved in surgery?

My interest in surgery stems from my time as a final year dental
student. During a Maxillofacial surgery elective attachment at St
Richards Hospital, Chichester there was a large road traffic accident. I worked throughout the night with the surgical team in the
reconstruction of those involved in the accident. This is where my
early interest in surgery began. After completing my medical studies at Guys Hospital I went on to do a number of surgical jobs in
A&E, Anatomy Demonstration, General Surgery, ENT and Plastic
Surgery. I then went on to complete a Specialist Registrar rotation
in Plastic Surgery on the Pan-Thames scheme and eventually subspecialised in Craniofacial surgery in light of the training I had completed previously, with specialist Fellowships in the Craniofacial
units at the Chelsea and Westminster Hospital and Great Ormond
Street Hospital as well as a Head and Neck Fellowship at the Royal
Marsden Hospital.
Why plastic surgery?
I have always been interested in art and especially enjoyed pottery
whilst at school. Plastics is a specialty where there is a meld of
science, surgery and artistry. It requires the surgeon to be manually
dextrous, with good visuo-spatial ability as well as the ability to plan
ahead.
Describe a typical day.
I get up at around 6.15am. I am usually in the hospital by 7am to
sort out my administrative duties. The pre-operative ward rounds
start around 8am. I spend most days operating. It is not unusual
for operations to last 6-8 hours with several consultants operating simultaneously. 8 hours feels like a few minutes because
one becomes so engrossed in the surgery. I finish the day with a
post-operative ward round at about 6.30pm and am usually back at
home at 8.30pm.
What is the most important thing you learnt as a student?

To adopt a holistic approach to surgical care. The surgery itself only forms a small part
of the care of a patient and one must understand their psychological and social backgrounds. Surgery as a specialty is a predominately postgraduate apprenticeship. It is
important to develop your communication skills and to develop other parts of patient
care whilst at medical school.
I understand that you are involved with the charity Facing the World. How did
you become involved and what are the charities main aims?
I have been involved in the charity since its inception whilst working as the Craniofacial
Fellow at Chelsea and Westminster Hospital with my colleagues Mr Norman Waterhouse and the late Mr Martin Kelly. My brother is a charity lawyer and helped found it.
We, along with a number of other volunteer surgeons, offer complex facial reconstructive surgery that usually requires postoperative intensive care facilities not locally available to children across the world. These children otherwise have no chance of finding
the surgery to overcome their disfigurement. We also support research and have PhD
opportunities in partnership with Imperial College London. We are also in the process
of collaborating with centres in Vietnam and Ghana. An exchange programme has
been organised where senior surgeons from Vietnam come to train in the UK for a
period of 6 months and then take back their knowledge and disseminate it within their
own departments.
What advice do you have for those wishing to pursue Plastic or Craniofacial
surgery as a career?
Firstly, be honest with yourself about whether you have good manual dexterity. It also
helps if you have an artistic bent. Learn more about the profession and understand
that Plastic surgery is much more than just Aesthetic/Cosmetic surgery. The main
thing when choosing a career is to follow your heart, and if you really want to pursue
something then go all out for it. Plastic surgery is an immensely wide ranging, and
rewarding profession.
Kalpesh Vaghela
Year 5 Medicine, Imperial College London and LSJM Panellist
vaghela04@imperial.ac.uk
55
EDITORIAL
Dear Reader,
Welcome to the Global and Community Health section of the inaugural edition of the LSJM. My panel and I hope, in this section, to
inform, educate and stimulate debate on a wide range of healthcare issues, both at home and abroad.
We recognise the short and precious nature of your free time and with this in mind have selected articles that appeal due to their originality,
importance and clarity. Exposs on resurgent tropical illnesses and calls for worldwide vaccination programmes sit with a unique piece
examining the effect of bird flu on smallholder poultry farming, in what I hope you will find to be an interesting and entertaining section.
Two of the articles illustrate neglected diseases, namely sleeping sickness and chikungunya, which Big Pharma and governments have
ignored, and that are now increasing in virulence. I believe though, that slowly but surely, change is afoot in global health. As you will read
in our news area, Glaxo-Smith-Klines pledge to simultaneously discount the price of medicines to developing countries and to create a
drug patent pool is an encouraging sign. This, together with the advent of philanthrocapitalism, the application of techniques borrowed
from successful businesses to create more efficient and transparent charities (as seen in the Bill and Melinda Gates Foundation) will,
I hope, be a transforming force in the future.
This edition of the journal is themed unhealthy behaviours. We link to this theme with a fascinating article comparing food addiction to
drug addiction. Obesity has reached epidemic proportions worldwide and is now a major contributor to the global burden of disease. Time
is rapidly running out for governments to act, before we are faced with a crippling healthcare crisis and this socially acceptable unhealthy
behaviour merits more serious engagement throughout society.
Community health has undergone a not-so- quiet revolution in the past few years, with a greater emphasis being placed on preventative
medicine. The tragic death of Jade Goody has done much to highlight the importance of cervical cancer screening, and our section
boasts a topical article dealing with possible screening initiatives for cervical cancer in the developing world, together with the potential
ramifications of nation-wide vaccination projects in these countries.
We live in a world where every year 1.4 million children under 5 die of diseases that could have been prevented by routine vaccination.1
Such figures are beyond the pale and as future medical professionals we would do well to remember the words of the Global Health
Council, When it comes to global health there is no them, only us. I hope that the LSJM in the future will do much to illustrate the dire
need for doctors and medical aid in the developing world and that this will encourage some of you to lend your extraordinary talents to
those in need away from these shores.
I would like to end by thanking my co-ordinator Katherine Sharrocks, my panel, peer and expert reviewers and of course the exceptional
authors whose work I have had the privilege of reading. Editing this section broadened my horizons greatly and I hope that engaging with
these articles does the same for you.
This journal can only improve with the participation of medical and allied health students. With this in mind, if you have any comments,
criticisms or suggestions then please write to gchm@thelsjm.co.uk, with Letters to the Editor in the subject line. Also, if you are
interested in writing for the publication then do submit your work by email. I look forward to hearing from you.
Best wishes
Vishal Navani
Section Editor of Global and Community Health
References:
56
1.
http://www.who.int/immunization_monitoring/diseases/en/
57
NEWS
REFLECTIVE PIECE
Big Pharma GSK in price slash and patent
pool pledge
Sandra Sadoo
Drug giant Glaxo-Smith-Kline (GSK) will offer medicines at a 25%
reduction to 50 developing countries, affirmed CEO Andrew Witty
at Harvard Medical School.
This groundbreaking move by the company involves the sharing of
800 of its patents to third parties researching neglected diseases
such as tuberculosis.
It has been pledged that 20% of profits made from these
selected countries will be invested back into the development
of infrastructure such as health clinics. Middle-income countries
such as Brazil and India will also be proposed a cost cut. Drug
treatments for malaria, hepatitis B and asthma are amongst those
included in the scheme.
These proposals came 12 days after GSK showed itself to be
another victim of the economic downturn by axing 6,000 jobs
worldwide.
It is hoped that the worlds second largest pharmaceutical company
has raised the bar and will challenge other pharmaceuticals to
question their practices. In Wittys words, Society expects us to
do more in addressing these issues. To be frank, I agree. We have
the capacity to do more and we can do more.
Witty acknowledged that the investment costs to Glaxo are likely
only to extract up to 2m of the 30m that Glaxo make annually
from its sales to the lowest-income countries.
The minister for international development, Ivan Lewis said to the
Guardian, Were all concerned about the economic circumstances
were living in and the danger that that will push an increasing
number of people into poverty. Lewis believes that Challenging
pharma to do their bit ... is entirely legitimate.
Naltrexone is a drug which blocks receptors in the brain responsible

for the highs drinking can produce. It has been available in daily
tablet form for some time, but in 2006 the United States Food and
Drug Administration approved a long-lasting formulation, which can
be injected into muscle once a month. A small study has been undertaken in Cambridge, Massachusetts, which shows the injections
decrease the frequency and severity of drinking sessions.
Heavy drinking represents an enormous public health burden across
the globe. David Rosenbloom, a specialist in substance abuse
from Boston University, says these injections may have a huge
significance for public health, and he envisages them being offered
to repeat drink-drive offenders.
At a time when the public health implications of binge drinking are
constantly in the news, Naltrexone injections may yet prove a real
shot in the arm in the fight against alcoholism.
Published previously in Perspectives (UCL MEDSIN). Taken with
permission from magazine and author
A new weapon in the arsenal against

cervical cancer
The fight against cervical cancer has been augmented with a series
of defining blows; safe and effective vaccines have been developed
against oncogenic Human papilloma viruses (HPV), national vaccination programmes have been rolled out in several countries and
public awareness about the condition has increased. These events
should fuel a reduction in the rates cervical cancer and its associated mortality. However, these changes have benefited a few lucky
countries. In many low resource countries, where the prevalence
of HPV and cervical cancer are higher, a solution still needs to be
found. Results from a cluster-randomised controlled trial in rural
India may provide an answer.
It is clear that the sense of social responsibility of pharmaceutical

firms is increasing. The anticipations are that knowledge-sharing
and more affordable drugs for impoverished countries will
accelerate the development of new drugs and broaden the access
of the worlds poor to essential medicines.
Sankaranarayanan et al showed a significant reduction in advanced

cervical cancer incidence and mortality using a single round of
HPV screening compared to cytology and visual inspection of
the cervix with acetic acid (VIA).1 HPV screening was found to be
more objective, reproducible and easier with regards to training.
However, it was more expensive than other screening programmes.1
Cytology or VIA can then be used in HPV-positive patients to assess
the risk or presence of cervical cancer respectively.2 Those without
cervical cancer can then receive cryotherapy reducing the risk of
progression to malignancy. The authors suggest that HPV screening
should not be used in women under the age of 30 because of the
tendency of these lesions to regress thus discarding the need for
treatment.1 This study provides an encouraging option for resourcelimited countries to curb the incidence of cervical cancer and its
associated socio-economic implications.
A Shot for Alcoholics?
Reference
Michael Malley
m.malley@ucl.ac.uk
2.
Glaxo nonetheless have been criticised in their decision to

withhold their HIV patent rights, due to a conviction that other
efforts are addressing the need for anti-virals. Lewis hopes that
in a meeting with executives of rival drug firms, he will be able to
increase the participation of companies in such a patent pool.
1.
Sankaranarayanan R, Nene B, Shastri S et al. HPV Screening for

Cervical Cancer in Rural India. N Engl J Med 2009;360:1385-94.
Schiffman M and Wacholder S. From India to the World -
A Better Way to Prevent Cervical Cancer. N Engl J Med 360;14
Mukhtar Bizrah BSc (Hons)

m.bizrah@gmail.com
For many, the Flu may be an inconvenient state of health one has
to put up with once or twice a year. For wary historians, however,
the emergence of a pandemic Influenza A(H1N1) flu outbreak
may mean the beginning of a humanitarian crisis. The last global
outbreak was that of the Hong Kong flu in 1968, killing 3 million
people. The true global implications of a flu pandemic, however,
may be more accurately reflected by the Spanish flu in 1918. Killing
50 million people around the globe, it is one of the deadliest
known events in human history.
Conflict of interests:
Mukhtar is an executive
member of the LSJM.
To date (5 June 2009), the World Health Organisation (WHO)

has confirmed 19273 cases of swine flu in 48 countries. Of the
117 resultant human deaths, 97 have occurred in Mexico and 17 in
the United States (US). Yet the true number of those infected is
estimated to be much higher. Although 10053 cases have been
reported in the US to date, the director of the National Center
for Immunization and Respiratory Diseases, Dr Anne Schuchat,
stated that this is the tip of the iceberg -- We estimate more than
100000 cases. This may not come as a surprise seeing that most
people with flu symptoms do not see their family physician. Of
those that do, a considerable number do not have swabs taken for
laboratory analysis.
Is an H1N1 pandemic inevitable then? As the WHO gets closer to
raising the pandemic alert level from phase 5 to 6, it has laid great
emphasis on the fact that this is simply a reflection of demographical spread, rather than severity of illness. Europen Union (EU)
Health Commissioner Androulla Vassiliou comments: It is very
likely that we will reach a pandemic, but this does not mean that
it will be deadly. More questions are consequently being posed
regarding the true virulence of the virus and impact of an H1N1
pandemic.
Wendy Barclay, chair of Influenza Virology at Imperial College in
London, analysed influenza A(H1N1) genes to find that H1N1 has
no genetic features of a highly pathogenic virus at all. She told
The Lancet Infectious Diseases that rather it looks as though this
virus should target the upper respiratory tract and not the lung.1
Nancy Cox, the chief of the Center for Disease Control (CDC) influenza division has also stated that the swine flu is not as virulent
as the Spanish flu causing the 1914 outbreak, and this over the past
few weeks has become more apparent. As a matter of fact, it may
be much less deadly than the ordinary flu, which is estimated to kill
around 36000 people in the US every year.2
Yet there are numerous unknown factors affecting ease of spread
and individual response to H1N1 flu. Individual immunity is a principal factor, which is why very young and very old individuals are at
greatest risk of mortality from ordinary flu. To this date, it is still not
certain if humans possess any immunity to H1N1 flu. The CDC has
You would not think it would be a problem giving shots to alcoholics. However, a different type of shot may well help recovering
alcoholics a monthly injection to prevent craving for alcohol.
58
Influenza A(H1N1): Echoes of the Spanish Flu?
Image: Electron microscopy

image of the newly identified
H1N1 influenza virus: US
Center for Disease Control and
Prevention
stated that older populations may have immunity against H1N1 virus,
as 64% of the cases reported to the CDC are individuals aged 5-24
years. But this remains uncertain as other factors such as young
people travelling more may have come in to play.
A major concern is spread of the virus to developing countries
in the southern hemisphere, whose populations according to Dr
Chan, Director-General of the WHO are most vulnerable and
as a result should prepare to see more than the present small
number of severe cases. Charities such as Oxfam have repeatedly
warned that these populations are at great risk due to shortage of
potentially life threatening treatments.
There seems to be one certainly common theme in much of our
knowledge about H1N1: Uncertainty. Dr Nikki Shindo, a WHO
medical health officer, may have described the current situation
best: The worst-case scenario is the virus will mutate and become
Tamiflu (Oseltamivir)-resistant. The best-case scenario is that it
causes only mild illness and continues to respond to Tamiflu. It is
too early to make definitive conclusions regarding the aftermath of
a looming pandemic, and only time may give the answer. For the
time being, however, the re-emergence of a pandemic as deadly as
the Spanish flu seems like a remote scenario.
Reference
1.
2.
Shetty P. Preparation for a Pandemic: Influenza A H1N1. The

Lancet Infectious Diseases Vol. 9, Issue 6, pp. 339-340 June 2009.
Thompson WW et al. Mortality associated with
influenza and respiratory syncytial virus in the
United States. JAMA 2003; 289(2):179-186.
59
PERSPECTIVE
PERSPECTIVE
From Equasy to Obesity
densities may subserve a reward-deficient state in both obese

individuals and drug addicts that drives compulsive eating and drug
use respectively. Furthermore, dysregulation in the orbitofrontal
cortex and other prefrontal areas may form a common neuronal
substrate underlying food and drug craving behaviours. Repeated
use and craving are two fundamental features of psychological
dependence, such as that seen in long-term users of cannabis.
Chronic ingestion of high fat foods, however, does not induce a
physical dependence typified by withdrawal symptoms.
Haran Sivapalan BA (Hons)

Year 4 Medicine Kings College London
haran.sivapalan@kcl.ac.uk
doi:10.4201.lsjm/gch.002
Obesity exhibits the bio-psychosocial

properties of a serious addiction, albeit
a socially tolerated one
On 11 February 2009, the UK Home Secretary Jacqui Smith

rejected suggestions from the Advisory Council on the Misuse of
Drugs (ACMD) to downgrade ecstasy from Class A to Class B.
Ecstasy or MDMA (3,4 methylenedioxy-N-methamphetamine),
notorious for its use within the rave scene, therefore remains on the
list of the most harmful drugs along with heroin and crack cocaine.
Previous obduracy of the government on this matter, with its
rejection of the Home Affairs Committee report in 2002 and the
Runciman report in 2000, may have spurred the chairman of the
ACMD, Professor David Nutt, to write an article comparing the
risks of ecstasy use to that of horse-riding. Published in the Journal
of Psychopharmacology, the article, entitled Equasy: an overlooked addiction with implications for the current debate on drug
harms, served to highlight the illogicalities in societys attitude
to the harm of illicit drugs in relation to the harm of other more
socially accepted activities.
Extending from these notions, it may be argued that the ingestion
of highly calorific, high-fat and unhealthy foods is harmful in the
context of the present obesity epidemic. Would policies similar to
those implemented to control illicit drugs be successful in curtailing the exigencies of the obesity trend?
The classification system, stipulated by the Misuse of Drugs Act
passed in 1971, discriminates drugs into three classes: A, B and
C, on the basis of harm. The term harm, however, is nebulously
60
Social Harm
The social ramifications of obesity primarily include considerable
economic costs. Obesity generates direct costs, such as those
of diagnosis and treatment, as well as latent costs, such as from
lost income due to morbidity or mortality. In the USA, such costs
amounted to $68.8 billion for the year 1990 illustrating that this
public health problem is of similar economic magnitude to drug
addiction. Other societal harms may possibly comprise damage
to psychological wellbeing. Unlike other drugs, notably alcohol,
high-fat foods do not exert social damages through the effects of
acute intoxication.
defined and Nutt castigates the systems arbitrary foundations with

seemingly little scientific basis. As an alternative, Nutt suggests
that harm should be evaluated in three domains: physical harm,
dependence and social harm. Unhealthy foods can be argued to be
harmful in each of these ways.
Physical Harm
While high-fat foods may not be physically harmful in terms of
acute toxicity, their chronic ingestion causes physical disease both
directly and indirectly, through the promotion of weight gain and
obesity. Obese females with a Body Mass Index exceeding 35kg/
m2 have a 93-fold increased risk of developing type II diabetes
mellitus. In addition, obesity increases the risk off cerebrovascular
and gallbladder disease. In terms of the direct repercussions of a
high-fat diet, studies on human subjects suggest a causal role in
vascular endothelial dysfunction and hepatic steatosis. In contrast
to intravenous drug administration, oral ingestion of food is not
associated with any serious secondary harm.
Dependence
Applying the concept of dependence to foodstuffs remains
abstruse, but there is a burgeoning body of evidence suggesting
obesity has psycho-physiological commonalities with drug addiction. Administration of calorific foods and drugs has both been
shown to activate mesolimbic dopaminergic reward networks in
the brain. Similarly, relatively low striatal D2 dopamine receptor
There are other conspicuous differences between obesity and drug

addiction. Food is necessary for survival, whereas drugs are not.
The composition of what is deemed unhealthy food is subject to
more heterogeneity than the specific active substance of a drug.
Given the parallels between drug addiction and excessive caloric
dependence, however, the question arises whether public health
policies used to regulate the supply and demand of drugs can be
applied efficaciously to tackle obesity.
A renewed and energetic public education campaign could be
used to reduce the demand for unhealthy foods. This would involve
the dissemination of information about their associated health
risks to schools, places of employment and through the media.
The potency of this method has precedence in smoking cessation
campaigns, which have been effectual in reducing nicotine use.
Despite this, educational strategies require long periods to evoke
change and it is questionable whether this strategy alone would
abate an obesity epidemic.
cost to the consumer and generate a disincentive to smoke or

drink. A similar system of tax on unhealthy foods could favourably
modify dietary choices. Additionally, as food has a lesser propensity
to cause dependence in comparison to nicotine, demand is likely
to be more price elastic. While simultaneously dissuading unhealthy
food consumption, revenue created from these schemes can be
used to fund healthcare. Alternative economic strategies involve
placing minimum prices on unhealthy foods. One major criticism of
applying these policies is that they penalise poorer people far more
than those with higher disposable incomes.
Conclusion
Clearly, obesity exhibits the bio-psychosocial properties of a
serious addiction, albeit a socially tolerated one. Whereas the
Equasy example questioned the aggrandisement of drug-related
harm compared to other socially accepted harms, a parallel issue
is the relative leniency granted towards unhealthy foods. With the
prevailing obesity epidemic, a period of cultural upheaval in the
attitude toward these foods is required. High-fat, calorific, junk
foods are reinforcing drugs that drive compulsive eating and as such
must be subjected to stringent social, economic and legal policies.
If the obesity problem is to be solved, the state, producers and
consumers of food must all grant credence to the notion of obesity
as an addiction.
Reference List

Nutt DJ. Equasy An overlooked addiction with

implications for the current debate on drug harms.
Journal of Psychopharmacology 2009; 23 (1): 3-5.
Nutt DJ, King LA, Saulsbury W, Blakemore C. Development
of a rational scale to assess the harms of drugs of
potential misuse. The Lancet 2007; 369: 1047-1053.
Jung RT. Obesity as a disease. British Medical
Bulletin 1997; 53: 307321.
Motomura W, Inoue M, Ohtake T, Takahashi N, Nagamine M,
Tanno S, et al. Up-regulation of ADRP in fatty liver in human and
liver steatosis in mice fed with high fat diet. Biochemical and
Biophysical Research Communications 2006; 340: 1111-1118.
Volkow ND, Wise RA. How can drug addiction help us
understand obesity. Nature Neuroscience 2005; 8: 555-560.
Legislation
The success in tapering the prevalence of nicotine use may also
stem from legislative measures. A minimum age for purchasing
tobacco and, more recently, the banning of smoking in public
areas, clearly limit the opportunity to indulge in nicotine use. In
theory, similar measures can be applied to curb obesity. While
outlawing certain foods may be construed as extreme, more
moderate measures, such as nationwide restrictions on the types of
food that can be sold in schools, could prove beneficial. Like the
nicotine precedent, legal restraints can be imposed on advertising
and may enforce the inclusion of health warnings on food packaging. Such legal schemes are, however, clearly contentious in that
they present a potential affront to civil liberties and consumer
freedoms. Such moves would also undoubtedly engender a
powerful political lobbying and subversive response from the
processed food industry, one of the most influential, wealthy and
well-organised groups in our society.
For licit drugs such as nicotine and alcohol, pricing is an important
factor in the regulation of public usage. Heavy taxes increase the
61
REVIEW
REVIEW
Poultry vs. Poverty:

The Social Impact of HPAI on
Smallholder Poultry Farming in
the Developing World
Peter D. Liddle BA (Hons)
peter.liddle@kcl.ac.uk
The term developing in the context of countries and economies is

employed here strictly in the statistical sense as defined by the United
Nations Statistics Division (UNSD), and should not be considered
as a judgement of relative development in a broader sense; or an
acceptance that such comparisons are possible or useful.

and references see
thelsjm.co.uk.
Where the rooster crows,

there is a village.
Shambala proverb, Tanzania8
Although recognized in fowl for over one hundred years, and

reported formally in 1959,1 Highly Pathogenic Avian Influenza
(HPAI) captured widespread public attention early in 1997, spurred
by the first reported human infections of the H5N1 subtype in Hong
Kong.2 The emergent zoonotic properties of the virus provoked
rapid mass media coverage, and 6 fatalities amongst the initial 18
laboratory confirmed cases fed urgent speculation of an impending
human pandemic. Whilst the Hong Kong outbreak was contained
and controlled with relative rapidity, subsequent human infections
in other regions of China were reported throughout 2003/4, and
in January 2005 the World Health Organization (WHO) modelled
a best case pandemic scenario, projecting excess global deaths
ranging from 2 7.4 million.3
Since this alarming analysis, however, it has become apparent that
HPAI viruses, including the H5N1 subtype, have the propensity to
bind deep within the lungs, in contrast to more common seasonal
influenza viruses which attach to cell linings in the nose and
throat.4, 5 This seems to impede human uptake of the virus, both
in terms of zoonotic and human-human transmission.2 As a result,
whilst occurrences have spread geographically throughout South
East Asia, Africa and Europe, the most recent WHO update reports
a much smaller figure than predicted: 407 laboratory confirmed
cases of human H5N1, 254 of which have resulted in fatality.6
Due in part to comprehensive media coverage of the concerns
of public health specialists, the general academic and public
perception of HPAI was initially one of understandable
apprehension. The vast majority of literature throughout 2004/5
concerned risk assessment, damage limitation, and containment
strategies in the first instance; followed by financial and industrial
economic analyses as costly public health measures were employed
62
in South East Asia and Africa. However, as human HPAI has yet to
approach pandemic levels, public opinion seems increasingly to
consider the virus to be the latest in a string of unjustified public
health scares, following variant Creutzfeldt-Jakob Disease (vCJD)
and Severe Acute Respiratory Syndrome (SARS).
Unfortunately, this apparent reduction in concern is not
representative of the lessening global significance of HPAI, and
undermines a vast array of social and economic impacts which
have yet to be assessed to the necessary degree. The fundamental
importance of smallholder poultry farming in the context of diet,
development, poverty alleviation and gender equality throughout
non-Western countries is broadly recognized,7, 8, 9, 10, 11 and
compels a more holistic analysis of the negative effects of HPAI and
associated containment measures.
The Global Importance of Poultry
The International Food Policy Research Institute estimate
that 30% of animal protein consumed globally is derived from
poultry products, representative of a 10% increase since 1990.12
Furthermore, this figure is expected to increase to 40% before
the year 2015, and meeting this demand has rendered poultry
production the fastest growing element of the global meat
industry.9 In the context of avian influenza, it is important
to recognize that a huge proportion of this production and
consumption occurs in the regions of Asia and Africa: economies
within which the overwhelmingly predominant farming system is
that of rural smallholder poultry rearing in local communities.
Family Poultry (FP) is defined by the International Network for
Family Poultry Development (INFPD) as the extensive or semiextensive rearing of poultry in small numbers, through non-salaried
family labour.11 This form of poultry production accounts for 84%
of Africas poultry flock13; some 1.17 billion birds8; whilst surveys
in Kenya14 and Malawi15 indicate that chickens are kept by 90%
and 95% of the populace respectively. Similarly, more than 90%
of households in a survey conducted in Western India16 and 89%
of households in rural Bangladesh17 keep family poultry. These
statistics demonstrate the ubiquitous nature of smallholder poultry
rearing throughout the developing world, and bring the negative
impact of HPAI and associated control measures into perspective.
Family Poultry as a Means of Poverty Alleviation
Whilst United Nations Millennium Development Goals (MDGs)
aim to have halved extreme hunger globally by 201518 recent figures
estimate 792 million individuals continue to suffer malnutrition.19
Branckaert and Guye (2000) assert that sufficient intensification
of agriculture has not developed in Low-Income Food-Deficit
Countries (LIFDCs) to feed growing populations, and thus larger
tracts of land will have to be reallocated to staple food crops
in these nations. As arable land is a finite resource, this in turn
will ultimately be prioritised over pasture and fodder, negatively
impacting livestock populations. As a result, many development
projects have recognized the importance of poultry as a livestockderived protein resource and a means of financial stability that
does not require arable land to rear. It is widely supported that
alternatives such as these must be developed if MDGs are to be
achieved.11, 19, 20
Why poultry is such a crucial tool for poverty

alleviation and international development10, 21
poultry is a near ubiquitous resource in developing
countries
relatively low cost technology and low initial financial
investment
often delegated to marginal groups, such as women,
children and the elderly
land is not required for successful poultry production
Many family poultry schemes have already been successful in the

developmental context. Chitikuro and Foster22 calculated that in
Central Tanzania, an average flock size of 5 chickens increases the
income of women by US$38/yr, representative of a 10% income
increase. An alternative study conducted in NDjamna, Chad23
revealed that profit from sales of poultry related produce was
spent variously between clothing, food, medicine, soap, and
reinvestment, suggesting that economic benefits are widespread
and generate income in excess of self-sustenance. Kabatange
and Katule24 demonstrate that one chicken laying 40 eggs at 50%
hatchability will, in subsequent generations, produce more meat
over 5 years than a range-fed cow, which itself will not reach
slaughter weight for 5-7 years.
Given the significance of global malnutrition, and the apparent
viability of FP poverty alleviation models, it follows that the
true threat of HPAI may lie not in the human pandemic, but the
jeopardising of poultry-based development initiatives, and the
insurance and economic stability achieved through smallholder
poultry farming internationally.
Women, Children and Chickens: Gender Equality
through Poultry
In the context of FP production, it is highly significant that poultry
farming is a realm of agriculture which, throughout Africa and Asia,
is traditionally associated with at-risk groups: primarily women,
children and the elderly7, 8, 11, 25 and within which economic
contributions from women are often deemed more acceptable.26
For this reason, FP development programs are, in some cases, able
to address the issue of gender inequality. One particularly lauded
example of this approach is an initiative termed The Bangladesh
Poultry Model.26
The Bangladesh Poultry Model (BPM) is derived from the
Bangladesh Smallholder Livestock Development Project, first
implemented in 1991.27 It specifically targeted women in rural areas,
enhancing productivity of poultry rearing in the Dhaka region of
Bangladesh. Through poultry skills, education and the organization
of upstream and downstream enterprises (e.g. training of chick
rearers, feed mixers and poultry healthcare workers) the project
both improved poultry production in the region, and increased the
confidence and financial stability of the women involved.27 The
BPM and similar development schemes are of invaluable benefit
to their communities, and are jeopardised by HPAI and associated
control measures.
63
REVIEW
References
The Social Impact of HPAI
1.
Whilst the direct risk posed to human health by H5N1 is

undoubtedly a reality, the current lack of human HPAI uptake
ought not to imply a reduction in impact, especially in the related
academic literature. It is clear that; in light of the broad and
complex role played by poultry in the developing world both at
the community and household levels; the participatory, holistic,
trans-disciplinary approaches advocated by Guye8 and others are
entirely necessary, particularly in the realms of poverty mitigation
and gender equality.
In Soth East Asia, countries hardest hit by avian influenza include
Cambodia, Indonesia, Thailand and Vietnam,28 whilst Nigeria,
Burkina Faso, Cameroon, Cote dIvoire, Djibouti, Egypt and
Sudan represent the current course of the virus in Africa.8 In the
Vietnamese example, studies29 show production in smallholder
poultry farms to have decreased by 57% in 2004; the first year
of avian influenza outbreak; whilst sales of smallholder poultry
suffered a 150% decrease in the same year. Furthermore, the
biosecurity measures recommended by public health organizations
are heavily reliant on widescale avian depopulation9 resulting
in a direct 10-15% loss of annual income for Vietnams poorest
families a figure that is likely to increase to almost 50% when
accounting for the fact that such families are unable to consume
their own produce.11 Worse still, these impacts are not limited
to the short term, but potentially extend far into the future,
as the implementation of new biosecurity and confinement
measures, stringent licensing and inspection effectively favour
commercialization, and drive smallholder poultry underground.31
2.
3.
4.
5.
6.
7.
8.
9.
10.
Food and Agriculture Organisation of the United

Nations. Avian Influenza. EMPRES Transboundary
Animal Diseases Bulletin. 2004;25:1-9.
World Health Organisation. H5N1 Avian Influenza: Timeline
of Major Events [monograph on the Internet]. 2007 [cited
2009 Feb 11]. Available from: http://www.who.int/csr/
disease/avian_influenza/Timeline_07_Aug27.pdf
World Health Organisation. Avian Influenza: Assessing
the Pandemic Threat [monograph on the Internet].
2005 [cited 2009 Feb 11]. Available from: http://www.
who.int/csr/disease/influenza/H5N1-9reduit.pdf
Shinya K, Ebina M, Yamada S, Ono M, Kasai N,
Kawaoka Y. Avian Flu: Influenza Virus Receptors in
the Human Airway. Nature. 2006;440:435-36.
Van Riel D, Munster VJ, de Wit E, Rimmelzwaan GF,
Fouchier RA, Osterhaus AD, et al. H5N1 Virus Attachment
to Lower Respiratory Tract. Science. 2006;312:339.
World Health Organisation. Cumulative Number of Confirmed
Human Cases of Avian Influenza A/(H5N1) Reported to WHO
[monograph on the Internet]. 2009 [cited 2009 Feb 11]. Available
from: http://www.who.int/csr/disease/avian_influenza/
country/cases_table_2009_02_11/en/index.html
Guye EF. Gender Aspects in Family Poultry
Management Systems in Developing Countries.
Worlds Poultry Science Journal. 2005;61:39-46.
Guye EF. Evaluation of the Impact of HPAI on
Family Poultry Production in Africa. Worlds
Poultry Science Journal. 2007;63:391-400.
Mack S, Hoffman D, Otte J. The Contribution of Poultry to Rural
Development. Worlds Poultry Science Journal. 2005;61:7-14.
Permin A, Pederson G, Riise JC. Poultry as a Tool for Poverty
Alleviation: Opportunities and Problems Related to Poultry
Production at Village Level [monograph on the Internet]. Australian
Centre for International Agricultural Research; 2000 [cited
2009 Feb 11]. Available from: http://www.kyeemafoundation.org/
rural_poultry/content/SADC_Workshop/pr103chapter29.pdf
In the context of the extensive and hugely positive impact of

smallholder poultry rearing throughout the developing world,
the true extent of the threat posed by avian influenza becomes
apparent. Whilst current preventative or curative measures have
the propensity to cull and contain, these practices in isolation
may severely undermine, if not destroy the contributions of
smallholder poultry rearing to international development.
Furthermore, restrictive legislation could potentially commercialize
poultry production to the extent that rural smallholders could be
effectively encouraged to rear poultry in clandestine, concealing
outbreaks of HPAI, and increasing the danger of a human
pandemic.11, 31
In Thailand, studies have shown that qualitative analysis of local
attitudes, and the provision of culturally-contextualized information
regarding HPAI has stimulated locally derived control measures.
In addition, although costly for governments, financial
compensation for rural farmers also makes concealment of HPAI
outbreaks less likely, and mitigates economic losses to some
extent. Such culturally and locally contextualized measures,
it appears, are able to influence poultry rearing practice in
smallholder environments, and thus, in conjunction with carefully
planned biosecurity measures, may provide an avenue through
which both the public health and broader social impacts of HPAI
can be more effectively minimized.
64
ARTICLE
ARTICLE
Chikungunya
Cholan Anadarajah
Year 4 Medicine, Barts and the London

ha06199@qmul.ac.uk

and references see
thelsjm.co.uk.
Overview
Chikungunya is a viral haemorrhagic fever caused by an alphavirus,
which belongs to the Togaviridae family.1 This single-stranded
RNA virus is also known as Buggy Creek virus due to it causing
boggy and creeky joints, as well as other arthralgic symptoms.2 It is
transmitted via the Aedes aegypti (yellow fever mosquito). Recent
research shows that the virus may have mutated slightly by altering
its genotype, thus enabling the Aedes albopictus (Asian tiger
mosquito) to also be a vector.3
Outbreaks have taken place in tropical countries, more recently
creating an endemic in India, Sri Lanka and the Maldives. In 2006
34% of the population (about 265,000 people) on Reunion Island
caught this virus and of those 237 people died. However, this rare
disease is generally not fatal.4
The Chikungunya virus (CHIKV) causes high fever, pain in the joints
and rashes on the body. All these symptoms are also characteristic
of Dengue also transmitted via bites from the same type of
mosquitoes leading to difficulty in achieving a definitive
diagnosis. Therefore, all other possibilities must be eliminated
before diagnosing chikungunya.5
History
The first known outbreak of chikungunya took place in 1952 at the
border between Tanganyika (now Tanzania) and Mozambique,
where the illness was named in the local Makonde language literally meaning that which bends up due to it causing the sufferer
to maintain a stooped posture.6 It was first described in 1955 by
Marion Robinson and WHR Lumsden.7
66
The first outbreak in India was in 1963 in the state of Calcutta,

followed by outbreaks in 1964, 1965 and 1973. However, the
genotype of the CHIKV has mutated and now displays the African
genotype as opposed to the original Asian genotype. Through
2006 the epidemic has spread to the neighbouring countries of Sri
Lanka, Maldives and the Reunion island.8
Chikungunya virus
CHIKV is a positive-strand RNA virus surrounded by a lipid-containing envelope with 2-3 surface glycoproteins that mediate attachment, fusion and penetration. The virus is spherical, 60 to 70nm in
diameter, and displays icosahedral symmetry. The nucleocaspid is
about 40nm in diameter.9
The complete genome of the CHIKV is 11824 nucleotides long.
The partial sequences of NS4 and E1 genes have been analysed
phylogenically to reveal three different CHIKV phylogroups. These
were samples from:10

West Africa
Asia
East, Central and Southern Africa (ECSA)
The original type of CHIKV that caused the Indian Ocean outbreak
belonged to the Asian phylogroup. However, two mutations to
the E1 envelope protein, caused it to change to the West African
phylogroup. This made the virus more likely to enter mosquito cells
and replicate after the insect has fed on the blood of an infected
person, causing the re-emergence of the disease.10
Vector
Chikungunya is transmitted by mosquitoes belonging to the Aedes
genus, found in tropical and subtropical zones. Aedes is derived
from the Greek for unpleasant due to the fact that it acts as a vector for many diseases, including dengue and yellow fever. The life
span of a typical adult mosquito is 15 days, and they occupy human
habitats (living rooms, offices etc).11
Thus treatment for chikungunya mainly consists of symptomatic

relief, with analgesics, antipyretics and fluids. Paracetamol is given
to relieve the symptoms of fever and joint pain. Bed rest is essential
and mild exercise may improve stiffness and joint pains.13 Rudraksha
healing (involving spiritual meditations) also touted as a potential
homeopathic treatment. However, again there is no conclusive
evidence to substantiate this.14
The initial vector for chikungunya was the Aedes aegypti mosquito
responsible for transmission in the Asian and ECSA phylogroup.
However, it was noticed that chikungunya still developed in areas
where these types of mosquitoes were not present. Aedes albopictus, was then discovered to be a vector for CHIKV. This mosquito
is more commonly associated with the West African phylogroup.3
It should be noted that only the female mosquitoes suck blood
from humans (undertake hematophagy) and thus the males are not
disease vectors. Females need blood to support the development
of their eggs. They mainly bite humans, usually 3-4 times a day for a
satisfactory meal, injecting saliva which acts as an anticoagulant in
the human.12
Prophylaxis
Vector control is the most effective way to prevent disease.13
One way of eradicating mosquitoes is to eliminate their habitat stagnant water at homes, schools and work places. Mosquitoes will
then not be able to breed and eventually die off.13
Signs and Symptoms

On becoming infected there is usually an incubation period of
about 3- 12 days when no symptoms are evident, followed by a
sudden onset of various symptoms.2
Prognosis
Chikungunya is an illness from which most people recover completely. However some, especially tourists, develop joint pains
that can last for a few months. 12% of patients will have chronic
arthralgia three years after disease onset.1
Most of these symptoms will last a few days, if not a few weeks.
However, research has shown that some patients may have obdurate joint pains for many months. Especially in cases with tourists
becoming infected in a tropical country, but still suffer joint pain
after returning home.13
Signs and Symptoms3
high fever up to 39C
rashes around the limbs and trunk
headaches
infection of the conjunctiva (potential photophobia)
erythema
flagellate pigmentations on face & extremities
ulcers over scrotum
Futher prophylaxis can be achieved by long-sleeved clothing, insect

repellent and the use of mosquito nets at night. Public Education
matters. Many may not know how to prevent acquiring disease. It is
therefore the responsibility of governments and Non-Government
Organisations to educate and also to supply the necessary
equipment to ensure disease prevention.
The very few associated deaths are mainly due to poor preventative
measures, inappropriate use of antibiotics or lack of resources to
treat symptoms. It also has not affected the Western world as yet,
though the virus could mutate further and impact the rest of the
world.
Referencing
1.
2.
3.
Diagnosis
Following a full history and examination, it is important to
exclude Dengue as a differential, often done by the presence
of haemorrhage. However, the definitive method for diagnosing
chikungunya is to undertake an Enzyme-Linked ImmunoSorbent
Assay (ELISA) to see if Immunoglobulin M (IgM) is present in the
blood.1
4.
Treatment
There is no specific treatment for chikungunya. Although vaccine
trials took place in 2000, a lack of funding halted research due
to a number of factors. Firstly, although many people were being
infected by CHIKV, very few people actually died as a result.
Furthermore, most infected individuals were in third world countries which led to a lack of initative amongst Big Pharma to invest
in research and development. One drug that is being looked into
is chloroquine, used in the treatment of malaria. Clinical trials are
being conducted to see its use as an antiviral agent against the
CHIKV. However, the results are not yet conclusive.3
7.
5.
6.
8.
9.
10.
McMorran J, Crowther DC, McMorran S et al.

chikungunya haemorrhagic fever [online] 2005. Available
from: http://www.gpnotebook.co.uk/simplepage.
cfm?ID=1523580948 [accessed 2/3/2007].
CBWInfo. Chikungunya fever: essential data [online] 1999.
Available from: http://www.cbwinfo.com/Biological/
Pathogens/CHIK.html [accessed 2/3/2007].
Martin E (2007). EPIDEMIOLOGY: Tropical Disease Follows
Mosquitoes to Europe. Science 317 (5844): 1485.
Charrel RN, de Lamballerie X, Raoult D. Chikungunya
Outbreaks The Globalization of Vectorborne Diseases. The
New England Journal of Medicine. 2007;356(8):769-771.
Carey DE. Chikungunya and dengue: a case of
mistaken identity?. Journal of the history of medicine
and allied sciences. 1971;26(3):243-262.
Joint UKBTS/NIBSC Professional Advisory Committee.
Chikungunya Virus [online] 2006. Available from: http://
www.transfusionguidelines.org.uk/docs/pdfs/position_
statement_09_2006_07.pdf [accessed 2/3/2007].
Robinson M, Lumsden WHR. An epidemic of virus disease in
Southern Province, Tanganyika Territory, in 1952-53. II. General
description and epidemiology. Transactions of the Royal Society
of Tropical Medicine and Hygiene. 1955;49(1):33-57.
Yergolkar PN, Tandale BV, Arankalle VA et al. Chikungunya outbreaks
caused by African genotype, India. Emerging Infectious Diseases
[serial on the Internet]. 2006;12(10). Available from: http://www.
cdc.gov/ncidod/EID/vol12no10/06-0529.htm [accessed 2/3/2007].
International Committee on Taxonomy of Viruses. Chikungunya
virus [online] 2006. Available from: http://www.ncbi.nlm.nih.
gov/ICTVdb/ICTVdB/00.073.0.01.007.htm [accessed 2/3/2007].
Schuffenecker I, Iteman I, Michault A et al. Genome
Microevolution of Chikungunya Viruses Causing the Indian
Ocean Outbreak. PLoS Medicine. 2006;3(7):1-13.
67
REVIEW
REVIEW
Camus Nimmo BA (Hons)

c.nimmo@ucl.ac.uk

and references see
thelsjm.co.uk.
Introduction
Human African Trypanosomiasis (HAT), more commonly known
as sleeping sickness, is classified as one of the worlds neglected
tropical diseases (NTDs). The World Health Organisation (WHO)
currently recognises 15 NTDs which until recently had received
very little attention from both the worlds media and scientific
communities.1
The incidence of HAT has followed a very interesting path. At the
end of the colonial era in Africa (around 1960), the disease had
been all but eradicated in most countries due to vigorous control
policies put in place by the incumbent powers. However, following
independence, new African governments had other priorities and
many of these policies fell into disarray. By 1997, new cases had
reached a peak of 35,000.2 This coincided with a recrudescence
of international political interest in NTDs in general, and over
the following 10 years the incidence has been more than halved
to around 15,000 new cases in 2006 (Figure 1).3 With such a
promising decline in cases, over the last 10 years, is it reasonable
to hope that a further 10 years can see the complete elimination of
the disease? And what lessons can we learn from HAT that apply to
other infectious diseases worldwide?
About HAT
HAT is caused by a single-celled protozoa from the Trypanosome
genus. It is transmitted within human populations and between
humans and animals by the tsetse fly vector. There are 2 major
species affecting humans: Trypanosoma brucei gambiense and
Trypanosoma brucei rhodesiense. The major features of each are
summarised in Table 1. Both types have a significant impact on
human health as well as an economic - caused by the infection of
livestock. In the first stage of the disease the parasites infect the
blood and lymph. In the second stage they cross the blood-brain
barrier and affect the CNS. The treatment options for HAT are
limited and old-fashioned. The options at each stage are shown in
table 1.
Past Successes and Failures
Almost complete control of HAT was achieved across Africa by
1960 by the previous colonial administrations. At the beginning of
68
the 20th century this involved simple measures such as evacuating

people from epidemic areas. By the middle of the century methods
had advanced through using blood-based tsetse traps to spraying of
dichlorodiphenyltrichloroethane (DDT) after its discovery during
World War 2.4 Use of rigorous dedicated surveillance and control
teams finally drove down the number of new cases to being virtually
undetectable by the late 1960s. Post independence, most African
countries did not see the dedicated HAT teams as worth continuing
due to high running costs and the apparent elimination of the
disease.4 Sadly, ensuing social upheavals over the next 40 years
allowed further epidemics to occur, and infection to spread once
more.
Current Successes
Between 1995 and 2006, a leading factor in the falling
incidence of HAT was the reduction in hostilities in countries
that had suffered ongoing civil wars for long periods, particularly
Democratic Republic Congo, Angola and Sudan. These changes
have allowed WHO-sponsored programmes to develop in these
countries over periods where they can begin to have an impact.3
There are significant differences between factors involved in
control of gambiense and rhodesiense HAT. Gambiense is
well controlled using tools targeted at infections in the human
population, and most of the drop in HAT cases over the last 10
years has reflected a decrease in gambiense infection. However,
rhodesiense HAT is less well controlled by these measures as it has
a large animal reservoir as well. Between 1995 and 2006, there
has been a 26% reduction in rhodesiense cases, but with an even
larger increase in the interim. This compares with a 69% decrease in
gambiense cases.3
Challenges for the Future
Of the 36 countries classified as endemic for HAT, it had been
eradicated or almost eradicated in 20 by 2006. An informal WHOsponsored meeting in 2007 involving representatives from these
countries concluded that it was an eradicable disease.5 The way
forward for eradication involves continuing increased surveillance
and monitoring, which is best carried out using a combination of
primary health care infrastructure and specialised teams.6
Neglect in Drug Development

In terms of drug development, HAT suffers the same fate as other
NTDs - an area of medicine which with far fewer drug advances
than almost any other. The latest drug to be licensed for second
stage gambiense HAT was eflorinthine 19 years ago involving
multiple daily iv infusions, which carry a significant burden in terms
of cost, infrastructure and availability.8 It is safer than melarsoprol
which causes fatal encephalopathy in 10%9 and has regional pockets
with substantial resistance. The advantage of melarsoprol is that it
can be administered as a simple injection,8 and is still the only drug
that can be used for second stage rhodesiense HAT. Clearly neither
drug is ideal, and further research is needed. Unfortunately, there
are no drugs currently being investigated after phase III clinical trials
for pafuramidine maleate were stopped in 2008 following safety
problems,10 after receiving over US$35m from the Bill and Melinda
Gates Foundation.
The epidemiology of HAT is well understood, as shown by the

effectiveness of simple control measures put in place initially over
50 years ago when political will was present. I see no reason why
this should not be implementable in the future, and be able to lead
to the control of HAT once more. However there is always a risk
of return, it is important that research into HAT continues in the
meantime.
The main challenges for the future are to develop better monitoring
techniques so that cases can be easily identified. Hopefully the
past will emphasise to us the importance that HAT does not suffer
from the problems of its own success and be made a lower priority
for funding and international effort.
References
1.
2.
3.
4.
5.
Vector Control
Currently methods for control of the tsetse fly vector include aerial
spraying of low concentrations of pesticide. This is rapidly effective
but expensive and complicated to implement11. Selective spraying
of insecticide onto animals on which tsetse flies feed is an effective
alternative in settings where a smaller region is affected12. Potential
strategies for the future involve further investigation of tsetse
genomics to develop a genetically modified tsetse fly that is unable
to carry Trypanosoma parasites13. However, this work is still many
years off providing any practical interventions.
6.
Conclusion
Looking at the graph showing incidence of HAT over the last 100
years makes astonishing viewing, emphasising the importance of
understanding the interplay of epidemiology, medicine and politics
when considering healthcare.
10.
7.
8.
9.
WHO List of Neglected Tropical Diseases [cited 2009 Mar 7].

Available from: http://www.who.int/neglected_diseases/diseases/en/
WHO Report on Global Surveillance of Epidemic-prone
Infectious Diseases. p95-106. Available from: http://
www-tc.iaea.org/tcweb/abouttc/strategy/thematic/pdf/
presentations/tsetse_flies/WHO_Report_Diseases.pdf
Weekly Epidemiological Record. 2006 Feb 24;81:6980.
de Raadt P. The History of Sleeping Sickness. Fourth
International Cours on African Trypanosomoses, Tunis.
2005 Oct 11-28. Available from: http://www.who.int/
trypanosomiasis_african/country/history/en/index.html
Report of a WHO Informal Consultation on Sustainable
Control of Human African Trypanosomiasis [cited 2009
Mar 7]. Available from: http://whqlibdoc.who.int/
hq/2007/WHO_CDS_NTD_IDM_2007.6_eng.pdf
Samarasekera U. Margaret Chans vision for
WHO. Lancet 2007;369:1915-1916.
Deborggraeve S, Claes F, Laurent T, Mertens P, Leclipteux
T, et al. Molecular dipstick test for diagnosis of Sleeping
Sickness. J Clin Microbiol 2006;44:2884-2889.
Balasegaram M, Young H, Chappuis F, Priotto G, Raguenaud
ME, Checchi F. Effectiveness of melarsoprol and eflornithine
as first-line regimens for gambiense Sleeping Sickness
in nine Mdecins Sans Frontires programmes. Trans
R Soc Trop Med Hyg. 2009 Mar;103(3):280-90
Blum J, Nkunku S, Burri C. Clinical description of
encephalopathic syndromes and risk factors for their occurrence
and outcome during melarsoprol treatment of human African
trypanosomiasis. Trop Med Int Health 2001;6:390-400.
Press release: Immtech Focusing On New Infectious
Disease Programs Following Discontinuation of
Development of Pafuramidine. Released 2008 Feb
22 [cited 2009 Mar 7]. Available from: http://www.
immtechpharma.com/documents/news_022208.pdf
Table 1: Features of gambiense and rhodesiense HAT

T. b. gambiense
T. b. rhodesiense
Geographical spread
West Africa
East/South Africa
% of all HAT cases
90
10
Disease specificity
Mainly humans
Humans and wild/

domestic animals
Time frame
Chronic
Acute
Acute symptoms
(weeks to months)
Few
Swelling at bite site

Occasional headaches
Irregular fevers
Pruritis Adenopathies
Chronic symptoms
(months to years)
Severe headaches
Sustained fever
Sleep disorders
Altered mental state
n/a
Drug
treatment
Stage 1
Pentamidine
Suramin
Stage 2
Melarsoprol
Eflornithine
Melarsoprol
Figure 1: HAT cases reported annually 1937 - 2006
Number
Is it time to put the lights out

on sleeping sickness?
Diagnostic Techniques
New diagnostic mechanisms are sorely needed to if the downward
trend experienced over the last 10 years is to be maintained.
Diagnosis of gambiense relies on a blood spot card agglutination
test, followed by microscopy to look for parasites. Diagnosis of
rhodesiense is more challenging, as the card agglutination test does
not work and relies on access to skilled staff and equipment, which
may often not be available.
Year
69
ARTICLE
ARTICLE
A short introduction to
the human papilloma virus
and a consideration of the
implications of global
vaccination
Polly Jordan
BSc in Adult Nursing
Year 2 Medicine, Barts and the London
pollyredman@googlemail.com
Cancer of the cervix is the second most common cancer among

women worldwide, with an estimated 471,000 new cases (and
233,000 deaths) in the year 2000.1 Almost 80% of cases occur in
developing countries, where in many regions it is the most common
cancer among women and responsible for about 15% of all new
cancers.2 Cervical cancer often affects younger women and the
disease has significant emotional and financial cost implications.

and references see
thelsjm.co.uk.
Persistent infection with high-risk human papilloma virus (HPV)

is the primary cause of cervical pre-cancer and cancer.3,4 HPV
16 and 18 are high risk types as they are most commonly linked
with cervical cancer, although several other HPV types are also
carcinogenic.5 HPV 6 and 11 are known as low-risk HPV types as
they are uncommonly found in malignant lesions but are causative
agents of ano-genital warts, recurrent respiratory papillomatosis,
and in rare cases, have been associated with cancers of the larynx,
vulva, penis and anus.6,7
Image: HPV in cervical epithelium
70
Prophylactic HPV vaccines are now available for clinical use.

The two licensed vaccines are Cervarix (bivalent), which is active
against HPV types 16 and 18, and Gardasil (quadrivalent) which
is active against HPV 6, 11, 16 and 18. Meta-analysis shows HPV
vaccine efficacy of both vaccines to be high, with significant
reduction in the risk of infection from HPV16 and 18 in vaccinated
cohorts.8 The question that now needs to be addressed is to whom
the vaccine should be given to in order to gain maximum effect.
The current vaccines are projected to prevent 75-80% of cases of
cervical cancer.4
Cervical cancer is uncommon in countries with planned, population

based screening programmes such as the UK and Norway, which
have two of the most effective programmes in the world. However,
cervical cancer is common in Eastern Europe and in developing
countries due to insufficient cervical screening. This results in many
patients presenting with advanced lesions at the time of diagnosis,
as demonstrated by studies from Uganda.9
The highest impact of prophylactic vaccination would be
observed in countries without screening programmes. Successful
implementation in developing countries would depend on
resource availability (the current cost of the vaccine is likely to
be prohibitive) as well as overcoming significant obstacles such
as conservative views on teen sexuality, lack of understanding
regarding HPV, relatively low school attendance and geographical
barriers to vaccine delivery.
Initial cost-benefit analyses of HPV vaccination suggest that
vaccination of boys would not be cost-effective as prevalence
would be low following comprehensive vaccination of girls.10
However, vaccination of males would boost herd immunity
through reducing the pool of disease. Additional benefits include
protection against genital warts and some cancers of the perineum
and anus. Homosexual men are a particularly high- risk group who
would benefit. Gardasil is licensed for administration to both sexes
and has been shown to provide close to 100% protection against
genital warts.7 Further cost-benefit analyses would be required
prior to the inclusion of boys in a comprehensive vaccination
programme.
HPV vaccines have been shown to be effective in women who
have never been infected with HPV16/18 and in those who have
no current infection.11,12 For this reason, in the UK the target
age group is pre-pubertal girls in order to vaccinate prior to the
commencement of sexual activity.
Cost-effectiveness studies of the HPV vaccine are focused on
countries in the developed world, many of which have established
cervical screening programmes. For example in Ireland, base-case
incremental cost-effectiveness ratio was found to be 17,383/
Life year gained, suggesting that vaccinating against HPV 16 and
18 would be cost-effective.13 A Canadian study concluded that
vaccinating 12-year-old girls is likely to be cost-effective, with a
significant reduction in cervical cancer mortality being observed.
Concurrent vaccination of 12-year-old girls with a cervical screening
programme has also been found to be cost-effective in Germany,
with 120 girls requiring vaccination to prevent 1 case of cervical
cancer.15
In the UK, it is anticipated that there will be a 70% reduction in
cases of cervical cancer and 400 lives per year saved following the
introduction of the immunisation programme16. In terms of cost,
Gardasil and Cervarix are both priced at 80.50 per vaccination,
requiring a course of 3 injections over a six-month period1.7 A
national immunisation programme for 12-year-old girls commenced
in September 2008, at an estimated cost of 100 million per
year18. A catch-up programme for 14-18 year-old girls is also
scheduled at a cost of 200 million. A decision has yet to be made
on the benefit of catch-up vaccination for women in the 18-25 year
age group. The Joint Committee on Vaccination and Immunisation
(JCVI) suggest that vaccinating this age group is not a cost-effective
strategy but recognise that it could benefit some individuals.16

The national cervical screening programme is to continue in the
UK at an estimated cost of 157 million per year.19 However,
modifications to the existing programme are required in order
for a national immunisation programme to be cost-effective.20
Modifications are likely to include increasing the age at which
women first present for screening and increasing the screening
interval.
The benefit to women in developing countries without established
screening programmes or the resources available for effective
treatment of premalignant and malignant disease of the cervix
would surely be even greater. The difficulty lies in the cost of the
immunisation programme and the infrastructure and compliance
needed to deliver the course of the vaccine (3 vaccines over a 6
month period).
A cheaper alternative to a worldwide vaccination programme
would be identifying and targeting sub-populations at high risk of
infection. The difficulties of this strategy have been highlighted
as there is no threshold number of risk factors that predicted HPV
infection with sufficient specificity or sensitivity.21
In conclusion, evidence supports the vaccination of women
across the world. A population based programme, rather than an
opportunistic programme, would provide maximum effect. When
the emotional and social benefits (e.g. reduction in working
days lost) are included, the case for investing in HPV vaccination
becomes even stronger.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Parkin, D.M. Bray, F.I. Devesa, S.S. (2001) Cancer burden in the
year 2000. The global picture. Eur J Cancer, 37(Suppl 8): S4-S66.
IARC (2005) IARC Handbooks of Cancer Prevention:
Cervical Cancer Screening. Volume 10. Lyon:
International Agency for Research on Cancer.
Wallboomers, J.M. Jacobs, M.V. Manos, M.M. et al. (1999)
Human papillomavirus is a necessary cause of invasive
cervical cancer worldwide. J Pathol, 189: 12-19.
Bulk, S. Berkhof, J. Bulkmans, N.W. Zielinski, G.D. Rozendaal,
L. et al. (2006) Preferential risk of HPV16 for squamous
cell carcinoma and of HPV18 for adenocarcinoma of the
cervix compared to women with normal cytology in the
Netherlands. British Journal of Cancer, 94(1): 171-175.
Pagliusi, S.R. Teresa, A.M. (2004) Efficacy and other milestones for
human papillomavirus vaccine introduction. Vaccine, 23(5): 569-578.
Greer, C.E. Wheeler, C.M. Ladner, M.B. Beutner, K. Coyne, M.Y.
Lang et al. (1995) Human papillomavirus (HPV) type distribution
and serological response to HPV type 6 virus-like particles in
patients with genital warts. J Clin Microbiol, 33(8): 2058-2063.
Lacey, C.J.N. Lowndes, C.M. Shah, K.V. (2006) Burden and
management of non-cancerous HPV-related conditions:
HPV 6/11 disease. Vaccine, 24(Suppl 3): S35-341.
La Torre, G. de Waure, C. Chiaradia, G. Mannocci, A.
Ricciardi, W. (2007) HPV vaccine efficacy in preventing
persistent cervical HPV infection: A systematic review
and meta-analysis. Vaccine, 25(50): 8352-8358.
Makokha, T. (2007) Pilot study of human-papilloma-virus
vaccine in Uganda. The Lancet Oncology, 8(5): 372-373.
Newall, A.T. Beutels, P. Wood, J.G. Edmunds, W.J. MacIntyre,
C.R. (2007) Cost-effectiveness analyses of human papillomavirus
vaccination. The Lancet Infectious Diseases, 7(4): 289-296.
71
EDITORIAL
The unhealthy and unlawful face of medical technology: a story of India

For centuries in India, infant selection has included neglect, strangulation, suffocation, and poisoning.1 One reason for Indias steadfast adherence to these practices is
the fact that it has conventionally been a patriarchal society.2 Infant sex-selection has increased further in the past few years due to the wide array of pre-natal sex selection
technologies that are available on the market, conveniently allowing one to choose the sex of a child before birth.3 Some of the techniques used to determine the sex of an
unborn child are sperm-sorting, pre-implantation genetic diagnosis and sex selective abortion facilitated by ultrasonography, amniocentesis and chorionic villus sampling.
In a booklet compiled by the United Nations Population Fund (UNFPA) and Indian representatives, it was reported that the normal sex ratio for children aged between 0 to
6 years is 940-950 girls per 1000 boys.3 However, according to the booklet, the 2001 census showed only 927 girls per 1000 boys in India and it is reported that the ratio
stands at a mere 770 in the Kurukshetra district of Haryana, 836 in Ahmedabad, and 846 in the South West district of Delhi despite the fact that these regions are amongst
the most prosperous in the country.3 In fact, The Lancet shockingly reported that in the past 20 years, some 500 000 female foetuses have been aborted every year in
India, which amounts to 10 million missing girls from Indias population.4
Though there are no specific data to suggest that the above figures have been contributed by female foeticide using sex selection technologies, rather than the age-old
practice of female infanticide, according to UNICEF, A report from Bombay in 1984 on abortions after pre-natal sex determination stated that 7,999 out of 8,000 of
the aborted fetuses were females.5 If in 1984 itself female foeticide in India was pretty rampant, with the number of girls per 1000 boys having declined from 962 girls in
1981 to 945 girls in 1991 to an all-time low of 927 girls in 2001,3 it can be submitted that the increase in the latest sex selection technologies has made sex determination a
significant contributor to the adverse child sex ratio in India.3 Furthermore, the fact that the child sex ratio has consistently declined though many awareness campaigns have
been conducted nationwide in the past few decades, clearly indicates that increased awareness about the value of women as equal stakeholders in the society has not had
any significant impact on the societal behavior of Indians when it comes to son preference.
In Indian law, Section 4 of the Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act 1994 states that pre-natal diagnostic techniques can
only be employed to detect chromosomal abnormalities, sex-linked genetic diseases and congenital anomalies and section 6(c) further provides that no person shall, by
whatever means, cause or allow to be caused selection of sex before or after conception. More importantly section 5(2) provides that no person including the person
conducting the sex selection procedure shall communicate to the pregnant woman concerned or her relatives or any other person the sex of the foetus in any manner.
Section 18(1) of the Act provides that no genetic counselling centres, laboratories or clinics can be opened after the commencement of the PNDT Act unless they are
registered under the Act.
The question however is, can healthcare professionals who are working in genetic counselling centres, laboratories or clinics be blamed for the problem of adverse child
sex ratio in India? To put it crudely, the obsession for son preference in India has made the practice of sex selection a very lucrative business for Indian medical professionals.2 Therefore, Chander in his paper claims that the above legislative prohibitions encourage doctors to do little more than fake their reports and covertly engage in sex
determination.2 Where corrupt medical professionals and son-crazed parents and relatives are in collusion with each other, it becomes virtually impossible to investigate
the underlying reasons why pre-natal diagnostic techniques are employed in many cases. In fact, a Delhi doctor admitted that doctors usually employ code phrases like the
sky is blue and you are in the pink of health to indicate male and female foetuses respectively, despite the legislative prohibitions in place.6
The undesirable behaviour of genetic healthcare professionals highlighted above can easily be classified as the height of all unhealthy healthcare behaviours. As the next
upcoming generation of healthcare professionals, we should bear in mind the integral clause of the Hippocratic Oath that above all we should do no harm. We should also
be aware that though the child sex ratio in England is nowhere close to the ones in countries like India and Chinas.3 1ZA and IZB of the Human Fertilisation and Embryology Act 2008 provide that sex selection is not allowed except for medical reasons. Therefore, as future healthcare professionals, we should do everything in our power to
abstain from selfish and irresponsible behaviours that have the potential to contribute to crises like the adverse child sex ratio in India.
Rani Preatarshini Subassandran
Section Editor for Health Law and Ethics
References
1.
2.
72
3.
4.
5.
6.
Andrea Krugman Being Female Can be Fatal: An Examination of Indias Ban on Pre-Natal Gender Testing 6 Cardozo J. Intl & Comp. L. 215 (1998) at pg 221
Vineet Chander Its (Still) a boy : Making the Pre-Natal Diagnostic Techniques Act an Effective weapon in Indias
Struggle to Stamp out Female Feticide 36 Geo. Wash. Intl L. Rev. 453 (2004) at pg 455
Missing: Mapping the Adverse Child Sex Ratio in India India, Office of the Registrar General and Census Commissioner, June 2003
Shirish S Sheth, Missing Female Births in India, The Lancet, Vol. 367, Issue 9506, 21 January 2006, pg 185 186
Zeng Yi et al, Causes and Implications of the Recent Increase in the Reported Sex Ratio at Birth in China, Population and Development Review, 19:2 (June 1993) p. 297
Alison Wood Manhoff, Banned and Enforced: An immediate answer to a problem without an immediate solution- How
India can prevent another generation of Missing Girls, 38 Vand. J. Transnatl L. pg 889
73
NEWS
All authors are panellists of
LSJM Health Law and Ethics
REVIEW
Greece bans smoking
Marilena Smyrnioti
A recent study of the European Commission placed Greece on the
top of the list as the country with the highest percentage of smokers. The countrys Ministry of Health has been pushing to implement a ban outlawing smoking in all public places that will take
effect from July 1st, 2009. Previous relevant laws had been widely
ignored. Additionally, unlike most European Union countries, there
has been no age limit on the purchase of tobacco a policy that has
been in the spotlight. In the face of the new deadline, the smoking
debate has heated up.
Smoking has been increasingly transforming from a primarily
unhealthy behaviour to one that is deemed unethical: am I allowed
to expose non-smokers to the harmful effects of cigarette smoke?
Is it ethical to allow people to continue harming themselves with
a known harmful substance? This is a debate that could go even
further if we start wondering about the ethics of the banning
campaigns: is it ethical to ban someone from a public place due
to a bad habit? Is it ethical to force someone to change a habit?
Whatever the view of the individual, more and more countries are
introducing smoking bans and our minds are being made up for us.
Torture and the medical profession at Guantanamo Bay
Dhupal Patel
The release of prisoners from Guantanamo Bay has been a primary
objective in Barack Obamas presidential campaign. The camps
are infamous for their harsh conditions, deemed incompatible with
human rights.
Recent investigations carried out by the International Committee
of the Red Cross surrounding the medical personnel at Guantanamo, have brought the institution into further disrepute. It is thought
that members of the medical profession were witness to some of
the forms of torture. Their role was to advise whether certain treatments could continue or whether they ought to be stopped, based
on the detainees medical statistics and observations. The example
of waterboarding is particularly contentious and refers to a
particular form of torture that simulates drowning. In this instance,
medics were on hand to measure the patients oxygen levels, using
this as a guide as to whether the practice could continue or not.
These findings have inevitably provoked outrage as such behaviour
ultimately goes against the ethos of medicine which according to
Hippocrates can be summed up as to do good or to do no harm.
However, as more details emerge about the atrocities at this camp,
it is likely that we will discover more practices that go against the
very principles society should be abiding by.
There is now a new dilemma with respect to pharmaceutical companies and advertisement. The European Commission is proposing
a law to allow drug companies to provide health information and
advertise their products in the media to the general public.
Although there was a resounding no in the European Parliament
when the law was first proposed in 2002, some feelings have since
changed. The proposed main argument for the change is based on
giving patients as much information as they want regarding their
medications, therefore giving them the autonomy to make their
own decisions. Critics also speculate that there is a change of
opinion within the EU as the European pharmaceutical industry
is falling behind the USA and Japan. Their opinion is that if we
increase the information provided then we increase the demand for
the products therefore giving the industry a boost.
Aziz Ahmed BSc (Hons)

m0601115@sgul.ac.uk
doi:10.4201.lsjm/hle.003
However many are against changing the law arguing that the information provided can never be independent or reliable. The fear is
that if doctors and pharmacists can fall into the trap of being bribed
to buy a product then there is a danger that consumers may also be
bribed by such companies. After all, there is a difference between
giving people information and trying to influence their decision
making and promoting a product.
Assisted suicide with Dignitas
Rebekah Robson
Dignitas is a Swiss euthanasia group that run the Dignitas Clinic
near Lake Zurich in Switzerland. Founded in 1998 by Swiss lawyer
Ludwig Minelli, it is rumoured that nearly 900 people have died at
the clinic, 100 of which have been British.
With the news of the assisted suicides of Peter and Penelope Duff
(who both had terminal cancer) at the controversial Dignitas clinic,
and with the former health secretary, Patricia Hewitt, calling for
clarification in the law on assisted suicide, this debate has been
pushed back onto the front pages. It is also rumoured that Lord
Joffe is planning on introducing a new bill on assisted dying this
year. Under the previous bill, only those with months to live would
be given the privilege to choose to die, and so one wonders, even
if a new bill were to become law, how many people would continue
to end their lives at Dignitas nonetheless?
Organs are a scarce resource, particularly non-regenerative organs

such as the heart. There are currently around 8,000 patients on the
UK organ transplant list with around 400 annual deaths due to a
lack of organs.1 With such a limited resource in such high demand
it is imperative to establish the optimum methods of allocation for
both the donated organ and the potential recipients.
A limited resource
The ethical implications of using cadavers as an organ source are

similar to those found in xenotransplantations. Again, are we going
against natural law by removing organs from one individual and
placing them in another? There are also some religious objections
for example, followers of the Japanese religion Shinto believe that
it is a crime to injure a dead body, leading to a refusal to donate or
receive organs from cadavers.2
The UK currently has an opt-in system meaning an individual has to

volunteer to be registered on the NHS organ donor register. There
are currently 10,926,428 people listed in the UK as organ donors.1
Nearly eleven million potential donors seems like a lot, however
most of these individuals will not die in conditions that allow
for their organs to be used. There has been much controversial
discussion recently about the introduction of an opt-out system,
where individuals are automatically listed as potential donors.
This system is already used in several countries, including France,
Spain and Belgium.
Live donors are another possible organ source, such as a person

donating one of their kidneys whilst retaining their other kidney.
Live donations have significant clinical advantages in terms of
survival rates with fewer complications and rejections.3 One of the
most serious ethical considerations is the issue of non maleficence
where it is the duty of the clinician to do no harm. Are doctors
contradicting this central tenet of medical ethics by removing
organs from a healthy donor?
Source of organs
The three main sources of organs are animals, cadavers and live
humans. Research into animal organs as a source for transplantation
(xenotransplantation) is subject to many ethical and practical
questions. The issues to consider with xenotransplantation
(such as pig heart valves), include conflict with religious beliefs,
immune rejection and the possible risk of diseases (e.g. porcine
endogenous retrovirus) crossing the species barrier and infecting
humans. Research into this remains inconclusive, however the
possibility of disease transmission cannot be underestimated
as patients undergoing organ transplantation are susceptible to
infectious diseases due to the use of immunosuppressive drugs.
Other issues to consider include respecting the animals rights and
whether we are violating natural law by placing non-human organs
inside patients. A significant problem when instigating discussions
about xenotransplantation is the initial shock that it can elicit.
Proposed European relaxation of ban on advertisement

of prescription drugs in the media
Jennifer Davies
There has been much debate in the media over the past few years
There has been much debate in the media over the past few years
about drug representatives using gifts and financial incentives to
reel prescribing doctors and pharmacists into buying their companys products. The overruling feeling was that it is unethical for
doctors to be persuaded by drug companies into prescribing a drug
and the decision should be made based on evidence from various
reliable trials and studies.
74
Allocating Organs: Two bodies,

one heart
With live donations also comes a more sinister problem, how

do we ensure the donor is making a voluntary decision and is
not being coerced? Financial coercion is already a problem in
many third world countries where organs are sold to wealthy
individuals. Transplantation tourism is now a considerable problem
with patients travelling from industrialised countries to third
world countries in order to purchase organs. The Human Organ
Transplants Act 1989 was introduced in the UK to prevent organ
trafficking. The act states organs cannot be exchanged for payment
and donations must be voluntary, it also recommends psychological
counselling for both parties.
Organ allocation is important as we have a limited number of
organs, so we must decide which patient receives an organ and
which patient does not. Once organs are obtained, they must be
allocated amongst the hundreds of potential recipients. Current
UK practice takes into account the urgency, length of time waiting
and the quality of the match in terms of size and tissue matching.
75
REVIEW
REVIEW
This will also vary dependant on the organ type being transplanted.
There are many principles used in organ distribution - Dosseter et
al4 classifies these into eight main principles:
The urgency principle - this is often used in life threatening
situations, priority is given to patients with the greatest need,
for example those at immediate risk of death are given the
highest priority. The urgency principle has been criticised as it
can overwhelm rational thinking in situations that are emotionally
charged. The urgency principle selects patients that are at
immediate risk of death. This can then lead to the allocation of
organs to patients who might not utilise the organs to their full
capacity. Therefore, an organ that may have kept a chronic patient
alive for 5 years is instead allocated to a patient in acute distress
but even with the organ can only expect to survive 5 months.
How do we establish which patient can most benefit from or
utilise an organ? There are many factors that influence how well
a patient utilises an organ. Perhaps the most important factor is
graft success. According to Guttman et al,5 patients in critical
care often have lower rates of graft success, thus not utilising the
organs full potential. The urgency principle has been criticized for
lacking fairness; patients with chronic diseases may be on a waiting
list for several years, whilst another patient with acute injuries may
receive an organ immediately because of their life-threatening
situation. An apparent lack of fairness could have an adverse effect
on public perception as equal treatment of patients is seen as
one of the most important factors in organ transplantation and its
management.
The utility principle - also known as the medical efficacy principle is
based around optimising the health outcome of the patient. It uses
physical factors such as the patients age, HLA matching and type
of illness to allocate organs. These factors are associated with the
health outcome, for example a close HLA match between patient
and donor means there is less chance of organ rejection.

The lottery principle - this system is based on random selection and
disregards clinical information. According to Dossetor, patients
would accept this principle whereas clinicians would not as it
ignores their professional expertise. Irrespective of how much we
debate and discuss organ allocation there will always be a sense of
unfairness. However, with the lottery principle all patients have an
equal chance of selection. The lottery principle has potential uses
in situations where fair judgement cannot be reached.
The queuing principle - perhaps the simplest principle, it is based
on allocating organs based upon time spent on the waiting list for
an organ. In its purest form clinical factors are ignored, and the
organ is offered to the patient who has spent the most time on the
list. Clinicians and patients have been known to take advantage
of this system by applying to multiple transplant schemes, so it is
important to integrate different waiting lists and prevent patients
from applying to multiple lists. The queuing principle can be
viewed as the fairest and least discriminative, however it also has
several limitations such as its inflexibility: the queuing principle
does not make considerations for patients in medical emergencies
that require immediate organ transplants.
The financial principle - is based on market forces of supply and
demand of organs. Here affluent patients have an advantage and
76
are able to gain priority, an occurrence especially prevalent in the

developing world. The ability to pay is seen all over the world,
even in developed countries such as the UK where transplant
programmes are government run. Here the ethical implications are
clear: ideally, organ transplantation should be fair and accessible
to any patient, if money is involved the process might be subject
to abuse. Again we have to balance this against an individuals
autonomy. Todays society places great emphasis on the rights of
individuals to choose what happens to their own bodies. Following
this line of thought, it can be conceivable for an individual to sell
one of their own organs, not only would this respect the individuals
autonomy but it might also increase the number of donor organs
available. Whatever one thinks of the financial principle, the selling
and buying of organs is a fact and one that will likely be around for
as long as organs are a rare commodity.
The social worth principle - Rescher6 identified this controversial
method of allocation, which takes into consideration a patients
social worth. This is measured by various factors including the
patients social situation, their previous usefulness to society and
their future potential. Should we favour a 25 year-old doctor who
could help hundreds of patients over a 25 year-old vagrant? This
type of approach is seen to be unacceptable in countries where
the organ transplant programme is publicly funded, however it
has been utilised most notably in Seattle where the programme
was introduced in the 1960s with the initial development of
dialysis treatment. Selection criteria were developed due to the
high expense and limited availability of treatment, they included
questions such as value to community and number of dependants.
How do we define social worth? Who has the right to decide
what is socially worthy? The societal approach can be seen to
reduce an individual to a socioeconomic entity, in turn leading to
discrimination against patients that are from lower socioeconomic
groups.
Conclusion
matching and age. The points a patient accumulates from different
algorithms are combined to give each patient an overall score,
which determines where on the waiting list a patient is placed.
Another advantage of using a points system is that we can now
undertake objective research into how we allocate organs and we
can compare allocation systems on a nation-wide or global basis.
To use only one ethical approach for organ allocation leads to

a perception of unfairness. How we define patients suitable for
organ allocation should take into account the medical, social and
emotional viewpoint, thus perhaps using an algorithm to integrate
the aforementioned ethical ideas would be the optimum way of
doing this.
The introduction of an algorithm system in the USA illustrated the

biased allocation that was prevalent under the old system. Research
demonstrated a bias of kidney transplants in the USA towards men
over women, the young over the elderly and white patients over
black patients.7 The main advantage of using a points system is
the transparency of the process. Removing the ambiguity around
the issue makes the process more systematic and less subject to
bias. By using such systems, we can develop centralised policies
that are open to inspection. We also alter the patient-doctor
relationship by removing individual clinicians from the allocation
process. As physicians are no longer expected to allocate organs
to individuals, this should improve the patient-doctor relationship
leaving clinicians to fulfil their role as impartial advocates for all
their patients.
References
1.
2.
3.
4.
5.
6.
7.
Organ Donation Facts [information sheet online] NHS online

25/11/2007 [25/03/2008]. Available from http://www.nhsdirect.
nhs.uk/articles/article.aspx?articleId=562&sectionId=34
Namihira, E. Shinto concept concerning the dead human
body. Transplantation proceedings. 1990; 22(3): 940-1.
Nicholson, M. Kidney transplantation from asystolic donors.
British Journal of Hospital Medicine. 1996; 55(1/2): 51-56.
Dossetor, J. Ethics issues in organ allocation.
Transplant Proc. 1968; 20:1053-1058.
Guttman, T and Land, W. The ethics of organ allocation: The
state of debate. Transplantation Reviews. 1997. 11, 197-207.
Rescher, N. The Allocation of Exotic Medical
Lifesaving Therapy. Ethics 1969; 173, 178-79.
Veatch, R. Transplantation ethics. 2002;
Georgetown University Press; 118-137.
The needs of the programme policy - this is an offshoot of the

utility principle (the medical efficacy principal), where decisions
are based on clinically relevant information such as HLA matching
and disease prognosis. However, the main difference between
the utility programme and the needs of the programme policy is
the clinicians primary concern. Clinicians using the needs of the
programme policy are seen to secure the future of the programme,
sometimes at the detriment of patient health. Financial security is
achieved through continued success of operations so the clinicians
select patients that are at low risk using the utility principle criteria.
Macroallocative public policy - this is the nation-wide approach to
health care used by the government to dictate health care policies.
Factors are usually non-clinical, the most important usually being
monetary and availability of organs, these are factors not sensitive
to individual needs.
The eight principles mentioned all have their advantages and
disadvantages, so which principles should we use to allocate
organs? Perhaps a points system might be the solution, where
we integrate the different principles and develop a universal
answer to the dilemma. One such points system exists in kidney
transplantations called the European transplant algorithm. Here
clinicians use a number of algorithms to assign points to patients
and eventually allocate organs, each algorithm takes a different
aspect of organ allocation into consideration for example HLA
77
PERSPECTIVE
PERSPECTIVE
Promoting IVF: The (un)hidden

effects of playing God
Chantal Bohren
m0401801@sgul.ac.uk

and references see
thelsjm.co.uk.
Introduction
On the 25th of July 1978 the first baby conceived in vitro was born.1
The worlds press went into overdrive in a race to break the news.
The hyperbolic headlines screaming BABY of the century and
Test Tube Baby2,3 announced the birth of Louise Brown. The Time
magazine sensationally described the palpable expectation of the
newborn as the most awaited birth in perhaps 2000 years.2
The scientific breakthrough in reproductive biology of human
species by means of in vitro fertilisation (IVF) was heralded by
some commentators as a miracle of modern medicine. However,
few advances in medicine sparked off such far-reaching controversy,
as the intervention in the act of procreation. With repercussions
on ethical, moral and social aspects of human life, creation of life
outside the womb could be interpreted as usurpation of Gods
powers. Was the interference into Gods domain the opening of
the Pandoras Box?
This article will first provide the contextual background of this
issue. Subsequently, economic, political and religious aspects as
key drivers affecting public and private sector policies, as well as
societies views and attitudes, will be explored. Though the issues
will be considered in the aforementioned order, the problems,
concerns and questions surrounding this subject are tightly
interlinked.
Screening IVF
With an estimated 4% 14% of all couples in the reproductive age
being affected by infertility,4 it is not surprising that reproductive
medicine has mushroomed over the past few decades. Since the
birth of Louise Brown, approximately 3.5 million newborns were
delivered as the result of eggs and sperms being introduced to
each other in a Petri dish.5 In the UK, around 35,000 women had
IVF treatment in 2006, resulting in more than 10,000 live births.6
The average success rate varied significantly across age groups,
ranging from 31% for women under 35 to 4% for women above 44
years of age.6 More than one fifth of all treatment cycles resulted
in multiple births.6
78
IVF treatments are still tremendously expensive. According to the

latest figures by the Human Fertilisation and Embryology Authority
(HFEA), the cost for undergoing the therapy in the UK ranges
between 4000 and 8000.6 The NICE1 guidelines affords each
couple a maximum entitlement of three state funded IVF cycles;7
a vast majority of care trusts pay only for one.5 As a result, in 2005,
two thirds of the provided treatment cycles were paid for privately.5
Compared to most Western European countries, the current
funding scheme in the UK is more taxing on patients.5 In contrast,
the most extensive state subsidies for IVF are provided in Israel.
In fact, irrespective of marital status and sexual orientation, Israeli
women can repeat the treatment cycles as many times as needed
until two children have been born.8,9
To pay or not to pay?
If governments were to ask a Homo economicus whether statesubsidised IVF was a viable business proposition, the answer would
most probably be in the affirmative. In fact, the body of research
concurs that if a long term perspective is taken into account, it is
profitable for governments to fund IVF treatments.10,11,12,13 However,
IVF services are available to less than a quarter of all the 191
member states of the World Health Organisation (WHO).14
Strikingly, even in industrialised nations of the West, utilisation of
IVF is far below the optimal level.4 The key reason for the lack of
governments funding is the elevated costs associated with the
IVF therapy.3, 4,15,16,17 As a result, in most countries patients have
to pay part or all of the treatments cost out of their own pockets,
reinforcing the notion that only affluent people can purchase
superior products and services. The current predominantly selffunded system discriminates against people who cannot afford the
treatment. Some observers suggested that inadequately funded
procreation programmes effectively result in a form of financial
eugenics.18 In fact, researchers discovered that people benefiting
from IVF treatments primarily share a few key attributes, namely
race, age, education and financial status.4,15 Consequently, the
ethical concern is that IVF treatment, or access to it, does not
benefit people in society equally.
With IVFs unsatisfactory permeation in society, the elicited

question is whether there are more cost effective birth increasing
measures at governments disposal? According to the finding of
a comparative study benchmarking IVF against the provision (or
increase) of child benefits, funding test-tube babies is more cost
effective.19 In the current climate where most western countries
are faced with sub-replacement fertility rates, economic rationale
would strongly suggest an increase in state subsidies for IVF
treatments.19
IVF and the NHS a brief introduction.
Myopic regulation?
In liberal societies the reproductive realm has historically been a
private affair. However, by opening a new frontier through IVF, one
more bastion has fallen under governments remit. Given the many
nations different stance to ethical questions on reproduction and
health care services, it is understandable that legislation introduced
across these countries are conflicting and competing.20,21 For
instance, egg donations are treated very differently in different
countries. Whereas Germany and Switzerland prohibit such
procedures, the US allows them.21 In the UK eggs can only be
donated, but not sold.20 A further example is the provision of
infertility treatments in most Western European countries, whereby
only heterosexual couples and pre-menopausal women are allowed
receive such treatments.
28% for women under 35 years of age,

24% for women between 35-37 years of age,
18% for women between 38-39 years of age, and
11% for women between 40-42 years of age.
By and large, as a result of legal restrictions and prohibitions

applied in certain countries, people with purchasing powers
fulfill their desires in jurisdictions that allow the purchase of the
required services and products.21 Some observers have described
this international market phenomena as reproductive tourism.4,20,21
The ethical merit embodied by such a commercial system is
questionable, as the cost of international exchange is also
carried by societies which are opposed to assisted reproductive
procedures.22
Therefore, the question of whether the result of a self-regulated
marketplace is more advantageous might be raised? The key benefit
of such an arrangement is the inherent flexibility in responding to
emerging technological advances without the need to issue new
legislation whenever new procedures become available.21 However,
relying on the invisible hand of free markets to take the decisions,
might potentially open the doors for abuse. It is not hard to imagine
that exuberant demands of parents coupled with the inquisitive
nature of scientists would establish, or fast-track, the concept
of Designer babies with boundless procedural permutations.
Corroborating this reflection is the recent announcement by a
fertility clinic in the renowned liberal state of California. The US
clinic revealed that it extended the array of reproductive options,
offering prospective parents the choice of traits like eye and hair
colour for their future offspring.23
Potentially, the ethical middle ground between the consequences
of an inconsistent prohibitive market and the vagaries resulting from
a free market might be a regulated market.20,22 At a macro level,
international laws restricting the ethically most severe occurrences
of commercialism would need to be passed.20 At a national level,
guidance could be provided by an independent organisation.
Following the HFEAs well devised structure and function, the
organisation would license fertility clinics, monitor and approve
procedures for assisted reproduction, enforce a Code of Practice,
inform the general public and monitor research initiatives.22
IVF (In-Vitro Fertilisation) is a method for assisted conception where an egg is fertilised with
sperm outside the body.
The most notable variable that affects the success of IVF is age: younger women tend to have
healthier eggs. Because of this women over the age of 45 are not recommended for IVF as the
success rates are too low and conception using older eggs is more likely to result in chromosomal
abnormalities, birth defects and miscarriage. The NHS1 quotes the success rates as follows:
The NICE2 guidelines state that 3 cycles of IVF treatment is offered if:
the woman is between 23 and 39 at the time of treatment AND
one or both of the couple have been diagnosed with a fertility problem OR
there has been at least 3 years of infertility.
There are many risks associated with the treatment including multiple births and ectopic
pregnancies.
For more information on this please use the websites from which the above information was
obtained. These are:
1.
2.
3.
NHS choices website. Accessed 19th April 2009. http://www.

nhs.uk/Conditions/IVF/Pages/Introduction.aspx
NICE guidelines. Accessed 19th April 2009. http://www.nice.
org.uk/guidance/CG11/publicinfo/pdf/English
HFEA website. Accessed 19th April 2009. http://www.hfea.gov.uk/index.html
Against God?
And God blessed them, saying, Be fruitful and multiply, and fill the
waters in the seas, and let fowl multiply on the earth.24
- Holy Bible: Genesis 1:28
Adhering to the divine instruction, initially given by God to Adam
and Eve, has historically been easy and enjoyable for the human
species. However, the process of generating new life in the natural
way eluded a minority but increasing part of the population. The
availability of new technologies has imposed on various religious
leaders the challenge of providing guidance to their devout
followers.
The Roman Catholic branch of Christianity opposes IVF because it
separates the procreative purpose of the marriage from its unitive
purpose.25 Playing God by means of assisted reproductive
technologies is considered improper human arrogation of the
divine power. In Italy and many Latin American countries, the
Roman Catholic Church applied pressure on legislators to restrict
or prevent access to IVF treatments.4,26
In contrast, imitating God by acting in ways of beneficence,
mercy and compassion is encouraged in Judaism.22 Henceforth,
the IVF policy in Israel is very liberal and strongly supports pronatalism.8,9 Similarly, Islamic faiths support and welcome assisted
reproduction,22 though only insofar as the familys genetic lineage
is retained.4,27
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ARTICLE
PERSPECTIVE
References
The analysis of ethical questions surrounding IVF is subjected to
varying principles, values and priorities embodied by religious
communities. Therefore, it is comprehensible that different
conclusions can be drawn, each with its content-specific ethical
merits. However, arguing what is best for a liberal society, based on
ethical instructions derived from religious prescriptions is a rather
daunting and dubious task to fulfill.28
1.
2.
3.
4.
Conclusion
Understanding all the implications of promoting IVF is extremely
difficult, and is most likely impossible. The availability and
accessibility of IVF treatments is the intricate product of economic,
political and social forces, manifesting themselves in public and
private sector policies, as well as religious and cultural principles
and instructions. Ethical reflections and public debate about how
IVF is changing Life in its broadest sense are paramount.
At a personal level, the stories painted by the world of assisted
reproduction, with IVF as the magic token, are touching and
often tragic. However, stretching societal principles and values
to accommodate the desires of individual parents and inquisitive
scientists is an uncharted and critical path to walk. In some
interpretations of the Pandoras Box, the opening of the jar did
not release evils, ills and plagues, but rather the golden light of
Creation. In the case of IVF, the opened jar released the miracle of
new Life though it raises many ethical questions.
5.
6.
7.
8.
9.
10.
TIME. Test-Tube Baby: Its a Girl. TIME. [Online] August 7

1978. Available from: http://www.time.com/time/magazine/
article/0,9171,948239,00.html [Accessed 5th March 2009].
TIME. The First Test Tube Baby. TIME. [Online] July 31 1978.
Available from: http://www.time.com/time/magazine/
TIME. Frenzy in the British Press. TIME. [Online] July 31
1978. Available from: http://www.time.com/time/magazine/
Nachtigall, R. International disparities in access to infertility
services. Fertility and Sterility 2006; 85: pp. 871875.
The Economist. No IVF please, weare British. The
Economist. [Online] July 17 2008. Available from: http://
www.economist.com/world/britain/displaystory.
cfm?story_id=11750879 [Accessed 5th March 2009].
Human Fertilisation and Embryology Authority (ed.). The
HFEA Guide to Infertility. London: HFEA; 2007.
National Collaborating Centre for Wonems and Childrens
Helath. Fertility: assessment and treatment for people
with fertility problems. Clinical Guideline. London: Royal
College of Obstetricians and Gynaecologists; 2004.
Birenbaum-Cermeli, D. and Dirnfel, M. In Vitro Fertilisation
Policy in Israel and Womens Perspectives: The More the Better?.
Reproductive Health Matters 2008; 16(31): pp. 182191.
Birenbaum-Cermeli, D. Cheaper than a newcomer: on
the social production of IVF policy in Israel. Sociology
of Health & Illness 2004; 26(7): pp. 897-924.
Svensson, A., Connolly, M., Gallo, F. and Hgglund, L. Longterm fiscal implications of subsidizing in-vitro fertilization
in Sweden: A lifetime tax perspective. Scandinavian
Journal of Public Health 2008; 36: pp. 841849.
Jessica Whitehead
Year 3 Medicine (GEP), St. Georges University of London

m0600174@sgul.ac.uk
Introduction
The birth, in California, of the worlds second set of live-born
octuplets on 26 January 2009 (and the only set to all have survived
for more than a week), has caused a great deal of controversy in
the media.1 The case has also raised many questions about the
motives of the doctors involved, as well as the ability of the mother
to care for her children. The six boys and two girls were born at 30
weeks gestation, to 29 year-old Nadia Suleman, who already has
six children through In Vitro Fertilisation (IVF). In this pregnancy,
it appears that she had six embryos transferred, two of which later
split into two pairs of identical twins. At the time of writing, all of
the babies are stable, with very few requiring oxygen, and there do
not seem to be many health concerns.2
Want to advertise
Multiple births are a common outcome of Assisted Reproduction

Technologies (ART), of which IVF is probably the best known.
However, this is an extremely unusual outcome. Many pregnancies
of quadruplets, triplets or even twins result in long-term problems
for the babies themselves and their families and therefore use a lot
of resources.3 Because of the real dangers to mother and babies
from a multiple pregnancy, several methods are used to try to
ensure that only a singleton, or, at worst, a twin pregnancy results.
These include limiting the number of embryos transferred, or
HERE
80
The dangers of multiple births:

the Octuplets story
sales@thelsjm.co.uk
reducing a multiple pregnancy to one or two foetuses. This article

will discuss the problems of multiple pregnancies, as well as
embryo transfer and some of the ethical issues relating to
pregnancy reduction.

and references see
thelsjm.co.uk.
Some dangers of multiple pregnancies

Despite the fact that 66% of couples undergoing IVF who were
surveyed by the British Fertility Society and Child (a UK infertility
self-help organization) felt that having twins would be an ideal
outcome,4 there are many reasons why multiple pregnancies are
not encouraged.
Prematurity is one of the greatest dangers facing multiples, with
twins on average being born at 37 weeks, triplets at 33.5 and quadruplets at 31.5.5 Infant mortality increases as prematurity increases,
as shown in a report of preterm birth and mortality rates produced
by the Office of National Statistics.6 In 2005, figures for England
and Wales showed a 85% mortality in the 283 infants born at 23
weeks. At 26 weeks the percentage of deaths was lower; 24% of
704 live births. And by 31 weeks the infant mortality rate was 3% of
1935 live births. However, this is still 15 times higher than the 0.2%
mortality rate for infants born between 38 and 40 weeks.
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ARTICLE
ARTICLE
Premature infants who survive are at increased risk of many longerterm complications, compared to term infants. For example,
retinopathy of prematurity was found in 66 % of infants born weighing less than 1.25 kg. 7 In addition, the EPIPAGE study found that
half of babies born between 24 and 28 weeks had a cognitive or
motor impairment at 5 years, compared to a third of children born
between 29 and 32 weeks.8
There are other health problems associated with being one of a set
of multiples; these include twin to twin transfusion, polyhydramnios
and Central Nervous System disability. The increased risk here is
independent of prematurity. A common example is the three to
seven-fold increase in cases of cerebral palsy amongst twins which
has a background risk of 0.2% in singletons9 and a ten-fold increase
among triplets.10
The immense publicity and lack of privacy which higher order
multiples are subjected further adds to the stress faced by such
pregnancies. The current media attention on the octuplets is likely
to be long term and very intrusive.
Ethical issues surrounding the care of extremely premature neonates
The ethical issues in this case will now be discussed according to Beauchamp and Childress four principles.11 These are; the
requirement to do good (beneficence), to not do harm (nonmaleficence), to respect autonomy and to consider the justice of
different options.
The potential outcomes of acting which in many infants is in the
form of aggressive treatment measures often appears to be in
their best interests. For a few babies, particularly ones born at the
extremes of viability or who are very ill, the clinicians view may be
that such intervention will fail to save the childs life and hence
futile. Alternatively it may be that the resulting quality of the childs
life would be so poor that he or she should be allowed to die.12 In
these situations to continue to treat the child aggressively might
actually be doing harm.
Autonomy is a difficult concept when considering very young
children, as they are often unable to indicate their wishes or lack an
understanding of ensuing consequences. This is perhaps even more
difficult when our actions result in a child who will be developmentally disabled such that he or she will never be autonomous. The
mother often represents the infants interests in these cases.
The issue of justice is particularly relevant when discussing resource
allocation, as it involves considering the impact of any decision on
other patients, the community and the population as a whole. Premature babies may sometimes require long in-patient stay conjuring
the image of bed blockers. 13 The health service unfortunately has
limited resources and this raises questions whether heroic interventions such as the resuscitation of extremely premature neonates is
appropriate when these babies are likely to suffer significant disability, and therefore increase demand for already limited. In 2006,
the United States health service spent $26 billion on the care of
infants born preterm.15
The issues discussed often become abstract when faced with actual
families and the clinicians concern will usually be for the individual
neonate condition and prognosis.
82
Methods used to avoid high-order multiple births

For the reasons already discussed, it seems desirable to try to
reduce the number of multiple births without affecting the number
of IVF successes.
Reduced number of embryos transferred
Medically, the best outcome from IVF treatment would be one
baby resulting from the transfer of one embryo. Although a small
chance of this embryo splitting into twins exists, the likelihood of
higher order multiple births would be negligible.16 Elective single
embryo transfer has been suggested.17 To increase the chances of
successful implantation two or more embryos are usually transferred.
In the UK, the Human Fertility and Embryology Act Code of Practice 2007 governs the number of embryos per cycle.18 The HFEA
permits women under 40 using their own eggs, and all women using donor eggs, the transfer of two embryos per cycle. For women
over 40 using their own eggs, three embryos can be transferred.
Failure to comply with this Code can lead to the institution losing
its license and the individual doctor being disciplined. The Code
also states that if any woman who fits the criteria for single embryo
transfer has more than one embryo transferred, the reason should
be documented.
In the United States there are no legal restrictions on the number
of embryos which can be transferred. However, guidelines
published by the American Society for Reproductive Medicine
(ASRM) give a list of situations where the prognosis is favourable
(for example, in the first cycle of IVF or if there are good quality
embryos). 19 In these situations, one cleavage stage (three-day old)
embryo could be transferred in a woman under 35, two in a woman
aged 35-37. These recommendations provide guidance only and
there is no legal requirement to follow them. The only repercussions may be expulsion from professional organizations and the
inability to obtain insurance.20 Although audits by the ASRM and
the Centre for Disease Control (CDC) encourage clinicians to
comply, many may feel that these guidelines take clinical autonomy
away from them.
In an article by the Associated Press, it was noted that reports filed
by clinics with the CDC showed that less than 20% of clinics were
following these guidelines. 21 Despite this, it seems that it is very
unusual to need to transfer six embryos in a single cycle, especially
as, in the case of Nadia Suleman, she had already been successful several times. Her doctor may be investigated for this by the
ASRM.22
However, selective reduction carries its own risk of miscarrying all

of the foetuses, with a loss rate of 4.5% for triplets, 8% for quadruplets and 11.5% for quintuplets.24
The ethics surrounding foetal reduction are interesting particularly
because there are two patients (or in the case of a multiple pregnancy, three or more). When considering beneficence, one has to
look at the best interests of the mother and all of the foetuses. The
mothers best interests may be in remaining healthy and therefore
selective reduction. This is because selective reduction lowers
the obstetric risks to the mother posed by higher order multiple
pregnancies. However the psychological impact of destroying
one or more of much-wanted babies must not be underestimated.
The parents and surviving siblings may feel lasting guilt, although
research has shown that most couples felt that selective reduction
had been the right choice for them. This suggests that the parents
tend to value the autonomy they are given by making the decision
for themselves. 25,26
In opposition to the best interests of the mother and surviving
infants however, are the interests of the foetus(es) which are
selected for destruction. This raises all of the issues surrounding
termination of pregnancy, including the rights of the mother compared to the rights of the foetus. Currently only the mother has any
legal rights before the delivery of the baby.27
Reports suggest that Nadia Suleman refused selective reduction.29
This is not an unusual reaction, and is a decision supported by many
pro-life groups arguing that every foetus has an equal and intrinsic
right to life from the moment of conception.30 Failing to reduce
the number of foetuses can result in a worse outcome than with
the Suleman babies. Mandy Allwood, in 1996 decided to continue
with her octuplet pregnancy sadly all the babies were born too
prematurely to survive.31
Conclusion
Current reports suggest that Nadia Sulemans octuplets are
clinically stable with no medical problems at present. However,
the long-term sequelae of prematurity may take years to become
apparent. They are also likely to face the challenges experienced by
multiples, such as lack of individuality and increased demands for
parental attention.
Referance
Tedmanson S. Woman gives birth to Octuplets in California.
The Times Jan 27 2009 Available from: http://women.
timesonline.co.uk/tol/life_and_style/women/families/
article5596036.ece [Accessed 8th April 2009]
2. Tedmanson S. Woman gives birth to Octuplets in California.
The Times Jan 27 2009 Available from: http://women.
timesonline.co.uk/tol/life_and_style/women/families/
article5596036.ece [Accessed 8th April 2009]
3. Mistry H, Dowie R, Young TA, Gardiner HM; TelePaed
Project Team. Costs of NHS maternity care for women with
multiple pregnancy compared with high-risk and low-risk
singleton pregnancy. BJOG. 2008 Feb;115(3): p 416.
4. Murdoch AP. How many embryos should be transferred?
Human Reproduction, 1998, 13: pp 26662669.
5. Macfarlane AJ. Early days. In: Botting BJ, Macfarlane AJ, Price
FV, (eds). Three, four and more; a national survey of triplet
and higher order births. London, HMSO, 1990: pp 8098
6. Moser K, Macfarlane A, Chow YH, Hilder L, Dattani
N. Introducing new data on gestation-specific infant
mortality among babies born in 2005 in England
and Wales Health Statistics Quarterly Autumn
2007, Office of National Statistics, London
7. Allin M, Rooney M, Cuddy M, et al; Personality
in young adults who are born preterm.
Pediatrics. 2006 Feb;117(2):pp 309-16.
8. Larroque B, Ancel PY, Marret S, et al; Neurodevelopmental
disabilities and special care of 5-year-old children born before
33 weeks of gestation (the EPIPAGE study): a longitudinal
cohort study. Lancet. 2008 Mar 8;371(9615):pp 813-20.
9. Stanley FJ, Blair E, Alberman E. Cerebral
palsies: epidemiology and causal pathways.
London: Mac Keith, 2000.
10. Petterson B, Stanley F, Henderson D. Cerebral palsy in
multiple births in Western Australia. American Journal
of Medical Genetics, 1990, 37: pp 346351.
1.
Despite the media circus, however, it is vital to remember that

these are eight new individuals, and whatever actions the adults in
their lives have taken, they have the same right to individuality, happiness and privacy as any other children.
Selective reduction of fetuses

This is an option offered to a woman who is pregnant with two or
more foetuses. The decision is normally made relatively arbitrarily
about which foetus(es) to destroy, and the procedure is then
performed, usually by the injection of potassium chloride into
one or more of the foetus(es). The risk of premature birth and
other complications in the surviving foetus(es) can be reduced by
selective reduction, For example, reduction from a triplet to a twin
pregnancy reduces the risks of birth before 28 weeks from 8.5% to
3%, and increases the percentage of babies born and taken home
from 79% to 93%.23
83
PERSPECTIVE
PERSPECTIVE
Baby shambles?
Katie Honney BSc (Hons)
k.honney@ucl.ac.uk

and references see
thelsjm.co.uk.
Adolescent pregnancy has long been a contentious topic, but in

the past decade, this issue has become one of the most frequently
cited examples of the perceived societal decay in the United
Kingdom. In 2007, 40,298 adolescents under the age of 18
became pregnant.1 Analysis of these statistics and trends indicate
that teenage pregnancy is not an exponentially growing phenomenon in Britain. Nonetheless, the number of births to teenagers is
considered unacceptable. The complexities surrounding the issue
of teenage pregnancy are widespread, some of which extend beyond the scope of this article. Rather, the concept of parenthood,
the implications for both young parents and their children and the
subsequent impact upon primary care and society have provided the
focus for this discourse. In addition, whilst most studies found in
the literature focus on the antecedents and consequences of teenage pregnancy in relation to young women, research that directly
examines the contributions of the men involved is scant. Thus it
is also important to explore the role of the adolescent father and
broaden the discussion of these significant issues.
Parenthood
The quality of parenting is a crucial factor in the healthy growth and
development of a child. Parenting involves both the care and affection of the child, and the natural desire to raise them in a way that
facilitates them to succeed in life.2 The transition to parenthood
can be a stressful time for many, regardless of age or background.
For teenage parents, such stresses are likely to be compounded by
their typically underprivileged backgrounds as well as the addition
of the normative changes throughout adolescence, such as identity
and relationship formation.
Whilst adolescent parents may well have desirable intentions for
their children, several research studies report that the majority of
teenage pregnancies are unplanned, and the outcomes for the
parents and their child in terms of life chances are negative.3
Implications for young parents
Teenagers who give birth during their adolescent years tend to
function less effectively in numerous areas than their peers who
delay childbearing4. This recent research has indicated that many of
the negative outcomes of adolescent parenthood, such as low educational achievement and poverty, precede rather than stem from
84
early parenthood. Nevertheless, it states that teenage pregnancy

adds to the limited prospects of the already disadvantaged adolescent. These outcomes include poorer psychological functioning,
lower rates of school completion, reduced levels of marital stability
and additional non-marital births, less stable employment, higher
rates of poverty, and slightly greater rates of health problems for
both the mother and child as compared with peers who postpone
childbearing.4
In addition, there are a number of long-term negative health
outcomes for young mothers. Teenagers usually go to their doctors
much later in pregnancy than older women,5 meaning they often
miss out on preconception and first trimester healthcare, such as
folic acid supplementation, to help prevent neural tube defects.
Almost half of all teenage mothers smoke during pregnancy, with
health and economic consequences for both mother and baby.6
There is some evidence of higher rates of pregnancy complications
and maternal mortality for teenage mothers.6 Forty percent of
teenage mothers have an episode of depression within one year of
childbirth, and postnatal depression may be up to three times more
common in teenage mothers than their older counterparts.6
In addition, questionnaire data from a Department of Health study
highlighted that teenage mothers were significantly more likely than
older mothers to: receive means-tested benefits; not have worked
recently; not to have school or university qualifications and to be in
social housing7. However, when adjustments were made for factors
at baseline associated with teenage pregnancy such as poverty,
living in social housing, lone parenthood, and leaving school before
16, the teenage mothers in the study were no more likely than the
older mothers to have poor outcomes.7 This confirms the view that
social exclusion may be implicated by teenage pregnancy but does
not necessarily cause it.
Having said this, not all teenage parents have parenting problems
and it is vital that generalisations are interpreted as generalisations
only. Further research will prove invaluable in exploring variations in
adaptation to early parenthood.
The forgotten father
Reviewing the social and psychological literature of the 1970s
concerning adolescent childbearing, Chilman cited the problem of
insufficient attention to the attitudes and behaviours of males in

respect to adolescent parenthood as one of the major problems
in the conceptualisation of teen pregnancy.8 From the information
available, it is generally agreed that fathers tend to be two or three
years older, on average, than teenage mothers. However, in the
recently publicised case of Alfie Patten he was two years younger
than girlfriend Chantelle Steadman, a fact that has caused much
concern among policy makers. Like teenage mothers, male adolescents tend to be from lower socio-economic classes, are often
continuing an intergenerational practice (many are from families
who experienced teenage childbearing and receive welfare), and
have low educational achievement.9
Having said this, research would suggest that young fathers do not
fit the stereotype once applied to the putative father. Many
desire involvement with their children: Furstenberg and Talvite
found that 90% of the fathers of babies born to adolescent women
remained involved with their children for at least one year after
birth.8 A study executed in Rochester, New York found that 68% of
teenage fathers were happy when they learned of the pregnancy,
although it was unplanned in almost all cases.10 Nonetheless, the
study also revealed that less than half the teenage fathers were
coping well with the situation. Infact, clinical depression was common and nearly half required referral for psychotherapy.10
Most prospective fathers are under a phenomenal amount of stress,
regardless of their age. Teen fathers must learn to cope with the
stress and uncertainty of fatherhood alongside the already difficult
events of adolescent development. During adolescence, the
individual gradually moves toward emotional, social and financial
independence. Teenage years are typically characterised by rebellion against adult values, narcissism and self preoccupation. Such
normative adolescent changes conflict strongly with the emotional
and financial responsibilities of fatherhood. Difficulty in resolving
such conflict accounts for the frequency of depression in teenage fathers and indicates their need for psychological services.11
Quinlivan and Condon undertook a cross-sectional cohort study
to compare levels of psychological symptomology in fathers in
the setting of teenage compared to non-teenage pregnancy. The
results revealed that significantly more fathers in the setting of
teenage pregnancy met the criteria of having Hospital Anxiety and
Depression (measured using a sub scale that analyses anxiety and
depression in hospital patients), when compared to older fathers.11
Negative reactions from parents and social exclusion among peers
can deepen such depressive symptomology within young fathers
and lead to subsequent long-term health implications.12 Such
research highlights that teen fathers have unrecognised psychological symptomology that requires appropriate services along with
teen mothers.
Implications for the children of adolescent parents
New research has made substantial advances into the effects of
early childbearing on the functioning and well-being of young
parents. However, the same level of attention is yet to be directed
towards the study of the children of teenage parents. Having said
this, a number of small-scale studies have examined the cognitive
and behavioural functioning of children of adolescent mothers
compared with older mothers. Few differences were found in
infancy, however, in the pre-school years delays in cognitive development emerged. Pre-school children of teenage mothers also
began showing behavioural problems, including higher aggression
levels and lower impulse control, than their peers born to older
mothers.9 Further discrepancy between children born to teenage
mothers compared with older mothers, is evident in adolescence
too. Higher rates of grade failure, delinquency, early sexual activity
and pregnancy have been recorded.9 However, these studies are
now considerably outdated and more recent research, since the
introduction of improved support for teenage parents and their
children, is required to accurately comment on such issues.
Obstetric and neonatal outcomes of teenage pregnancy also have
negative associations compared to those born to older mothers.
In a retrospective case-control study executed over five years at
a tertiary care teaching hospital, teenage pregnancy was found to
be associated with higher pregnancy induced hypertension, preeclamptic toxaemia, eclampsia, premature onset of labour, fetal
deaths and premature delivery. Increased neonatal morbidity and
mortality were also seen in babies delivered to teenage mothers.13
Such findings introduce a complex argument based on the concept
that children born to teenage mothers are at risk of significant
health complications and thus begs the question as to whether
there should be more of a duty to prevent such morbidity from
occurring at all.
Implications for primary health care
Teenage pregnancy and motherhood have implications for several
different aspects of primary health care. The pregnant teenager is
considered a high-risk obstetric patient given the increased risk of
maternal and infant mortality apparent in teen pregnancy.13 Primary
Care Trusts (PCTs) will be required, on an already overstretched
budget, to provide care for these higher risk patients.
Finally, and perhaps even more significantly, there is the implication of care required to deal with longer-term adverse health
consequences associated with teenage pregnancy. For example,
primary care physicians will have a duty to recognise the increased
prevalence in vulnerability of parents to clinical depression and
depressive symptomology in the year after delivery.15 The provision
of health education and contraceptive services is relevant to the
prevention of unplanned teenage pregnancy.
More needs to be done allow appropriate support both ante and
post-natally to be provided for teenage parents and their children.
Implications for society
Teen pregnancy obviously has a major impact on the lives of the
people directly affected, yet it also has broader implications for
society. With regards to the broadly publicised Alfie Patten and
Chantelle Steadman case, in which a 12 year old boy and 14 year old
girl conceived a child, Ed Balls, the Secretary of State for Children,
Schools and Families said: Its not right it looks so terrible. It has
got to be sorted out. I want us to do everything we can as a society
to make sure we keep teenage pregnancies down.16 The case
reignited concerns about the rate of teenage pregnancies and the
sexualisation of children at increasingly early ages and condemnation resonated across the political spectrum.
Although there are several health risks and biological problems
related to teenage pregnancy, some of the strongest concerns
for policy makers are the social and economic consequences that
result from young parenthood. The high costs that come with
having a new baby combined with a lack of income and support
85
SHORT CASE
PERSPECTIVE
No consent, no defence
for adolescent mothers can have very disparaging effects on the

socio-economic status of teenage-headed families. Experts do not
agree over what should be done about teenage pregnancy. Many
of its problems are due to how it is regarded by society. Social
disapproval may mean that young women avoid health care and may
not complete their education while pregnant or return to education
after the birth of their child.
Consent is at the heart of medical practice, obtain it and

treat patients, flunk it and face the consequences,
says MPS writer Sara Williams
In recent decades, in Britain at least, teenage pregnancy has

become labeled alongside cardiovascular disease, cancer and
mental health as a major public health problem.17 However,
arguments do exist that propose teenage pregnancy should not
be conceptualized as a public health problem but rather a reflection of what is considered to bein this time and placesocially,
culturally and economically acceptable.18 Nonetheless, there are
profound socioeconomic consequences of teen pregnancy which
must receive timely intervention so as to avoid setting a social
precedence. Teenage pregnancy is a significant global challenge
and the health, social and economic issues that it raises are of deep
concern to all those people involved in the care of young people.
It is important to establish the issues and implications of teenage
pregnancy for all parties involved. In so doing poverty, deprivation,
poor educational achievement and low expectations have all been
identified as key factors ontributing to the high rates of teenage
pregnancy.1 It is widely recognised that teenage pregnancy and
early parenthood are, in certain circumstances, associated with
a number of negative consequences, including poor educational
achievement, poor physical and mental health, poor employment
prospects, and poor housing. In turn, these factors are inherited by
the children of teenage parents, predisposing them to the same risk
factors and outcomes. It is clear that reducing the rate of teenage
conceptions and improving outcomes for teenage parents, could
make a significant contribution to the overall reduction of social
and health inequalities in the UK.19
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
86
Department of Health. Office for National Statistics

and Teenage Pregnancy Unit Teenage Conception
Statistics 1998-2007. London: 2009
McWhinney I. A Textbook of Family Medicine. 2nd Ed.
New York: Oxford: Oxford University Press Inc; 1989
Department of Health.Teenage Pregnancy Research
Programme briefing: Long term consequences of teenage
births for parents and their children London: March 2004
Coley RL and Chase-Lansdale PL. Adolescent Pregnancy and
Parenthood. American Psychologist 1998;53(2): 152-66
Simms M. and Smith C. Teenage mothers: late attenders
at medical and antenatal care. Midwife, Health Visitor
and Community Nurse 1984;20:192-200
Botting, B., Rosato, M. and Wood, R. Teenage mothers
and the health of their children. Population Trends
Office for National Statistics 1998;93: 19-28
Department of Health (2007). Teenage Pregnancy
Research Programme: Teenage Parenthood and Social
Exclusion A multi-method study. London; 2007
Tuttle J. Adolescent Pregnancy: Factoring in the father of the
baby. Journal of Paediatric Health Care 1988;2:240-244
Coley RL and Chase-Lansdale PL. Adolescent Pregnancy and
Parenthood. American Psychologist 1998;53(2): 152-66
Elster AB, Panzarine S. Unwed teenage fathers: Emotional and health
educational needs. Journal of Adolescent Healthcare 1980:1;116-120
Consent is at the heart of medical practice, obtain it and treat

patients, flunk it and face the consequences, says MPS writer Sara
Williams
A 22-year-old mother died recently after giving birth to twins.
A Jehovahs Witness she was reported to have refused a vital blood
transfusion.1 Doctors can be confronted by these cases at any
time and its important to remember the powers of a doctor are
conferred by those they treat, so if the patient is a competent
adult, where theres no consent there can be no treatment.
In the same vein, care can only be given if the person consents to
it. Any procedure from the simplest taking of blood pressure, to the
more complicated repairing of an aortic aneurysm requires consent.
This does not mean that you have to repeatedly ask for patients
explicit consent for every minimally intrusive activity. If a patient
complies with a request Would you hold out your arm please so
I can bandage it? you can assume that you have their consent by
implication.
Is written the same as verbal consent?
Verbal consent is just as valid as written consent, except in
circumstances where the law requires written consent, such as
some forms of fertility treatment. So view consent as a process
rather than a signature on a form; it results from open dialogue
between you and your patient, so the sooner you get into this habit
the better.
Where there are disputes over whether valid consent was given,
the key is not whether a patient signed a form, but whether they
were given all the information they needed to make an informed
decision. This should be documented in the medical record
alongside evidence of the procedural risks and warnings discussed
as well as any fears expressed by the patient.
Competence
New rules have recently come into force in England and Wales
under the Mental Capacity Act 2005, which clarifies the
assessment of a patients capacity and treatment of patients who
lack capacity. An assessment of a patients capacity should be
based on their ability to make a particular decision. Assume that
they have the capacity unless it is demonstrated that they have not.
Some patients, for example, need help to communicate a decision,
but this does not mean that they lack capacity. There is a two-stage
test to apply when deciding whether a patient has the capacity to
consent to treatment:
1. Does the person have an impairment or a disturbance in the
functioning of his/her brain or mind?
2. If so, does it mean that the person is unable to make a specific
decision when they need to?2
What if consent is not taken?
Many MPS clinical-negligence claims are settled because valid
consent was not obtained, or the evidence for it was missing from
the notes. In theory, where harm has befallen the patient and valid
consent was not obtained, the doors are open for allegations of
professional misconduct and even criminal charges of assault or
battery, although these are extremely rare.
You need to be familiar with GMC guidance and follow it.
Otherwise if there is a complaint your professional conduct could
be called into question. So communicate effectively with your
patients from the outset and protect yourself and your practice.
Case study
While working in A&E, Foundation Year 1 Dr Y saw an elderly patient
who was experiencing nausea and vomiting. She took appropriate
steps to start treatment including the insertion of a Venflon in the
patients arm.
A couple of hours later, the patients family arrived and became

alarmed about the extensive bruising around the Venflon which
had been used. The patient alleged that Dr Y had inserted the IV
cannula incompetently and without her consent. The patients
family complained to the hospital and to the GMC.
Dr Y rang MPS and was immediately put in contact with a medico
legal adviser who gave her advice and support throughout the
subsequent investigations. She was able to meet her adviser and
eventually, after numerous exchanges of correspondence and
scrutiny of the case notes, the GMC referred the matter back to
the hospital.
A meeting was arranged by the hospital complaints officer
between Dr Y and the patient, in which Dr Y acknowledged that
although she had told the patient she was inserting a Venflon, she
did not warn her about the pain and bruising it might cause, and
apologised.
Outcome
The patient accepted the apology and was assured that the doctor
would always fully explain her actions in the future. The issue here
was that Dr Y failed to obtain valid consent because the patient did
not have all the relevant information. The GMC expects patients
to be given all information material to their decision. It is not
justifiable to withhold information on the grounds that it may prove
worrying or generate anxiety.3
Useful links

General Medical Council

Department of Health guidance on consent
www.dh.goc.uk/policyandguidance

MPS guidance

MCA code of Practice
1.
2.
3.
Mother dies after refusing blood 5 November 2007 BBC News

DCA, Mental Capacity Act 2005: Code of Practice, 2007, p. 45
General Medical Council, Seeking Patients Consent: The
Ethical Considerations, November 1998, para. 10.
87
CAREERS
The recent GMC attempt to define unhealthy behaviour has placed medical students firmly under the spotlight. In a story picked up
by the mainstream press, the BMA have urged caution over these new criteria, which seem to threaten professional censure for bad
behaviour even before students have qualified.
In our inaugural issue, we take a closer look at the new obligations outlined for medical students, and ask what do they mean for healthcare
students in general?
Those who support the guidelines argue that medical students and indeed all healthcare students are afforded specific responsibilities
which other students are not, and along with those rights of access and authority comes the added responsibility of early professional
behaviour. In a hierarchical system where training consists, in part at least, of a sort of apprenticeship, patients may not be able to
distinguish students from healthcare professionals. Thus students should be able to act-up in terms of their attitudes and behaviours.
Yet how comfortably does this sit with the traditional work-hard, play-hard stereotype of doctors-in-training and nurses-to-be? Critics fear
the medical regulators risk using a sledgehammer to crack a nut.
The GMC is at pains to emphasise that these guidelines are just that, and that they have little jurisdiction over medical school admissions.
The hope then has to be that these guidelines are used discerningly by medical schools and universities who hold the careers of thousands
of students in their hopefully not-so-heavy hands.
Personal and professional attributes are also high on the agenda for those who have just received their F1 allocations. We look at how
the system has worked this year and hear from students who have just gone through the process. Did the new weighting of academic
achievements disadvantage those in the 1st academic quartile? For the first time it was possible to link your application with a friend or
partner but how was this done and what assurances were there?
There is also talk of a national qualifying exam being used as a future differentiator of foundation allocations. To unearth the background
and issues surrounding this controversial idea dont miss issue two of the LSJM.
Bringing professional attitudes to their training may be less of an issue for those who come to the healthcare sector via a more
circumlocutious route. Increasingly, graduate places are being offered on healthcare courses, and a former advertising executive explains
why she made the jump from promotion to physiotherapy.
We also compare the training of graduate medics at home and away and look at whether the Australian graduate admissions model, now
adopted at some schools in the UK is succeeding in attracting candidates to healthcare.
Without a doubt career pathways in all healthcare professions have always been a moveable feast. We anticipate that this will continue.
LSJM Careers hopes to guide you through the myriad options that face you from the moment you start studying, and continue throughout
your careers. By keeping you up to date with the latest developments in the healthcare sector, and offering tips and insights into paths less
trodden as well as the more popular career choices, we hope to make your training time more enjoyable and worthwhile.
88
Rob McGuire and Sonia Damle

Section Editors of Careers
89
PERSPECTIVE
PERSPECTIVE
Fitness to Practise - What does

it mean for students?
Matko Marlais*, Aneurin Young
Year 4 Medicine, Imperial College London
doi.10.4201.lsjm/car.001
What does fitness to practise mean to you? We all know that

committing crimes or engaging in unprofessional behaviour can
get us thrown out of medical school, but the remit of fitness to
practise spreads much further than that. You may steer clear of
drugs, avoid violence and respect confidentiality, but many other
issues could call your fitness to practise into question. Can you
honestly say that you have never been rude to a colleague, engaged
in patient contact without making it clear that you are a student, or
embellished your CV a little? These and many other actions could
affect your fitness to practise. In addition, illness could strike any
one of us and this guidance sets out new ways of dealing with those
whose health threatens their ability to be a medical student.
In the past, fitness to practise policies have been set entirely by
individual medical schools, without clear guidance from external
bodies. That is about to change. It has been increasingly recognised
that unstandardised procedures threaten to treat students unfairly
or to fail in their attempts to protect patients from those who
are not fit to practise. As a result the General Medical Council
(GMC) and the Medical Schools Council (MSC) has released new
guidance: Medical students: professional values and fitness to
practise.1 Here we explore how these new guidelines could affect
you.
The GMC aims to protect, promote and maintain the health and
safety of the public by ensuring proper standards in the practice of
medicine.2 As part of this mission, it defines and polices fitness to
practise issues for doctors and has offered the following definition
of fitness to practise:
To practise safely, doctors must be competent in what they do.
They must establish and maintain effective relationships with
patients respect, patients autonomy and act responsibly and
appropriately if they or a colleague fall ill and their performance
suffers.
But these attributes, while essential, are not enough. Doctors
have a respected position in society and their work gives them
privileged access to patients, some of whom may be very
vulnerable. A doctor whose conduct has shown that he cannot
justify the trust placed in him should not continue in unrestricted
practice while that remains the case.3
90
Whilst it is recognised that students are not doctors, as medical

curricula start to include patient contact at an earlier stage it
becomes apparent that guidance, similar to that for doctors is
necessary.
Set out below are some of the main ways in which students might
compromise their fitness to practise:
Criminal Offences
These are some of the more obvious reasons for which a students
fitness to practise may be questioned. The new guidance gives
some examples: assault, theft and financial fraud to name a few.
Whilst it is obvious that violent behaviour is unacceptable for a
student doctor, other offences such as financial fraud may not
be so clearly linked to fitness to practise. Any behaviour which
compromises the trust placed in us by patients is potentially a
fitness to practise issue.
University life provides a vast array of criminal temptations! Medical
schools are famed for their culture of drinking and high jinx. But
when does this behaviour cross the line into criminality? Many of
us have done things we regret after a heavy session at the union,
but as medical students we must always be mindful that when jovial
pranks turn into violence, criminal damage or theft, our careers are
threatened.
Unprofessional Behaviour
Some examples of unprofessional behaviour in the new guidance
include: poor time management, breach of confidentiality,
rudeness and poor communication skills. Whilst some may feel
it is excessive to review a students fitness to practise because of
poor communication skills, the new guidance emphasises that it
is not just the seriousness of an offence but also repetitiveness
of offences which may bring about a fitness to practise review.
Hospitals are stressful places and students are constantly placed
under pressure to perform. In this context it would be easy for
a student to fail to obtain proper consent for a procedure, to
become habitually rude to those around you or to fail to maintain
the appropriate boundaries between a medical professional and
a patient. As doctors-in-training it is our duty to keep in mind
the importance of treating patients with respect and acting
professionally towards colleagues. Failure to do so could bring into
question your suitability for a career in medicine.
What actions can be taken against students?

Formal Warning: This is the first option available to the fitness to
practise panel. The warning would be placed on record and would
have to be disclosed when applying for registration as a qualified
doctor. In addition, the student would be placed under supervision
so that their progress can be monitored by the medical school.
Conditions: This option obliges the student to take defined
actions and observe limitations on his or her practise. These
conditions aim to protect patients and provide a means by which
the student can be supported and guided to becoming fit to
practise, either by addressing poor behaviour or returning to
good health.
Probity
This is an important and under-recognised part of the GMCs
key guidance, Good Medical Practice4. Probity encompasses all
aspects of integrity which are essential for doctors to maintain the
trust placed in them by patients. As career progression in medicine
becomes ever more competitive, the temptation to dishonestly
enhance your CV grows. Have you ever considered forging a
signature in a logbook, exaggerating your achievements in a CV
or application form, or falsifying research to enhance your chance
of getting published and earning a few vital MTAS points? Any of
these actions would call into question your probity. A few white
lies on an application form may not seem like a big deal, but any
dishonesty calls into question your integrity.
Health
The inclusion of health as a fitness to practise issue is a strength of
the new guidance. Whilst it is made clear that very few disorders
would automatically require a fitness to practise review, there
is a broad range of conditions which could potentially impact
on a students graduation and subsequent fitness to practise.
The guidance emphasises the requirement to seek appropriate
medical advice at an early stage and encourages medical schools
to support students through health problems by making reasonable
adjustments. Each student would be assessed individually for the
impact that their health problems might have on their ability to
practise. This new guidance emphasises the duty students have
to listen to medical advice which aims to allow them to practise
safely and to observe any limitations which must be placed upon
them. For instance, students who are infected with HIV or hepatitis
B will usually be allowed to continue in their education as long as
they carefully observe the guidance which is given to them to avoid
exposure-prone procedures and protect patients.
Protecting Students, Safeguarding Patients
Fitness to practise policy must balance two important factors: firstly
the GMCs overriding duty to protect patients from poor medical
practise, and secondly the need to treat students fairly. As set out
in the councils purpose statement above, these guidelines are
formulated to ensure that vulnerable patients are protected from
those whose fitness to practise has been called into question. In
order to safeguard patients, the guidelines must provide strong
tools which schools can use to address concerns or to prevent
students from continuing to see patients if the concerns cannot be
resolved.
Temporary Suspension: A temporary suspension from medical

school with a resulting delay in graduation can be imposed if it
is felt that this period will allow the student to address his or her
behavioural issues or health problems.
Permanent Expulsion: If the transgression is exceptionally grave
or if it is felt that no other measure will sufficiently protect patients,
a student can be permanently expelled from medical school. This
may be employed in response to serious offences including sexual
offences, exploitation of a patient, gross disregard for a patients
safety or a failure to understand and comply with concerns which
have previously been dealt with using less severe measures.
In light of the power of fitness to practise procedures, standardised

procedures aim to ensure that students are treated fairly. In line
with recent recommendations for doctors and other medical
professionals, this guidance incorporates ways to resolve fitness to
practise issues without resorting to expulsion from medical school.
This is a vital shift of focus, allowing fitness to practise procedures
to help students with problems to learn, develop and become
better doctors.
This guidance integrates with other documents, especially Good
Medical Practice, the Doctors Guide to Good Practise, and
Tomorrows Doctors,5 which sets the standards for the expected
knowledge, skills, attitudes and behaviours of students. This
unified approach provides a firm foundation for students to better
understand what is expected of them as a student and when they
qualify.
Patients, students and medical schools all benefit from clear,
effective and fair fitness to practise procedures. This guidance
significantly improves and standardises those processes. Very few
of us will ever undergo formal hearings, but it is important that we
are all aware of the range of problems which could influence our
fitness to practise, and how we can expect to be treated if our
suitability for a career in medicine is called into question.
Reference List

General Medical Council, Medical Schools Council.

Medical students: professional values and fitness
to practise. 11-3-2009. Ref Type: Report
General Medical Council. Role of the GMC. 2009.
Ref Type: Internet Communication
General Medical Council. The Meaning of Fitness
to Practise. 2009. Ref Type: Report
General Medical Council. Good Medical
Practice. 2006. Ref Type: Report
General Medical Council. Tomorrows
Doctors. 2003. Ref Type: Report
91
PERSPECTIVE
PERSPECTIVE
Gemma Webb
Physiotherapy student, Kings College London
Towards the end of my first degree I studied the psychology of

advertising and persuasion, and after a weeks work experience in a
media agency, I was hooked.
Five years down the line, three agencies and a few promotions later
my passion had somewhat evaporated. There I was, working well
into the night - talking to target audiences to sell products for other
people, yet somehow still penniless at the end of the month. So
whats new you say? Surely, its inevitable to feel like this when you
spend so much time at work?
Well, if you spend an average of 50 hours in the office each week
as I did, your working week quickly becomes half your waking week!
This excludes the time spent thinking about all the things you have
to do on the way to work. In effect, it equates to an awful lot of
time in an okay career that no longer excites you.
This is how I felt two years ago. After a particularly busy period
at work I was knackered, bad-tempered and run down. Over
Christmas I thought deeply about whether this was the career path
for me. On the plus side, it paid reasonably well, and if I continued
to work hard I could have worked my way up the company.
However, I looked at my bosses - all overworked and trying to keep
numerous work and personal plates spinning - and decided it simply
wasnt for me. I spent time thinking about the aspects of my job
that I enjoyed; working in a team, solving problems, negotiating,
talking to people. And then there were the things I didnt like so
much; stuck behind a computer, writing powerpoint documents,
balancing budgets and sitting in endless meetings. I considered
switching to a job in marketing, but would that be any different? It
may have offered temporary relief to my situation, but the lack of
fulfillment would have inevitably returned.
At school I had enjoyed biology at A-level but had been put off
pursuing it. My teachers spent their time focusing on the alreadyfuture doctors and vets in the group instead of giving those who
needed that extra bit of help to do well. Oddly enough, an
interest in human biology had remained, and I had a pile of free
New Scientists by the side of my desk at work that I would read for
my own pleasure. Id also taken up running three years earlier to
combat stress at work had become interested in training effects
on the body and optimising my performance. Could I develop the
things I enjoyed into a whole career?
92
At school physiotherapy had been something I had looked at

but the high grades had put me off. I am not now and never have
considered myself as particularly academic. However, I decided to
look into retraining to become a physiotherapist. I assumed that I
would need to take science A-levels to be considered eligible to
apply, fully appreciating that I may have to do this at night school
while continuing to work. To my surprise I learnt that there were a
handful of accelerated physiotherapy courses for those who already
had a science-based degree. So instead of the traditional three year
course I could be qualified within two years and my fees would be
covered. Things were looking up.
But what about the financial aspects? The accelerated course was
full-time so I would have to leave my job. My boyfriend and I had a
flat we owned so there would be a mortgage to pay, as well as the
balance of my first student loans that I still had to pay off. I had the
usual credit card and overdraft debts and no savings to speak of. At
this point some might be discouraged, but I did not let this put me
off. With the support of my boyfriend and my family, I worked out
a realistic plan, focusing on reducing my debts and putting some
money aside each month that would help me cover my living costs.
I also found out that I would be able to apply for a means-tested
bursary which, though not a substantial amount, would at least offset some of the costs. I was lucky because my parents offered to
help each month. I also planned to ask my then-employer if I could
continue working one day a week.
Despite knowing that it would be difficult financially, I remained
optimistic and tackled each challenge one step at a time. I did
some work experience, I was accepted on to the course at Kings
College, London, in March 2007. It gave me the same high as
when I completed my first marathon in 2005.
Two years later, it is still tough. Whilst in advertising, I had become
used to a certain standard of living and three holidays a year. These
are all now a thing of the past, and even my student discount wont
justify the monthly shopping trips I used to make! I started to bike
to work, I took my lunch in every day, much to the amusement
of my colleagues. When I finished work and started at university
I negotiated to do a day a week at my old agency. I started
babysitting for my friends and I signed up for focus groups. Ive
always been fiercely independent, preferring to pay my own way,
but Ive accepted that for the time being I should accept others
generosity.
*Details correct at time of going to press.
Career Change
Sources of Funding:
A Sunday afternoon surfing the web is time well spent. There
is a wealth of financial support available. Here are just a few
suggestions to get you started.*
1. The NHS Bursary:
What is it?
An annual payment which is either income assessed (your own,
parents or partners earnings), or non-income assessed depending
on the course you are studying. It includes payment of tuition fees.
It will normally be made in equal instalments over 12 months, you
will then be required to re-apply if your course is over a year long.
Eligibility?
To access this, you must have been offered an NHS-funded place
on a full or part-time course in an area such as medicine, dentistry,
physiotherapy, radiography, speech and language therapy, nursing
or midwifery.
How much do I get?
If you are on an income assessed course it depends. The basic
rate for courses in 2008/09 for those living in London is 3,306
and 2,287 for those outside London. However there is a helpful
online bursary calculator which can help you get an idea of what
you may be entitled to on the website.
Pros & Cons:
+ There doesnt seem to be a downside! f you are successful at
getting a place on an eligible course you should definitely apply for
this as they will help towards things like placement costs. Those of
you who have children or dependents may be eligible for top-ups.
To find out more visit http://www.nhsbsa.nhs.uk/students
2. Career Development Loan (CDL)
What is it?
A bank loan for those wishing to retrain or develop skills in their
existing career. It will help you fund up to two years of education.
The loan is an arrangement between the Learning Skills Council
(LSC) and three high street banks. The LSC pays the interest on
the loan whilst you are training and then for a month after youve
stopped training. You then repay the loan over an agreed term at a
fixed rate of interest. The loan can help cover cost fees and living
expenses.
One of the challenges of going back to studying is accepting that

you are starting a career and that you may be treated differently by
some. In my previous career I was a senior member of my team, I
managed a couple of people. Nowadays I am supervised by senior
physiotherapists who are often younger than me. In the early days
this was hard for me to accept. I felt that it ignored all I had given
up. Its important to accept that when starting a new career you
have a lot to learn and you have to start at the beginning again.
However I feel that my age and experience has also benefited
me in many ways. In my new career, connecting with people and
effectively communicating with them is core to my practice, my
previous experience has been invaluable and my supervisors often
comment on the ability of older students to establish relationships
with patients.
How do I get it?

You must be over 18 and a UK resident. If you qualify for a nonmeans tested bursary or receive a student loan you will not be
eligible. Check the CDL website to see if your course is eligible for
this product.
How much can I get?
You can borrow between 300 to 8,000. Barclays, the Cooperative Bank and the Royal Bank of Scotland all offer career
development loans.
Pros & Cons:
+ The loan is interest free whilst you study.
However, it is still a loan and you will have to start paying it back
a month after you qualify (with interest) so you need to think about
the monthly repayments and whether you can afford them. The loan
is for courses that are up to two years long. If your course is longer,
you can still apply, but be aware that you will need to start paying
back the loan whilst you are still studying, (and therefore perhaps
not earning). To find out more visit http://www.direct.gov.uk/en/
index.htm and search for career development loan.
3. Part Time Work
What is it?
This could either be work in your former guise, work in your newly
chosen industry, or something completely unrelated.
How do I get it?
Try to stay on your former employers good side! You could
approach them for part time or freelance work, either on a regular
basis or during university holidays. Make use of any contacts
Try to find paid employment in your new career sector, for example
as a healthcare assistant, or in an administrative role.
Upskill before leaving your previous career! Short courses such as
sports massage or sports training might be useful services that you
can offer, whilst studying.
Pros & Cons:
+ This option will not only provide valuable income, but may also
increase your experience of your new work environment.
Remember though, that your course may be extremely
demanding at times, so be realistic about how much you will be
able to work on top of this. Universities often discourage students
from having part time jobs, so be careful if you are asked about how
you will be funding your course when being interviewed for a place!
When I left my first career the economy was doing well and it
wasnt until the following summer that things began to slide.
I guess despite it being tough financially for me with hindsight I
made the right decision at a good time. As my colleagues tell me
getting your first physiotherapy NHS post may be competitive but
once achieved Im hoping that my occupation will be recessionproof. My old colleagues continue to work long hours. Although
Im told business is good the pressure is greater than ever to do
what it takes to keep their clients businesses afloat, and no doubt
salary reviews will be harder than ever to negotiate. Had I not taken
this chance, I would have been in a similar position, with similar
responsibilities and undoubtedly with more cash in my pocket,
but I would still be stressed-out, unfulfilled and frustrated. Dont
be afraid to change an average career into something better. Take
that first step, and who knows? It may just be the beginning of an
exciting new life.
93
INTERVIEW
ARTICLE
Graduate Entry Medicine
Amit Verma*, Ajai Verma

Year 3 Medicine, Monash University, Australia
amit_verma5@hotmail.com
Admission into medicine is traditionally a highly competitive
challenge. The ferocious struggle to gain entry has intensified in
recent times as institutions seek candidates who are well-rounded
and compassionate as well as academically gifted. Such a shift in
thinking has meant that many traditionally qualified candidates have
missed out, as medical schools seek to test candidates abilities
through entrance examinations such as the Graduate Australian
Medical Admissions Test (GAMSAT) and the Undergraduate
Medicine and Health Sciences Admission Test (UMAT). As graduate entry into United Kingdom (UK) medical programs in particular
increases1, there has been a similar trend towards supporting these
models as a method of establishing the worthiness of candidates.
It is paramount that the value of these models in producing multifaceted and balanced doctors is examined, before such a practice
is firmly established in the United Kingdom.
Rebecca McConnell, BA (Hons)
Year 3 Medicine (GEP), Nottingham University
What preparation did you undertake for the GAMSAT?
I have A-levels in biology and chemistry and also a degree in physiology. I bought an A level chemistry revision book, a physics GCSE
book and the revision papers from GAMSAT (which were really
worthwhile).
Describe two positive experiences of your course.

- I really liked problem based learning. It forced me to study at
home in preparation for a session.
- The relationship between GEM students and the teachers was
much more adult to adult than my first degree.
To what extent did you find your undergraduate background useful

in the GAMSAT?
My degree incorporated biochemistry, neuroscience, endocrinology and renal physiology. These subjects are very relevant to
medicine but in terms of the GAMSAT they really only helped with
the biology questions. Before I did the GAMSAT I had been working for charities for about 10 years and the experience I gained in
the marketing and fundraising departments helped a lot towards the
essay writing section of the exam.
Describe 2 negative experiences of your course.

- Some of my colleagues not quite being the mature students
that we are supposed to be.
- The fear of practical exams. I always hated someone watching me
do something.
Did you feel that your prior academic learning and life experience
were helpful in the problem solving, critical thinking and writing
skills that the GAMSAT is supposed to test?
I believe that my prior academic and work experience have given
me problem solving and critical thinking skills but I am not sure if
they were fully tested in the GAMSAT.
Is the GAMSAT in your view a useful appraisal tool for entry into
graduate entry medicine (GEM)?
I think the science part of the GAMSAT probably helps people who
havent done science before learn some basics before they start the
GEM course. As for the comprehension and essay sections, I guess
they test your level and understanding of English but I am not sure
what else.
Do you believe that you will be ready to practice at the end of your
course and if not, why?
I think we will be well prepared to be doctors. In terms of practical
and clinical experience, GEM students get the same amount of
exposure as the undergraduates. Our added life experience can
help with the understanding of social and communication issues but
may also make us more cautious doctors, which is not necessarily a
bad thing.
What sort of reactions towards your graduate medicine degree have
you had?
From undergraduate students the reaction was really good. They
were very curious when we all merged together and seemed glad
to have someone with questions they can ask. Both junior and
senior health care staff seemed curious about GEM and what we
did before. I havent really come across any of the stereotyped old
consultants who think that graduate students dont do
enough Anatomy.
Since 1997, the intake onto medicine degree courses has increased
by more than 60 per cent in the UK.2 This growth is particularly
in evidence when looking at the rise in numbers of graduate entry
places. This fact alone offers reason to scrutinize the effectiveness
of the GAMSAT process in delivering the best potential doctors to
medical schools. The GAMSAT is an exhaustive examination designed to test candidates problem solving and critical reasoning in
the physical and social sciences, as well as written communication.3
While in theory this test is designed to distinguish deserving candidates, there is a stream of evidence, such as a study by Groves et al
that suggests that performance in the GAMSAT is not significantly
indicative of performance later in medical school.4 This finding is
endorsed by a similar study in the United States by Mitchell et al
which found that the Medical College Admission Test (MCAT)
predictive scores were only slightly higher in Medical School than
high school.5 When considering this evidence, however, it must be
kept in mind that the study by Groves et al only takes into account
candidates who achieved above the required GAMSAT score
threshold, so that this data may not be completely indicative of the
general population.
Studies relevant to the United Kingdom have gone as far as to show
that measures of knowledge, such as A-levels, are in fact more
predictive of performance than tests of reasoning aptitude.6 However, this may be due to an under-exploration of the personal and
emotive factors needed of doctors combining with this finding.7
Such findings reflect the tendency for tests such as the GAMSAT
to potentially discriminate against undergraduate candidates, and
restrict the talent pool of potential future doctors.1
The recent proposal of a lower age restriction1 upon entry into UK
medicine has been rejected as unrealistic due to workforce demands and the pressures of staff turnover. Ironically, this rejection
of such a limitation may, in fact, serve to decrease the skill set of
prospective doctors. Evidence showing more mature-aged candidates with prior degrees and a diverse range of life experiences are
more suitable for entry juxtaposed against recent school-leavers1,
underscores the usefulness of the GAMSAT in this regard.
In addition, post-graduate entrants have been shown to demonstrate a high level of inquisitiveness and more emotional maturity
than their less experienced counterparts.1 A recent study has also
shown that students from non-biological science backgrounds are
not at any grave disadvantage to their colleagues and are just as
likely to succeed in their graduate medicine programme.4 In fact, it
is of note that several clinicians have found teaching and interacting
with junior doctors who may be several years older than themselves a daunting experience.8 Despite this possible drawback,
the GAMSAT has drawn praise from several sources in its ability to
discriminate between candidates, though the level and scope of
this differentiation between different regions is unclear.1
The intake of medical students continues to rise throughout the
UK and around the world over seven undergraduate and postgraduate medical programmes have been established in Australia
over the past nine years. Before that, no new programmes had been
created since the 1970s.9 Such an increase in the number of graduate programmes means the need for entrance examinations which
can accurately determine a candidates ability in a wide range of
reasoning, interpretive and interpersonal domains must be
continually reassessed rather than accepting current practices
which may not necessarily identify the best candidates. Overall,
when seeking validation for the introduction of the GAMSAT based
on Australian findings, it is important that selectors keep in mind
that the program is still in its infancy overseas9, and that evaluation
over a longer period of time will yield more significant and useful
results.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
94
Rushforth, B. Life in the fast lane: graduate entry to

medicine. BMJ, 16 Oct 2004. http://careers.bmj.
com/careers/advice/view-article.html?id=479
Bligh J. More medical students, more stress in the medical
education system. Med Educ 2004;38: 460-462.
Kulatunga-Moruzi C, Norman G. Validity of admissions measures
in predicting performance outcomes: the contribution of cognitive
and non-cognitive dimensions. Teach Learn Med 2002; 14: 34-42
Groves M., Gordon J, Ryan, G. Entry tests for graduate medical
programs: is it time to re-think? MJA 2007; 186 (3): 120-123
Mitchell K, Haynes R, Koenig J. Assessing the validity of the updated
Medical College Admission Test. Acad Med 1994; 69: 394-401
McManus IC, Powis DA, Wakeford R, et al. Intellectual
aptitude tests and A levels for selecting UK school leaver
entrants for medical school. BMJ 2005; 331: 555-559.
Lievens F, Coetsier P. Situational tests in student selection:
an examination of predictive validity, adverse impact and
construct validity. Int J Selection Assess 2002; 10: 245-257.
McCrorie P. Graduate students are more challenging,
demanding, and questioning. BMJ 2002;325: 676.
Lawson K., Chew M., Van Der Weyden M. The new Australian medical
schools: daring to be different. MJA 2004; 181 (11/12): 662-666
95
ARTICLE
INTERVIEW
European Working Time

Directive
Jennifer Turner
Year 4 Medicine, St. Georges University, London

m0400240@sgul.ac.uk
doi:10.4201.lsjm/car.002
This summer, the NHS is slated to achieve full compliance with

European legislation, limiting working time to 48 hours week. The
Department for Health is currently considering appeals for the
special dispensation of 52 hours to local services where there
remain special difficulties. Even allowing for such concessions,
trainee healthcare professionals are likely to be effected by these
new regulations.
A recent national news story about the European Working
Time Directive (EWTD) and how it may affect the training of
junior doctors quoted a trainee orthopaedic surgeon. Speaking
anonymously for fear of jeopardising his career, he said did not feel
experienced enough in the surgery he will soon be expected to
perform solo, as a result of the reduced number of hours he can
work under the new legislation. While his blacked out face and
actor-disguised voice smacked of sensationalism, his concerns
about the impact on professional training and patient safety are
shared by many.
The issue of working hours and the potential impact on trainee
doctors is by no means new. In 1998, Britain finally signed up to
the European legislation after much resistance from the previous
government throughout the 1990s.
Management of the Health Service is becoming increasingly
centralised. The European Working Time Directive is set to protect
all workers within the European Union from being compelled to
work too many hours, and aims to guarantee the amount of rest
they get and minimum annual leave requirements. Proponents of
the new legislation claim that the new rules will benefit business as
well as the individual - as the workforce become increasingly tired,
productivity falls. The magic number of 48 hours was determined
to be the perfect balance between quantity and quality of work and a contented workforce. Despite the theory, the directive has
remained a hotly debated topic, and the implications of this new
piece of legislation have already been far reaching.
Since signing up to the agreement, all UK employees cannot
be compelled to work more than 48 hours a week. Following
Government negotiations, which led to a 12 year preparation
period, a few exceptions were made. For the moment, doctors
and doctors-in-training were permitted to be contracted for longer
hours. However, since the legislation was agreed, the NHS is slowly
being brought into line. Since 2003, the maximum contract for
a trainee became 56 hours. As of this August, the training week
96
will be further reduced to 48 hours. But at what cost? Has the

Government used their 12 years of easing in time well enough to
prepare hospitals for such drastic changes? Most importantly, will
the changes ultimately be of benefit to healthcare professionals
and those who use healthcare services?
As always, arguments have been put forward on both sides of the
fence. Stories of junior doctors working for more than 100 hours
a week have passed into professional folklore, and even with the
aid of rose-tinted glasses, it is unlikely that anyone will claim the
old system as perfect. In fact, working conditions for juniors often
became so extreme some gave up on their career. Family life
became a distant memory, as work began to consume their every
being. Working upwards of 80 hours a week led to an overtired
population of juniors, who were undoubtedly making mistakes
simply through lack of sleep. Nonetheless, many hospitals relied
on the huge number of hours put in by the junior doctors to get
through the inevitable workload. Some members of the profession
consider these unearthly first few years a rite of passage to be
endured, however others, often most vehemently, would disagree.
It used to be such that time spent on-call was not included as
work if you were not actively seeing patients, however any amount
of time you are on these duties under new legislation all counts
towards the 48 hour limit. This means that for many, there will be
lost opportunities to undertake activities such as audits, clinical
based education and taught courses with proportionally more time
dedicated to non-training duties. It is clear, therefore, that in the
same length of time, doctors employed under these new rules
will not have had the training that their senior colleagues have
benefited from. Many juniors have reported having to undertake
training in their free time in order to achieve even the basic
competencies expected of them. This is something that has been a
particular issue for surgical trainees.
hours without recompense. Over half of them felt that the reduced
hours would be a good thing for both their health and social life.
However 64 per cent agreed it would a negative effect on training.
Many of those surveyed also believed that trainees should be able
to opt out of the directive, that long hours can sometimes be
dangerous for patients under their care and that the overall duration
of training should be increased to ensure competence before
qualification. This clearly means ever-increasing postgraduate
training time, but is something that the UK needs to prepare for if
we want our doctors to be of the highest standard.
How this legislation will affect patient care remains to be seen.
More alert, happier doctors can only be a good thing. However,
potentially more protected teaching time and increasingly
restricted hours will mean fewer doctors in the hospital at any
one time. NHS reforms attempting to mitigate this, such as
the introduction of nurse practitioners, remain too recent for
evaluation. An opt-out scheme seems viable, but would some
trainees feel pressured by their employer, or their training demands
to do so? Would such an option risk undermining the spirit of
protection with which the legislation was adopted in the first place?
With the NHS aiming to be fully compliant in less than three
months, one thing is clear. Whatever the advantages and
disadvantages of the legislation, the directive is here to for the
foreseeable future. Changes to postgraduate training are needed
fast in order to ensure both short and long-term patient care is not
compromised.
What preparation did you undertake for the GAMSAT?

I completed the Des ONeill training course, which is a series of workshops and booklets
that you can do at home. This course helped a lot and it was extremely useful in the exam.
To what extent did you find your undergraduate background useful in the GAMSAT?
My background is in physiology, pathology, chiropractic clinical skills and 2 years of
radiology. I found this virtually useless for the GAMSAT.
Did you feel that your prior academic learning and life experience was helpful in the problem solving, critical thinking and writing skills that the GAMSAT is supposed to test?
Not really because the focus of my last course was on research and clinical reasoning. I
didnt find that the exam tested it too well which was surprising since research requires
good writing skills. If I were to take a course specifically to prepare for the GAMSAT I would
have majored in Organic Chemistry and English Literature.
Is the GAMSAT un your view a useful appraisal tool for entry into graduate medicine?
I think perhaps, but only because it is a hurdle.
Describe two positive experiences of your course.
As a whole, the course was well organized.
The resources available are extensive.
Anecdotally, Im sure many trainees are consistently working over

their 48 hour requirements. Reduced hours do not mean fewer
patients, and surely cannot mean a reduced level of care?
One foundation doctor said any doctor worth his salt will not
leave work as the clock strikes five if there are still patients to
attend to. Its an attitude commonly echoed, and one instilled
from student level onwards. However, overtime that was previously
was paid for will no longer being thanks to the curtailment of
the working week. A BMA postal survey of showed that 50% of
respondents have felt pressure to work beyond their contracted
Nicolas Smoll, BA, MSc

Year 2 Medicine Gippsland Medical School, Monash
University Australia
Describe 2 negative experiences of your course.

Unlike the rest of the course, the problem based learning groups lacked organization.
Do you believe that you will be ready to practice at the end of your course and if not, why?
I am sure I will be fine.
What sort of reactions towards your graduate medicine degree have you had?
The undergraduate students were sometimes apprehensive about having post-graduate
students on their course and the senior health care staff were always interested in our
backgrounds.
97
PROFESSIONAL BRIEFING
PERSECTIVE
The Blame Game

Nick Lelos
Year 4 Medicine (GEP), St. Georges
University of London
Litigation culture is on the rise, with record payouts and higher
profile cases hitting the headlines. What can you do to minimise
the risk of it happening to you?
In the past decade, healthcare practitioners and doctors in
particular have seen the rise of a new phenomenon: the tendency
of patients to litigate. The targets of litigation tend to be the
providers of healthcare, about perceived damage caused to
patients following the intervention they had, or indeed had not,
received.
Litigation in all employment areas particularly healthcare seems to
be rapidly on the rise in the UK,1 though it has not quite reached
the status quo of the US.2 There are several reasons for this
increase. One reason is because the mystique and glamour of the
doctor that older patient generations may have been enthralled by
has been worn down substantially through the media.
A blame culture is also becoming more prominent, where unmet
expectations can be expected to lead to formal complaints. The
younger generations have also been raised in a culture where the
customer is always right, and healthcare is perceived as a right,
extrapolated from the Human Rights Act 1998.
The increased emphasis on a patient-centred approach is another
factor not to discount. Media effects have been wide-ranging,
such as the popularisation of medical jargon and knowledge
through television series, by the loss of respect and public trust
through scandals in the press and by the well publicised, high
damages awarded to successful litigants as seen by the tripling of
money awarded to litigants for obstetric cases between 1996 to
2001 to 1.6 billion, or money awarded even forty years after the
incident itself, such as in Norfolk with Mr OBrien.4 An important
difference is the technological aptitude of the public. The younger
population of patients is more claim conscious, and also more
knowledgeable in how to access information from the internet.2, 3
Perhaps the reason for the rise of litigation against doctors is
simply that medicine has become a victim of its own success.
Many patients now have unrealistic expectations of the power
of medicine. As well as this, the number of investigations and
tests that can be offered to patients renders the detection of
abnormalities almost unavoidable. 5 The end result is that the more
expert doctors are, the more likely they are to be sued if something
is not detected, when considered in retrospect.
An area rich with such examples is the field of antenatal testing
which, by improving drastically over the years, has seen a drastic rise
in litigations.2 It is almost inevitable to detect abnormalities, and
there are also false negatives or false positives possible with every
test to consider. With hindsight, the patient can to question the
care they received, and if they feel so inclined, sue.
While such lawsuits are not yet as successful in the UK as in
the USA, their numbers are increasing, with certain specifics

specialities standing out as prime targets: General Practice,
Obstetrics & Gynaecology, and Paediatrics.3
The key to all such litigation claims relies on the medico-legal
concept of negligence. In order to prove that a doctor has been
negligent, the plaintiff has to establish that there was a duty of
care owed to them, which was breached by not achieving the
standard of care required, which then led to the damage brought
forward by the complaint.5 This is proving particularly harrowing
for junior doctors, who may be unsure or not as confident as an
understandably worried or anxious patient would like them to be.
This in turn may lead to perceived lack of quality in the care they
receive.
This all begs the question what can be done to protect oneself
as a medical student or junior doctor? Perhaps defensive medicine
is the answer. Carrying out medical practices in order to avoid a
law suit, as opposed to acting in the patients best interest, can
have serious consequences. Patients can face unnecessary tests
and procedures, at considerable financial cost to the healthcare
system, and at increased risk of harm to the patient. Alternatively,
difficult or high risk patients may be avoided by nervous physicians.
Superfluous radiography, lumbar punctures or unnecessary
operations are among the procedures more commonly overordered.2
The irony is that the development of this type of practice, primarily
to protect oneself, can be construed as negligence in itself.3 To
recognise this fact, and the effect of law suits on doctors morale
as well as their medical practices is vital, as the fear of litigation can
lead to discontent and quitting the profession. 1
If defensive medicine is not the answer, the question remains
what can be done? The answer is simple enough, though trite:
candour and communication. Act in the best interests of the
patient at all times, use your clinical judgement and if uncertain,
always consult colleagues and seniors.6 The current healthcare
system in the UK distributes responsibility equally and jointly within
healthcare teams.
Mistakes are easily made as they are part of human nature and the
learning process of medicine. Of course, the stakes are high when
considering an individuals health, but when mistakes are admitted
and apologies freely offered, a great deal of anger and a betrayal of
trust can be avoided.
References:
1.
2.
3.
4.
5.
Mulcahy, L. 2003, Disputing doctors: the socio-legal

dynamics of complaints about medical care, MaidenheadPhiladelphia, Open University Press. Pp. 30-149.
Jauhar, S. 2008. Eyes Bloodshot, Doctors Vent Their
Discontent. July 18 2008 THE NEW YORK TIMES
Harpwood, V. 2007 Medicine, Malpractice and
Misapprehensions, New York: Routledge-Cavendish.
Sources: http://news.bbc.co.uk/1/hi/england/norfolk/3216151.
stm, http://news.bbc.co.uk/1/hi/health/7033658.stm
Harpwood, V. 2001 Negligence in Healthcare: clinical
claims and risk, London, InformaUK Limited, pp. 5-64.
Capsticks, J.B. 2004 Making amendsthe future
for clinical negligence litigation, BMJ 328:457-459
(21 February), doi:10.1136/bmj.328.7437.457
Professor Nigel Leigh, BSc, PhD, FRCP (UK), FMedSci

Professor of Clinical Neurology; Director, Kings MND Care and Research Centre;
Co-Director, MRC Centre for Neurodegeneration Research, Kings College London
As an undergraduate, getting your head around neurology is no mean feat. As
well as a detailed anatomical knowledge of that most complex of organs the
brain as well as the whole network of nerves and synapses leading to and from
it, a proper understanding of this system also requires a certain talent for logic,
deduction and detective work. Is it a fascinating discipline, with many research
opportunities and diagnoses to determine, or is it more often a case thats too
hard to crack?
For award-winning consultant neurologist Professor Nigel Leigh, who has spent a
lifetime trying to unravel the mysteries of Motor Neuron Disease, it is clearly the
former. And he has some advice for students who suffer from a little documented,
but well-known condition that he terms neurophobia. There is a core and
basic set of skills to learn in Neurology, He says, rather reassuringly. Once
you have that, and you have disposed of your fear, you have the makings of a very
interesting subject.
Professor Leigh is a world renowned specialist in motor neurone diseases (MND),
a group of disorders in which motor neurones which control muscle activity such
as movement, walking, speaking, swallowing and breathing are progressively
destroyed. These disorders have held his interest for more than a quarter of a
century. But what inspired him to pursue neurology in the first place?
The brain is the most interesting organ in the body, He said. Neurology
includes the mind and the whole gamut of nervous system disorders, and all
aspects are fascinating.
The Professors curiosity began at an early age, and he comes from a dynasty
of neurology giants. The eponymous Leighs Disease a rare neurometabolic
disorder was discovered by his father, who was also a neurologist. When I was
growing up we had books, phrenological heads and skeletons around the house
and so I developed a young and unhealthy interest in the human brain, he said
with a twinkle in his eye.
In 1986, Professor Leigh became particularly interested in MND. He said that
there was pitifully little in terms of treatment available before the 1990s.
In hospital a diagnosis would be made and then there would be a big black hole.
The patient would just be handed back to their GP, he said.
When a colleague voiced the same concern to him over coffee, he decided
that there was a need for change in the way that MND patients were treated.
Alongside an already burgeoning clinical practice, a research career was born.
When it comes to research, the Professor admits to thinking big and
ambitiously. Today, as well as being Professor of Clinical Neurology at Kings
College Hospital, he is also Director of the Kings MND Care and Research
Centre and until recently Deputy-Director, MRC Centre for Neurodegeneration
Research, also at Kings. Together with his teams, he continues to explore MND
at a clinical and molecular level.
Developing an understanding the neurofilaments and structural proteins of the
nervous system is a step towards to finding different treatments and perhaps
one day a cure for MND, He said optimistically, before being careful to qualify
his statement. We are nearer to finding a cure, if you can believe any cure is
possible, but we are still not close.
He spoke passionately of his research. The latest includes a large randomized

controlled trial for Parkinson Plus Syndrome and Riluzole treatment he carried out,
which was published in the journal Brain last January.1 He said: It was a big trial,
which involved follow up of blood, DNA sampling and collecting and analysing over
100 brains. The trial took place in France, Germany and the UK.
Leigh is also preparing a large scale drug trial looking at the effects of lithium
treatment on the progression of the disease.
With so many irons in the fire, he admits that balancing the demands of home and
the office is sometimes tricky. Its a difficult one, He said, sounding momentarily
troubled, but any doubt was swiftly swept away by an enthusiasm and energy for his
patients, which is easily evidenced.
A lot has changed since he began his career. Professor Leigh talks of a revolutionary
change in the attitude towards neurology as a whole. While there remain few cures
for many of the neurological conditions suffered by patients, greater emphasis
is now placed on appropriate patient care. He believes that this can make a real
difference to the quality of peoples lives.
Palliative care and multidisciplinary teamwork is highly valued within neurology
today. Not only is a team essential for good patient care, but as a consultant you
have to have a good team to support you in the work you do.
In determining the appropriate course of care for often terminally ill patients, he
often finds himself having to make difficult decisions.
He gives an example of the constant round of choices which dramatically influence
a patients quality of life. To give you an example, most weeks well have to weigh
up the pros and cons of using a PEG (percutaneous endoscopic gastrostomy)
compared with a non-invasive technique.
The PEG enables patients to have a fluid diet through a tube that is placed directly
into the stomach via the abdominal wall. It prevents anxiety and difficulties the
patient may have with swallowing food and it also reduces the risk of aspirating food
into the lungs.
However, Professor Leigh points out: Just because there is a gizmo or technique
available, it is not always the best decision to go ahead and use it. To have the PEG
can be painful and when a patient has 3 months to live it might be better that one is
not inserted. He added, Palliative care is all about death with dignity.
He explains that although patient autonomy is an ideal concept, it is not always
as simple as asking the patient what they want. Often the patient will not want to
think about the situation or be the one to make the final decision. He added, The
patient and family will always be given a proper consultation but often the decision
is pushed back on to you. You cannot run away from those decisions.
Despite the difficult decisions, he remains positive about his patients, and finds that
his patients remain optimistic also. Working with MND you do get terribly tragic
situations, but by and large patients are very positive, courageous and grateful.
I can never remember a time when I didnt want to do neurology.
Laura James
Currently intercalating in medical journalism
References
1.
98
http://brain.oxfordjournals.org/cgi/content/full/132/1/156
99
PERSPECTIVE
PERSECTIVE
UK Foundation Programme
Anna Mead-Robson
Year 4 Medicine, St Georges University of London
m0502048@sgul.ac.uk
This summer will see the UK Foundation Programme enter its

fourth year; having negotiated an updated online application
system, over 7,000 medical students have now been allocated to
F1 programmes around the country. In previous years, criticism of
the allocation system has arisen from both technological difficulties
and controversy around the suitability of ranking candidates by
computer.1 However, while some students this year may naturally
have been disappointed by the outcome of their application, the
process seems to have run more smoothly and to have attracted
fewer objections than in the past.
As in previous years, a candidates score and subsequent
placement depends on several factors: their academic ranking
whilst at medical school, other academic achievements - such as
additional degrees, national awards and publications - and their
answers to a series of questions that aim to assess the personal
attributes necessary to become a foundation medic, as laid out by
the GMCs Tomorrows Doctors.2 Such attributes include good
communication skills, the ability to prioritise and work effectively
as part of a team, the ability to cope under pressure and, above all
else, the recognition of the importance of patient-centred care.
This year, changes made to the online form meant that, for the
first time, candidates were able to link their application with
someone elses such as a partner or close friend although this
option is not without pitfalls: the foundation school to which
any pair are allocated is dictated by the lower-scoring candidate,
and while a couple may be placed within the same deanery this
does not guarantee they will be working within the same hospital.
Nevertheless, the introduction of linking is likely to remain popular,
especially with students in long term relationships.
In addition, the weighting given to academic achievements was
once again altered this year. While candidates are still divided into
100
For me, medicine is a vocation

... deep down, it doesnt really
matter where I end up
quartiles by their medical school on the basis of exam results, their

academic ranking provided a maximum of 40 points, as opposed
to 45 points last year.3 The gap between higher and lower scoring
medical students was also narrowed meaning that those in the
bottom quartile scored just 6 points less than those in the top.
While there is still some debate around how much weight exam
results should carry, especially given the lack of a national qualifying
exam for all medical students4, most students seem to feel that the
current balance is acceptable.
Technically everyone who graduates is safe to practise, no matter
what their academic ranking at medical school said one final year
student at St Georges, University of London. I can see it irritating
some people that you can do well academically and still get a low
score, but it wouldnt be fair to allocate people on the basis of
their exam results alone. Your priority in medical school should be
becoming a safe clinician not one who excels in written exams.
Although this years statistics are not yet available, in the past two
years over 90% of candidates were allocated to their first choice
foundation school. However, some may end up many miles from
where they had hoped to work. Allocations are made on the basis
of preference rather than score5; if an applicant does not gain a
place in their first choice foundation school, regardless of their
score they will be allocated to the next school on their list that has
remaining places available which for some candidates may turn
out to be one of their last choices. The Foundation Programme
website provides data from the last two years which give a rough
idea of which foundation schools are the most competitive
although candidates are reminded that these figures fluctuate
each year, and it is impossible to predict which schools will be
oversubscribed, although traditionally the London deaneries have
always been the hardest to get into.
In the past, the overall number of posts available in the UK has

exceeded the number of candidates, and in an attempt to correct
this and to divert candidates to some of the less popular foundation
schools, an announcement was made after this years application
deadline that 120 posts would be scrapped across the country
including a loss of 24 posts in London. This sparked some outrage
and was criticised by the BMA medical students committee, and it
is likely that as a result a greater percentage of students will not be
allocated to their first choice school.6 However, candidates should
be reassured that there will still be enough posts to achieve a 100%
employment rate, despite a recent surge in foreign applications.
Nevertheless, following this years application round many students
remain positive.
For me, medicine is a vocation, explained a final year student at
St. Georges, deep down, it doesnt really matter where I end up,
especially at this stage when I do not know what I want to specialise
in, while another St. Georges fifth year medic pointed out, In
medicine we are very sheltered in this current economic climate
we are all lucky to have jobs wherever they may be.
References:
1.
2.
3.
4.
5.
6.
Hawkes, N. 2006 Pick a doctor by computer

fiasco The Times, March 4th
Tomorrows Doctors. 2003, available at: http://www.gmc-uk.org
Kelley, T. and Finnigan, E. 2008 Foundation
Programme 2009 sBMJ; 16:398-399
Kelly, C. and Burke, K. 2008 Should UK medical students
sit a national qualifying exam? sBMJ; 16:184
FP 2009: Foundation Applicants Handbook. 13th October
2008, available at: http://www.foundationprogramme.nhs.uk
Lelos N. 2008 120 Posts Axed Medical
Student Newspaper, December
Box 1: 2008: foundation school rankings

Most oversubscribed...
1. North West Thames
2. South Thames
3. North Central Thames
Most under subscribed...
1. North Yorkshire and East Coast
2. Northern
3. East Anglia
Box2: Foundation Programme applications Top Tips

1. Refer to the Foundation Applicants handbook for advice
it becomes available online each October. Visit http://www.
foundationprogramme.nhs.uk/pages/home/key-documents
for more details.
2. Most universities will offer some sort of support in the
form of lectures or one-to-one guidance ask for help if you
need to.
3. Make sure that you read each question very carefully. Be
prepared to spend time forming considered and relevant
answers it may take several hours before you are satisfied
with your response to a question.
4. Get a friend or tutor to proof-read your answers poor
spelling or grammar can result in a poorer score.
5. Remember to save your answers as you work your way
through the form.
6. Dont leave applying to the last minute!
101
ABOUT US
MEET THE TEAM
Surgery
Psychiatry
Global &
Community
Health
Section Editors:
Section Editors:
Section Editors:
Careers
Health Law &

Ethics
Medicine
Section Editors:
Section Editors:
Section Editors:
Editors in Chief:
About the LSJM

The London Student Journal Medicine (LSJM) is a student initiative
started by students from St. Georges University of London,
Kings College London, University College London and Imperial
College London with the oversight of Professors and doctors at
these institutions. It is a quarterly student journal that publishes
substantiated peer and expert-reviewed research in all fields of
clinical science and global health, along with topics relevant to
undergraduate medical education and interdisciplinary interest.
The LSJM is a platform for formal discussion of insightful research
and include the practical interpretation of topical and upcoming
news written from the perspective of the healthcare student/
practitioner.
The journal will be freely available as an electronic journal with
printed copies open to subscription.
Our Name?
The name London Student Journal of Medicine was chosen to
unite healthcare training in London.
Jonathan Cheah
Samuel Ponnuthurai
Vishal Navani
Sonia Damle
Rani Subassandran
Maham Khan
The LSJM was founded in London and its core publishing team
comprises of students from the five London medical schools.
The journal will however host articles and be opened to readers
globally.
The LSJM provides an umbrella under which Students can educate
each other and extend their knowledge to newly qualified
professionals and the general public. Thus provide an opportunity
for students to contribute to the evolving course of medical
education.
Milan Makwana
Alexander Ross
Harpreet Sood
Rob McGuire
Tiffany Munroe-Gray
Laura Vincent
Nana Seiwaa Opare
Administrator:
Helen Pickburn
Administrator:
Sharmin Badiei
Administrator:
Katherine Sharrocks
Administrator:
Rachel Owusu-Ankomah
Administrator:
Rebekah Robson
Administrator:
Samirah Toure
Creative Director
Jonathan Hyer
Panellists:
Ben Collard
Cassia Lim
Kalpesh Vaghela
Kartik Logishetty
Manaf Khatib
Panellists:
Deepak Kumar
Geraldine Dutta
Lucy Capildeo
Rachel Baigel
Amin Golmohamad
Panellists
Farhana Akter
Hina Khan
Sean Perera
Sophie Roberts
Reshma Shah
Panellists:
Catherine Rees
Ronit Das
Charlotte Spelman
Panellists
Jennifer Davies
Marilena Smyrnioti
Dhupal Patel
Panellists:
Thisbe Archer
Jocelin Hall
Tanya Mitra
Kush Patel
Lisa Yang
Andrew Swampillai
Designers &
Illustrators:
Robert de Niet
Robert Hare
Elaine Parker
Nathalie Epperlein
David Rawaf
Ella Beese
102
The Journal will also encourage students to formally address issues

pertaining to healthcare provision. Health promotion and disease
management form the principle focus of medicine as a discipline.
Medicine as an art can thus only be successfully effected through
interdisciplinary healthcare collaboration. The LSJM highlights the
importance of interdisciplinary collaboration by uniting students
from the different allied professions in the production of its
articles.
Honorary Patrons
Professor Joe Collier
Dr Deborah Bowman
Professor Parveen Kumar
Founders
The Founding Committee of the LSJM was established with
representation from all the University of London Medical and
Allied Health Institutions. The committee worked to ensure a
reputable academic journal, and as an executive, selected the
editorial board for the inaugural edition of the LSJM.
Chairs
Nana Seiwaa Opare
Committee
Mukhtar Bizrah (SGUL)
Sonia Damle (KCL)
Oluwadamilola Haastrup (KCL)
Jonathan Hyer (SGUL)
Sinan Khadouri ( Barts & the London)
Jasmin Lee (UCL)
Matko Marlais (ICL)
Rob McGuire (SGUL)
Toby Mitchell (Barts & the London)
Helen Pickburn (UCL)
Charlotte Spelman (Kingston)
Omair Shariq (ICL)
Claire Smyth ( Kingston)
Sian White (Kingston)
Special Thanks
Mr Patrick Musami, Miss Philippa Tostevin, Professor Macallan,
Dr David Winterbourne, Dr Scarpa Schoeman, Mr Elikem Tamaklo,
Dr Velislav Batchvarov, Mr Ray Hsu, Maataa Opare, Charlotte Roberts.
Executive Committees
The individuals on these committees ensure the continual running of the
journal. They are responsible for the design, marketing, legal aspects
of the journal. Other committees ensure the journal remains true to
its goals by having a fair interdisciplinary representation and contain
sufficient educational material of relevance to the undergraduate
healthcare student.
Education: Rob McGuire, Matko Marlais, Sinan Khadouri, Jonathan Hyer
Marketing/ Public relations: Jasmin Lee, Charlotte Spelman, Omair
Shariq, Sonia Damle
Finance: Helen Pickburn, Mukhtar Bizrah, Sinan Khadouri
Legal: Sonia Damle, Rob McGuire
Design: Jonathan Hyer, Robert de Niet, Robert Hare, Ella Beese, Elaine
Parker, David Rawaf, Elaine Parker, Paul Feakins, Adrian Ellis, Nathalie
Epperlein,
Allied health: Geraldine Dutta-Gupta, Claire Smyth, Jasmin Lee, Kristian
Lane, Alan Truman, Charlotte Spelman
Donations/Sponsors
Thanks to the Medical Protection Society, Work the Worlds, Royal
Society of Medicine, Mr & Mrs Owusu-Agyemang and Dr. & Hon.Mrs
Opare for their financial support.
103
Join the RSM

as a Student Member
for just 30
30 when paying by Direct Debit, 40 if paying by credit card
save on meetings and revision courses

15% discount on www.examdoctor.co.uk - online revision tool
online ebooks, medical ejournals and databases
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Visit www.rsmmembership.org for more information, or contact the Membership team,

membership@rsm.ac.uk or 020 7290 2991, quoting LSJM1P for an application form.
Upcoming RSM revision day

Becoming an FY1 doctor day
17 July 40 RSM Members, 55 non-Members
Great RSM prizes

open to students
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in association with the British Journal of Hospital Medicine
Submission Deadline: 7 September 2009
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lsjm 15 june 2009 volume 01

15 June 2009 Vol 01

The nations health compass

Sections of the LSJM

Global and Community Health pg.56

Health Law and Ethics pg.72

Nana Seiwaa Opare & Kevin Owusu-Agyemang

Nana Seiwaa Opare

lsjm 15 june 2009 volume 01

Also in this issue

Advice. Support. Defence.

The National Co-ordinating Centre for Health Technology

would do what we want to do with regards to our health behaviour.

lsjm 15 june 2009 volume 01

lsjm 15 june 2009 volume 01

LETTER TO THE EDITORS

The Written Word

Emeritus Professor of Medicines Policy,

Patients Do Not Understand Doctors

St. Georges University of London

Professor Collier is former Editor

A universal feature of living things is their capacity and

completeness also applies to the text generally, at least for articles

A small pilot questionnaire survey was conducted whilst on a

The results demonstrate that a significant proportion of patients,

The limitations of this study include: small sample size, possible

lsjm 15 june 2009 volume 01

lsjm 15 june 2009 volume 01

than if they understand. Finally, this study highlights that simple/

Table 1. Responses for each question in the questionnaire

1)"Your blood test has come back POSITIVE. Do you

2)"Your blood test has come back NEGATIVE. Do you

4)"If your condition is in REMISSION, what do

6)"If you were told your condition was BENIGN,

lsjm 15 june 2009 volume 01

Illustration: Robert de Niet

lsjm 15 june 2009 volume 01

Year 2 Medicine, Imperial College

This is a problem that continues all the way through to qualified

McCarron P, Okasha M, McEwan J, Davey Smith G.

lsjm 15 june 2009 volume 01

Obesity: The Next Generation

Risky business: are fast-living

Problems with the internet

Laura Vincent is the

A recent survey conducted by GP magazine has found that at least

lsjm 15 june 2009 volume 01

Another pint? Go on, its not

Year 3 Medicine, Imperial College

The first topic to surface in this discussion is undoubtedly alcohol.

Smoking does not seem to be as prominent in medical student

Perhaps we are unaware of what constitutes healthy behaviour, or

The lower limbs were the most obviously compromised.

The patient, JD, was a 24-year-old female who chronically abused

A healthy lifestyle - something we emphasise to patients seen on

Our grasp of the UK and US obesity problem has been found to

cally light touch, was diminished distally in the hands

Frank E, Elon L, Naimi T, Brewer R. Alcohol consumption and

lsjm 15 june 2009 volume 01

Prior to this event, JD had been treated for depression, opiate

lsjm 15 june 2009 volume 01

Differentials & Investigations

This meticulous process of exclusion left only alcohol-abuse as

The principal treatment was alcohol cessation and dietary vitamin