Sam Dogra's Blog, page 9

The Binding Giveaway! 10th September- 2nd October

Hey everyone, I've got good news. From today until 2nd October 2014, I'm going to be hosting another giveaway! This time I have five paperback copies of The Binding, and each comes with an exclusive signed print of Eliza and Ryan!




The giveaway is open to residents of the UK, USA and Canada.

So what are you waiting for? Enter now for a chance to win!

What do you do when you can't trust your heart?

All seventeen year-old Eliza Bryant wants is to avoid a Binding— the ancient spell that forces couples into a lifelong bond. It cursed her sister, and for the last two years it’s tried to claim her, too. Her monthly hiding ritual worked brilliantly, until the night she ran into Ryan, a mysterious bounty-hunter. Now Bound to him, Eliza must spend every moment at his side, else she’ll transform into an Unbound; a lifeless husk without mind or soul.

Unfortunately, Ryan’s not looking to settle, and Eliza is dragged into his crazy life on the run. Still, she’s not going to take this lying down. Between grappling with the false feelings conjured by the spell and fleeing an unseen enemy, she plans to find a way to break her Binding; a feat nobody’s achieved in two thousand years. The key to her freedom lies closer than she thinks, and it’s deeply connected to Ryan’s past.

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Goodreads Book Giveaway The Binding by Sam Dogra Giveaway ends October 02, 2014.
See the giveaway details at Goodreads. Enter to win

The Binding Giveaway! 10th September- 4th October

Hey everyone, I've got good news. From today until 4th October 2014, I'm going to be hosting another giveaway! This time I have five paperback copies of The Binding, and each comes with an exclusive signed print of Eliza and Ryan!




The giveaway is open to residents of the UK, USA and Canada.

So what are you waiting for? Enter now for a chance to win!

What do you do when you can't trust your heart?

All seventeen year-old Eliza Bryant wants is to avoid a Binding— the ancient spell that forces couples into a lifelong bond. It cursed her sister, and for the last two years it’s tried to claim her, too. Her monthly hiding ritual worked brilliantly, until the night she ran into Ryan, a mysterious bounty-hunter. Now Bound to him, Eliza must spend every moment at his side, else she’ll transform into an Unbound; a lifeless husk without mind or soul.

Unfortunately, Ryan’s not looking to settle, and Eliza is dragged into his crazy life on the run. Still, she’s not going to take this lying down. Between grappling with the false feelings conjured by the spell and fleeing an unseen enemy, she plans to find a way to break her Binding; a feat nobody’s achieved in two thousand years. The key to her freedom lies closer than she thinks, and it’s deeply connected to Ryan’s past.



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Goodreads Book Giveaway The Binding by Sam Dogra Giveaway ends October 04, 2014.
See the giveaway details at Goodreads. Enter to win

Investigations, Investigations, Investigations (Part 4)

Image courtesy of [anankkml] / FreeDigitalPhotos.net
The cornerstone of medicine remains the classic history and examination- let the patient tell their story, and the physician's hand of assessment can help pinpoint the diagnosis.

However, when diagnoses are unclear or can't be differentiated, that's where investigations come in. Sadly, today they're often over-used, but when used appropriately they offer a wealth of information that can help tailor all important management and get the patient on the path to recovery faster.

Following on from part one, where we looked at urine, part two which look at bloods, and part three which looked at imaging, this multi-part post will take a look at some of the common investigations performed, what they can tell us and the reasons why and when they should be used.

Our fourth and final part deals with some other tests that didn't fit into the above categories, but which are as important in assessing patients and helping to reach a diagnosis.

Part Four- Everything Else!

ECG/ 24hr tape/ exercise ECG


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An ECG (or EKG, electrocardiogram) looks at the electrical activity in the heart. While heart muscle beats on its own, it needs nerve activity to set things like rate (how fast it's beating) and contractility (how hard it beats). ECGs are actually extremely useful and can give a lot of information outside of just seeing the heart rhythm. We can do standard 12-lead ECGs, giving us an indication of what the heart is doing now, or 24hr tapes, where a holter is worn for 24hrs and the heart rate recorded continuously. This is often good to pick up abnormal heart rates associated with palpitations.

It's mostly used to detect arrhythmias (abnormal heart beats, such as atrial fibrillation (irregular pulse), supraventricular tachycardias (too fast), heart block and bradycardias (too slow), and 'missed' beats), but it can also look for cardiac disease (ischaemic heart disease or full blown myocardial infarction [heart attack], heart infections (pericarditis), heart enlargement, and in the case of heart failure it can even give us prognosis (how severe the heart failure is and the outcome of this). It can also pick up problems with the lungs, such as in pulmonary embolism, which can cause strain on the right chambers of the heart.

However, having a normal ECG doesn't rule out there's a problem with the heart, so it's not got a very good negative predictive value. Nevertheless it's an extremely useful tool in practice.

Further reading:

1. http://www.patient.co.uk/health/electrocardiogram-ecg

2. http://www.bhf.org.uk/heart-health/tests/ecg.aspx

24hr BP monitoring


Image courtesy of [photostock] / FreeDigitalPhotos.net
Whenever we visit the doctors for a blood pressure check, it's always high, right? But how can we tell it's because of 'whitecoat hypertension' (the BP goes up because you're stressed about seeing a doctor), or actual 'essential hypertension'? We measure BP over 24 hours, of course. This has become the standard for diagnosing true hypertension and helps to plan what treatments to start on.

The patient is given the machine to take home, and the monitor takes several readings through the day and night. If the overall average value and night values are above the limit, then we can start treatment. Not only is this test more accurate than measuring BP at single points on different days, it saves on the patient having to keep returning to have BP checks for diagnosis.

Some problems with this test though are that some patients can't tolerate it, and the fact that the machine needs to be loaned out. It also needs a patient to be aware of how to use it (so for example it could be difficult to perform in a frail elderly person requiring a lot of care).

1. http://www.bloodpressureuk.org/BloodPressureandyou/Medicaltests/24-hourtest

Pulse dopplers and ABPI


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A doppler machine works on a similar principle to ultrasound, except instead of projecting images, it projects sound. This can be very useful in looking at blood flow through arteries, as blood makes sound as it flows. We can measure this while changing blood flow as well via a blood pressure cuff, and hence we can give a ratio of how good the circulation is at the hands and feet. This is known as an 'ankle brachial pressure index', where we compare blood flow in the arm and leg at a given pressure. The lower this number is, the more likely it is you have severe circulation problems in the leg, which can lead to complications.

It's also used a lot in pregnancy, as we can detect the fetal heartbeat from around 14-16 weeks onwards, and is useful to check fetal wellbeing if the mother is experiencing problems.

However, the problem with this test are that it can give false readings (as patients with diabetes might have normal ABPIs but still have poor circulation), and it needs special training to be performed.

Further reading:

1. http://www.webmd.com/dvt/doppler-ultrasound

2. http://www.westcoastvascular.com.au/services/doppler-test/

Nerve conduction studies


Image courtesy of [renjith krishnan] / FreeDigitalPhotos.net
We also have the means to measure how well nerves transmit sensation and information! These are called nerve conduction studies and are very specialised. We measure the current running through a specific nerve (such as the median nerve in the wrist), and the speed and amplitude tells us whether there is any nerve damage. We can also do this following trauma or fracture and the patient still complains of nerve symptoms (tingling/ pins and needles/ numbness) following resolution of the original injury.

This test is necessary for a confirmation of a diagnosis of carpal tunnel syndrome before any surgery is planned. This is to also have documentation of nerve function pre-surgery, so that we know if the damage was there before anything was done.

The drawbacks are that it can be an unpleasant procedure (as needles are used to look at nerve function in specific muscles when testing for motor problems), it's very time consuming, and it needs specially trained neurophysiologists to perform.

Further reading:

1. http://www.patient.co.uk/health/nerve-conduction-studies

2. http://drprafullkdavemd.com/ncs.php

Electroenecephalogram (EEG)




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Electroencephalograms are similar in principle to the ECG/EKG, except these look at the electrial activity in the brain. This is often done to look for epilepsy. They can also be co-ordinated with video to look at what the EEG does if the patient has a seizure. However, they can be very difficult to interpret, and like with ECGs, having a normal EEG doesn't mean there's nothing wrong. Yet as with most tests, it needs to be interpretted in the clinical context to be of diagnostic value.

Further reading:

1. http://www.nhs.uk/Conditions/EEG/Pages/Introduction.aspx

Spirometry


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This is a breathing test that looks at the capacity and function of the lungs. It can be used to diagnose a variety of lung diseases such as asthma, COPD, and fibrotic lung disease. It's also good as a monitoring test to see if there is improvement/ worsening of lung function over time and before/ after a course of treatment. The patient is told to breath into a tube which measures air flow. By taking big breaths and breathing out quickly, we can then get measurements of lung capacity and volume, normal breathing volume, and how fast the patient can expel air from their lungs.

However it's a very time consuming test and does rely on accurate patient performance. It's also difficult to do in young children, as they might not understand instructions.

Further reading:

1. http://www.patient.co.uk/health/spirometry-leaflet

Angiography/ colonscopy/ arthroscopy

These can be both diagnostic and therapeutic tests, meaning that it can diagnose a problem and treat it at the same time. We'll take them individually.


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Angiography looks at the blood vessels, typically of the heart, but they can look at any artery (the picture above shows the arteries of the brain). For the former, a catheter  is placed in an artery at the wrist or groin, and dye injected. X-ray images are then taken at the same time, giving us a live 'snapshot' of blood flow through the coronary arteries. If there is any obstruction, from a plaque for example, then a stent can also be placed to remove the obstruction and improve cardiac blood flow, lessening symptoms of chest pain/ angina etc. The same principle is used for other vessels, such as looking in the limbs, again for obstruction or aneurysms.


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Colonscopy is using a fibre-optic camera to have a direct look at the bowel. This is the same for any 'scopy' test- so arthroscopy is putting a camera into a joint such as the knee, nasendoscopy gives a direct look at the nasal airways/ throat, endoscopy looks at the oesophagus (food pipe) and stomach. If any abnormalities are seen, instruments can be inserted in the fibre-optic tube and biopsies (tissue samples) can be taken. In some cases treatment can be done as well, such as removing small polyps from the bowel, injecting stomach ulcers, or washing out/ trimming cartilage in joints.

The major drawback in these tests are that they are very invasive, and have small but significant complications and risks. They also need to be performed by specialists in hospital, and this might require overnight hospital stays. Also, anything needing extensive treatment, like joint replacement/ multiple blocked arteries/ multiple polyps in the bowel can't be treated.

Further reading:

1. http://www.nhs.uk/conditions/angiography/Pages/Introduction.aspx

2. http://www.patient.co.uk/health/colonoscopy

3. http://www.nhs.uk/conditions/arthroscopy/pages/introduction.aspx

Sleep studies


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This is where patients are checked for problems with oxygen levels in the blood at night during sleep. The most common reason for this is obstructive sleep apnoea, where breathing can pause for a number of seconds during sleep, leading to a decline in blood oxygen levels. This leads to daytime sleepiness and poor concentration. In this test, the patient wears an oxygen monitor, and any 'dips' are recorded. Other parameters can be measured such as heart rate, blood pressure and body movement. If the pattern meets the diagnostic criteria, then a formal diagnosis can be made and suitable treatments tried, such as a positive air pressure machine.

Further reading:


1. http://www.nhs.uk/Conditions/Sleep-apnoea/Pages/diagnosis.aspx

2. http://www.ucmc150.uchicago.edu/sleep/studies.html

So that's my whistle stop tour of the major investigations available to use today! I hope you found it informative.

Investigations, Investigations, Investigations (Part 3)

Image courtesy of [anankkml] / FreeDigitalPhotos.net
The cornerstone of medicine remains the classic history and examination- let the patient tell their story, and the physician's hand of assessment can help pinpoint the diagnosis.

However, when diagnoses are unclear or can't be differentiated, that's where investigations come in. Sadly, today they're often over-used, but when used appropriately they offer a wealth of information that can help tailor all important management and get the patient on the path to recovery faster.

Following on from part one, where we looked at urine, and part two which look at bloods, this multi-part post will take a look at some of the common investigations performed, what they can tell us and the reasons why and when they should be used.

Part three deals with one of the more extravagant tests doctors can use- the various imaging that can visualise our internal anatomy.

Part Three- Imaging

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A picture paints a thousand words, yes? Or a scan can reveal things that other tests can't. Scans are a double-edged sword, however, in that they required skilled interpretation, and some things seen on a scan may have nothing to do with the symptoms the patient is experiencing. This is why scans are often rationed, and radiologists need a good clinical history to correlate what they see to what the patient feels.

It can be frustrating for patients who often feel the doctor they see should review their scans in front of them, but while we're competent to look at simple X-rays, we're only taught at a basic level to recognise barn-door obvious things in the more complex scans such as CT/ CAT, MRI and ultrasound. This is why the specialty of radiology exists, as they see hundreds of thousands of these scans and thus are much better to analyse more subtle changes.

So let's delve into the types of imaging available to us today:

-X rays


The humble X-ray still has plenty of uses today, from finding bone fractures to looking for chest infections or heart failure. Every doctor, radiologist or not, usually knows how to interpret an X-ray. Of course, the drawback is the radiation risk, which while it's extremely low and is generally very very safe, it can't be used in some situations like pregnancy. Still, it remains a very useful test.

The other drawback to X-rays is that they are a 2D image of a 3D structure, so you can miss things (like lung cancers that are behind the heart shadow), and it can be difficult to visualise structures. This is where CT comes in...

-CT scan

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Computed tomography, or computed axial tomography (CAT), is a step up from X-rays in that we can use it to picture the body in three dimensions and not two. The radiation dose is quite a step up, too, so again this imaging can't be used for everything, and certainly not in certain situations. It is excellent at assessing fractures, head injuries or brain pathology like stroke, looking at intra-abdominal organs (like liver, bowel, spleen, kidneys etc) and assessing spread of cancers. When used with contrast, it can also pick up blood clots in the lung or arterial dissections.

CT scans have become much more widely used, particularly by surgeons, as it allows them to visualise the organs in the abdomen without having to lay a scalpel on the patient and all the risks of laparotomy (open abdominal surgery), and hence they can plan surgery and hopefully account for otherwise unseen risks.

However, as it's based on X-rays, CTs are not so good for looking at soft tissues and can't see subtle changes. This is where the next imagine modality steps in...

-Magnetic Resonance Imaging (MRI)

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This, as the name suggests, is based on magnets, and the alignment of water molecules. This allows for very detailed imaging of soft tissues, and hence MRI is the best for brain scans (showing subtle changes, such as old strokes or demyelination, which can be a sign of multiple sclerosis), scans to look at spread of tumours in the pelvis/ neck, and spinal scans to look for spinal cord compression. There's also no radiation risk, either.

However, MRIs are complex, and not a pleasant experience. Patients need to be still for a long period of time (making it harder to scan children without sedating them), MRIs are slow, and also they can pick up totally insignificant things that may not correlate to symptoms, but we can't tell that.

Spin-offs of MRI include MRAs (magnetic resonance arteriograms, which look at the arteries specifically).

-Ultrasound

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Perhaps one of the safest imaging modalities, ultrasound has many uses, not just in pregnancy (as pictured above). It can assess abdominal and pelvic organs, look at complex joints such as the shoulder, help guide doctors to insert drains or central lines, it can assess lumps and bumps, and can help guide radiologist to take samples of said lumps (ultrasound guided biopsies or fine needle aspirations). It can even assess the heart, including the valves, the muscle wall, and how effective it's pumping blood. Best of all, there is no radiation risk. Sounds like the best of the lot, right?

However, as with all these imaging modalities, it does have its limits. The major one is that it can be very operator specific- that is, different ultrasonographers can interpret their findings differently. Also, things can get in the way, such as bowel gas, which can obscure the image, and with patients with a high BMI, it can be difficult to see, too.

Whew, so that's imaging! Oddly enough, there hasn't really been much change in the last few years, but who knows what the future will bring us...

The next and final part of this series will look at the leftovers, such as ECGs, 24hr tapes and the like.

Part 1- Urine

Part 2- Bloods

Lisa's Summer Reads Blog Tour 2014- A.F.E. Smith

Summer Reads Blog Tour - Week Ten A.F.E. SmithReblogged from lisawiedmeier.com. This summer she's hosting a fantastic summer reads blog tour, where authors get to share their favourite reads! So you might just find your next favourite book. She's also hosting a fab giveaway with some awesome prizes, so enter to win (link at the bottom of the post).

Drum roll please as we're already into week ten of our Summer Reads Blog Tour, and welcome A.F.E. Smith!

My name is A.F.E. Smith and I can usually be found online in the form of a robin. But I've been categorically told that I have to include a picture of my real face for this blog tour, so here it is ...

In human form, I work as an editor and also as a parent, and squeeze writing in around the edges. (My son is two and I have a daughter on the way, so the edges are pretty squeezed.) Things I like include snacks, books, complex maths problems, snacks, animated films and snacks. My debut novel, DARKHAVEN, is coming soon as an ebook from Harper Voyager.

It's a fast-paced fantasy whodunnit featuring love, murder and obsession, carriage chases, duels to the death and a very angry Wyvern, set in a unique city in the throes of industrial revolution. Here's a little bit more about it: Myrren Nightshade has been overlord of Darkhaven for less than a day, and already he has a brutal murder to deal with. Not just any murder, either. His father is the victim – and his sister Ayla is the only suspect. Born without the shapeshifting abilities specific to his bloodline, Myrren has always considered himself inadequate. But now it's up to him to prove his sister innocent before the law finds her guilty. Aided by a reluctant priestess, and hampered by a Captain of the Helm determined to block him at every turn, Myrren must navigate his way through a maze of secrets and lies to the truth at the centre – even if it could destroy him. Meanwhile, Ayla Nightshade has problems of her own. Fleeing from the threat of incarceration for a crime she didn't commit, unable to take refuge in her other form, she is alone and friendless. The only person willing to offer her aid is the man she despises above all others: the man she holds responsible for her mother's death.

If you'd like to know more about me or my work, here are a few links:
WebsiteFacebookTwitterGoodreads
And now for the most important part – my book recommendations! As a fantasy reader/writer, I've gone for books that have at least an element of fantasy to them. You may not have come across these books before, but they all deserve more readers. I keep my five-star ratings for books I've loved enough to read more than once, but I'm pretty sure all five of the following books will join that number someday ... .gr_custom_container_1406759184 { /* customize your Goodreads widget container here*/ border: 1px solid gray; border-radius:10px; padding: 10px 5px 10px 5px; background-color: #FFFFFF; color: #000000; } .gr_custom_header_1406759184 { /* customize your Goodreads header here*/ border-bottom: 1px solid gray; width: 100%; margin-bottom: 5px; text-align: center; font-size: 120% } .gr_custom_each_container_1406759184 { /* customize each individual book container here */ width: 100%; clear: both; margin-bottom: 10px; overflow: auto; padding-bottom: 4px; border-bottom: 1px solid #aaa; } .gr_custom_book_container_1406759184 { /* customize your book covers here */ overflow: hidden; height: 160px; float: left; margin-right: 4px; width: 98px; } .gr_custom_author_1406759184 { /* customize your author names here */ font-size: 10px; } .gr_custom_tags_1406759184 { /* customize your tags here */ font-size: 10px; color: gray; } .gr_custom_rating_1406759184 { /* customize your rating stars here */ float: right; }
A.F.E.'s bookshelf: summer-reads-blog-2014 The Traitor Gameby B.R. CollinsThis is a super-intense YA novel that explores a serious theme (bullying) in the real world as well as creating a fascinating parallel fantasy world. The two strands are well constructed and cleverly interwoven. Recommended for teens and... Zero Sum Gameby SL HuangI kind of wish I had written this book myself, given that it features a female protagonist whose superpower is being really good at maths. It's also full of action, well written and just plain awesome. Looking forward to the next in the ... Few Are Chosenby M.T. McGuireThis is comic fantasy, but like all the best comedy, it has a heart. By the end of the book, I defy you not to want to read the other three books in the trilogy (yes, in true Douglas Adams style this is a trilogy of four) to find out wha... The City's Sonby Tom PollockUrban fantasy in the truest sense of the phrase. The author's alternate London is consistently imaginative and inventive. Aimed at a YA audience but great for adults too, this book is for anyone who likes to be immersed in the familiar-y... The Golem and the Jinniby Helene WeckerA wonderful and atmospheric book, drawing on the mythology of two different cultures to create something new. It's a romance and a fantasy and a fairytale, yet at the same time it vividly brings to life the experiences of immigrants in t...
Share book reviews and ratings with A.F.E., and even join a book club on Goodreads. a Rafflecopter giveaway

Investigations, Investigations, Investigations (Part 2)

Image courtesy of [anankkml] / FreeDigitalPhotos.net
The cornerstone of medicine remains the classic history and examination- let the patient tell their story, and the physician's hand of assessment can help pinpoint the diagnosis.

However, when diagnoses are unclear or can't be differentiated, that's where investigations come in. Sadly, today they're often over-used, but when used appropriately they offer a wealth of information that can help tailor all important management and get the patient on the path to recovery faster.

Following on from part 1, where we looked at urine, this multi-part post will take a look at some of the common investigations performed, what they can tell us and the reasons why and when they should be used. Part two deals with perhaps one of the most important investigations available to modern medicine- blood!

Perhaps one of the most loathed tests for patients, as it involves needles, blood is an amazingly versatile substance, and it can tell us a lot about a patient.

PART 2- blood


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Today we have thousands of blood tests that can check for almost anything in terms of pathology, from inflammatory markers to vitamin and drug levels, to autoimmune conditions, kidney and liver function, and even whether you've had a heart attack or not.

It would be impossible for me to go through every single one, so I'm going to stick to the routine tests performed.

Note that I've not included reference ranges here, as many hospital use different machines which have different units, and it can be confusing.

Depending on what it's used for, blood needs to be taken in various different coloured bottles, as different reagents are needed to identify the compounds.

Full Blood Count (Complete Blood Count)


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This test assesses various blood components that come from the bone marrow. This includes haemoglobin (Hb), the molecule that carries oxygen in the blood; white cells (WCC, white cell count), the fighting force that give immunity to infection; platelets, the tiny fragments that stop bleeding, and lots of other smaller parameters that can all be useful.

Hb checks for anaemia (too little) or polycythaemia (too much), and in conjunction with other parameters (like red cell volume, mean cell volume) can also point to the cause (e.g. microcytic anaemia could be due to iron deficiency).

The WCC, if low, can indicate immunosuppression or bone marrow failure, or if high, acute infection or inflammation, or if very very high, leukaemia.

Finally, the platelets can give an indication of clotting ability and bleeding or thrombotic risk (e.g. low platelets, thrombocytopenia, can increase risk of bleeding, but too high platelets, thrombocythaemia, increase risk of clots in the body, including the coronary vessels of the heart, leading to a heart attck)

All in all, the FBC/CBC an extremely useful test for many different pathologies, and hence why it's included in the routine blood tests.

Biochemistry


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This is a broad term that includes:

- Urea and Electrolytes, looking at how the kidneys function, the concentration of important blood salts such as sodium and potassium, and how much kidney reserve you have.

- Liver function, looking at various liver enzymes, and how the liver functions. Specific liver enzyme increases can even tell us what's causing the problem, such as gallstones, alcoholic liver disease, or hepatitis. And even if the diagnosis is unclear, we can then use other tests like ultrasound to guide us.

- CRP (C-reactive protein). This is a non-specific marker of infection or inflammation. As such, when it's raised, it's not that helpful at all as any number of things can cause this, but when it's normal, it can help rule out serious infections, and if you repeat the test, we can also see if treatment is working (it should decrease). Some hospitals don't bother with it though, as it's so unspecific.

-Albumin and protein. Again these also act as markers of liver and renal function (if low, it means the liver's manufacturing capability is poor due to damage, or it could mean the kidneys have lost their filtering ability and all the protein is being excreted into the urine). We can also identify if there are any nutrition or absorption problems from the gut. If abnormally high, this can also be a sign of multiple myeloma. However, like with CRP, it's not a very specific test and so it needs to be read in the context of other results and the patient's symptoms.

- Lactate. This is a marker of anaerobic respiration in the body. Why is this important? Well, our cells need oxygen to survive, and normally use oxygen in aerobic respiration to create energy. But in oxygen starved states (such as running a marathon, or if you've got a severe chest infection), the body is so low in oxygen it needs to convert to a non-oxygen means of making energy. It's not good to have lactate in high concentrations for a prolonged period, and it's a good marker to look at the severity of an acute illness where the body is severely starved of oxygen (such as chest infections, sepsis, major heart attack etc).

- Hormone profiles include the thyroid hormones (thyroid stimulating hormone, TSH, T4 and T3), the female and male sex hormones such as oestrogen, progesterone, testosterone, FSH [follicle stimulating hormone] and LH (luteinising horming], prolactin [important in breast feeding and benign tumours of the pituitary], cortisol [natural steroid]). These are important for endocrine problems.

-Glucose and HbA1c are useful for diagnosing and monitoring diabetes. HbA1c is 'glycosylated haemoglobin'. The premise of this test is to look at long term diabetic control. It works because it's measuring the amount of glucose that has stuck to part of the haemaglobin we talked about earlier. As the life span of a red cell (where the haemaglobin is) is about 90 days, we can therefore see that the higher the amount of glucose stuck to the cell, the higher the blood sugar has been over those 90 days. Targeting the HbA1c can be useful to prevent or reduce the risk of diabetic complications.

-Drug levels. Digoxin, lithium, sodium valproate, pheyntoin, aspirin, paracetamol (acitomenophen) and many other drugs can also be measured, either in terms of acute poisoning or overdose, or to monitor safe dosing and compliance to treatment.

- Cardiac Troponins. These tiny protein molecules are release when the heart muscle (myocardium) is damaged, and can be a great indicator if there has been heart muscle damage, either from a heart attack, atrial fibrillation or infection. While they are pretty specific for this, note that some conditions like chronic renal failure, pulmonary embolism and others can cause a 'false' high level, so interpret with caution.

Clotting


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This looks at the clotting factors produced by the liver (which work in conjunction with platelets to stop bleeding). If these are abnormal, it can be an indicator of liver disease or severe infection.

The INR (international normalised ratio) is also used as a standardized marker for warfarin therapy, which is used in the treatment of blood clots (thromboembolism) and in prevention of formation of clots.

The APTT (activated partial thromboplastin time) is used to monitor heparin therapy.

Like with liver function, patterns of clotting abnormality can pinpoint the diagnosis. We can also test for some specific clotting factors (like factor 8, which is affected in haemophilia), which can help exclude or confirm diagnosis.

Group and Save/ Cross Match


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This is used for patients requiring or who may require a blood transfusion, either as an emergency (cross match, the sample is processed very quickly but it's only basic type specific blood) or after an elective operation (group and save, processed more slowly but more type specific blood is issued). This test must be repeated after a transfusion is given, as a patient may develop antibodies and so different blood needs to be matched to prevent an immune reaction.

Immunology Testing


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These highly expensive and non-routine tests look for antibodies, typically those causing autoimmune conditions like rhematoid arthritis These tend to be quite specialised and need to be interpreted in a clinical context. Alone they are quite useless, as the results are given in titres, not absolutes, and have a wide interpretation.

Examples include rheumatoid factor (RF), although you CAN have RA with a negative RF), anti-neutrophil antibody (ANA), anti-double strand DNA (specific for systemic lupus erythematosis, SLE) anti-Ro, anti-La (it's like a piano song isn't it?), and many more.

- Serology. This looks at antibodies against infection, such as rubella, chicken pox, and others. More complex testing is done for things like HIV and Hepatitis B. This helps us to see if a patient has had a previous infection to this disease, is having a current infection, and if they have immunity. This is also used for to check that a vaccine (typically Hepatitis B) has worked.

Whew, that was a lot of blood tests, and there's still so many more I haven't covered!

Part 3 will move onto another very common set of testing- images.


Further reading:

1. http://www.nhs.uk/conditions/blood-te...

Lisa's Summer Reads Blog Tour 2014- Michel Prince

Summer Reads Blog Tour - Week NineMichel Prince

Reblogged from lisawiedmeier.com. This summer she's hosting a fantastic summer reads blog tour, where authors get to share their favourite reads! So you might just find your next favourite book. She's also hosting a fab giveaway with some awesome prizes, so enter to win (link at the bottom of the post). Week nine in the Summer Blogs Tour is here and I'm hoping you've been enjoying meeting new faces and trying new reads. It's time to welcome Michel to my blog tour, another friend I met through Authonomy when we were all just newbies starting out. You won't want to miss out on her reads list and her own books. Check them out if you're a romance junkie like me, you won't be disappointed!

Michel Prince is an author who graduated with a bachelor degree in History and Political Science. Michel writes new adult and adult paranormal romance as well as contemporary romance.With characters yelling "It's my turn damn it!!!" She tries to explain to them that alas, she can only type a hundred and twenty words a minute and they will have wait their turn.  She knows eventually they find their way out of her head and to her fingertips and she looks forward to sharing them with you.  

When Michel can suppress the voices in her head she can be found at a scouting event or cheering for her son in a variety of sports. She would like to thank her family for always being in her corner and especially her husband for supporting her every dream and never letting her give up.


Michel has been awarded Elite Status with Rebel Ink Press in 2013, the service award for her local RWA chapter Midwest Fiction Writers and is a Pro member of RWA.  She lives in the Twin Cities with her husband, son, cat and new puppy. 

Find me on Facebook, Twitter, MichelPrinceBooks
One Last Rodeo Betsy Flynn's star is rising as she serves as the color sports reporter for the local CBS affiliate. Her focus, knowledge and high heels have become a staple along every sideline in Minneapolis, but a rodeo has come to Minnesota and this Texas transplant will have to go back to her roots.

Five years ago pick-up man JT Long chose his best friend’s rodeo career over the love of his life, Betsy.J As JT’s rodeo shows up in Northern Minnesota he quickly realizes his chances of winning Betsy back are getting slim as he learns he only has one last rodeo to win her heart.

*Break out the fireworks and get ready to kick off your summer with this HOT new collection of stories. One Last Rodeo is part of the Red Hot and BOOM multi-author series (stands alone for reading enjoyment).Buy Links:AmazonBarnes and NobleAllRomanceebooksKobo SmashwordsShared Redemption Former slave Nye ended his life in 1859 after losing his love.  The angel Gabriel has offered Nye a chance at redemption by hunting demons as a member of the Frozen. With less than seven years left until his salvation, Nye is staying on the straight and narrow – until a woman gets caught in the crossfire during a demon hunt.

After receiving devastating news, Kiriana Kladshon moves across the country, only to get caught up in the world of The Frozen.  Nye and Kiriana are pulled into an attraction neither can control. Will it be their ultimate demise or their greatest salvation?Damarion, is leading a group of female demons on a mission. During his punishment on Earth, Damarion learns of dangers within his coven trying to stop him from returning to his love, still trapped in Hell and A love he was so sure was true...Buy LinksSecret Cravings PublishingAmazon Barnes and NobleAre BookstrandChrysalis In the annals of dysfunctional families, the Chisholm’s are working their way to the top. Drug abuse, an unwed mother with multiple fathers, and the questionable cash flow for the 'pretty one'. All this from a seemingly normal, two parent middle class family. But were the choices truly made of their free will?

Bad choices are a Chisholm family trait, one that confounds the youngest child, Ellie, who's trying to separate herself by making smart decisions. And falling for Oscar Jeffreys, the hottest guy at school, would be number one on the list of Chisholm family disasters. Yet the crazy part is it’s not a one sided attraction. Somehow Ellie has caught Oscar Jeffreys’ eye. Sure she could see the barriers between them. Race, age, popularity. They were at opposite ends of the spectrum. But a demon set to destroy her family? She can't see that.

Oscar provides security and acceptance Ellie never imagined she deserved. As the passion of first love grows, Ellie honestly believes she has a chance to beat the odds and live a happy, normal life. Then her world collapses around her. With the help of a guardian angel, Ellie learns of a world that has unknowingly surrounded her for years. And she'll have to find strength buried deep inside to save not only her future, but flush out and stop the demon in her midst.Ellie will have to learn that sometimes the hardest lesson about growing up is accepting that you're worth more.

Buy LinksAmazonBarnes and NobleARe Kobo Smashwords#gr_updates_widget{ border-radius: 5px; background-color:#fff; border:solid #683205 10px; -webkit-box-shadow: 0px 0px 4px 1px #595959, inset 0px 0px 0px 1px #7D730B; -moz-box-shadow: 0px 0px 4px 1px #595959, inset 0px 0px 0px 1px #7D730B; box-shadow: 0px 0px 4px 1px #595959, inset 0px 0px 0px 1px #7D730B; padding:15px 0 35px 15px; width:250px; height:330px; } #gr_footer{ margin-bottom:10px; } #gr_updates_widget p{ padding:0px; margin:0; font-size:14px; } #gr_footer img{ width:100px; float:left; } #gr_updates_widget img{ border-style:none; } a Rafflecopter giveaway

Investigations, Investigations, Investigations (Part 1)

Image courtesy of [anankkml] / FreeDigitalPhotos.net
The cornerstone of medicine remains the classic history and examination- let the patient tell their story, and the physician's hand of assessment can help pinpoint the diagnosis.

However, when diagnoses are unclear or can't be differentiated, that's where investigations come in. Sadly, today they're often over-used, but when used appropriately they offer a wealth of information that can help tailor all important management and get the patient on the path to recovery faster.

This multi-part post will take a look at some of the common investigations performed, what they can tell us and the reasons why and when they should be used.

PART 1- urine

(image source)
It's amazing how much information we can obtain from the humble urine sample. Even before we had all the fancy urinanalysis testing we have today, we could diagnose diabetes (though I am not an advocate of returning to the days when doctors had to taste urine for sweetness in order to do this!)

Some of the commoner tests we can do include:

Pregnancy test

Image courtesy of [sattva] / FreeDigitalPhotos.net
This is possible thanks to a substance known as beta human chorionic gonadoptrophin, which is secreted from the early placenta after implantation of a fertilized egg. It's also very specific (as it's extremely rare for this substance to be found outside of pregnancy, although other causes exist, such as certain testicular tumors). Now widely available in various guises over the counter, it's a great quick and accurate test.

This chemical can also be measured in blood, and comparing numbers can help in the management of miscarriage and ectopic pregnancy (more on this in the next part)

In a medical context it's extremely useful, as if a woman of reproductive age presents with abdominal pain we can use it to exclude an ectopic pregnancy, which can have life-threatening consequences if not picked up early.

Urine dip

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From a tiny stick coated with various reactants, we can diagnose if particular substances are in the urine, such as protein, glucose, blood, leucocytes (white cells, the cells that fight infection) and nitrites (an indicator for infection in the urinary tract by some bugs).

Of course, as stated above, the reason for doing the dipstix will govern how to interpret the results (e.g. a lady presenting with burning pain on passing urine, or a man complaining of blood in the urine, or a boy with kidney problems that means protein is leaking out when it shouldn't). It can also be the earliest sign of kidney disease and other systemic diseases. Quick and easy to perform, it's perhaps one of the most useful bedside tests we have.

Further reading:

1. http://imc02.hccs.edu/BiologyLabs/AP2...

MSU (mid stream urine)/ urinanalysis

If the dipstix shows something in the urine, it's usually sent on for this test. This is where the sample is sent to the lab and they look under the microscope for signs of infection, signs of inflammatory changes or 'casts', and if they can grow any bugs. If bugs are grown, they can then test which antibiotics work against it, which is extremely useful as it means we can make sure the patient is on the right antibiotic to clear the infection.

24 hour collection tests

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These are more specialised tests, often done in a hospital setting. The common ones are protein excretion, VMA (a chemical secreted by a type of adrenal tumour), and cortisol (the natural 'steroid' hormone). These can be quite difficult to perform, though, as they require accurate collecting of urine, avoidance of temperature distortion, and it takes time to process results.

Further reading:

1. http://www.urmc.rochester.edu/encyclo...

2. http://www.healthline.com/health/24-h... 1

So, as we can see, urine is a very useful bodily sample that can diagnose a range of conditions!

Next time, part 2 will look at the next most tested body fluid, blood.

Lisa's Summer Reads Blog Tour 2014- Kay Kauffman

Summer Reads Blog Tour - Week EightKay KauffmanReblogged from lisawiedmeier.com. This summer she's hosting a fantastic summer reads blog tour, where authors get to share their favourite reads! So you might just find your next favourite book. She's also hosting a fab giveaway with some awesome prizes, so enter to win (link at the bottom of the post).

Tick tock, tick tock, it's week eight in our Summer Reads Blog Tour and I've come to welcome Kay Kauffman to our madness! Kay is another lovely online friend from Authonomy who I've been chatting with now for a number of years. She's fun, has a gentle spirit that I simply adore, and will be the first to gather her popcorn bucket when Sam and I start our online battles!  Let's hear it up for Kay!

As a girl, I dreamed of being swept off my feet by my one true love. At the age of 24, it finally happened…and he’s never let me forget it.  A mild-mannered secretary by day and a determined word-wrangler by night, I battle the twin evils of distraction and procrastination in order to write fantastical tales of wuv…twue wuv…with a few bad haiku thrown in for good measure.

I reside in the midst of an Iowa corn field with my hopelessly devoted husband and his mighty red pen; four crazy, cute kids; and an assortment of adorable kitties, chicks, and bunnies. My first novel, The Price of Mercy: Book One of the Lokana Chronicles, is currently undergoing a major rewrite in advance of another round of queries.  My poetry collection, Tuesday Daydreams: A Journal in Verse, is available on Amazon. Capturing the life and imagination of the author in vivid detail, these poems touch on joy and loss, life’s everyday hassles, and the many faces of Mother Nature. AmazonAmazon UKAuthor Links:BlogFacebookTwitterPinterestTumblrGoogle + Goodreads .gr_custom_container_1401931422 { /* customize your Goodreads widget container here*/ border: 1px solid gray; border-radius:10px; padding: 10px 5px 10px 5px; background-color: #FFFFFF; color: #000000; } .gr_custom_header_1401931422 { /* customize your Goodreads header here*/ border-bottom: 1px solid gray; width: 100%; margin-bottom: 5px; text-align: center; font-size: 120% } .gr_custom_each_container_1401931422 { /* customize each individual book container here */ width: 100%; clear: both; margin-bottom: 10px; overflow: auto; padding-bottom: 4px; border-bottom: 1px solid #aaa; } .gr_custom_book_container_1401931422 { /* customize your book covers here */ overflow: hidden; height: 160px; float: left; margin-right: 4px; width: 98px; } .gr_custom_author_1401931422 { /* customize your author names here */ font-size: 10px; } .gr_custom_tags_1401931422 { /* customize your tags here */ font-size: 10px; color: gray; } .gr_custom_rating_1401931422 { /* customize your rating stars here */ float: right; }
Kay's bookshelf: summer-reads-blog-2014 The Amulet of Kingsby Will Macmillan JonesIn the first book of the series, we meet the goodies (Chris and Linda, Ben and Grizelda, Fungus and the Banned), the baddies (Ned and the Watches, the Grey Mage, Caer Surdin), and an assortment of other characters (the Edern, the Tuatha,... Kindar's Cureby Michelle HauckThis was a fantastic story. Mal was, for me, a bit hard to read, and I felt at the end that…well, not to give anything away, but I felt he must have been a wonderful actor. I loved Sir Henry – he reminded me strongly of Seymour. And... Bad Bishopby Irene SoldatosSo, what did I think? I thought it was great. It reminded me very strongly of the classic literature that I love so much. I didn’t put everything together until the very end, which I always enjoy. It’s nice to be kept guessing. And ... City of the Sunby Juliana MaioOnce I started this story, I couldn’t put it down. Well, okay, I could, obviously, or it wouldn’t have taken me so long to finish it, but when I wasn’t reading, I was thinking about it. Mickey and Maya wouldn’t leave me alone; they dem... Chasing Azraelby Hazel ButlerI could not put this book down. I stayed up past the witching hour reading this book on more than one occasion and was sorely tempted to just read the whole thing in one sitting, but my day job had other ideas (apparently they like thei...
Share book reviews and ratings with Kay, and even join a book club on Goodreads. a Rafflecopter giveaway

Top 10 Pet Peeves of Epic Fantasy

I've always been a fan of fantasy, but I've also always been very particular about certain aspects of the genre, especially the great sweeping epics. I've read many enjoyable books set in amazing worlds that have made me feel like I'm really there, but having said that, there are other books that I've not touched or left unfinished because of their cliched staleness.

So here's a list of my Top 10 Pet Peeves in Epic Fantasy! Remember, this is entirely subjective, so feel free to disagree.

10.  Resetting Time


This is when seasons, days, calendars and how time passes in these fantasy world are totally re-written. I'm not naive enough to think that all fantasy worlds are calibrated to Earth's setting of a 24hr day and 365 days per year, but there are ways to write about this without going over the top by having someone (or worse, write in an appendix) explain how time is measured. There's already so much we have to suspend our disbelief for- don't make my brain overload by having to calculate how many 'tides' have passed. And don't be even lazier and tell me that the protagonist is 'twelve summers old'.

9. Prophecies


I dislike these not only because they're so overused, but also because they usually tend to cause a hundred plot holes to open at once. Suddenly the easiest way of resolving the plot isn't possible anymore, and the Dark Lord is untouchable save for the hero, blah blah...

Not to mention they're just so uninteresting. Even when you can play loosely with the exact wording, they add nothing to the story, other than for some old crone to go 'I told you so' at the end.

8. Fantasy racism


One thing I really can't stand is the hierarchy of the races in epic fantasy. Aloof elves who know everything and think themselves above it all, the comic relief/ extremely loyal and hard workers the dwarves, the scheming goblins, and poor, pathetic, WEAK mankind at the bottom. Much of this comes from Tolkein, but it's not entirely his fault. He'd lived through two World Wars and had seen the horrible cruelty humans are capable of, and that got reflected in his books (much as his critics love to argue over this). But as Tolkein laid the new blueprint for epic fantasy, his imitators haven't strayed from this, and it's getting old.

At the same time, you hardly ever seen any ethnic characters, either. They're all Caucasian, perhaps with an odd accent here and there, and anything darker skinned tends to be on the side of evil. Make things interesting, add some variety within the races!

7. Fetch quests


I know, I've put this here when I am totally guilty of committing the same sin, but don't worry, I hate myself for it just as much! I am trying desperately to get out of this habit, but it's really hard because fetch quests do make writing so much easier. I mean, you get to mention all those places on that map you spent ages designing, you get to explore new environments and recruit all the valued team members, and it lets you drag the story out, too.

But it's very, very old, and very, very predictable. We need to move on (myself very heavily included) and try newer narrative styles.

6. Calling a horse a flight-foot (and other esoteric nonsense)

(image copyright Sam Dogra)
I hate pretentious naming in fantasy, particularly for animals. By all means have unique and interesting creatures, but don't try and get all fancy by giving them unpronounceable names. If it has four legs and is a domesticated mode of transport, it's a horse, not a 'darkling trotter' or whatever you want me to call it. And if it thrives in the night and drinks blood, it's a vampire, not a 'shadow stealer'. Similarly for names of mountain ranges, forests etc- don't start shoving unnecessary apostrophes in there!

5. Black and white morality


A lot of epic fantasy falls into this trap. I mean, there's always a DARK Lord, right? And his army of minions (all horrible abominations) etc. And while some stories will play with side characters, the true heart of the story remains a good vs. evil conflict. A very unbalanced one, too, as often the bad guy is evil just because he's evil, and the one with the tragic backstory is the anti-hero.

Booooring! Blur the lines a little, please. Maybe even play with our expectations and let us find out the 'good' side isn't good after all...

4. No technological progression/ stale settings


Medieval is the popular age in which most epic fantasies are set...and that's where they stay! We never see any hint of progression in any field, never mind if there's advanced magic. You'll have soldiers who can wield fire with their hands, but nobody will have thought about basic sewage planning or explore the potential of a flushing toilet.

Even if you look at our own history, technology progression has been extremely speedy, with more advances taking place in the last 100 years than the last 1000, so you can't even say it's not realistic to show progress! At least give me hints of what people are trying to do; humans are creative and innovative, don't shut them down because 'magic' is already there.

3. WAAARR! And Politics.


This is probably one of the most subjective items on this list (I mean they all are, but this even more so). I'm really NOT a big fan of the whole story getting geared towards, and climaxing in, a huge battle of two enormous armies. Going back to the good vs. evil thing, I just find this incredibly dull. Most of the time we know the good will win, and I don't really care which of your favourite characters dies for the cause, because the outcome is the same.

Even worse than this is when there are chapters and chapters of boring political discussion leading up to it as well, where the voice of reason is drowned for sake of glory and conquest. I don't mind a little of it- it's important, of course, and adds tension- but when it becomes a main focus I lose interest fast. I don't care about how intricate the back-stabbing system of your court is; just make the point you need to and move on!

2. Gender Stereotypes


Epic fantasy is really bad at this. Always a male hero and love interest who isn't a character in their own right but is just there so we know the hero HAS a love interest, or, if she's a 'strong female', her only reason to exist is to fail miserably so the hero can look good saving her. Ladies tend to be sparse in number, and if there is more than one lady it's usually to fuel a pointless love triangle, and they're not going to do anything except talk about said potential love interests.

Even the political savvy ladies are evil queens, everything is over-sexualized (even the 'virgin' character who needs to remain pure for her powers to work- where's the male mage where this rule applies?), every woman who's not the princess/ talented magician is a wench or old crone...yawn, yawn, yawn!

Write me a character first who happens to be a woman, not the other way around. Don't make her play second fiddle to the hero, either; make her stand on her own and support him/ her. There will be gender expectations in fantasy society, of course, but don't let that stop the women being people first.

1. Orphaned protagonist/ Chosen Ones


This one HAD to top the list! I am so sick of Chosen Ones! Always orphaned, always stumbling into their heritage from humble origins, always following the same stale single path of destiny...eugh, it drives me insane! They're always so average, they have no personality or qualities that let them stand on their own outside the Chosen One role, and they hold story immunity until the end.

By all means, Chosen One arcs can work, but can we please stop repeating the same tropes everyone's been using for like the last 2000 years? Can they have parents for once? Can they be aware that they still posses free will? Pretty please? Tales of Symphonia did it right, you can to!


So, that's my list. What are you major pains in epic fantasy? Let me know!