THE FOOTT MEMORIAL LECTURE PROFESSOR COLIN JOHNSON

The Foott Memorial Lecture meeting of the Society took place at the Ampfield Golf Club on 13th February 2019. The President, Dr Terry Wood, was in the chair. The minutes of the previous meeting were read and approved. A period of silence was held in memory of Dr G H Foott. The President invited Professor Colin Johnson to deliver the lecture which was entitled “Quantity and Quality: Life in a Cancer Centre”.  Professor Johnson started by making some observations on some similarities between himself and Dr Foott. He said that this lecture was partly about quantity of treatment for pancreatic cancer at Southampton’s Regional Cancer Centre but very much about researching quality of life for patients with it. When he started to research the quality of life of pancreatic cancer sufferers some years ago there was nothing written about it and, he added, he was thought to be a bit cookie to be doing it. Now everyone is researching this aspect. The quality of life assessment is how the disease affects patient’s physical, emotional and cognitive functions; and how the effects of pain, gastro-intestinal symptoms, cachexia and malaise and the consequences of learning about a poor prognosis affect them. To do this one had to devise suitably robust questionnaires. At first he didn’t know what or how to ask the questions; for instance the impact of symptoms is different from their severity - it is about the patient’s perception. Now they have developed numerous questionnaires for different age groups, analysis of symptoms, comparison of long term survivors with normal people and he discussed their various results. The team have now progressed into computer adaptive questioning. Professor Johnson then discussed quantity of care. The first recorded operation for pancreatic cancer took place in 1896 in Bologna and the patient unfortunately died. The most successful operation for pancreatic cancer was developed by Alan Oldfather Whipple in 1935 in Columbia. A difficult and extensive operation that demonstrates the principle that the more operations you do the better the survival rates. The results have improved steadily since records began in the 1940s. During the 1990s it became evident that specialist surgeons doing 15 - 20 procedures a year had very much better outcomes when compared with surgeons performing Whipple operations less frequently, so much so that the NHS set up Specialist Treatment Centres in the early 2000s. Southampton is one of them. Initially there was only one surgeon but now there are four and the overall mortality here is 3% against the UK standard of 5%.

The President thanked Professor Johnson for his very interesting lecture. The meeting was closed at 9.50 pm

Dr Henry Goodall on New Forest Airfields

An ordinary meeting of the Society was held at the Ampfield Golf Club on Wednesday 9th January 2019. The President was in the chair. The President then introduced the speaker Dr Henry Goodall who spoke to the title New Forest Airfields in the Second World War. Dr Goodall is Chair of the Board of Trustees of the Friends of the New Forest Airfields, FONFA as it is known. It was formed in the mid 1990s to inform and educate people about the airfields and the people who served in them. He said there were 12 airfields in the New Forest. Apart from Calshot, which opened in 1913, they were all constructed between 1940 and 1944. In 1940-41 those at Ibsley, Hurn, Beaulieu, South Holmsley and Stoney Cross were all built as large 3 concrete runway airfields. They were rather close together for the large number of planes using them. Somewhat later extra airfields were constructed at Needs Oar, Bisterne, Lymington, Winkton and Ibsley using Sommerfeld Steel Tracking  - a system using steel mesh with strengthening rods that could be quickly laid and taken up. Dr Goodall reviewed the history of each of the airfields and their different contributions to the war effort. In 1944 with the build up to the Normandy landings there were 1200 fighters and bombers flying multiple sorties from the New Forest airfields 24 hours a day. Stoney Cross was also used to operate secret supply drops to the resistance and for the glider-borne landings at D Day. He said that at 9.15pm on the eve of D Day his Father in Law was at Stoney Cross preparing to be towed in a glider for Northern France. Dr Goodall told us about the FONFA museum at Bransgore dedicated to preserving the history of these airfields, which is run by very knowledgeable volunteers, and the memorial at Holmsley South airfield which FONFA paid to have restored.

The President thanked Dr Goodall for such a fascinating talk about this aspect of our local history. There being no other business the meeting was closed at 10.10pm

Southampton Medical Society. Minutes of meeting on 5th December 2018 with Dr Greg Warner on Football Medicine

An ordinary meeting of the Society was held at the Ampfield Golf Club on Wednesday 5th December. The President was in the chair. After he had opened the meeting  a minutes silence was held in the memory of Dr Douglas Pearce and Prof. Anthony Frew. The President then introduced the speaker Dr Greg Warner who spoke about Football Medicine.  He entertained us with a light hearted resumé of of his life in football. He was a GP in Romsey for 26 years before becoming a full time football doctor. He was approached by the then Saints doctor, Dr Chris Lawrence, asking if he would like to help out at Saints.This eventually led to a full time appointment which he has held on and off ever since. At one stage he was also MO to Portsmouth Football Club at the same time. He told us of his relationships, good and bad, with numerous managers. Harry Redknapp is his favourite, but he enjoyed the company of many of the others. He described the changes in professional qualifications that have become necessary over the years. He himself had a lot of casualty experience from working in A&E for many years, which was fine at the start but with time specific diplomas became necessary. He started with a diploma in Sports Medicine followed by a time in New Zealand researching and writing an MSc in Sports Medicine. He then discussed the difficult nature of the Appointment Medical saying it required great clinical acumen and attention to detail in both history taking and old fashioned examination in order to be not caught out. He said there was far too much reliance on scans nowadays - both at this medical and after injuries. Club Chairmen who had spent a lot of money on a player often, in their ignorance, thought scans were the answer to everything - and perhaps better than their MO’s opinion. He also considered there was too often a rush to surgery after injury which was unnecessary if only time had been taken to perform physiotherapy and await a natural recovery. The medical department budgets of the teams he served were much lower, and their players were out of action for less time, than comparable high budget clubs. He said a lot of the work is in fact general practice, as you weren’t only dealing with injuries but with the personal problems and ailments as well. He thought that the experience of being a good GP was the best qualification to becoming a good football club doctor.

Southampton Medical Society. Minutes of meeting on 31st October 2018 with doctors who had received Foott Memorial Bursaries as final year students

An ordinary meeting of the Society was held on 31st October at the Ampfield Golf  Club. The President was in the chair. The presenters at this meeting were Drs Claire Holton, Rosalind Henderson, Liam Jones and Isabel Dugdale who, as medical students, had received Foott Memorial Bursaries to study abroad.

Claire Holton visited the Kisiizi Hospital in Uganda which had been flooded and destroyed and rebuilt just before she arrived. The hospital provides general services and has 42,000 patients. It  is also the only psychiatric hospital in Uganda. Claire elected to spend time in psychiatry and obstetrics. She said that alcohol problems, violent crime and its consequences, poverty causing late presentations, and illegal abortion were common in Uganda. She spent 3 weeks with the community outreach teams. They visited communities 3 times a week providing psychiatric, where they saw over 100 patients a day, maternity and paediatric care and physio outreach. In her obstetric attachment she spent time in the Mothers Waiting House where mothers would come from afar early in their pregnancy and stay until delivery for a one off payment. It was a service conceived to try and overcome the consequences of delayed presentation of serious obstetrical problems many of which carry a high mortality for mother and child. She is still in touch with the hospital and she thanked the Society for the bursary.

Roz Henderson visited India and Sri Lanka. In India she spent 2 weeks at the Nishtha Rural Health, Education and Environment Centre. It is very remote. They provide health services in their daily clinics, education to the local community teaching them about their bodies and how to stay healthy as well as teaching organic vegetable gardening. They also support the education of children and youth to prepare them for a modern world. Roz worked in the clinic where a wide range of different treatments were used; classical medicine, herbal treatments, acupuncture and traditional treatment- such as cottage cheese for mastitis and cabbage leaves for arthritis. She did home visits hiking up mountains to get there and went on first aid training days. She then transferred to Sri Lanka to the Jaffna teaching hospital for 2 weeks O&G and then 2weeks in the psychiatry department which she said was the most difficult thing she did. She attended outpatients and visited inpatients ,where the conditions were very poor with barred windows and patients chained to beds. In the evenings she met with other medical students for teaching sessions with each other. She thanked the Society for the bursary.

Liam Jones went to Palawan in the Philippines to study emergency medicine. It is wet and humid so malaria and dengue are endemic. He visited the Adventist Hospital where there is a focus on health and wellbeing  and a vegetarian diet. He worked in the ER which is staffed by SHOs and interns only, working in 24 hour shifts and then 24 hours off. The patients are diagnosed and treatment is initiated in the ER. They can refer patients to a consultant for a review. Liam was surprised by the skills of his fellow doctors who had learnt to perform so many different invasive investigations and treatments themselves. He was seeing severe RTAs, work injuries, dog bites with the possibility of rabies, CVAs, suicide attempts, which are frequent, and dengue. He also presented 2 interesting cases, one of severe dengue and the other of hydranencephaly. He thanked the Society for the bursary

Isabel Dugdale was unable to attend and sent an audio presentation by email. She attended the Hemas Hospital in Galle in Sri Lanka for 6 weeks. She was in the emergency assessment centre which involved dealing with numerous RTAs and also surfing injuries. There was also an epidemic of tonsillitis and a number of cases of dengue. She then returned to UK to spend 3 weeks with the NHS organ donation and transplant service. She shadowed the paediatric ICU team, the neuro ICU team and had a week at their operations centre in Bristol. She thanked the Society for her bursary.

The President and Dr Harnish Patel then withdrew to review the presentations and they awarded the prize for the best presentation to Dr Clare Holton. There being no other business the meeting was closed at 10.00pm

Southampton Medical Society minutes of meeting October 1st 2018. Professor Sedgewick on life in Sri Lanka

An ordinary meeting of the Society was held on Wednesday 7th March 2018. The President was in the chair. A period silence was held in memory of Drs Keith Bramley, Nikki Crawford and David Rands. The President introduced the speaker Professor Michael Sedgwick who spoke to the title Snakes and Life in Sri Lanka. When he retired from Southampton University he said he wanted to experience another culture. He had had a number of Sri Lankan senior registrars and trainees in Southampton and had always been interested in the country.  He took a post as Professor of Physiology in Peradeniya University Medical School near Kandy. He outlined the history of the island and said the country is populated by Tamils originating from India, Moors from the North East who are Malays, Parsees of African origin who were imported as slaves and the people of the Vedda tribe who are aboriginal hunter gatherers and live in the central jungles. Knowing that his early trainees would be returning to Sri Lanka to practice medicine without the help of sophisticated investigations he emphasised the art of listening to the patient while taking a history and the detailed examination of patients. These clinical skills were demonstrated fully by one of the first trainees he had in Southampton Dr Nimal Senanayake, he later became Professor of Medicine and Dean of the Peradeniya Medical School, who on his return to Sri Lanka saw several young girls with wrist drop and hand weakness in a short time and he realised that an epidemic was developing amongst Tamil girls who were tea pickers. It was the custom for Tamil girls, at the time of their first period, to undergo a ceremony involving drinking and anointing with Gingili Oil which is made from sesame seeds. Puzzled, he investigated this further and found the oil they were using was diluted with motor oil. Motor oil contains tricresyl phosphate, a known neurotoxin. His prompt action meant that only 20 cases occurred. Then Michael told us about his research into the Intermediate Syndrome. Drinking organophosphorus insecticide is a common suicide method and inhibits acetylcholine esterase and many patients die of respiratory failure. Some make a steady recovery but others enter into an intermediate state of continued nicotinic stimulation of the neuromuscular junction which is usually fatal. They found that by doing sequential EMGs starting in the first 24 hours that they could predict which patients were likely to develop IMS and their treatment could be tailored appropriately.  Delayed polyneuropathy is common too. He then told us about Sri Lankan snakes; cobra, krait, Russell’s viper and the hump nose viper. Then there is the 7 headed cobra - the defender and protector of all. The A&E sees about two snake bites a day. He then mentioned Sri Lankan diseases. Malaria is not a problem today as static water is dealt with. Leishmaniasis is on the increase. Dengue is endemic and if you survive to day 5 you will be alright he said. Idiopathic renal failure occurs because of arsenic in the water supplies from draining off treated fields. The metabolic syndrome is increasing rapidly, especially in monks. Rabies occurs as well. Mental illness is similar to the UK but they don’t recognise depression - its just a bad time. Sri Lankans he said also like Ayurvedic Medicine, a folk medicine consisting of the use of herbs, infusions, incantations and rituals. He then finished with a tour of unusual sights and scenes.

The President then thanked Professor Sedgwick for his very interesting talk. There being no other business the meeting was closed at 10.00pm

MINUTES OF THE 2017 AGM

SOUTHAMPTON MEDICAL SOCIETY
President Dr Margaret Keightley BSc FRCGP

The AGM of the Society was held on Wednesday 5th April 2017 at the
Royal Southampton Yacht Club.

    The President welcomed members to the AGM [which followed a talk previously reported].

1.    Apologies were received from Drs Jill Glasspool and John Glasspool, Henry Goodall, Richard         Godfrey, Alan Johnson, Brian Milne, David Rands, Mike Sedgwick, Derek Sapsford and Terry Wood.

2.    The minutes of the last AGM were approved.
Proposed by Dr John Dracass
seconded by
Dr Phillip Carter
3.    Matters arising
a. Membership fees: The membership fee was confirmed at £40
b. Bankers Orders were discussed and the advantages of automatic increases in subscriptions         explained but no vote was taken on the matter
c. Gift Aid forms and a proposal to open a Cafbank account: Dr Alex Freeman proposed opening a Cafbank account. She said that there were considerable advantages. One was that administering Gift Aid is done by the bank and another is that subscriptions are more easily managed. She said that every little helps if administering these aspects can be devolved to the bank. She said the cost would be, at present, £5 a month.
4.    Venue for next year and planned talks: The meeting agreed that they would like to continue         meeting at the RSYC. Dr Frank Akerman outlined the proposed programme for the next season.
5.    Chairman of the Trustees of the Society, Dr Richard Buckle: He reported that it had been a good  year for stock markets and the investments administered by Investec have done well. The value ha  increased by £6470 compared with £3500 last year.
6.    Election of Auditor: The treasurer proposed that we continued with Stone Osmond. Proposed by Dr Nancy Shepherd and seconded by Dr Alex Freeman and carried unanimously.
7.    Election of Officers: The following were elected:    
         Hon. Treasurer: Dr David Rowen [Dr Nancy Shepherd is standing down
         Hon. Secretary: Dr Alister Hutchin

    Proposed by Dr Alex Freeman, seconded by Dr John Dracass and carried unanimously.

    The post of Vice President was vacant
8.    Election of the committee: The following were elected:
        Dr Frank Akerman
        Dr John Dracass
        Dr Alexandra Freeman  
        Dr Margaret Keightley
        Mr Brian Milne
        Dr Martin Radford
        Dr David Rowen
        Dr Derrick Sapsford

    Proposed by Dr Phillip Carter Seconded by Dr David Rowen and carried unanimously.
9.    AOB:
 a. The President thanked Dr Nancy Shepherd for all the work she had performed for the Society. She had taken over at a difficult time when HSBC was putting pressure on the Society to remove its assets which involved a lot of work for her. The meeting concurred.
b.  The Yacht club had announced that there would be an increase in the cost of dining next season of £2.50
c. The President reported that Mr Iain Chisholm, the Vice president, had unavoidably been unable to attend the meeting and would be inaugurated as President at the October meeting.

There being no other business the meeting was closed at 10.05pm.

MINUTES OF THE 2018 FOOTT MEMORIAL LECTURE. PROF ANDREW LOTERY

An ordinary meeting of the Society took place at the Royal Southampton Yacht Cub on 7th February 2018. The President, Mr Iain Chisholm, was in the chair. The minutes of the previous meeting were read and approved. A period of silence was held in memory of Dr G H Foott then the  President invited Professor Andrew Lotery, Professor of Ophthalmology in Southampton, to deliver the 2018 Foott Memorial Lecture. Professor Lotery said he felt there was a connection between him and Dr Foott as they were both Irish. He was in the Royal Navy as was Professor Lotery’s father. Before 2002 there was little interest in AMD. There are 50 million people world-wide suffering from it. It has reached epidemic proportions because of increasing age of the population; by the age of 75 one in three will suffer and by 85 one in two. He said his research strategy is to build a DNA library for genetic eye research and they have more than 5000 samples now; to build clinical trials, and he thanked our President for the ‘great' support that  he had given him in this; and to embrace new research such as gene therapy and artificial intelligence. Iain Chisholm, he said, was the first ophthalmologist to set up a macular clinic - but at that time there was little to be done. Now there is: over 300 patients a week in this area are being injected with Avastin and they now have a mobile injection suite. The UK now leads the world and the NHS should be proud of this. He then described the case of a patient with resistant central serous retinopathy and how he had tried the selective aldosterone receptor antagonist eplerenone with remarkable benefit. This observation has now become the first multi-centre randomised placebo controlled trial of this therapy involving 22 centres.

Professor Lotery said that searching for genes was important. The finding of the gene involved in Doyne’s Honeycomb Dystrophy has spurred on the search and 19 genes involved in AMD have now been identified. It is considered that AMD is strongly genetic and associated with Complement Factor I overactivation. The future for eye diseases is bright. Gene therapy and DNA editing are happening. The ability to study the retina with Optical Coherence Tomography not only informs of local retinal changes but has the ability to predict disease such as cardiovascular disease and possibly diabetes, hypertension, your smoking status as well as age and gender. Professor Lotery finished by saying that Dr Foott was interested in education - and so was he, he said. Training the next generation of academic ophthalmologists is vital for saving more sight. 

After a period of questions the President thanked Professor Lotery for his fascinating lecture. The meeting was closed at 10.05pm.

Dr David Saunders on The Death of Cromwell January 10th 2018

An ordinary meeting of the Society was held on Wednesday 10th January 2018. The President was in the chair. He introduced the speaker Dr David Saunders who spoke to the title “The Death of Oliver Cromwell”. Oliver Cromwell was born in Huntingdon in 1599. Very little is known about his early life. He was educated at Sidney Sussex College, Cambridge and after that  he became the MP for Huntingdon. In 1630 he had a religious conversion into extreme protestantism. In 1649 he was a signatory to the sentence of death of CharlesI. In 1651 when Charles II, with the support of a Scottish army, marched south Cromwell caught up with him at Worcester and defeated him. Cromwell was then offered the crown by parliament but he refused it. There followed a number of different “parliaments” which Cromwell finally dissolved by force and in 1653 Cromwell was made Lord Protector of England for life. He died in 1658. He had had a series of fevers for some years and then died unexpectedly. There are three theories. The first was malaria. Plasmodium malaria was endemic from Norfolk to Portsmouth though this form is rarely fatal. The second was septicaemia from infected kidney stones and the third poisoning. An autopsy was performed but with no diagnosis resulting. He had been prescribed mercury with antimony and Dr Saunders considered that the symptoms were those of heavy metal poisoning. The body was meant to have been embalmed but exploded and so for his lying in state an effigy was used. He was said to have been buried in Westminster Abbey. Following his death Cromwell’s son became Lord Protector but dies after 274 days resulting in a power struggle and this is only resolved when General Monck invited CharlesII to return to England. One of the conditions was that the king should offer a general pardon to those involved in his father’s death but he excluded those involved in his sentence. However the main three were dead and so orders were given that their bodies be exhumed and executed at Tyburn. However only the bodies of Cromwell and Lord Chief Justice Brabham could be found. They were beheaded and the heads stuck on poles attached to Westminster Hall where they remained until blown off during a storm in the reign of JamesII. A guard picked up Cromwell’s head and took it home and stuffed it up his chimney. On his death his son sold it and it disappears until 1710 when it was an exhibit in a museum of curiosities. In 1787 it was sold to a Mr Hughes for £230 and exhibited again at 2/6p a visit but no-one paid to see it. It was eventually sold to a Mr Wilkinson in whose family it remained until 1949. In 1934 they had it studied and compared with portraits and death masks and it was accepted as the head of Oliver Cromwell. In 1960 the head was buried in the antechapel of Sidney Sussex College Cambridge though the exact location is a secret.

Following questions the President thanked the speaker for his interesting talk and closed the meeting at 09.50pm.

The Great War Cemeteries - A Journey. Dr John Garfield. January 14th 2015

An ordinary meeting of the Society was held on January 14th 2015. The President Dr John Dracass was in the chair. A minutes silence was held in the memory of Professor Jack Howell and Dr Peter Todd. The minutes of the last meeting were read and approved. The President then introduced the speaker Mr John Garfield who spoke to the title The Great War Cemeteries – A Journey.  ‘This is not a lecture’, he said, ‘I want to provoke thoughts and comments. It is an unfinished journey’. The journey started when he was lent a Zeiss Ikonta  camera at Cambridge. He became fascinated by the process of photography and the artistic possibilities of black and white. When he arrived at St  Mary’s there was a superb enlarger he could use and he found being in the darkroom composing a picture was inspirational. In 1961 he visited  a war cemetery in France in winter . The low sun and enhanced shadows produced very powerful images.  Through a contact at the War Graves Commission he was then able to arrange to visit all their cemeteries  and take photographs.  He put on an exhibition of these photos  at the Camden Arts Centre to which the publisher Leo Cooper came and which resulted in his first book, The Fallen, being published. He was asked by Professor Gavin Stamp, who had also been to this exhibition,  to do a room of Lutyens war grave designs in an exhibition of Lutyens work that Professor Stamp was curating at the Hayward Gallery. John Garfield visited many of the cemeteries with his friend the late Mr John Jenkins [a Southampton urological surgeon] and  both of them liked to spend time alone to absorb the meaning of these places. This collaboration resulted in the 1986 Foott Memorial Lecture in which they presented a moving evening of photos and literature. Mr Garfield then asked us ‘are the words on the graves and memorials  appropriate?’  ‘Glory and Glorious’ he found difficult. Do we have Glory because we won? He was not sure if similar wording appears on German memorials. ‘Honour and Honourable’: he asked what is Honour ? Is it derived from dulce et decorum est?  ‘Revere and Reverence’: ‘I revere people who went to fight but Reverence?’ ‘God’: each side had its particular God and each side thought He would help them.  There were other words usually written by a post-war generation in the 1920s: ‘bitterness’ which  implies doubt about what was  done; ‘Sacrifice’ which is seen on so many memorials, which to him meant it was done voluntarily, and is often linked with Glory. ‘Hate’ is not mentioned in any of the literature. ‘Respect’:  He respected the generals and field marshals and asked us to put ourselves  in their position. ‘Desolation’ is a word he liked as it applies to so much of the First World War. Mr Garfield said to us that he needed guidance. This resulted in a stimulating discussion and here are some of the comments that were made. 

‘There is a desire for euphemism and rationalisation for the next of kin who need to know that the life was not given in vain.’

 ‘We went on a tour last year and were very moved but I agree with John there is a need to be on one’s own to contemplate.’ 

‘ I took my four sons  and the youngest, who is much younger than the others, looked at the rows of graves and said ‘all my older brothers could have been killed’  

‘Children see the cemeteries and it makes them  think how  wars come about and how they affect us.’ 

‘War cemeteries will have a profound effect on future generations too – but now we ship the dead home and the graves are dispersed  around the country and the impact will be lost’ 

‘Clapping the cortege – surely silence is appropriate?’ 

‘Clapping is an indication of  our appreciation of the life given.’  

‘Visiting the [888,246] poppies at the Tower of London brings back the futility of war. Each poppy also represents the 30 or 40 relations and friends who were also affected.’ 

The President thanked Mr Garfield for such a memorable evening. He hoped the long discussion was to his satisfaction though we had not come to a conclusion. 

He then announced that the committee had decided that the Society  should use Gift Aid and if possible members should sign up.

There being no other business the meeting was closed at 10.05pm.

The Modern Management of Stroke. Dr Pamela Crawford. November 3rd 2015

An ordinary meeting of the Society took place on 3rd November. The President was in the chair. The minutes of the previous meeting were signed. The President announced the deaths of Dr Peter Todd and Professor Jack Howell.

The talk was given by Dr Pamela Crawford, Stroke Physician at Southampton General Hospital, who spoke on the Modern Management of Stroke. She did this by going through seven different clinical scenarios.
They now have a co-ordinated team at the Southampton University Hospital and, like most DGH's, can offer a 24 hour thrombolysis service. However, thrombolysis is not suitable for all patients. If given more than 6 hours after the stroke, it can be harmful. It is not without risk and because of this Dr Crawford often has quite difficult ethical discussions to have with patients, or their families if the patient's comprehension is impaired. A CT scan is rapidly performed after admission, the Ambulance Service having pre-warned the ED that a probable stroke case would be arriving. The Median time to CT from arrival in ED is 18 minutes. If the CT indicates a bleed then a follow up MRI is organised as a bleed can conceal an underlying tumour early on. If someone presents and is appropriate for thrombolysis, and can be treated within 90 minutes, which is by no means unusual, the Numbers needed to treat (NNT) in order to get an “excellent” outcome are only 5, which compares well with any cardiological interventions, she said.  

Someone with a small lacunar infarct can be admitted, scanned, treated, have their risk factors addressed and be home the same day with community Stroke Team follow up. Review by the specialist nurse is at 6w and 6m. Patients admitted to the stroke unit all have a swallowing assessment as pneumonia is a common cause of death.

Atrial Fibrillation causes big clots and therefore big strokes. For some cases clot retrieval can work, but this requires the availability of an interventional neuroradiologist and an anaesthetist. 

If there is doubt about the amount of ischaemic, but not yet dead, brain that is present, a perfusion scan can help differentiate, and inform the decision as to further management. 

In younger patients in whom brain swelling can cause death, a hemicraniotomy can be performed. The portion of removed skull is kept within the abdomen and can be re-implanted later, though this does not always go smoothly.  This saves lives but patients are usually left with residual disability. 

After the talk there were many questions, which Dr Crawford kindly answered. She was thanked for her very interesting presentation and there being no other business, the meeting closed at 10.15pm.