Sean BENNETT, who was a naval medic, gave us details of the history of the Royal Hospital of Greenwich, now the Maritime Museum. As you might expect, it was the French who were to blame by fighting with the Royal Navy, and injuring sailors. The Hospital was founded in the late 17th century as an alternative to turning severely injured sailors on to the streets to beg. It was largely for long-term rather than acute care, although developments on board ship meant that both kinds of care were provided. Some residents stayed for many decades, attending daily church parade and working when they were able, but under a tight discipline. It was the seaman’s version of the Chelsea Hospital for wounded soldiers, but was open to merchant seaman as well as military, there being no real differentiation between the two in the past. The first patient was admitted in 1705, and the hospital finally closed in 1873 when it became the Royal Naval College.
Catherine LEFORT presented an overview of the radiography of thoracic opacities, and the advances in understanding of subtle differences with wider use of CT. Small pneumothoraces are obvious where they might be missed on a basic CXR. Even miliary TB can be difficult to spot, and CT is diagnostic.
Nicola STRICKLAND gave her usual clear exposition, this time of imaging of various forms of intracranial haemorrhage and disease, telling us, for example, that a subdural haematoma gives a sickle-shaped (concavo-convex) picture as distinct from the biconvex appearance of an extradural, usually associated with trauma. We learnt about imaging to show salvable brain in the penumbra of a stroke, only recently visualisable using specialist techniques. She also showed us early work on hyponutrition of the brain which can be early evidence of dementia.
Sylvie FLAIS updated us on breast screening and cancer diagnosis and the dilemmas particularly in younger women. There are major discrepancies between various modalities such as ultrasound, mammography, MRI, and tomosynthesis might be the future. Clearly there is a balance between radiation exposure and potential benefit, so any method that reduces exposure while improving diagnostic accuracy is to be welcomed. She wonders whether the development of CAD systems will lead to redundancy in radiology: we think not.
Félicie PASTORE has been a loyal member of our club for over 20 years, and her tireless efforts in teaching medical students to speak the flawless and accentless English that she speaks were applauded by us all. She is retiring this year, but her final push has been the instigation of a specific test of medical English much above the level of for general or even scientific testing. CLES 3 takes 4h 20 mins, with a 3-hour slot to observe a video or listen to an audio presentation, perhaps from a conference or scientific paper; prepare slides and a presentation; then to present it to 2 examiners, one a doctor the other a teacher of languages. This is followed by a Q&A session, then an essay to be written in one hour. You can read more at www.medecine.ups-tlse.fr/anglais. We all hope that Félicie will continue to attend our meetings, and thank her for all these years of unfailing support.
Daniel WEBSTER told us about pandemic influenza. Some of our colleagues were confused by the number of different words concerning pigs: pig, pork, porcine, swine…We learnt that avian flu (H5N1) is more likely to be a cause of world-wide loss of many lives than other forms, with a death rate of around 50%, but that human to human transmission of this form is much less likely than others unless and until the virus recombines in a pig. Pigs are the only known species that can be affected easily by both human and avian influenza, so making them the intermediate for a major pandemic. The speed of transmission was demonstrated by the 2009 pandemic where WHO went from Phase 1, a possible pandemic, to Phase 6, a fully established one in only 2 months. Air travel has made the risks even greater than in 1918-19 with its perhaps 50 million deaths, largely in younger adults. He reminded us of the lack of major effectiveness of anti-viral drugs.
Atholl JOHNSTON, who is a member of a national working group on the subject, talked about the risks and laws around alcohol, drugs and driving. There have been no reductions in the ratio of drink drivers involved in accidents in the past 20 years despite legislative changes and alterations in public acceptance. He pointed out the evidence of the hugely increased risk of accidents with increasing blood levels, such that there is a 25 fold increase at 100mg%. The risk is lowered with habituation to alcohol and worsened greatly with inexperience (of alcohol or driving), but there is a measurable effect even at modest levels. Drugs, prescription or illicit, are known or presumed to be dangerous also. The testing (FIT or Field Impairment Test) is much more subjective than the simple use of a breath analysis for alcohol, and there does not seem to be a good correlation between the test used and formal assessment of driving in controlled conditions. In fact, low to moderate levels of THC in the blood if anything might improve performance on some measures. However, when mixed with alcohol, as it almost always is, the effects are dramatic, and the risk of accident increases synergistically. Tests of drivers involved in accidents in France showed that in 7000 cases where drivers were considered at fault, 21% were alcohol positive, 7% cannabis, and less than 1% other illegal drugs. Random testing of 1000 drivers in UK had 10% positive for diazepam and 5% for opiates. He finished by challenging us to consider the possible effects of the frequent polypharmacy in our aging population.
Jean-Pascal FOURNIER presented his study on physicians’ compliance with guidelines for the monitoring of renal function in patients on antihypertensives who started on NSAIDs also. The information was available from the database of reimbursement of costs. The results were disappointing. There were 6663 on diuretics and/or ACE I or II, and 25% were started on NSAIDs. Under 11% had renal tests after 3 weeks, and even higher-risk individuals did not have better rates. The advice in the two French equivalents of our BNF are contradictory, and neither is the same as the BNF on the subject. This is clearly part of the issue. There is also lack of clarity about who is responsible, as many patients are looked after by renal physicians and by their GP. Doctors also underestimate the risks of this combination (literature is clear) and overestimate their performance. Computer screen warnings are often over-ridden or ignored, perhaps because there are simply too many of them.
Pierre BISMUTH showed us the development stages of a website to assist general practitioners to take over more completely the monitoring of children between 0-2 years. It seems extremely comprehensive, and UK GPs were amazed to see the seven areas of intervention (nutrition, psychomotor development…) at 12 different points over those 2 years. An interesting debated ensued about the role of health visitors and GPs in the UK, and the lack of similar workers in France. The site is at a development stage, and the issues around it clearly include accuracy, updating, ease of use vs comprehensiveness, cost. The amount of time required to use it fully looks extensive, and each area has basic pages, an overview in more detail and reference pages also.
Antoine KOURILSKY is a 6th year student. He presented a study of genetic risks and testing for intracranial aneurysms and haemorrhage. This was a large study using multifactorial genetic analysis of a European population compared with a Japanese one. Cases and controls were chosen in both sites, as this allowed geneticists to look at potential loci of endothelial control genes. The potential appears to be for screening in the future for a devastating condition, but there is an enormous amount of work before there is any likelihood of a diagnostic test, even for apparently high-risk families. We applaud his clear presentation in English of an extremely technical area of medicine.
After coffee on Friday we had the student presentations for the James Tudor Prize.
Elizabeth MCKIERNAN had been on her elective in Morocco, but as her future may be in the History of Medicine she chose to present an excellent talk on the Black Death. She argued that the standard explanation of bubonic / pneumonic plague remains the most likely diagnosis, but that there may have been other diseases involved or confused at the time.
Imogen PTACEK told us of her trip to Rwanda. She was involved in obstetric and family planning work in rural areas, and explained the development of training for isolated midwives. They are being provided with mobile phones to allow rapid consultation on high risk cases. The country is recovering after the genocide, and family planning, particularly condoms, are now accepted, even in a religious country. Rates of HIV/AIDS may be lower than neighbouring countries.
Richard ROSCH presented a terrific paper on the potential impact of loss of biodiversity on human health. He was in Madagascar, and noted that zoonoses are commoner when the natural host is reduced. (This was also mentioned with regard to rats and the Black Death in the earlier talk).
Tom SLATER worked in a Paris ITU/HDU, and was given responsibility for one or two patients a day. He described the routine work, and then gave a well-presented case report of ARDS.
Mary THORNTON, also in Paris, gave a case report of a difficult presentation of secondary syphilis. It is a condition many of us never see, but we all remember that it is the great mimic. The case report was put into context with some illustrations of other clinical cases. Mary was subsequently awarded the James Tudor prize by Mr Rod Shaw of the Foundation at the House of Lords dinner.
On Saturday we started a little late after the Gala Dinner!
Karelia Ruffert LIPSON challenged us with a complex and technical presentation on the various types of adrenomyeloneuropathy and the potentials for stem-cell transplantation. There are subtypes, all being X-linked, with abnormalities of the ABCD1 gene. The most severe is cerebral, with death in 2-3 years. There seems to be potential for autologous grafts using blood stem cells and lentivirus. A lesser form causes spastic paraplegia. Research in a murine model showed potential for benefit using both autologous transplantation and antioxidant therapy. It appears that damaged cells are cleared by macrophages which also die and affect neighbouring cells by releasing oxidants.
Ayat BASHIR is a 3rd year student in Newcastle. As a project she studied endothelial cells from cord blood, and defined an economical way of culturing them. This appears to be a novel way of getting cells to express angiogenesis, and should allow further research into diseases with possible links to abnormalities of angiogenesis, including cancers and possibly IHD. The work appeared to be very advanced for a student just starting on a laboratory track and we look forward to watching her later career as a medical scientist.
Catherine SAINT QUENTIN presented a paper on the benefits and difficulties of sectorisation and moving to a community base in Child and Adolescent Psychiatry. We recognised the problems as very similar to the UK. One major difference seemed to be the rapidity of access to her service compared with many of ours.
Michael KELLY gave one of his clear presentations on medico-legal practice. He talked about the chain of causality; Bolam; Wong (the lack of defence of “usual way of doing things” if it is clear that it is wrong). He pointed out many of the misunderstandings about the law and medicine, such as the balance of probability argument, which means that even bad care leading to death is not culpable if more than 50% of similar patients would have died in any case. He indicated the huge charges now required for high-risk practice such as obstetrics, which means that private practice is almost unaffordable. He took us through the process of a defended negligence case, and made many of us glad to have avoided that particular part of practice. The amount of work and expertise required to act as an expert witness is simply astonishing.
Fraser EASTON spent a year in Geneva after completing Foundation 2. His experiences were positive, but the combination of the very different system, the medical abbreviations (even our French colleagues struggles) and his Scottish accent led to amusement amongst the secretaries when he dictated his notes. However he had a wonderful time medically, and his mountain skills improved immensely. He was awarded the Will Reynish Award for 2012.
We ended another successful meeting with a presentation from Zara BIELER on the Warwick Medical French course which she has taken over from Gareth Williams, and by Solène Le Gouzouguec who did a stage in UK including 2 weeks with Zara, another spell in urban general practice and a period with Mark Savage in his Manchester diabetic service. She clearly benefited from her stay both medically and linguistically, and that is a very appropriate point to conclude this report.