Category Archives: Resources

Coronavirus – Practical Advice

Updated Version – 20/03/2020

NEW: Going to the supermarket

New evidence emerging on Coronavirus survival on surfaces. This was actually sent to me by one of my patients!

Be careful when you go to the supermarket. The shopping trollies, self check outs, cash, pushing in pin numbers etc, all potentially dangerous. And there are no handwashing or disinfecting facilities at the entrance / exit. Then you touch your car keys, steering wheel and gear shift. Consider washing goods, fruit etc with soapy water. You dont know who has touched it before. And all the Coronavirus infected people have to shop, too. Most of them are mildly sick. We really need supermarkets to provide disinfection or handwashing facilities at their entrances / exits because we cannot stop food shopping during the crisis.

Self isolation advice: Read here if you have symptoms and here if you don’t.

Introduction

The article below is for my subscribers to my website www.nhsevent.info. I wanted to put some information together that may help you in your journey in these uncertain times. Please be aware that this article is not written by a Coronavirus expert, but by a GP. Some of the messages may be soon out of date, others may be valuable for a long time.

Why is Coronavirus important?

Coronavirus is a new virus. There is no immunity in our population. Therefore potentially up to 80% of us can get it (but its likely to be much lower). Most people just have a cough and a fever or a fever alone. But some patients, particularly the elderly, patients with chronic conditions or an impaired immune system are more at risk of serious illness or even death. Many of us think it is like a flu / viral pneumonia, but we still have a lot to learn and don’t know everything. And crucially, unlike the flu, we do not have a vaccination available to us.

I am having a hip replacement in a hospital, tomorrow, should I cancel?

You should talk to your hospital if you are high risk or if you have any signs of a viral infection including symptoms of Coronavirus. All hospitals are required to put their patients safety first. They will cancel your operation if necessary. You really only should go ahead with a procedure if you are low risk. If you are very worried about not getting your procedure done, because you are in a lot of pain and most routine procedures will soon be stopped, try to call your consultants secretary and get put into a slot as soon as possible.

I cannot get any Hand Gel, what should I do to disinfect my hands?

Regular handwashing will remove 99.9% of all virus and bacteria on your hands. You do need to keep your skin moisturised, though. There is usually the principle of “viral load”. To get infected by any virus you need a good number of the virus into your system, usually about 1000. Few conditions, like Hepatitis, require less virus to become infected and people with reduced immunity also may need less virus. We don’t know what the viral load for Coronavirus is, but as handwashing with soap binds the virus it is a good strategy.

How about sending my kids to school?

While the schools have not closed yet, you should be careful if your child is on immunosuppressant drugs, is severely obese, has severe asthma or needs a flu jab for any other reason. You should also now separate vulnerable adults living in the same household as your children. Children are vectors (transmitters) of this disease, but healthy children seem to very rarely get seriously sick with this. They also will provide “herd immunity” for society in the future.

Areas of risk

Anything you have touched with dirty hands or others have touched is an area at risk, so wash or wipe it. Supermarkets are so full of people, they are like viral kettles, now. So what is high risk? The list is endless, but start here: Supermarket trolleys, supermarket self check outs, your steering wheel and gearshift, your mobile phone, not washing hands before eating. Public door knobs and door handles. Anything your kids touch unawares.  Wash your hands before you eat. Don’t eat finger food from buffets where others eat, too. Again, the list is endless.

NEW: How can I disinfect my toilet seat / doorhandles etc with what is still available in supermarkets?

Household bleach is a powerful disinfectant. Use small amounts, as advised on the label, in water and use to disinfect all surfaces that are resistant to it (dont blame me for a bleached surface, try a small area first in an invisible place). Always read the label. Also ensure to wear gloves and don’t bring into your eyes. After you have disinfected areas, wash away bleach with water. Alternatively, you may find disinfectant washing up liquid or other household disinfectants. The list is long.

I can’t get any facemasks

Most facemasks are only bits of tissue that cannot filter the virus. Virus filter masks are not easily available and currently quite expensive. But not to worry. What usually carries the virus are little droplets, that you cough or sneeze out when you first get a virus (in fact a recently published small article published on Sunday March 8th by a group of German scientists (not peer reviewed, not yet confirmed) suggests it is most infectious in the early stages and mild cases. And these droplets can be filtered by tissue. May this be the reason why the government has reduced the viral symptoms isolation period to 7 days, because the virus is not as contagious once the sneezing / early symptoms stop (pure speculation!)? But what does this mean if it is true?: Even a scarf, a pullover with high collar or a couple of pieces of normal kitchen roll secured with 2 rubber rings in front of your face provide good protection against the droplets and can help with some basic protection against any virus in caCatch it bin it kill itse somebody coughs or sneezes at you. Just replace it frequently.

My relative is on Chemotherapy / Radiotherapy for cancer, can I visit them?

No, you shouldnt. If you (have to) visit older or sick or vulnerable relatives or they are dependent on you, ensure they and you frequently wash their hands, door-handles and everything you or they touch. Keep a 2m distance whenever possible. Cover your face with tissue when you sneeze, cough or speak loudly (your relative may be hard of hearing). Ask them to cover their faces with a handkerchief or any other fabrics while you are around.

I am worried about getting my prescription medication

There is no worry, supplies are reasonably good at the moment. Try not to stockpile, order as you usually would.

I am worried about Paracetamol being completely sold out

The problem is that people are stockpiling. If everybody only buys what they need we will be fine. I am sure Paracetamol manufacturers will try to increase output in the next few weeks as long as supplies are not hampered by other factors. Remember, Paracetamol is a comfort drug, it isn’t really curing anything. If you have an illness, it makes you feel better, but by lowering your temparature you also decrease your metabolism and your temperature is increased to be able to make antibodies quicker. Use your current supplies sparingly.

What is better, handgel or handwashing?

It depends. But if you use handgel you leave a film on your hands that can in some gels later provide a breeding ground for germs. So frequent handwashing is vital.

I am vulnerable myself because of Type II diabetes .

You now need to self isolate. At the same time try to improve your self care and reduce your sugar levels if possible. Even lowering your weight by a stone may reduce your sugars so much that your immune system can kick in again. Patients with high sugar levels paralyse their immune system. If you are overweight: By acting now and going onto the 800 calorie diet immediately you may be able to build up your immunity in time for Coronavirus.

I have another condition that reduces my immune system

You should now self isolate. Read here for more information

What else can I do to reduce my risk of severe illness or death with Coronavirus?

  1. Stop smoking. Within 3 days of stopping, all the Carbon Monoxide in your blood is gone and the oxygenation of your blood will improve. Within 6 weeks the little hair in your bronchi will grow back to naturally get rid of debris, bacteria and germs. This gives you a better chance with Coronavirus as it causes breathing problems in severe cases.
  1. Ensure you eat a balanced diet not deficient of any nutrients you need
    • Increase your vegetable intake massively (at least 5-a-day, better 9-a-day!)
    • Reduce salt in your diet (to reduce your blood pressure)
    • Reduce fats and sugar in your diet (general drivers of obesity, pre-diabetes and diabetes)
    • Eat fresh food, cook yourself (avoid additives and bad fats, know what goes into your dinner!)
    • Avoid food additives, the list is endless.
    • Alcohol in moderation (also driver of obesity and impairing the natural defences of your liver)
  1. Loose weight (obese people have a higher risk of pre-diabetes and diabetes and many other conditions that can affect your immune system and resilience
  2. Keep well hydrated
  3. Be active, do plenty of exercise (not in a crowded gym, outdoors is better at the moment or at home with your own equipment or indeed without equipment like Pilates or Yoga.

When I am sick or worried with a cough or fever, I need to see my GP, right?

No, please dont come into the surgery, call NHS 111 or 999, depending on the severity of your symptoms. If they advise to call your GP, then contact the surgery via telephone or online (where available).

“I never get the flu, I don’t even have the flu vaccine, even if the surgery texts me. Therefore I won’t get Coronavirus”

You may be of ruddy good health and never get any problems, but you also may be relying on a phenomenon called “herd immunity”. It depends on the virus, but generally, if 70-90% of a population are immune to a virus, the rest won’t get it, because a virus cannot spread sufficiently. Therefore turning down vaccinations that are offered to you is usually unwise, because 1) you don’t protect yourself and 2) you don’t contribute to the greater good of “herd immunity”. Again, a person with health problems is more at risk and that is the reason, why they are the first patients we contact for the annual flu vaccine.

Important Links on self isolation:

Self Isolation with symptoms: https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/

Self isolation without symptoms: https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults

Dr M Kittel, March 12th 2020, updated March 14th

 

Dr Kittel’s Mental Health Resources – Bracknell

Adult Mental Health

Image result for mental health

Find below a list of Mental Health Resources that you may find useful for your own Mental Health journey. You may also wish to register on this website (see registration section on the right hand side) for occasional non-promotional local NHS information emails by Dr Kittel and Forest Health PPG.

  1. A list of Mental Health Self Support Messages by Dr M Kittel
  2. A list of counselling and other support organisations in and around Bracknell
  3. The excellent “Books on Prescription” service by Bracknell Library
    1. A prescription form
    2. A synopsis for every book
  4. A PHQ 9 and GAD 7 form for self assessment of Anxiety and Depression. Please take a completed form to your GP

Child Mental Health

Click here for a self help leaflet on Child Anxiety

 

Back Pain – Tips and tricks

Introduction

Low back pain and Sciatica are incredibly common conditions in highly developed, civilised societies. According to some reports, more indiginous societies (i.e. tribes in the Amazon etc.) rarely suffer back pain. This is probably due to better core strength in less civilised peoples.

Summary

What should I do with acute back pain in a nutshell: 5-point plan:

  1. Initially, take painkillers that you are not allergic to i.e Ibuprofen (beware indigestion) and / or Co-codamol (beware constipation) over the counter and take them regularly for a few days. Always read the drug information sheet in the pack. Don’t take them long term.
  2. Read the NHS write up on back pain, it contains lots of good information.
  3. Buy Robin McKenzie “Treat your own back” (see below)
  4. Ask your doctor  to refer you for physio if your backpain hasnt improved after 2 weeks or see your practice physiotherapist.
  5. Contact your doctor, should you have any “red flag symptoms” described in the NHS leaflet.
  6. If you suffer chronic back pain, improve your core strength with Pilates. There are many free courses, I am using “Trifecta Pilates” for my own back pain successfully. There are many sessions online.

More on Low back pain and Sciatica

These 2 conditions are the most common ones causing patients pain and disability. There is a really good overview on the NHS website . However, there are a few additional resources that I  would like to share.

  1. The Book: Robin McKenzie, “Treat Your Own Back” for a quick fix.
    • This is a 30 year old book based on a 60 year old method that my own doctor recommended to me and truly, with a few stretches, a lot of people are able to improve their back pain quite significantly. Thus, I believe it is the best £10 I ever spent on my own back.
  2. StartBack Tool
    • The StartBack Tool is a good tool to assess the chance of Chronification in Low Back Pain. Click here to download and complete it. The scoring method is explained on the second page. If you score highly, seek help early, as you are much more likely to suffer this condition for a long time.
  3. The Back Pain Booklet
    • Almost 20 years old, this booklet is still very relevant and helpful. Click here to download this file. It is double sided A5 and a bit tricky to print, but the content is very good

Why an MRI scan is commonly a useless investigation

An MRI scan is a tool to get a good 3D photograph of our spine. It is very sensitive to abnormalities like disc bulges, slippage etc. However, many people with disc bulges lead completely normal lives without any symptoms. Equally, people with entirely normal MRI scans suffer severe back pain. Click here for MRI scan results of the spine for normal people without back pain.

Should I see my GP with Low Back Pain?

Most GPs are not well placed to treat Low Back Pain. Apart from painkillers, with a various degree of side effects and health hazards attached to them, they often can do little to help back pain. However, many practices now employ senior physiotherapists (First Contact Physiotherapists), who can be helpful in the assessment and treatment co-ordination of Back Pain.

Of course there are exceptions where Low Back Pain has more serious causes and there is a good summary on the NHS website quoted above. If you think your symptoms may be more serious, you should see a health professional quickly.

Dr M Kittel, March 2019

 

 

A Kidney Friendly Lifestyle

Key Messages for good Kidney Health

  • Increase your vegetable intake massively (at least 5-a-day, better 9-a-day!)
  • Reduce salt in your diet (kidneys have to get rid of all salt from the body)
  • Reduce your protein intake significantly (protein clogs up kidneys).
  • Reduce fats and sugar in your diet (general drivers of obesity)
  • Reduce pesticides and environmental contaminants in your diet (again a lot of what both kidneys and liver do is getting rid of those)
  • Eat fresh food, cook yourself (avoid additives and bad fats, know what goes into your dinner!)
  • Avoid food additives, the list is endless.
  • Drink Plenty (unless you have very advanced kidney disease, here you need fluid restriction)
  • Be active, do plenty of exercise (general fitness helps your kidneys, too)
  • Stop smoking (always toxic, vaping is less toxic overall)
  • Alcohol in moderation.
  • Loose weight (obese people have a higher risk of kidney problems)
  • Be very careful with painkillers (i.e. Ibuprofen is a real enemy of good kidney health)
  • Research your kidney friendly diet, CKD etc online, start here

Background

Kidneys and CKD (Chronic Kidney Disease)

Related image

Kidneys are amazing organs. They detoxify our bodies on a daily basis and get rid of most things the liver and bowels cannot get rid off. And many people have healthy kidneys until their old ages. However, an increasing number or people in the UK have Chronic Kidney Disease. (CKD), similar to blood pressure is actually a condition rather than a disease as most people dont really suffer with it. Many people do not have any symptoms or only have minor symptoms until the condition is relatively advanced.

Doctors in the UK tend to warn patients when their eGFR (Glomerular Filtration Rate = the rate at which your kidneys work) drops below 60, which is an arbitrary, yet probably sensible line according to todays knowledge. NICE classifies most people with a

For a more complicated NICE classification of CKD click here

Diagnosis of CKD 3

Usually, patients need 2 readings of an eGFR (the rate at which your kidney works) below 60, 3 months apart, to be diagnosed with CKD stage 3. A single reading is not enough. Stage 3 means that you have now moderate disease (stage 2 is mild and stage 1 is normal and these stages are medically only important for people with pre-existing kidney damage).

Prevention of CKD3

However, I would encourage everybody with CKD 2 to already take measures to avoid their kidney function to drop. Aging drops kidney function anyway, but it is the acceleration of this drop we need to avoid. Simply go to the top of this page for the key messages.

I have got CKD 2 or 3 – What next?

  1. Dont panic – most people with CKD 3 will NEVER end up on dialysis or need a kidney transplant
  2. Get informed – the internet is your oyster. There is so much written about a kidney friendly lifestyle.
  3. Prepare – Change your diet, get fitter, try to be positive and happy if you can, drink plenty of water, implement the key changes listed above.
  4. Be critical – Protein clogs kidneys up, yet a lot of recipes even on really good websites contain too much protein and too little vegetables. Also, remember, replacing animal protein such as meat and dairy products with plant proteins such as beans, lentils and tofu is better for your kidneys.  Learn about kidneys. Make up your own mind. And do what you think is right.
 

Dr Kittel’s Anti-Constipation Cereal

Image result for constipationStart the day with a mix of fibre and seed containing foods with plenty of fluids can relieve constipation in 80-90% of patients.

  • Rye Flakes
  • Oat Flakes
  • Dried Fruit
  • Linseed
  • Pumpkin seeds
  • Sunflower seeds

 

  • All these incredients can be obtained at health food stores i.e. Holland & Barretts and mixed according to taste in a big cereal container.
  • Eating a bowl of this cereal every day will after a few days relieve most peoples constipation.
  • Patients suffering irritable bowel syndrome are advised to avoid dairy and eat the cereal using a variety of fruit juices.
  • Should you still suffer symptoms after starting your dietary changes, please see your doctor again.
  • For very young children that cannot yet have the above cereal I usually recommend to give Porridge with some Linseed and a mashed up banana for breakfast (mash and mix banana into hot porridge to cool down and add linseed). You can also put linseed into yoghurts etc.

Click here to download the recipy below in a printable .pdf.

Good Luck! – Dr Martin Kittel

 

How Much Physical Activity Is Good?

What Public Health England advises regarding physical activity.

We know from research that from all medical interventions we pay for to improve the health of the population and reduce hospital admissions exercise based interventions give some of the best investment returns. That’s for example why we paid for additional pulmonary rehabilitation interventions in Bracknell & Ascot in order to improve the life of patients with respiratory conditions. That is also why we have sponsored a lot of other activity based schemes.

And lets be fair: While most of us find it hard to stick to a daily fitness routine we all know how good it feels when we have been active. So, ask yourself the question.

  • When have you had your last muscle ache due to exercise?
  • When have you last been out of breath so you couldn’t talk because of exercise?

Find below information on how much activity is good for us. You may be surprised, but the body is made to sweat and be active!  If you are looking for a way to go from nothing to be able to run 5K, why not try the BBC “Couch to 5K challenge”.

However, a word of warning: Patients with chronic conditions, on permanent medication or otherwise disabled may have to start slowly when taking up exercise or may need support by a health coach or physiotherapist.

Adults and Older Adults

Children 0-5

Children 5-18

Pregnant Women

For more information please go to Public Health England https://www.gov.uk/government/publications/health-matters-getting-every-adult-active-every-day/health-matters-getting-every-adult-active-every-day

 

Why finishing your Antibiotics is still important

Please dont stop using Antibiotics because of todays news

 

Today the Telegraph and many other newspapers published a top of the frontpage article in which the headline suggested patients shouldn’t complete their courses of Antibiotics, but stop Antibiotics when they feel better. I believe this is irresponsible journalism considered the public health implications such a message carries.

The initial statement was based on a professional publication in the BMJ. This publication was intended to inform a debate between professionals, not intended for public education. I also believe 2 of the 4 key messages in the BMJ are not evidence supported and will write to the BMJ about this.

The BMJ argues the basic argument why we complete our Antibiotics is, apparently, not based on sound research, but on a statement of Sir Alexander Fleming, the inventor of Penicillin, at his Nobel Price speach in 1945 (he recommended to finish courses of Antibiotics to reduce resistance). The Telegraph unfortunately created a rather dramatic headline, taking the message out of context.

And of course Fleming had a strong argument. He had seen what had happened to one of his colleagues that had not enough Penicillin available and died. The BMJ writes: “When Howard Florey’s team treated Albert Alexander’s staphylococcal sepsis with penicillin in 1941 they eked out all the penicillin they had (around 4 g, less than one day’s worth with modern dosing) over four days by repeatedly recovering the drug from his urine. When the drug ran out, the clinical improvement they had noted reversed and he subsequently succumbed to his infection”. Only as recently as 2014 the prescribing guidelines for children for Penicillin and Amoxicillin, 2 of the most commonly prescribed Antibiotics, were doubled in all doses.

In fact, some of the BMJ article contains indeed very good and important information. It may be that the argument to stop Antibiotics earlier proves correct in time to come and after (a lot) more research. However, I dont think this can be generalised, I just believe that we need to get more specific advice for different conditions and patient groups.

And it may actually be correct that in some illnesses we could recommend to treat only until patients feel well. This may be the case for example in simple urine infections. It is also true in a lot of the viral illnesses that we take Antibiotics for without any good reason (in fact we should not have them in the first place).

Another argument sometimes quoted for stopping antibiotics early is that Antibiotics do not have to kill every last pathogen (=bacteria, bugs), but only enough for the immune system to get rid of it and therefore they do not need to be finished. This may be true in some infections in healthy individuals, but not in patients with co-morbidities (different chronic diseases) and reduced function of the immune system i.e. patients with diabetes, Rheumatoid Arthritis or older patients.

However, a good example where Antibiotics should not be stopped is an abscess. Particularly in dental abscesses the only thing that usually cures the abscess is removing the pus by removing the tooth or draining it through a root canal treatment. All antibiotics usually do is stop the spreading of the pus into the blood stream and therefore stopping blood poisoning. If you stopped the Antibiotics after you feel better you would usually soon feel worse again, the fevers and shivers and the pain would start again.

Another example may be tonsillitis. Pus can get stuck in crypts (little holes) in the tonsils and it is actually still recommended to take a 10 day rather than a 7 day course. Many patients that finish a course early or have been given too short a course are coming back with a recurrence of symptoms.

A lot of patients have to have very long courses of Antibiotics. Conditions that spring to mind are TB, HIV and even a condition as simple as acne. Also, other patients are on Antibiotics preventatively i.e. for the prevention of urine infection or after a splenectomy (removal of their spleen).

My plea is therefore to wait until new research and guidelines are released that support some of the scientifically scantily supported assumptions made in the press today and still to continue Antibiotics as prescribed by health professionals. For the moment the simple message ingrained into the mind of the public and health professionals remains: Do finish your course of Antibiotics unless advised to the contrary.

Please share or re-publish this article at liberty.

Dr M Kittel, 27/7/2017

PS: For the people interested in the academic part of the BMJ article: The 4 key messages of the BMJ and my first thoughts.

Key messages

  • Patients are put at unnecessary risk from antibiotic resistance when treatment is given for longer than necessary, not when it is stopped early
    My response: The first part of the sentence is likely to be correct although the evidence is based on relatively small trials and lots of assumptions. But the second part of the sentence “not when stopped early” only considers risk from Antibiotic resistance to patients. It doesn’t consider the benefits antibiotic treatment gives patients when taken correctly and for right amount of time not the risk of re-infection and an even bigger course of Antibiotics if they have to be restarted. It also puts generally healthy individuals into the same category as sick and immunosuppressed patients.

  • For common bacterial infections no evidence exists that stopping antibiotic treatment early increases a patient’s risk of resistant infection.
    My response: No evidence exists to the contrary neither. The absence of evidence is not evidence of absence. Simply identifying a lack of direct evidence, or randomized controlled trials, is not sufficient to overturn decades of clinical practice. And why change the guidelines and put vulnerable individuals at risk before we don’t have such evidence? Finally, potential antibiotic resistance in the future may be less of concern in an individual that is very sick at present?

  • Antibiotics are a precious and finite natural resource which should be conserved by tailoring treatment duration for individual patients. My response: This is 100% correct.

  • Clinical trials are required to determine the most effective strategies for optimising duration of antibiotic treatment. My response: I believe this is correct, therefore the strong recommendations within the BMJ article should be withdrawn and science should be supported to do the research needed to get us the answers to the questions that have been raised.

 

Planning to travel this summer? A well controlled blood pressure could reduce your insurance premium.

If you are planning to travel abroad this summer you should ensure now that your Blood Pressure (BP) is well controlled. An undeclared elevated BP reading in your medical records could invalidate an insurance claim, particularly if the problem is a stroke / heart attack or a blood clot during travelling. Thus, if you have had BP readings higher than 140/90 you need to see a doctor or nurse to ensure your BP is reduced.  If you have online access to your records, check it now. If not, get online access today.

Like any other medical condition even a normal blood pressure, if controlled with medication, has to be declared.

If you think you may have a note entry of a high BP, but your actual pressure is lower you can submit home readings performed to NICE guidelines (average of 2 readings twice a day for a week) . Your surgery can put those into your records. Please read this page and download the BP control sheet.

If you are on blood pressure medication and your BP is well controlled it could reduce your Travel Insurance Premiums. The entry of a normal BP in your records is very re-assuring.

And finally remember: Reducing Salt, Fat, Sugar, Alcohol, increasing exercise, vegetable intake and being happy and de-stressed all reduce your Blood Pressure. Happy Holidays.

Dr M Kittel, July 2017

p.s.: If you click on the picture you can see the poster bigger)