nm0370: you're not going to get any [1.5] I-T aids for this talk you're not 
going to get any slides [0.3] you can take notes if you want to [0.5] er i've 
prepared some handouts for you with everything i'm going to say on here so feel 
free [0.3] not to take any notes it's all on there [1.4] [laughter] the reason 
i teach this way is t-, [0.2] to get your attention [0.6] and er to hopefully 
prevent you from falling asleep for this talk [0.6] so [0.2] the subject of 
today's talk [0.2] is kidney stones [0.5] but first of all i'd like you to tell 
me what this is [0.9] i'm i can assure you i'm not a very good [1.8] 
ss: train 
nm0370: it's a train [0.2] okay [0.6] and [laughter] er [0.2] so [1.2] you're 
all trainspotters [0.2] er i can tell [0.7] because you know what a train looks 
like [0.7] er [0.6] and [0.2] the theme of this morning's talk is to try to [0.
3] persuade [0.2] those of you who are not trainspotters to become 
trainspotters actually it's very interesting the whole subject of trains [0.6] 
and why do you think that [0.4] kidney stone 
disease has got anything to do with trains and trainspotters [1.1] anybody [3.
5] think laterally [1.7] speak up [1.6] 
sm0371: movement of urine the flow of u-, 
nm0370: no no it's a trick question 
sm0372: we need trains to spot them [0.4] 
nm0370: sorry 
sm0372: we need [0.2] trains to spot them 
nm0370: very good very good i didn't think of that one [0.3] er [0.4] 
[laughter] i i think that [0.3] the reason why [0.2] it's similar to 
trainspotting is that most people think trainspotting is rather dull [0.5] and 
er [0.2] most people also think kidney stone disease is rather dull [0.4] n-, 
but i happen to find it very interesting and i'm trying to get convince you 
this morning that it is interesting and [0.2] trains are interesting [0.4] er 
[0.3] why do you think that trainspotting is dull [1.8] 
ss: 
nm0370: speak up [0.7] 
sm0373: 
it's monotonous 
nm0370: it's monotonous isn't it [0.4] it's very common there are a lot of 
trains about [0.6] and it seems quite easy doesn't it trainspotting but [0.3] 
you try sitting there on Crewe station all day long [0.2] writing those little 
numbers down [0.4] and er in fact it's a lot harder than most people think 
trainspotting and [0.4] and it's perhaps more interesting [0.2] than many 
people think and i'm going to try to convince you that [0.6] kidney stones er 
[0.4] are harder than you think [0.2] and perhaps more interesting than you 
think [0.4] why why are k-, why is kidney stone disease important tell me 
something about the [0.3] epidemiology of [0.2] kidney stone disease [2.3] 
sf0374: er 
nm0370: if you've got no idea say so 
sf0374: 'cause it causes an obstruction 
sf0375: no idea [0.2] 
nm0370: okay so it's a cause of obstruction yes [0.7] anybody else [1.7] 
sm0376: painful [0.2] it's painful
nm0370: 
painful [0.5] and in fact and that's the key and that's one of the similarities 
with trainspotting [0.4] er [0.5] [laughter] it's painful [0.5] and it doesn't 
really matter [0.8] and why doesn't it really matter [1.8] why does kidney 
stone disease not really matter [5.2] it doesn't kill you [0.6] so people don't 
care about diseases that don't kill you [0.4] and they care about diseases that 
do kill you and kidney stone disease is a classic disease which is very 
important very common but doesn't kill you [0.3] which is perhaps why nobody's 
interested in fact there isn't a single [0.2] group of kidney doctors in the U-
K looking into kidney stone disease at the moment so [0.3] if one of you wants 
to become famous do a [0.2] PhD on the pathophysiology of stone disease [0.5] 
so it doesn't kill you h-, how common is it [0.9] anybody [1.2] 
sf0377: very [0.2] 
nm0370: very [0.8] do you want to put some numbers on that [0.4] 
sf0377: no [laughter] [1.4] 
nm0370: anybody want to put some numbers on that [0.8] 
sf0378: 
ten per cent [0.4] 
sf0379: twenty-five [0.8] 
nm0370: it's yeah nearly actually twelve per cent of men five per cent of women 
have a stone [0.4] at some stage in their lives [0.3] and [0.2] kidney stones 
are a bit like trains they just keep coming they keep recurring [0.5] er and in 
fact fifty per cent of people of [0.3] of that vast number of people so many 
people in this room will have had a kidney stone at some point in their lives 
er [0.3] or are about to perhaps today [0.8] and [laughter] er [0.4] and fifty 
per cent of those people have another attack in the next five years [0.5] so 
it's suddenly becoming a bit more interesting it and what's interesting about 
it is it's [0.3] one of the commonest chronic diseases [0.3] but it's one of 
the diseases we know least about and it's one of the diseases that seems simple 
[0.7] but perhaps isn't so [1.3] perhaps this X-ray is really [1.1] a primary 
example of why [0.2] you think it might be simple what what does that X-ray 
show [2.6] gentleman in the front here [laughter] [2.5] 
sm0380: 
two kidney stones [0.2] 
nm0370: yeah very good two so you don't need to be a doctor you don't need to 
be a medical student to diagnose that [0.2] you see the spine you see the hips 
[0.2] and you see a couple of kidney stones [0.3] and what why do you think 
they're kidney sto-, what makes you say they're kidney stones 
sm0380: they're calcified 
nm0370: okay [0.2] so they're calcified [0.4] in fact most kidney stones are 
calcified [0.2] how many [0.3] kidney stones are calcified [2.6] guess 
calculate a guess if you don't know [1.0] 
sm0381: eighty per cent 
nm0370: eighty per cent eighty per cent are calcified and therefore you can see 
on a plain X-ray [0.2] but twenty per cent aren't [0.8] there are twenty per 
cent of trains you can't see [0.6] so it's suddenly becoming a more interesting 
disease so tell me about the [0.2] stones you can't see these two ladies [1.6] 
what are they made of stones you can't see [0.6] on a 
plain X-ray [0.9] 
sf0382: urate [0.4] 
nm0370: urate yeah what percentage of stones are urate stones [1.4] 
sf0382: two per cent [0.4] 
nm0370: about seven per cent [0.2] okay [1.3] and [0.3] there are a lot of 
causes of stone disease [0.3] and [0.6] in the first stage of this talk i'm 
going to talk about [0.3] the aetiology of stone disease c-, causes of stone 
disease and then we'll go on to [0.4] the treatment what we're going to do 
about it [0.6] so first of all [0.3] tell me somebody [0.2] the [0.3] most 
likely composition of that stone [4.1] i'll give you a clue [2.1] calcium [1.1] 
sf0383: phosphate 
sm0384: phos-, 
nm0370: sorry [0.6] 
sm0384: phosphate 
nm0370: no [0.3] 
sm0385: oxalate [0.3] 
nm0370: oxalate okay [2.6] so about [0.7] seventy-five 
per cent [0.4] of the calcium containing stones which are eighty per cent of 
all stones contain calcium oxalate [0.5] and in fact [0.2] the pathogenesis of 
these stones is ill understood [0.4] one of the [0.2] oldest operations in the 
history of mankind is what [1.2] what did the Egyptians [0.2] do [1.2] to 
people with stone disease [3.2] schistosomiasis the Nile [0.4] papyrus rolls 
tell me about the Egyptians [3.6] you're not a group of medical historians here 
[1.4] [laughter] but one of the earliest operations recognized by mankind is 
cutting for stone and Egyptians [0.3] used to cut for stone by putting a cut 
through there [0.3] so [0.2] bit of wine bit of beer and they used to cut into 
the patient's abdomen to remove stones but this is [0.3] one of the oldest 
diseases [0.5] in the history of mankind and one of the oldest operations in 
the history of mankind [1.4] okay [0.2] so would anybody like to be brave [0.4] 
and tell me [0.3] er about the pathogenesis [0.4] of [0.6] kidney stone disease 
in other words [0.4] the common causes of the common stones we've been talked 
about who's going to be brave and [0.3] tell me about some risk factors [2.5] 
sm0386: 
infection [0.4] 
nm0370: infection yes [2.6] 
sm0387: dehydration 
nm0370: dehydration yes more common in hot countries [2.0] 
sf0388: is it more common in men [0.5] 
nm0370: more common in men nobody knows why but almost all kidney disease is 
more common in men [0.4] i personally think it's because we don't get pregnant 
and women [0.3] er get all this lovely twenty-four-thousand mile service when 
they're pregnant and [0.3] all these diseases are found out and us men are left 
to rot [0.4] [laughter] in our forties and fifties and then we get stone 
disease and heart attack [0.5] and we leave our young wives [0.8] er [0.3] okay 
[3.5] [laughter] so who's going to help out the people at the back tell me [0.
3] a bit more science tell me about some of the things that are in the wee wee 
or not in the wee wee that [0.3] predispose to stone disease 
sm0389: 
diabetes [0.4] 
nm0370: diabetes no [0.7] well yes and no yes via papillary necrosis yes but [0.
2] yes and no [3.7] let's see how much reading you've been doing [0.2] 
sm0390: urate crystals 
nm0370: okay so there are certain abnormalities in the urine [0.3] that 
predispose to stone disease and what the urine is [0.4] is [0.2] a solution [0.
3] of [0.3] salts [0.7] and most of those salts are at a near supersaturation 
level [0.5] so in other words you don't have to do much to the urine for the 
salts to come out of solution [0.7] and some of the salts are as follows [0.3] 
urate at the back [0.2] anybody else like to offer any others [0.5] 
sm0391: cysteine [0.4] 
nm0370: cysteine that's y-, yes that's more of a specific you're right but more 
of a specific cause of stone [0.6] urate [0.4] calcium oxalate [0.3] if you 
have high levels of those in your urine that predisposes 
you to stone disease and low levels of cysteine [0.6] again how these factors 
interact we don't really understand [0.8] but there's a fair amount of evidence 
that people with any of those abnormalities are more likely to get stones than 
other people [0.4] it doesn't say it's a cause it's a risk factor [0.4] tell me 
about some more specific causes gentleman at the front cysteine anybody else [0.
9] give me some rare stuff [0.7] infection what type of stones do they produce 
[5.1] it's going to be a long morning isn't it [1.9] [laughter] you weren't 
expecting questions fired at you were you [0.6] you just lecture [1.1] don't 
want to be embarrassed at the front [1.3] struvite stones so-called infection 
stones [0.3] interestingly more common in women why do you think that is so [0.
7] 
ss: 
nm0370: speak up [4.1] it's 'cause women [0.2] are more likely to get U-T-Is 
it's as simple as that so [0.2] some stones most stones are more common in men 
but a few stones are more common in women [0.2] okay [0.3] there 
are some rarer causes of stones that i don't intend to go through today in 
great detail [0.3] there's something called a xanthine stone a 
dihydroxyxanthine stone [0.3] and a load of others you can look it up if you 
want to there are some very rare cause of stones but we're going to [0.2] 
mainly talk about the common causes of stone [0.6] okay [1.2] er [0.3] if you 
were going to choose one of those urinary abnormalities [0.9] as a problem 
which you can sort out in a patient with recurrent stones [0.2] what would it 
be [0.5] what do you think's the most common [0.3] of the things [0.2] that 
i've described so far [0.3] 
sm0392: low urine volume [0.5] 
nm0370: low urine volume yes and no lots of little old ladies drink four-
hundred mls a day and don't die and don't get stones [3.2] probably the calcium 
[0.4] of of the [0.2] risk factors for renal stone disease hypercalcuria [0.2] 
is probably the most important [0.3] in fact sixty per cent of people [0.2] who 
have [0.4] classical calcium oxalate stones [0.3] have [0.2] so-called 
idiopathic hypercalcuria so many of you in this room will 
have it [0.4] has anybody would anybody like to volunteer any normal ranges of 
urinary calcium excretion [1.6] this is a hard one isn't it [0.9] tell me the 
normal calcium there you go that's an easier question gentleman at the front 
you're going to get [0.4] poor chap's [laughter] going to get picked on [0.3] 
chap behind him [0.3] normal calcium level [1.4] 
sm0393: two-point-five [0.6] in plasma [0.4] 
nm0370: okay not bad okay two-point-two to two-point-six so you should know the 
l-, the normal levels [0.3] of all basic bioclinical parameters by now [0.4] 
and if you don't [0.3] i'd like you to learn them [0.5] because you're going to 
need them by the time you hit the wards [0.3] er [0.2] and you don't need to 
know the normal twenty-four hour urine excretion [0.2] i'm er i have to look it 
up [0.4] and er one to four millimole per twenty-four hours [0.5] of urine [0.
5] and there's an arbitrary line of over seven-point-five for men and 
six-f [0.3] point-two-five for women [0.3] but interestingly [0.3] er eight per 
cent of normal people [0.5] er who don't have stones [0.2] have so-called 
pathological hypercalcuria [0.2] what what does that tell you [1.2] if eight 
per cent of normal people have high levels of calcium in their urine [1.7] 
sm0394: there's something else there 
nm0370: yeah there are other factors involved and clearly this is only one 
factor [0.3] but it also tells you how we get normal ranges [0.3] how do you 
think [0.3] just as a slight aside how do you think [0.3] there's a clue how do 
we get normal ranges how do we develop these numbers of normal ranges two-point-
two to two-point-six [1.2] where do they come from [3.0] 
sm0395: a statistical average 
nm0370: statistical average but where do we get the data [1.8] 
sm0395: patient data 
nm0370: patient data where do we get that from 
sm0395: 
hospitals [0.2] 
nm0370: hospitals [0.2] which hospital where when [0.7] 
sm0437: renal wards 
sf0396: renal wards [0.3] 
nm0370: renal wards no not particularly i mean a lot of our normal ranges are 
taken from old studies of vast numbers of [0.5] er white [0.2] American males 
entering the army fifty years ago [0.2] and ma-, many of our normal ranges are 
completely wrong [0.4] er [0.2] but even if they are right [0.2] we still have 
to develop a normal range and what we do is we screen a vast [0.6] number of 
the population several thousands [0.2] and we say the normal range is within 
two standard deviations of the mean [0.9] and what's wrong with that [0.2] as a 
method of describing a normal range [8.3] 
sm0397: there's another five per cent of the population outside of that 
nm0370: very good okay so there's five per cent of normal people [0.8] se-, 
people who are seven foot 
tall aren't necessarily ill neither are people who are four foot tall [0.7] and 
it may be that people [0.2] either end of the normal range [0.4] er [0.2] the 
normal range are perfectly normal [0.8] so whenever you hear about a normal 
range and people hit you with statistics like i've done this morning you've got 
to think about how we develop those normal ranges what do they mean [0.3] so 
the fact that as i told you eight per cent of people who don't have stones [0.
2] have hypercalcuria [0.3] means [1.6] nothing [0.6] means absolutely nothing 
[0.2] it may be these are just normal people [0.3] tail end Charlie four foot 
people or seven foot people [0.3] so you should analyse [0.4] er at the end of 
this talk i'm going to give you a list of fifty facts and i want you to [0.3] 
analyse these facts [0.3] with er some degree of caution [0.9] okay [0.6] er [0.
3] tell me a little bit now about some more specific causes of [0.2] kidney 
stones right so we've had cysteine at the front [0.5] er [0.3] 
wh-, we've had infection and [0.3] a variety of other things at the back [0.4] 
what [0.2] anatomical problem might predispose you to stones [1.2] 
sm0398: stric-, 
sm0399: stricture [0.5] 
nm0370: strictures okay pelvic utero junction obstruction yeah [0.2] anything 
else [3.9] i'll give you a clue [0.9] this is a kidney [0.2] kidney-shaped 
thing [1.5] just for my own interest how big is a kidney [0.9] roughly [3.8] 
these two ladies [0.7] how big is a kidney [1.5] it's about the size of your 
fist okay [0.4] it's twelve by six by three [0.6] er with a minimum [0.3] er [0.
2] height vertical distance of ten centimetres [0.2] about a hundred-and-fifty 
grams one of the smallest [0.4] organs in the body it takes [0.5] a [0.2] fifth 
of the cardiac output so it's very important it's very small and i like it [0.
6] er [0.5] [laughter] so [1.2] now i've given you a few clues so [0.9] what 
other anatomical problems might predispose to stones we've said strictures [10.
2] okay [0.9] well what do you think [0.7] these bits of the kidney are called 
er [3.3] you've done lots of anatomy what are they called [3.8] 
sf0400: calyces [0.4] 
nm0370: calyces okay [0.3] can the calyces fall off [3.3] yeah what process 
leads to the calyces falling off [1.2] 
sm0401: [0.6] 
nm0370: sorry [4.4] oh dear [1.1] okay anybody [0.2] what process do you think 
could lead to the calyces falling off [0.2] i mentioned it already [3.5] okay 
papillary necrosis so there's [0.3] which has er [0.3] a variety of causes 
between diabetes sickle cell disease and lots of other causes [0.3] and these 
can fall off [0.7] block the drainage system stones can form behind it [0.3] 
cancers 
any obstruction [0.3] to the urinary tract anywhere where there's stasis [0.3] 
it can lead to [0.2] worsening in the supersaturation of the urine [0.6] so as 
well as having [0.2] the [0.5] biochemical [0.3] risk factors that we've talked 
about so far there are also anatomical risk factors to kidney stone disease [0.
8] okay [1.7] er [2.3] cystinuria just slight aside [0.6] gentleman mentioned 
it er at the front there [0.4] er [0.3] coming back to cystinuria [6.4] if you 
don't know anything [0.5] say you don't know [0.7] it's all right not to know 
[0.7] does anybody want to help him out [1.0] why is it important [8.9] no [1.
0] anybody [0.8] tell me a sentence about cystinuria [0.6] 
sm0401: it's hereditary 
nm0370: hereditary very good okay and that's why it's important [0.7] and a few 
causes of stones are hereditary [0.4] and therefore [0.5] if you find a patient 
with cystinuria [0.4] you might do what [0.7] 
sm0402: do an intensive history 
nm0370: yeah look at the rest of the family [0.3] you know look at the parents 
look at their children [0.2] 
warn them that they're going to develop kidney stones [0.6] they don't kill you 
but they're bloody irritating [0.5] they're very common [0.3] cystinuria [0.2] 
some studies up to three per cent of stones are [0.2] undiagnosed cysteine 
stones [0.6] and so this is important inherited cause [0.3] of kidney stones 
and there is very effective treatment for it [1.5] okay [1.0] er [0.7] now then 
[0.3] let's talk about how kidney stones present [0.6] let's er [0.3] pick on 
somebody else now [0.2] this gentleman here [0.2] how do you think kidney 
stones present [0.3] 
sm0403: pain [0.5] 
nm0370: pain 
sm0403: you can have pain in [0.7] even 
nm0370: okay very good so pain pain is the hallmark of kidney stone disease [0.
5] okay [0.2] tell me about the pain of kidney stone disease [0.4] 
sm0404: er acute [0.3] sharp pain [0.2] 
nm0370: yes 
sm0404: in the flanks 
nm0370: very good anything else about it [0.8] you're right [0.9] 
sm0404: er i don't know [3.8] 
nm0370: anybody want to help him out [0.4] 
sm0405: it moves [0.6] 
nm0370: 
it moves [0.3] particularly it radiates through the 
sm0405: spine to groin [0.4] 
nm0370: yeah loin to the groin [0.2] to the testicles in a man [1.1] 
sm0404: is it spasmotic as well [0.4] 
nm0370: yeah tell me more about the spasmodic nature of renal colic [0.8] what 
you're getting at [1.4] 
sf0406: er 
nm0370: what is a colic 
sm0407: contraction 
sm0405: the contraction's quite like an obstruction 
nm0370: very good okay [0.4] so the three main forms of colic [0.3] are [0.2] 
gallbladder colic kidney colic interstinal colic [0.3] when do you get 
interstinal colic [0.6] when you want to go for a poo [1.2] [laughter] you have 
faeces obstructing [0.4] your bowel [0.3] the bowel above the faeces contracts 
down on it and it causes pain and that's when you get colic you know it 
yourself [0.3] you're sitting there you're dying to get out of this lecture you 
really want to have a poo [0.3] it's a [laughter] big poo 
you've been building up to it [0.5] you had a curry last night [0.5] this is an 
important poo [0.3] [laughter] and you feel pain [1.0] in the tummy [0.3] and 
that's colic that's interstinal colic [0.2] and renal colic [0.2] is exactly 
the same type of pain [0.2] but much much worse and it's said to be [0.2] one 
of the worst of all pains [1.5] but there is a group of people that know it's 
one of the worst of all pains [0.5] who traditionally likes to mimic [0.6] 
renal colic and why [0.8] 
sm0405: drug addicts 
nm0370: drug addicts okay [0.2] it's very common for drug addicts to present to 
A and E [0.4] er with renal colic [0.3] and er there's probably a couple [0.2] 
er in this lecture at the moment [0.3] er trying to [0.2] er get some hints how 
to pretend to have renal colic [0.4] er [0.2] and when you're [0.2] housemen 
and S-H-Os it's important to look for people [0.3] who are pretending to have 
renal colic 'cause what they want you to do is give them some pethidine or some 
morphine or diamorphine [0.4] and er it's one of the classic catches [0.5] er 
[0.2] so renal colic is 
like all colics it's a spasmodic pain in other words [0.2] you have no pain you 
have terrible pain you have no pain you have terrible pain [0.5] and 
classically when there is no pain there is zero pain [1.0] so you go from 
complete absence of pain to severe pain [0.5] and a patient with renal colic [0.
3] usually writhe around while they're having an attack [0.6] and then when 
they're not having an attack they're absolutely fine so there is a classical 
picture of people with renal colic [0.7] but unfortunately it's not that easy 
[0.9] er [0.2] pain is not the only way in which kidney stone disease presents 
[0.3] wh-, why do you think pain is [0.2] not the only way in which kidney 
stone disease presents [5.0] 
sm0408: you're obstructing urine output 
nm0370: yeah [0.5] in other words the stones may have appeared [1.7] finish my 
sentence [2.4] [laughter] it's like Blankety Blank this [1.6] the stones may 
have appeared [0.7] adverb [1.3] two syllables [0.9] [laughter] [0.4] 
sm0409: 
in the [1.0] er [laughter] [0.3] 
nm0370: slowly [0.9] so if things happen slowly in the human body [0.3] 
classically the pain [0.3] acquired related to that particular problem [0.3] er 
is non-existent [0.3] in other words there is no pain [0.6] er and this is true 
of many systems of the body if something grows slowly [0.4] the body becomes 
accustomed to it [0.4] and so it is possible to have severe [0.9] kidney stone 
disease [0.3] without causing obstruction nephropathy which can lead to 
dialysis transplants and everything horrible [0.3] meeting Dr namex [0.6] er [0.
4] and therefore we have to be diligent about looking for stone disease in 
people who don't have pain the pain is not the only presentation pain is the 
classical presentation [0.5] what are er some other atypical presentations of 
stone disease 
sm0410: haematuria 
nm0370: yeah haematuria [0.3] very good [0.3] macroscopic haematuria [0.4] er 
again it's pretty unusual pain is much 
more common anything else [2.8] 
sm0411: unconsciousness [0.6] 
nm0370: yeah yeah no true you know it [0.3] possible if you [0.3] er if you 
ruptured one kidney completely went into acute renal failure eventually you'd 
become unconscious and i've seen that happen [1.3] well [0.2] infection caused 
by the stasis behind the stone [0.9] can be a presentation [0.2] of kidney 
stone disease [0.4] and they say that [0.3] a single urinary tract infection in 
a man should always be investigated [0.2] women [0.3] don't matter too much 
you're always having U-T-Is [0.3] [laughter] soon as you become sexually active 
you start having U-T-Is perfectly normal [0.6] that's [0.3] er the name of the 
game can't do anything about it have one a year [0.3] it'll go away if you 
don't have antibiotics it'll go away if you do have antibiotics it's not 
serious and it's not going to cause kidney stone disease [0.9] but sometimes [0.
5] if a woman changes her pattern of U-T-Is from one a year or whatever [0.5] 
er then it may be a sign that 
she's developing a stone and if a man ever gets an infection they should always 
be investigated for stone [0.6] okay [0.4] so there are differences in the way 
we investigate men and women [0.9] er who do you think these [0.2] er patients 
present to [0.9] lady with the brown jumper there [0.5] who 
sf0412: G-P [0.2] 
nm0370: G-P yeah [0.2] quite often they'll go to their G-P first [0.3] and if 
they're not too bad [0.3] if they're bad where do they go 
ss: A and E 
nm0370: yeah they'll probably go up to A and E [0.2] and this is a problem 
'cause they're are coming up [0.2] and the pain is pretty bad so if you 
genuinely have it you also tend to go [0.3] fairly rapidly to A and E [0.8] and 
[0.3] they [0.2] go through a nice system [0.2] you see a triage nurse [0.3] 
Tony Blair ticks his boxes [0.2] [laughter] the patient is seen between four 
hours [0.3] you know all 
about that game don't you there'll be there'll be triage nurses and as soon as 
you see them we tick the box [1.4] and then we falsify all the data [0.3] to 
make us oh oh sh-, i'm on camera [0.4] [laughter] er [0.5] the er [1.1] to make 
sure that our hospital gets enough stars [0.4] anyway [0.2] er that's another 
story [0.8] so the patient comes up to A and E they're seen by a triage nurse 
[0.2] oh dear this might be renal colic and who who are they [0.9] pushed 
towards [3.6] 
sm0413: X-ray [0.2] 
nm0370: X-ray so they have an X-ray then what happens [0.3] who who who [0.4] 
who are they then next seen by [0.3] 
ss: surgeon 
nm0370: a surgeon [0.5] and this is a disaster [0.6] [laughter] when they see a 
surgeon [0.3] why is it a disaster they see a surgeon [3.6] 
sf0439: [0.9] 
nm0370: 
'cause they're completely non-thinking people who couldn't be physicians 
[laughter] is that what you said 
sf0414: yeah [0.2] 
nm0370: [laughter] okay [0.3] okay sorry i don't i don't don't let me put words 
in your mouth though [0.3] [laughter] er [1.7] oh that's on camera as well [0.
4] [laughter] er [1.7] no surgeons are good [0.5] because [0.5] they know how 
to get rid of the pain and they can spot white things [0.3] and they can spot 
it when they don't come out and then they know [0.9] what they have to do next 
[0.4] why are surgeons bad for kidney stone disease bearing in mind the 
epidemiology which we've talked about [0.6] 
sf0415: they only treat the problem [0.3] 
nm0370: sorry they don't look for the cause [0.5] and in many patients there is 
an identifiable cause [0.8] but there's one famous [0.2] American study where 
ninety-seven per cent of people in this study were 
found to have some form of biochemical abnormality [0.3] which some people 
wouldn't consider a cause [0.8] and are ninety-seven per cent of stone form is 
investigated course they're not [0.5] who [0.2] who do you think that the 
thinking surgeon tends to investigate [3.5] let's have some [0.4] er comments 
from the back so [0.3] two ladies with the scarves there [0.5] who's the 
thinking are you going to be a thinking surgeon [1.2] don't know yet [0.4] 
[laughter] okay [0.3] who do you think the thinking surgeon investigates [3.9] 
hundred-thousand people having stones every day [0.8] can't investigate them 
all [2.0] who do you think they who would they focus on [1.8] lady with the 
pink scarf [0.4] 
sf0415: no idea [0.2] 
nm0370: no idea lady next to her [0.8] 
sf0416: anyone with a family history 
nm0370: yeah good so if they've got a family history [0.2] they'll spot that [0.
8] if they're asked the question [1.3] 
but if they don't [0.7] oh yeah my mum had stone my grandmother [0.5] we've all 
got stones but don't know why [0.4] and er [0.2] so they don't particularly [0.
2] er investigate the people who should be investigated [0.4] er what most 
surgeons do is that they can count they can count up to [0.5] two [0.7] 
[laughter] and that's very important [0.4] for kidney stone disease because [0.
6] on the second stone which is the number [0.4] after one [0.2] [laughter] 
they know to investigate it and that's [0.2] what most surgical practice is [0.
3] they investigate people after the second episode of stone [0.3] unless the 
stones are particularly horrendous like those ones [0.2] or they have a 
staghorn calculus or something like that [0.3] what's a staghorn calculus okay 
it looks like a staghorn but [0.3] lady there [0.2] what do you think causes 
staghorn calculi [2.2] 
sf0417: 
i don't know [0.9] 
nm0370: anybody [1.2] 
sm0418: is that just still in the kidney 
sm0419: 
nm0370: sorry 
sm0420: is it still in the kidney [0.3] 
nm0370: still in the kidney [1.2] it's called staghorn because it looks like a 
staghorn [0.3] because it fills up the whole of the pelvic-caliceal system [0.
4] and some people would say that what i'm a-, what i'm trying to draw here is 
vaguely like the staghorn [3.2] what predisposes to staghorn calculi [0.4] 
which interestingly often don't present as pain [1.6] infection infection 
stones [0.5] er [0.3] so these are particularly common in women [0.4] and [0.4] 
a surgeon will know to investigate something like that because it's bad and 
it's big and it looks like a staghorn [0.9] and now [0.7] okay i've stood here 
as a physician slagging off my surgical colleagues who i work with on a daily 
basis [0.5] and [0.3] er [0.6] why do you think it's actually a good idea that 
they don't investigate [0.6] everybody [0.3] with a single stone [2.2] 
gentleman here [0.2] why is it a good idea not to investigate [4.3] we talked a 
bit about the epidemiology at the start [1.5] 
sm0421: 
because it's so common [0.2] 
nm0370: it's so common [0.8] and we can't possibly be investigating five-
million people [0.6] because it's too expensive [0.3] and you could argue [0.3] 
that er it doesn't really matter anyway 'cause they don't kill you and most 
people have one episode maybe two in their lives [0.2] it doesn't cause kidney 
failure [0.2] it doesn't cause obstruction [0.2] it doesn't cause any major 
problem [0.2] so it may be yet another way in which the N-H-S cuts corners by 
[0.2] only investigating people with [0.2] two or more stones [0.8] okay [0.3] 
who do who do you think [0.2] in most er [0.7] er [0.5] centres centres of 
excellence like Coventry actually [0.2] sets up kidney stone disease clinics [1.
5] it's a trick question [1.3] 
sm0422: nobody [0.2] 
nm0370: nobody absolutely nobody [0.2] there is no specialist [0.3] kidney 
stone disease clinic in Coventry in fact many of [0.3] the the big cities in 
the U-K unless a doctor has a particular interest in kidney stones [1.6] one of 
our surgeons does have [0.6] some 
interest in kidney stones [0.2] but it's not his primary interest [0.6] and 
none of the six nephrologists here have a particular interest in kidney stones 
so one of the commonest diseases [0.3] of all time [0.3] is [0.2] not looked at 
by anybody in particular just by a mishmash of people [0.6] and therefore 
mistakes are made [0.3] there is nobody to refer to [0.3] and in fact in the U-
K there are almost centres with an interest [0.3] in kidney stone disease there 
was one [0.3] at U-C-L in London i don't know if it's still going [1.2] er so 
there you go do your PhD the pathophysiology of stone disease become famous [0.
4] go on world tours set up a clinic in namex [0.3] [laughter] and you might do 
some good [0.2] okay [0.8] so [0.6] we've talked a bit about their presentation 
[0.2] what about their investigation [0.4] okay let's pick on somebody else 
gentleman with the [0.4] Nike black top tell me [0.2] how you'd like to 
investigate somebody who presents with a kidney stone simplest test first 
remember [0.3] bit of a 
touchy-feely namex students we do nice simple things first [0.4] [laughter] we 
don't go for M-R-Is [0.4] 
sm0423: X-ray [0.3] 
nm0370: X-ray [0.3] wrong [0.3] okay [0.2] it's simpler than that [0.4] anybody 
else 
sm0424: U-neg [0.8] 
nm0370: wrong simpler than that 
sm0425: palpate [0.4] 
nm0370: sorry [0.4] 
sm0425: palpate [0.4] 
nm0370: palpate well we've moved [0.2] you're right we would do that but we've 
moved on from [0.5] simple very simplest the most simple test of wee wee [0.2] 
sf0426: give us some clue [0.6] 
nm0370: giving you a clue [0.3] 
sf0427: a dipstick [1.0] 
sm0428: speaking of what are we testing for [laughter] [0.6] 
nm0370: a urinary dipstick [0.2] okay [0.2] possibly the simplest test of urine 
and possibly one of the most important [0.5] er [0.2] it can tell you lots of 
things [0.5] lots of things like whether there's protein in the urine [0.2] 
blood in the urine which would be consistent with stones [0.3] or is it [1.0] 
what is the blood [0.6] on a urinary dipstick caused by [1.7] the blood in 
inverted commas [1.1] 
sf0429: er lysis of red blood cells [0.3] 
nm0370: very good [0.3] so if you forget everything i say this morning [0.5] 
just remember this that the blood on a urinary dipstick [0.3] is not due to 
blood cells [0.4] it's due to haemoglobin in other words the lysis of blood 
cells [0.3] and why is that so important [0.2] and why do so many surgeons 
therefore [0.3] put people into acute renal failure [0.5] you've got to think 
laterally now [0.5] lady with the blue headband there [1.2] so why is that so 
important that the urinary dipstick does not measure blood cells [0.6] it [0.2] 
measures a component of blood why does that lead to so many clinical errors [1.
4] which you're not going to make 'cause you're never going to forget this 
'cause i've picked on you [1.2] right 
anybody help her out [0.8] 
sm0430: all the remaining debris from the cell is stuck in the kidney 
nm0370: yeah and [2.3] there are many other causes of haemoglobinuria other 
than [0.8] diseases where there is haematuria [0.5] so there are many causes of 
haemoglobinuria myoglobinuria [sneeze] et cetera all of which will give you a 
false positive blood inverted commas on [0.2] the urinary dipstick [0.4] so it 
is it is a good test and it's a bad test [0.3] and the reason it needs surgeons 
to call if you've an acute renal failure [0.2] is somebody presents with a 
stone [0.2] what do they do history examination blah blah blah lots of blood 
tests yah-dah-dah [0.2] X-ray I-V-Ps their standard first line investigation [0.
3] which contains nephrotoxic dye [0.5] and therefore somebody who's dyed about 
every rhabdomyolysis because some other [0.5] cause [0.2] is having an 
unnecessary investigation which will make them worse [1.0] and i have in my 
time saved a few people from [0.2] acute renal failure by [0.2] stopping 
surgeons do I-V-Ps [1.5] 
nf0432: 
five minutes 
nm0370: okay [0.7] so if you forget everything else i say today just remember 
that [0.9] that the blood on a urinary dipstick [0.3] is not [0.3] made 
positive by blood cells it may be [0.8] okay so other tests beloved of kidney 
doctors other than a urine analysis let's stick with the lady in the blue 
headband [0.4] the other simple test of the urine [3.2] other than putting a 
dipstick in [1.1] what would [0.5] twenty years ago if you were my houseman i 
was your consultant what would i be expecting you to do for my 
ss: taste it [0.7] 
nm0370: taste the urine possibly [laughter] [1.9] 
sm0433: sieve it [0.4] 
nm0370: sorry 
sm0433: sieve it [0.5] 
nm0370: 
sieve it and microscope it [0.7] because many causes of kidney stone disease 
can be diagnosed on microscopy unfortunately [0.3] it's a skill that most of us 
have now lost or forgotten [0.3] and [0.8] maybe i'm harking back to the good 
old days [laughter] when things were better when we had leprosy and T-V and 
[laughter] social deprivation but it was quite good fun to be able to make 
diagnoses by microscoping the urine which we no longer do and [0.2] some 
disease particularly s-, cysteine disease [0.3] where there's a classic type [0.
3] of benzene ring crystals can be diagnosed from simple microscopy of the 
urine you don't need any fancy tests [0.7] so yes [0.5] we go to do blood tests 
yes we go to do X-rays but we do simple tests first [0.3] an M-S-U probably [0.
3] basic blood tests including [0.2] a serum [2.4] what [0.2] 
ss: calcium 
nm0370: calcium why [0.8] 
sm0434: 
[0.3] 
nm0370: yeah well it's one of the commoner rare causes [0.3] so but most people 
with hypercalcuria are not hypercalcaemic so [0.2] everybody does the count and 
it's almost always normal and i think this is one of the reasons why [0.2] 
surgeons get fed up with investigating people with stone disease 'cause 
everything's always normal [0.3] but if they look for the things which were 
there they would find them to be abnormal in a lot of people [1.0] so we do 
those simple tests [0.3] er we do it twenty-four hour urine looking for calcium 
urate oxalate citrate all the other things [0.4] but you have to know how to 
interpret them and that's where it becomes a lot harder and again this may be 
[0.2] one of the reasons why most of these patients are not investigated [1.6] 
so plain X-rays are probably [0.2] the single most useful test in eighty per 
cent of people with greater instance of stones which is why [0.2] i brought 
that one up today [0.4] but most surgeons would do an 
I-V-P [0.3] as well as a plain X-ray why would they want to do an I-V-P give 
horrible nephrotoxic dye [0.4] with significant mortality [0.4] 
sm0435: want to check behind the stone [0.8] 
nm0370: yeah [0.2] to see if there's any obstruction behind the stone [0.7] er 
to see if they they need to do anything quickly [1.3] what size stones pass 
naturally [3.9] calculated guess if you don't know [0.9] 
sm0436: couple of millimetres [0.4] 
nm0370: sorry 
sm0436: couple of millimetres [0.2] 
nm0370: yeah less than four and we would watch a patient with a stone of less 
than four [0.2] millimetres [0.2] four above usually requires some form of 
intervention [0.4] how can we intervene how can we [0.2] extract stones [0.2] 
lady with the brown top on again [1.2] 
sf0412: er [4.4] blocked by the er 
nm0370: ex-, speak up sorry shush everybody listen [0.3] 
sf0412: 
[laugh] [0.4] er i don't know [0.5] 
nm0370: this again we sometimes shout at the stones we can use sound waves to 
shout at the stone [0.5] sometimes we can go up there pull them out and various 
[0.5] er [0.4] horrible instruments [0.2] er usually done under G-A though not 
always [0.3] er [0.2] we can use a Foley basket we can shatter them we can get 
them out there are various ways of doing that [0.3] the last resort is an open 
operation doing what the Egyptians did it does work [0.5] er [0.2] but er it 
does leave quite a big scar [1.0] okay [1.1] so they're the investigations we 
tend to do [0.2] on patients with [0.2] recurrent kidney stone 
disease and perhaps we should investigate them all [1.0] er [0.4] finally [1.0] 
er [0.4] i'd like to now convince you [0.3] that this disease which you all 
thought was boring [0.3] er unimportant and like trainspotting is not such a 
boring trainspotting disease [0.2] first of all 'cause about ten per cent of 
you roughly are going to have one of these in your lifetime [0.4] it's going to 
hurt [0.4] it's going to [0.5] stop you from going to work and is likely to 
happen again [0.9] and [0.3] if we did make some effort to get interested in a 
disease which is about as interesting as trainspotting [0.3] we might be able 
to stop some of these attacks from happening [0.7] okay thank you very much