News – The Student Physiologist

Cardiologist’s Kitchen

Barely a month goes by without a national newspaper displaying words like “science says _________ is bad for your health”.

Daily_Mail_24_1_2017 — Don’t get me started…

I concede that *some* of these headlines might be correct, but it’s worth taking them with a pinch of salt, if you’ll pardon the pun; firstly, “science” isn’t an all-powerful being that performs every possible study single-handedly, so it’s difficult to know exactly who has put forth the particular claim and how many people through whom the information has passed before it gets to the news media, and secondly, “science says…” doesn’t necessarily mean it’s double-blind, peer-reviewed, evidence-based or ethically funded, so between the debunked results of Andrew Wakefield’s infamous autism/ MMR study and big pharmaceutical companies potentially protecting their interests by omitting unfavourable study data, it isn’t a great idea to believe that eating bacon causes your lips to fall off, simply because the junior science editor for The Daily Express tells you it does.

What, then, do you believe? Nobody wants to find themselves being brought into a Cath Lab, and they don’t want the uncertainty that comes with not knowing whether the food that they’re eating is going to help put them in that position. This is where Cardiologist’s Kitchen comes in; Consultant Interventional Cardiologist Ali Khavandi would rather intervene well before you’re being consented for an invasive procedure, and addresses issues with cholesterol, weight, blood pressure and diet by way of a pre-emptive strike using evidence-based dietary and lifestyle changes.

alikhavandi — Cooking Cardiologist, Ali Khavandi

Not unlike this site, the initiative began as a humble health-based blog in 2015, featuring advice and recipes, and was borne through personal, clinical experience. Khavandi’s passion for both cardiology and cooking pushed him to create a resource, and seek a wider market using the same mechanisms employed by the media and the food industry, but using an evidenced basis in cardiovascular wellbeing. The Health Foundation has since granted the Cardiologist’s Kitchen project an award that has allowed the trial of this innovative approach to healthcare to really take off!

Currently, Cardiologist’s Kitchen has partners in GP surgeries, a restaurant and various South West England food suppliers that combine to make conduit for the project’s entire message. Despite still being in relative infancy, Cardiologist’s Kitchen has made headway, and continues to open up avenues via which to get the message out there.

Patients with new or existing high blood pressure can get a CardioKit pack at affiliated GPs. I got one to sample, which contained some money off vouchers, health advice and information about the project. In addition, The Bunch of Grapes gastropub, found in Bradford on Avon, just outside Bath, offers some menu heart-healthy menu items devised by both Ali Khavandi and head chef Steve Carss (I’ve sampled some of these too; they’re delicious).

Chinese Chicken — *The recipe for this Chinese chicken and more, is available on the Cardiologist’s Kitchen website*

The website is the real central feature of the initiative, with healthy recipes, incentives for transforming your attitude to heart health, and evidence-based discussion on food fact, cutting through scaremongering in the bad science which can sometimes surround food.

Rather marvellously, it encourages the use of local suppliers by offering deals and home delivery on their seasonal produce. They’re also in the process of developing ready meals specifically designed to improve cardiovascular health.

By using CardioKit, the aim is to lessen the need for medication, and support local business as well as your own heart. If you’re reading this, and it applies to you as a patient, then I urge you to have a look. If you’re a practitioner, definitely do the same, and get in contact with the CardioKit team to see how you can get involved.

For more on Cardiologist’s Kitchen, visit their website at: cardiologistskitchen.com

Inspired by the advice presented on Cardiologist’s Kitchen, I made a rather lovely Jamaican beef curry, the (really easy) recipe for which I will share here:

250g lean diced beef

4 banana shallots, thinly sliced

1 x jalapeno chili, diced. (Leave the seeds in if you’re a daredevil)

1 x carrot, peeled and chopped

1 x small sweet potato, peeled and diced

1/2 mango, diced

2 garlic cloves, sliced

1 box passata

1 tbsp. jerk paste (jerk seasoning will do fine, but add 2 tbsp.)

1tbsp garlic granules

1 tsp. tomato puree

100ml chicken stock

Greek yoghurt

Flat leaf parsley, roughly chopped

Salt and Pepper, to taste

Rice, any kind, and enough to feed 2 people

With a little oil, brown the beef until sealed sufficiently. Add the shallots, sweet potato, and sliced garlic, and cook for another few minutes. Throw in all of the other ingredients and reduce heat. Simmer for 60 mins, or until the beef is tender, and use this time to cook your rice. Serve with some chopped parsley and a dollop of yoghurt.

Is Screening all Young People for Cardiac Disease Cost Effective?

In Western medicine, especially the U.K. and U.S.A., mandatory screening for cardiac disease in young people doesn’t exist.

The NHS currently offers screening for the following:

Newborns (blood, cardiac, hearing tests, and physical examination)
Pregnancy (foetal abnormalities, blood tests, and infectious disease)
Diabetic eye testing (annual follow-ups for cases confirmed in >12 year olds)
Cervical (every 3 years for 26-49 year olds, and every 5 years for 50-64 year olds)
Breast cancer (50-70 year olds, 70+ individuals can self-refer)
Bowel cancer (55-74 year olds)
Abdominal Aortic Aneurism (65 year old men. Over 65s can self-refer)

These tests are designed to aid in patient healthcare and to alleviate the long-term financial burden on the heath service, but as you can see, they’re fairly narrow in their scope. Aside from newborns, the vast majority of the screening programmes cater to individuals in later life, or after index presentation/diagnosis. If one suspects an abnormality, then of course, there are many private options available, and in fact, cardiac screening for precursors to sudden cardiac death (such as hypertrophic cardiomyopathy) is in place for young athletes. Given that the estimated number of young people with the abnormality currently stands at 1 in 500, it has been theorised with this and other cardiac diseases in mind, that mandatory screening for young people could ease the cost on the NHS, enhance patient treatment/safety and the emotional fallout that comes as a result of the morbidity associated with serious cardiac conditions.

The results of a nationwide U.K. screening programme known as Cardiac Risk in the Young imply that mass-screening that also encompasses ECG in addition to the standard physical exam and history increases the likelihood of early diagnosis and actually saves money.

The results are the endpoint of a 4-year process, involving roughly 30,000 young persons who were screened using the above methods, all of which were performed and interpreted using the relevant professionals and governing body guidelines.

8.1% of the 30,000 were deemed to produce an abnormal 12-lead ECG, 3.5% had an abnormal physical exam and/or history, and 0.5% showed abnormality in all three areas. 11.7% underwent echocardiography to confirm or deny the presence of dysfunction, 0.9% were referred for cardiac MRI, 1.7% were moved on to longer-term ECG monitoring, and 1.7% had exercise stress testing.

87 abnormalities associated with SCD syndrome were positively diagnosed at the 2-year follow up mark, accounting to 0.3% of the cohort, and 83% of this number was done so using the ECG alone. Interestingly this 83% was found in individuals who presented as asymptomatic, and would likely go undiagnosed otherwise.

The cost of this screening and subsequent treatment of a positive identification is estimated to be 20% lower than the cost of treatment and screening using current requirements, due to its lowering of false positives from 21.8% to 4.3%. This, in turn, lowers the amount of unnecessary follow ups, so this study may have great implications for young athletes, and non-athletes alike in helping to spot these potentially fatal conditions, many of which can be managed.

More on this story and more at: Cardiac Risk in the Young

Detecting CAD with Vocal Biomarkers

Beyond Verbal, an Israeli company leading the market in voice/emotion analysis software are making headlines thanks to their study with the Mayo Clinic, that shows that voice analysis can indicate the presence of coronary artery disease (CAD).

CAD is responsible for one of the highest cardiovascular mortality rates in developed countries globally, and whilst lower in developing countries, this figure is quickly rising. With this in mind, inexpensive, low-risk and non-invasive screening methods are a very desirable prospect. Currently, ECG, Exercise Tolerance Testing (ETT), Radionuclide testing and Pharmaceutical Stress Testing are the most common procedures used to screen for CAD, but, aside from ECG, each has contraindications, and/or is fairly invasive. Again, aside really from a simple ECG, each has a middling to significant associated cost attached to it. Technology that could reduce these costs and the potential for unnecessary testing presents a possible alternative to patients being referred to chest pain clinics and such, without a sure fire reason to do so.

Beyond Verbal have already used their vocal analysis software to find audio characteristics associated with Parkinson’s disease and autism, and have now turned their technology to CAD.

The Beyond Verbal/ Mayo Clinic study hypothesised, due to the association coronary atherosclerosis has with other systemic pathologies, that vocal processes and the structures responsible may also be affected.

150 patients, 120 of which presented for angiography of the coronary arteries and 50 healthy, or non-cardiac control patients had their voice recorded prior to the test. Beyond Verbal then used a variety of their analytical software to record three 30 second voice clips from each patient; the first (R1) was a predetermined script, R2 was a description of a positive experience, and R3 was personal like R2, only a negative experience.

The analysed results show a 19-fold increase in the likelihood of CAD in R3, the negative voice clip, irrespective of traditional cardiac risk factors such as age, suggesting there is indeed a link between CAD and voice.

BV hope that future development of this technology can be used to screen patients telephonically.

The poster outlining the study can be found here.

Beyond Verbal on the web.

The TSP resources relating to CAD can be found here and here.

Virgin Care Wins Bath and North East Somerset Adult Services Contract

On the 10th of November, after a long process of meetings between local council members, healthcare union staff and members of the public, Bath and North East Somerset council voted in favour of Virgin Care for its delivery of adult services in the area, rejecting the rival bid from ousted former controllers, Sirona CIC.

B&NES council have given their reasons for preferring Virgin Care for this role, citing their transforming services across the country and positive collaboration with GPs, care centres and charities as two of those at the forefront of the decision.

It is important to note that B&NES has made this decision with deep input from the local Clinical Commissioning Group and community champions over two years, so it is the culmination of a number of differing viewing perspectives and backgrounds.

The vote, which was 35/22 in favour of the Richard Branson-owned healthcare firm, marks the first time a for-profit organisation has been in charge of NHS contracts in the B&NES area. It has been met with vehement opposition from numerous individuals and local organisations since the bid was announced, and the company itself has previously been under scrutiny for its use of tax havens, quality of care, and alleged mistreatment of staff.

Screenshot (224).png — National outlets have lambasted VC in the not too distant past

In 2012, a Dispatches documentary revealed how under-target a Virgin Care centre was regarding Chlamydia screening, exposed a memo asking staff to take test kits home with them, in order to increase the number of screens executed and keep them in line with national targets.

A year later, emergency department medics and the CQC expressed deep concern with practice policy, after a VC-run centre triaged a patient using a receptionist as oppose to a healthcare professional. This proved fatal, but Virgin still defended their actions at a hearing, saying that the patient was appropriately treated.

Despite only being in the market since 2010, Virgin Care currently has NHS contracts worth a reported £1bn, and provides services across the country. It being a Virgin subsidiary and having its head offices in the British Virgin Islands, means it is exempt from corporation tax, but, tax aside, the company has said that all profits made by its B&NES services are to be re-invested into local healthcare delivery. At the same time, however, it has been made clear by the company itself and from other sources that Virgin Care are not looking to make profit from this deal.

Confused yet? I am.

With this deal citing a new precedent in the volume of healthcare services of which Virgin Care have control in the UK, confusion isn’t something that benefits patients, and the majority of middling to major news networks have sensationalised this to the point of farce;

The Canary used the headline “While We’re Still Recoiling from Trump, Branson Quietly Buys up the Biggest Chunk of our NHS…”

Given that this deal has been featured in local and national news for well over a year, spawned public and political backlash (acclaim too, in fairness), and has only now reached a conclusion, the word “quiet” isn’t even slightly appropriate in this case. Headlines such as these only serve to stoke the fire.

In order to try to cut through media Chinese whispers and rhetoric, I spoke to Liberal Democrat Councillor for Oldfield Park, Bath, Will Sandry. Will attended, and was an active part of the B&NES meeting, so I asked him for his thoughts on the deal itself, and what he thinks this means for service users in the Northeast Somerset area.

Virgin Care have never had charge of a number of the services, such as social work, which are contained under this Adult Services umbrella. As I see it, this makes service users guinea pigs in this case. Would it be fair to say that this is something of a risky move on B&NES’ part?

It’s fair to describe service users as “guinea pigs” because some of the services have not been provided by a private company before, and a key element of Your Care Your Way is a redesign of services so the services themselves will change during the contact. I don’t think this is “risky” because I have faith that the wellbeing of service users will remain paramount.

During the meeting you were, along with one of your Labour counterparts, in favour of moving for a deferral of the vote so as to further scrutinise numbers you felt didn’t “stack up”, appearing to cite distraction techniques and I quote, “Jedi mind tricks”. What about the numbers and overall proposal sounded alarm bells for you?

In our meeting papers the costs of the services were listed as remaining static for 7 years. I did not have confidence that was achievable. The papers were glossy but had scant financial detail. I had also asked for details of the Virgin Care management team that would deliver the contact, but I could not get a clear answer as to how much of their time would be allocated to delivering the B&NES contact. These are the main reasons I wanted more time for scrutiny.

The most vocal reactions from the public have been almost unanimously negative; a petition, anti-privatisation websites and protest marching, as well as cries of “shame” from those who attended the meeting. We know from recent referenda and elections that small samples of public opinion may not represent the view of the community, so with that in mind, what have you and your colleagues heard from service users on the street?

Apart from the vocal reactions you describe I’ve not had any direct concerns raised by service users. I suspect that the vast majority of people don’t know or mind who delivers their care as long as it remains available to them and free at the point of use.

Conservative councillor Anthony Clarke assured the meeting that Virgin Care were not looking to make profit from this deal. I personally find it strange, and indeed improbable that a for-profit organisation isn’t looking to make a profit from a £700m deal. How is the proposed budget going to monitored and how will it be enforced by the council?

I don’t know, but would presume it will be by the Council’s Health Scrutiny Panel or the B&NES Heath and Wellbeing Board. Profit is an interesting thing. An organisation can have legitimate costs (for example the cost of using the “Virgin” brand) but not record any profits for accounting purposes. I don’t know what (if anything) Virgin Group will be charging Virgin Care for the use of the Virgin brand.

What happens if this figure is exceeded? Comparing news reports from this year, it already appears to have increased by £200m, so how does the council aim to allay concerns and potential indignation that a for-profit organisation (who controversially escape corporation tax) may possibly have a future need to utilise tax payers’ money in order to do its job?

Savings can also be made by redesigning a service to deliver the same outcomes – this was always the aim of Your Care Your Way. Ultimately if that doesn’t work I imagine that the tax payer (local or national) will pay or there will be a reduction in the levels of service available.

Has anyone shed any light on how Virgin Care plan to reinvest profits that they have assured us they aren’t trying to make?

We in healthcare treat patients using a risk:benefit ratio, wherein the potential risks of a treatment should be less than the benefits they could provide in order to make them viable. Given that the issues surrounding Virgin Care’s practices have been documented nationally, were these problems taken into account and considered to be outweighed by the benefits a VC-driven service could provide?

As an opposition Councillor who voted against the deal, this is a question for those who voted in favour of it. In B&NES we have good Heath and Social Care, in part because we don’t play a political game over it. Nobody would thank us for that. If it could have been proven to me that the deal was the best for our residents I would have supported it despite any personal political concerns about privatisation. Let’s hope it is a good deal for service users, but I could not be convinced about the finances of it.

Finally, Will, our whole healthcare system hinges on its patient-centred approach. Given the vote for Virgin Care, despite the vocal opposition to it, it can be logically assumed that the majority of the council feel it will bring about positive changes. What sort of changes can service users expect to see under Virgin Care? What has been proposed that betters the existing system?

I can’t speak for those who voted for the deal, but it is logical to assume they did feel it would bring about positive changes. The contact is too big to list what specific changes might be made, but I imagine any changes will attempt to keep the same beneficial outcome for service users while reducing costs.

These represent the thoughts and opinions of Cllr Sandry himself, and are not necessarily indicative of those held by his associates, or by Bath and North East Somerset Council

Fitbit’s Familiarity with Class Action Lawsuits

Fitbit, the wearable fitness tracker, has gone from strength to strength since its launch. The company recorded a record $1.858 billion (!) in revenue at the close of the 2015 financial year, and, due to its affordable price tag, everyone from we regular folk, to soon-to-be ex-P.O.T.U.S. Barak Obama can be seen wearing one. That said, Fitbit are known to court controversy; in 2015, it was suggested that the advertised “sleep-tracker” in the company’s Flex model was inaccurate, and over-logged sleep. This case is still ongoing, but it is important to note that it is not suggesting negligence with regards to health; rather that the product itself was falsely advertised. It remains to be seen how this case will play out, but as if that wasn’t enough, at the beginning of the year, a multiple-plaintiff class action lawsuit was filed, with a study showing evidence that Fitbit’s PurePulse technology was woefully inaccurate during exertion.

The study, performed by a team at California State Polytechnic, compared exertional heart rates acquired via the wearable device and from an ECG. After exercising 43 individuals for 65 minutes, it was noted that the various Fitbit models displayed a heart rate that differed by up to 22bpm compared to that on the ECG, and that some didn’t display a heart rate at all.

According to the study’s team, there exists a distinct lack of rigorous, scientific testing in the wearables market (this is further suggested by lawsuits filed against other, similar product developers), but Fitbit have dismissed both this statement and the study itself, citing bias and, perhaps humorously for reasons I shall soon disclose, a lack of scientific methodology. Fitbit have stated that they perform extensive testing during development, and have pointed towards another study which purports to have found PurePulse products to be highly accurate, although it is important to note that this particular study tested a sample size of two (yes… two).

Wearable devices aren’t anything new, but with technological advances, they are no longer being seen as simply fitness trackers and companies are exploring their application in healthcare. As this gains further traction, accuracy will be incredibly important. In fact, one of the plaintiffs in this case, an 82 year old woman, has alleged that her device underestimated her heart rate by such a margin, that were she to have tried to reach her supposed target heart rate, she would have likely done serious damage to her health, so it is already having a potential impact.

The company’s financial growth since the launch of this generation of devices is thought to be largely due to PurePulse, what with it being the most heavily marketed new feature, so Fitbit’s request that the case be dismissed has last week been denied. Judge Susan Illston has decided that the plaintiffs case has sufficient merit, with regard to fraudulent claims about Fitbit’s accuracy, so it will be considered in court. This does not necessarily give an indication as to the outcome, however.

TSP Mobile: ECG

EDIT: The Android version of TSP Mobile: ECG is available for download, but due to the way in which Google Play operates, I have been unable to offer it for free. The iOS version, when available, will be gratis for the promised 14 days however. Still no word from Apple when that will be, but I have been assured that it is being vetted as I type this, so fingers crossed!

Original article follows:

Well, that TSP mobile app I promised…

I’ve been saying I’d do it for months and, despite remaining fairly quiet with information about starting, I actually have been working on it. So much so, in fact, that the bulk of the development is finished! It’s in final stages of testing, after which it will be available on the Google Play and iOS app stores, where it will be free for the first two weeks of release, so please download it and leave some constructive feedback and a review.

The app features tutorials on ECG analysis, exercise and ambulatory ECG, cardiac flow and cycles, action potentials and useful formulae for trace analysis. Each section is laid out in an easy to follow format, with colourful diagrams and both real and illustrated ECG traces.

Heart rate and QTc calculators are included to aid analysis without leaving the app, and also access to the website blog, so you need never miss an update.

This slideshow requires JavaScript.

I hate advertisements in apps, so in order to keep TSP mobile ad-free, I will charge £1 to download it after these introductory 14 days are over. In an ideal scenario, I would keep it completely free, but it has been, and continues to be, a rather expensive endeavour from both a chronological and economical standpoint especially for my shallow, student pockets, so I hope you understand why I have decided to charge.

Stay tuned to TSP via site, Twitter or email for a release date. It’s very soon!

Ethical Implications of Switching Off a Pacemaker

On the 24th of September, the BBC reported the story Nina Adamowicz. Nina, a 72 year old lady with an Implantable Pulse Generator (IPG) who, after having the device for almost 20 years, has requested it be switched off.

After suffering a minor infarct, Adamowicz had said that her continued deteriorating health became too much to bear, said she felt like she was waiting in line to be executed, so she requested her device be switched off. She is reported as stating “It isn’t about ‘I want to die’; I’m dying”.

Her case was referred to her local trust’s ethics committee, who, after careful deliberation decided to proceed in line with the wishes of Mrs Adamowicz.

Before passing away on the same night that her device was switched off, Nina Adamowicz stated that she believed she had the right to decide whether or not she wanted the IPG on or off, and stood by her decision.

This case is thought to be the first of its kind in the UK, but Chicago device specialist Dr Westby Fisher professes to doing this exact thing on a dozen separate occasions. Westby considers the ceased action of an implantable device to removing a feeding tube, or switching off a ventilator.

In particular, in a piece for massdevice.com, Fisher tells of a patient who refused dialysis, saying he’d rather let nature take its course. The patient, who also had an IPG, requested that this was switched off, so Westby agreed, and the next day switched off tachyarrhythmia detection on the device. Fisher says that he feels that both he and his patient did the right thing, together.

I for one, am confused as to the ethical pathway involved in coming to both this decision, and that of the ethics committee associated with Nina Adamowicz.. Assisted suicide is complex, but with respect to these scenarios, is defined as the intentional encouragement or assistance to a patient in ending their own life and it is still illegal under the 1961 Suicide Act of UK law . A medic who administers an overdose of muscle relaxants to a patient whose condition is diagnosed as being terminal, even at the behest of that patient, would be punishable by UK law with manslaughter or murder and potentially serve the maximum terms associated with each.

Why then, is hitting the off switch on a pacemaker not considered to be comparable to the example given previously? Patients with implantable devices often have them to combat life-threatening arrhythmias, so in turning them off, this can effectively issue a death sentence to that patient. I’m not arguing for or against any form of assisted death; I neither understand its intricacies or feel it is my place to denounce or advocate something with which I have had precisely zero experience, I’m simply confused as to why an immediate form of assisted dying is outlawed, and something so similar (on the surface at least), is not. Adamowicz’ clinician has said that other professionals are split in their opinion on his decision, with some feeling it to be “uncomfortably close to euthanasia”.

Is it fair to patients with terminal diagnoses that are forced to travel to countries such as Switzerland, wherein some forms of euthanasia are legal, simply because they do not have an IPG? Does the severity of the condition have any part to play? How similar do individual cases have to be so as to render one illegal and another not so? I have a feeling that this case will spark long debate throughout the medical and legal professions in the UK, and will follow its progress closely.

BBC article

Westby Fisher’s blog

Review: Epicardio Simulation v1.5 (Trial)

EDIT:

After writing this review, I got my hands on the full version. So this review continues here.

Epicardio offer a 60% discount to full-time students

Download for Windows/OSX:

Trial (Free)
Paid (£149-£215)

Developer: Epicardio.ltd

Studying ECG can be one hell of a mountain to climb, especially when you’re at the novice level of cardiac education. Due to how vital it is, it’s imperative that you can not only make the distinction between Mobitz II AV Block and sinus arrhythmia, but also understand the intricacies of the cardiac conduction behind them, and all of the other rhythm abnormalities. Learning these things like the back of your hand is one thing, but combining all that knowledge is, at times, overwhelming. So after 12 months of scouring the internet, trying to find a decent cardiac anatomy and 12-lead ECG simulation tool, I was over the moon to stumble upon Epicardio Simulation; a cardiac electrophysiology tutorial application, developed by Epicardio ltd.

The program is available in 3 main forms; Epicardio ECG, ECG and Pacing, and 3-day trial. As I don’t have £149 kicking around (the price of the basic ECGcentric offering), I can’t review the full version and all of its features, but the 3 day trial version (which is £0), is well within my price range. Thus, I shall only be commenting on the features with which I have been able to sample.

Thankfully, the collection of features available to trial version users is still extensive, so I have lots to cover, and perhaps I’ll spring for the full version when funds allow. The question is: does the trial impress enough to warrant the large expense? Let’s investigate further:

Almost as soon as you open Epicardio, the vibrant display hits you; a large, anatomically accurate heart fills most of the screen as colourful depolarisation waves travel across the atria, and down through the ventricles. The live single lead ECG tracks with concordance, and the right hand menu buttons are nicely presented and clearly display exactly what they do.

Depolarisation mechanics can be viewed through the heart as a whole, or each section on its own. Atria, ventricles, bundle branches and coronaries, can all be viewed independently whilst depolarisation occurs, so it’s possible to learn how the various components of the cardiac system operate during each cycle.

Further structural overlays can be added, in the form of the vena cava, thoracic cage and a translucent torso, further adding to the ability to understand the heart’s positioning in humans.

The electrical readout on the lower region of the screen comes with the option of cycling through all 12 leads on the standard ECG, individually, but as well the real time single lead ECG, users can also activate a live 12-lead, which again updates in real time with each cardiac cycle. This mode itself allows for different viewing styles, including the layout presented on most standard ECG printouts, which is perfect for students. It also features all the subtle morphology differences and minor, unavoidable muscle tremors that one would find on a real ECG recording. Calipers are a welcome feature, too, and they work well in Epicardio, allowing for measurements that students will definitely have to become proficient in throughout training.

Further customisation options are numerous; the colours of the depolarisation waves are changeable, as is the colour of the backdrop. Rather than simply offering pre-set rhythms, Epicardio allows you to manually alter heart rate, and, possibly more importantly, AV delay, so it’s possible to visibly alter the depolarisation wave on the beating heart in the centre of the screen, and see the live trace display a prolonged PR interval.

A most welcome feature is the electrode view option. A click on this button brings up a moving image of the heart within the thorax, and the standard precordial electrode sites. These electrodes can be moved anywhere and the real-time result displayed on the recorded trace, so it’s rather nice to be able to explore the difference in the voltage/time graph that occurs with electrode misplacement.

A defibrillator option allows you to shock the heart, although this was of limited use to me, as I did not have access to the fibrillatory rhythms that come with the paid version, but the artificial pacemaker below it allows the user to alter pacing pulses and observe the changes on the ECG.

My issues with Epicardio range from those that exist simply because the version I tried is restricted, to those that are nought but minor niggles, so I shall focus on those minor niggles, as oppose to content I simply have not paid to access.

The ECG trace, whilst being incredibly customisable, would feel much more authentic if it were set against a proportional image of standard ECG paper; being able to view the trace against the background most students will see throughout studies would be a great primer in the early days of study, and considering the trace speed is adjustable, I was disappointed it wasn’t a feature.

The option buttons look lovely, offer genuine function and, once you’ve been through the tutorial and played around with them, make perfect sense. It would perhaps be helpful if a brief explanation appeared when the mouse pointer was placed over each one, however, as it was a struggle remembering what the more vague options actually did, especially for the first few hours of using the program.

However, as I stated, these are only minor gripes. Epicardio is a wonderful and genuinely fun bit of software to use. I’ve got a feel for how beneficial having this in the beginning of my studies would have been. The layout, options, functionality and simplicity of using Epicardio are all near-perfect, so I can’t wait to get a hold of the full version, complete with pacemaker-specific options. If you have a spare weekend, then follow the link at the top of the page, and download the free trial. If you have a spare £149/£215, then follow the same link and download the full version, as if it’s provides even 50% more features than the demo, I can be certain it’s worth it.

I will review the full version as soon as I can.

Holiday-Only Arrhythmias

During the festive season, its easy to indulge in excess; too many sprouts, an increase in afternoon napping, festive drinks… You know the score. It isn’t all smiles and sunshine, though, as we shall see.

One particular result of all the festive excess relevant to cardiac professionals, has been reported across the globe, but particularly in Entirely Fictitious Primary Care Centres (EFPCCs); Bacardi Branch Blocks, or BacBBs

BacBBs are thought to affect the heart as a whole, but it can be seen that they have a particularly odd effect on the ventricles, and cause an odd, never-seen-in-real-life depolarisation wave on the ECG, that actually defies physics and medical science by going back in time!

Symptom sheets compared with the compiled ambulatory data have shown unanimously that BacBBs are present sporadically within sinus rhythms, but coincide with that one-drink-too-many during a family game of Monopoly (Mr Moneybags isn’t thought to be an underlying cause, so the activity isn’t seen as a risk factor).

Atrial activity stops altogether, presumably because the SA node just forgets what it’s doing, as it’s seen enough crepe paper hats and screwdriver sets fly from crackers to last it a lifetime.

After an episode of BacBB, sinus rhythm resumes, and the patient will return to whatever their festive-norm may be until the next instance.

This phenomenon seems to disappear entirely during the first couple of weeks of January, when normal working hours begin again, hence, I feel that it is triggered by the holidays themselves.

None of this is being researched, or is even disputed, because it is both totally false, and invented entirely by me.

Bacardi Branch Block

Common holiday rhythm abnormality only found during the festive season, and even then, only in fictitious settings
HR between 80-120bpm
- Depends entirely on board game leader-board position
No P waves
Abnormal ventricular action
- Resembles upturned cocktail glass
Is thought to only contribute to familial tolerance levels during prolonged exposure to each other

HAPPY HOLIDAYS FROM EVERYONE AT THE STUDENT PHYSIOLOGIST!!

The Art of Anatomy

Remember those anatomy and physiology lectures that tortured you? Remember all that terminology that was relentlessly thrown at you for hours every week? Remember the pop-quizzes? Remember wishing there was an easier way to store all the information you were given?

Of course you do.

A few institutions have employed a rather novel way of encouraging learning by doing, by combining art and anatomical learning. Cathal Breen of Analyse fame kindly sent me a copy of the University of Ulster’s journal outlining a study he was a part of, that brought the two disciplines together.

The study focuses on exactly what I outlined in the first paragraph: the difficulty in learning anatomical names and information via textbooks and lectures alone. Students from radiology and cardiac physiology formed groups and learned by painting anatomical structures on each other, using textbooks, presentations and spoken word.

By encouraging students and staff to engage in the teaching and learning process in this creative manner yielded incredibly positive results: student feedback referred to the sessions as “enjoyable”, “helpful” and “interesting”, citing the experience as one that makes things clearer, too. The study humorously points out that the first three statements are not things that have been used to describe A&P before (thanks to my own experience, I imagine this to be an indisputable fact).

Obviously, there may be issues with inhibition when it comes to each individual, so to get around this, painting onto clothing; t shirts, gloves etc, is an option. Lecturer participation is a must, so the whole thing seems to lend itself to full participation from everyone and bonding in a shared learning experience.

Students pointed out that this style of learning made them aware of discrepancies between actual anatomy and the pictures contained within the textbooks they used, and that gave them a better understanding of the internal geography present in the body. In recent years, the practice has been adopted by numerous institutions, and the twitter page @artandanatomy showcases some of the wonderful body-painted works of art that have cropped up across the globe.

So, what do you think? Would this be something you feel would make the learning process easier for you? Sound off in the comments below and let us know.

Ref:

Breen, C., Conway, S., Fleming, K.,. (2010) The Art of Teaching Anatomy – A Case Study. Perspectives on Pedagogy and Practice 1 (1), pp. 17-30.

Images courtesy of @artandanatomy