Did This Get Lost In The Covids?
In October 2019, I wrote Asthma Carbon Footprint ‘As Big As Eating Meat’ and it made me think, when I just read it.
I would normally follow up a post like this, but I don’t remember doing anything like that.
The Wikipedia entry for the COVID-19 pandemic in England, starts with this paragraph.
The COVID-19 pandemic was first confirmed to have spread to England with two cases among Chinese nationals staying in a hotel in York on 31 January 2020.
It looks to me, that like everybody else in England, I had the Covids on my mind.
Is Respimat A Zero-Carbon Inhaler?
Just to be sure, I asked Google AI, the question in the title of this section and received this reply.
The Respimat soft mist inhaler is considered to have virtually no associated carbon emissions from its operation because it does not contain the high global warming potential (GWP) hydrofluorocarbon (HFC) propellants found in metered-dose inhalers (pMDIs).
While it has a substantially lower carbon footprint than traditional pMDIs, it is not strictly “zero-carbon” when considering its entire life cycle, which includes manufacturing, materials (stainless steel, aluminium, polymers), and end-of-life disposal. These factors contribute a small product carbon footprint (PCF).
According to Google AI, a reusable version is available.
A reusable Respimat device has been introduced, which further reduces the carbon footprint by up to 71% over six months compared to the disposable version because the device itself is kept longer, reducing manufacturing impacts.
Google AI says this about NHS guidance.
Health bodies like the NHS encourage the use of lower-carbon inhalers like the Respimat or dry powder inhalers (DPIs) as part of their net-zero targets, provided they are clinically appropriate for the patient.
But it does seem that Respimat devices are helping to cut global warming.
What Is The Patient Experience Of Respimat?
Google AI gave this answer to my question.
Patient experience with the Respimat inhaler is generally very positive, with high satisfaction for its ease of use, handling, and the “soft mist” it produces, leading to high continuation rates in studies; patients find it easier than many older devices and report good effectiveness, though common side effects like dry mouth, cough, and sore throat can occur.
Key Aspects of Patient Experience
- High Satisfaction: Over 85-90% of patients report being satisfied or very satisfied with the Respimat’s handling and the ease of inhaling the mist.
- Preference Over Other Devices: Many patients prefer Respimat over traditional metered-dose inhalers (pMDIs) or dry powder inhalers (DPIs), finding it easier to use and more effective.
- Soft Mist Technology: Patients appreciate the gentle, slow-moving mist, which helps deliver medication effectively and feels different from a typical puff.
- Good Adherence: High satisfaction often translates to continued use, with physicians reporting high patient adherence and continuation rates after studies end.
- Improved Technique: While initial use might need guidance, pharmacist-led interventions show significant improvements in patients’ inhalation technique over time.
That doesn’t look bad to me!
Could Immunotherapy Drugs Be Delivered By An Inhaler?
We always felt the device could deliver other drugs.
Google AI gave this answer to my question.
Yes, immunotherapy drugs could potentially be delivered by an inhaler, and this approach is a promising area of active research and development, particularly for treating lung cancer and respiratory diseases like asthma.
Rationale and Research
- Targeted Treatment: Inhaled delivery allows for high concentrations of the drug to be delivered directly to the lungs, which is particularly beneficial for treating lung-specific conditions like lung cancer or severe asthma. This localized approach aims to maximize the therapeutic effect where needed.
- Reduced Side Effects: By concentrating the medication in the lungs and minimizing its systemic absorption into the bloodstream, researchers hope to significantly reduce the severe side effects (e.g., systemic toxicity, autoimmune reactions) commonly associated with traditional intravenous or oral administration of some immunotherapies and chemotherapies.
- Patient Convenience: Inhalation is a non-invasive administration route, which is more convenient and comfortable for patients compared to injections or intravenous infusions, potentially allowing for self-administration and improving patient compliance.
The Soft Mist Technology could surely be a help!
Was Osborne Reynolds The Greatest Fluid Dynamicist?
I have to ask Google AI this question, as some of the discussions that led to creation of Respimat, took place in my house at Debach, where Osborne Reynolds had lived.
Google AI gave this answer to my question.
Osborne Reynolds is considered one of the most influential and foundational contributors to the field of fluid dynamics, though naming a single person the “greatest” is subjective. His work fundamentally shaped modern engineering and physics and remains central to the study of fluid flow today.
Key Contributions to Fluid Dynamics
Reynolds’ most significant achievements include:
- The Reynolds Number: He identified a crucial dimensionless parameter (now named the Reynolds number) that determines whether fluid flow is laminar (smooth and orderly) or turbulent (chaotic and eddying). This number is a foundational concept used across all engineering and physical sciences.
- The Theory of Turbulence: In an 1895 paper, he established the standard mathematical framework used in the study of turbulence, introducing what is known as the Reynolds-averaged Navier–Stokes equations.
- Experimental Validation: His elegant, yet simple, dye experiments visually demonstrated the transition between flow regimes, providing clear empirical evidence for his theories.
- Theory of Lubrication: He developed the Reynolds equation in 1886, which still underpins the analysis of hydrodynamic lubrication in modern bearings.
- Heat Transfer and Similitude: His research into heat transfer between solids and fluids led to significant improvements in boiler and condenser designs, and his work on hydraulic similitude enables engineers to use scaled-down models (e.g., in wind tunnels for aircraft design) to predict the performance of full-scale machines.
How Many Good Ideas Did The Covids Delay?
It could be that the roll-out of Respimat for was delayed by the Covids!
But it wouldn’t have been the only idea to have been delayed in that way!
Can A Broken Humerus Affect Your Hand And Wrist Long Term?
Sixty-four years ago, my left humerus was broken at school and I don’t think the local hospital fixed it too well. I also don’t think I had the best of physiotherapy, after some of my experiences with physios since my stroke, which have been of a generally very high-quality, from both the NHS and private physiotherapists.
The wrist has not been misbehaving itself recently, so I asked Google AI, the question in the title of this post and received this reply.
Yes, a broken humerus can affect your hand and wrist long-term, especially if a nerve like the radial nerve is injured during the fracture or surgery. This can cause temporary issues like wrist drop, which is the inability to extend the wrist and fingers, often improving with therapy. In rare cases, if nerve recovery is incomplete, surgical procedures may be necessary to restore function, though most fractures have an excellent long-term outlook with proper rehabilitation.
Note.
- I certainly didn’t have proper rehabilitation in 1961 at Highlands Hospital in Winchmore Hill.
- I wonder if I have actually suffered from wrist drop in recent years.
- I suspect that now there are better treatments available.
Google seem to have scraped the article from the respectable Cleveland Clinic.
Why Has My Left Humerus Got Worse In The Last Few Months?
I wonder, if it is new BYD buses on route 141.
- I always sit or stand downstairs, as at 78, I don’t want too risk climbing the stairs.
- The buses are more pokey and the seats are narrower than say a Routemaster or other British bus.
- On Routemasters and other British buses, I usually sit on the far-right seat to protect the humerus.
- It is getting increasingly knocked if I sit in the left-hand seat of a right-sided pair, by peoples’ backpacks.
- The seats are narrow on the BYD buses, and if sitting in a left-hand seat of a left-sided pair, my left humerus rubs against the outside wall of the bus. This is worse with a large person in the right seat.
- If I sit in the right-hand seat of a left-sided pair, it’s usually better, but if there’s a large person in the left seat, because of the narrow seats, the arm get knocked.
- On the BYD buses, there are no forward facing seats downstairs on the right side.
- There are some forward facing seats at the right side at the back, but they are difficult for me to climb into.
- The corridor from the front to the back in the bus is narrow and I sometimes bump the left humerus.
- I met a lady with a pram, who finds the corridor narrow for her pram.
- The step-up and down into the bus is higher and puts strain on my knees, unless I get it right.
I do wonder if the BYD buses were designed around smaller oriental people.
I certainly never had these problems, when I was riding on on Routemasters and other British-designed buses.
For the next few works, I will avoid travelling on the BYD buses unless I can sit in the right-hand seat of a pair, by myself.
I can also stand, if the bus isn’t too full. Looking back, I feel, I don’t mind standing on the buses.
I will now be forwarding this post to those that know me well.
Uncomplicated Pancolonic Diverticular Disease And Stress
This afternoon, I found myself in a stressful situation and my gut played up. Was it my uncomplicated pancolonic diverticular disease and stress actually playing up?
So, I asked Google AI if there was a link between uncomplicated pancolonic diverticular disease and stress and got this answer.
While there’s no direct causal link, stress may exacerbate uncomplicated pancolonic diverticular disease, potentially by influencing the digestive system and increasing the risk of anxiety and depression, which are often associated with diverticular conditions. Some theories suggest stress can disrupt the autonomic nervous system, leading to spasms and inflammation that can trigger flares in diverticular disease. Managing stress through healthy lifestyle choices, such as a high-fiber diet and regular exercise, may help reduce risk and support the digestive system.
This doesn’t deny a link, but it would appear to be secondary.
The source used by Google AI is the NHS web site.
As a follow up, I asked Google AI if there was a link between uncomplicated pancolonic diverticular disease and a high-fibre diet and got this answer.
For uncomplicated, pancolonic diverticular disease, a high-fiber diet is recommended to prevent complications by promoting softer stools and preventing constipation. Increase fiber intake by gradually adding whole grains, fruits, vegetables, nuts, and legumes, while also drinking plenty of fluids to aid digestion and prevent bloating. A balanced, high-fiber diet can help manage symptoms and reduce the risk of developing symptomatic diverticular disease.
The source used was this paper on the National Library of Medicine, which was entitled Role Of Fiber In Symptomatic Uncomplicated Diverticular Disease: A Systematic Review.
Surgeon Invents Plastic-Reducing Urine Collection Pot
The title of this post, is the same as that of this article on the BBC.
This is the sub-heading.
A hospital specialist has invented a new product that manages to reduce plastic and simplify the process of testing urine.
These three introductory paragraphs, add more detail.
Consultant urologist Dr Nick Burns-Cox has been working on his own innovation, the Pee-In-Pot (PiP) for 10 years.
Made from bamboo and sugar cane, it removes four items from the current urine collection process, three of them plastic.
Mr Burns-Cox, who works at Musgrove Park Hospital in Taunton, said he hoped it would cut down the use of single-use plastic in the NHS and reduce the chance of errors.
I like the design of this simple device.
But, personally, I hope it becomes universal, as I have trouble giving urine samples.
I had my stroke in Hong Kong and the Chinese nurses, were so aggressive, when it came to taking urine samples, they have given me an aversion to them.
In my view the device could help the patient psychologically, at what could be a difficult time.
Why Do Major Rail Projects Go Over Budget?
The title of this post, is the same as that of this article on Rail Technology Magazine.
This is the sub-heading.
Experts from the National Infrastructure Commission (NIC) will be questioned by the Transport Committee on their work advising the Government on planning major transport projects this week.
This is the introductory paragraph.
The cross-party Committee will ask witnesses, including NIC Chair Sir John Armitt, why infrastructure projects such as HS2 go over budget, how the Department for Transport can manage them more successfully, and the Government’s ability to learn from mistakes or from positive examples in other countries.
In my time, I have written a lot of project management software and it has generally sold well, especially in the fields of aerospace, construction, defence, oil & gas and vehicles. It has also sold well in Australia, France, Korea, Norway, The Netherlands and the United States.
In the UK, two major areas of Government ; rail and the NHS did not use any of my software, despite having large numbers of suitable projects, whereas nationalised companies like British Aerospace, British Leyland and Ferranti were big users. The Chevaline project, which was the refurbishment of the UK’s nuclear deterrent by the Callaghan Government also used my software.
I do find this split strange. A retired MP once told me, that it is traditional.
But Rail and the NHS always seem to get it wrong! Is it because, they are two government departments that deal a lot with the General Public?
On the other hand, the Inland Revenue seem to do better. But my planning software was used to plan the move to Telford!
Perhaps, there is a lot less traditional thinking in the Inland Revenue.
I Had My Fifth Endoscopy Yesterday And The Fourth Without A Sedative!
After two at Addenbrooke’s in Cambridge, this was my third endoscopy at Homerton in East London.
The most difficult part was not eating for eight hours before and only drinking water for four hours before.
I have mild anaemia and they were looking for cancer.
Luckily for me, they didn’t find any.
I did however lose nearly a kilo in weight.
Was that the diet or the long walk to the bus, which took me home?
Endoscopies At Homerton
On their information, they sent me, Homerton said they prefer to do endoscopies without a sedative.
I suppose it is more efficient, as Addenbrooke’s told me nearly thirty years ago.
Conclusion
I am certainly not worried about endoscopies and if your doctor says you have should one, make sure they talk you through it sensibly.
Years ago, I was on holiday in Capri and met a party of about six American gastroenterologists, who were horrified, that I had had two endoscopies without anaesthetic.
But then, I think they were more worried about the fees, that the anaesthetist didn’t get.
When Homerton investigated my gallstones, I said I’d be happy to undergo the procedure without a sedative, although, the specialist private surgeon, doing the procedure for the NHS, was accompanied by an anaesthetist. In the end the anaesthetist just stood by, in case he was needed and the surgeon did his first endoscopy without a sedative. He was very pleased with everyone’s performance including mine.
Thoughts On The NHS Infected Blood Scandal
In the early 1970s, I was working with the Chief Management Accountant of a retail bank, writing a computer system to analyse and compare the performance and costs of all their branches.
We used scatter diagrams and other graphical techniques to show all the branches on single sheets produced by line printers on a powerful time-shared computer. It would be so much easier today.
Any branch not following the rules was often found sitting alone away from the mass of branches on the graphs.
I remember one branch had costs, that were much higher than expected. It turned out it was the Stevenage Branch, where the premises were rented rather than owned freehold.
Expanding The System To Other Industries
The Accountant, who had also been Chief Accountant of a FTSE 500 company, felt that the techniques we had developed had other applications in the management and auditing of large companies and organisations.
Sadly my partner in crime, died of cancer and I went on to other things.
From my own generally good family experiences of the NHS, I feel that this sort of analysis used rigorously could give early warning of some of the scandals we’ve seen in the NHS.
Around the turn of the century, I used similar techniques to improve the manufacturing quality in a diesel engine factory.
Conclusion
Perhaps we need an independent Office of NHS Responsibility?
Application Of Control Engineering Principles To The Calculation Of Pharmaceutical Drug Doses
Today, I was asked by an eminent cardiologist to give my opinion on this scientific paper in the Journal of the American Heart Association, which was entitled Personalized Antihypertensive Treatment Optimization With Smartphone‐Enabled Remote Precision Dosing of Amlodipine During the COVID‐19 Pandemic (PERSONAL‐CovidBP Trial).
This was the background to the study.
The objective of the PERSONAL‐CovidBP (Personalised Electronic Record Supported Optimisation When Alone for Patients With Hypertension: Pilot Study for Remote Medical Management of Hypertension During the COVID‐19 Pandemic) trial was to assess the efficacy and safety of smartphone‐enabled remote precision dosing of amlodipine to control blood pressure (BP) in participants with primary hypertension during the COVID‐19 pandemic.
These were the methods and the results.
This was an open‐label, remote, dose titration trial using daily home self‐monitoring of BP, drug dose, and side effects with linked smartphone app and telemonitoring. Participants aged ≥18 years with uncontrolled hypertension (5–7 day baseline mean ≥135 mm Hg systolic BP or ≥85 mm Hg diastolic BP) received personalized amlodipine dose titration using novel (1, 2, 3, 4, 6, 7, 8, 9 mg) and standard (5 and 10 mg) doses daily over 14 weeks. The primary outcome of the trial was mean change in systolic BP from baseline to end of treatment. A total of 205 participants were enrolled and mean BP fell from 142/87 (systolic BP/diastolic BP) to 131/81 mm Hg (a reduction of 11 (95% CI, 10–12)/7 (95% CI, 6–7) mm Hg, P<0.001). The majority of participants achieved BP control on novel doses (84%); of those participants, 35% were controlled by 1 mg daily. The majority (88%) controlled on novel doses had no peripheral edema. Adherence to BP recording and reported adherence to medication was 84% and 94%, respectively. Patient retention was 96% (196/205). Treatment was well tolerated with no withdrawals from adverse events.
These were the conclusions.
Personalized dose titration with amlodipine was safe, well tolerated, and efficacious in treating primary hypertension. The majority of participants achieved BP control on novel doses, and with personalization of dose there were no trial discontinuations due to drug intolerance. App‐assisted remote clinician dose titration may better balance BP control and adverse effects and help optimize long‐term care.
About Myself
I am a Graduate Control Engineer, who graduated from the University of Liverpool in 1968.
I then worked at ICI in Runcorn for eighteen months, before moving to ICI Plastics Division, because of the untimely death of my father-in-law.
One of my tasks at Welwyn, was to look at control algorithms for chemical plants. For this I often used a PACE 231-R analogue computer.
Note.
- These computers could solve up to a hundred simultaneous differential equations at one time.
- They were programmed by wiring the various amplifiers and potentiometers together to simulate the equations.
- There were only a few transistors in these powerful machines, as all electronics were thermionic valves.
- Two of these machines wired together, were used to calculate the trajectories of the Apollo missions.
They were the unsung heroes of bringing Jim Lovell and Apollo 13 home safely.
Determining Control Algorithms
In a typical problem, I would model the a section of a chemical plant and the control system around it.
This would then lead to recommendations, as to the design and operation of the plant, so that it performed as required.
It could be argued that the body of an animal, is a very complicated integrated chemical plant, with a sophisticated control system.
For instance, if sensors around the body, say you are slightly low on fluids, your brain determines you should have a drink.
Many control loops on a chemical plant are controlled by proportional–integral–derivative controllers, which are commonly known as three-term controllers.
This is the first two paragraphs of the Wikipedia entry for three-term controllers.
A proportional–integral–derivative controller (PID controller or three-term controller) is a control loop mechanism employing feedback that is widely used in industrial control systems and a variety of other applications requiring continuously modulated control. A PID controller continuously calculates an error value
PID systems automatically apply accurate and responsive correction to a control function. An everyday example is the cruise control on a car, where ascending a hill would lower speed if constant engine power were applied. The controller’s PID algorithm restores the measured speed to the desired speed with minimal delay and overshoot by increasing the power output of the engine in a controlled manner.
I wouldn’t be surprised that the app in the smartphone used in the PERSONAL‐CovidBP Trial contained a form of three-term controller.
These are some points about three-term control algorithms.
Changing Of External Factors
One that was the villain in a problem, I dealt with, also affects my body – the weather.
I was asked to look at the problem of a chemical reaction, that overheated in hot weather. But the plant operators solved it by better insulation and ventilation of the plant and the standard three-term controller adjusted itself automatically to the new conditions.
After my stroke, I am on Warfarin for life. I test my own INR with a Roche meter and I have noticed that atmospheric pressure affects my INR. I change my deose accordingly, using a simple algorithm, of my own design.
The More You Test The More Precise The Control
If you take the cruise control example used by Wikipedia, speed is monitored continuously, as I hope, it would be if you were driving yourself.
But obviously, in many systems, where you are using an input with discrete values to control a system, you can’t be as precise as the data you collect.
When my son was dying from pancreatic cancer, he was fitted with a morphine pump, that he could adjust himself to dull the immense pain he was enduring.
- His nerves and his brain ascertained the pain level.
- He then adjusted the morphine level.
- He could get very precise control of his pain, because he was measuring it continuously.
But he was only using simple one-term control (proportional).
Derivative Control Can Be Difficult To Get Right And Can Even Go Unstable
Derivative control is mainly to stop overshoot, but sometimes you will find that it can go unstable, so two-term(proportional+integral) controllers will be used.
How I Control My INR
As I said earlier, I am on Warfarin for life and test my INR with a Roche meter.
The NHS typically tests patients about once every six weeks, which in my opinion as a Control Engineer is too infrequent.
I usually test myself a couple of times a week.
But every so often, I evaluate what daily dose gives me an equilibrium INR level of 2.5.
For the last three years, I have found a dose of 3.75 mg keeps me more or less on 2.5.
- As Warfarin comes in 1, 3, 5 and 10 mg. tablets, I alternate 3.5 and 4 mg.
- Warfarin tablets are easily cut in half using a sharp knife.
- I record INR and dose in a spreadsheet.
I have been doing this now for over ten years.
Is This A Unique Property Of Warfarin?
In this time, I have had five medical procedures, where surgeons were worried, that as I was on Warfarin, I might bleed too much.
For the first, which was to remove a lump from my mouth, the private surgeon wanted to charge extra for an anaesthetist. In the end, I asked what INR he wanted and he said 2.1 should be OK!
- So I reduced the Warfarin level and tested every day.
- I judged it correctly and had an INR of 2.1 on the day of the operation.
- The operation went incredibly well and I went home on public transport.
- The lump turned out to be benign.
- I’ve not had another lump.
After the operation, I increased the Warfarin level and tested every day, until it regained a level of 2.5.
On analysing my doses through the date of the operation, I found that the total amount of Warfarin, I didn’t take to reduce my INR to 2.1, was the same as I took to bring it back up again to 2.5.
Is this a unique property of Warfarin?
Since then I’ve had two cataract operations performed in a private hospital, where the NHS paid. Interestingly, they wouldn’t trust my own INR readings, so I had to get my GP to take the measurement.
I’ve also had gallstones removed by endoscopy at the local Homerton NHS hospital.
- For cases like mine, the hospital hire in a surgeon from the posh Wellington private hospital for one day a week, who brings the specialist tools needed.
- I wrote about this in Goodbye To My Gallstones.
- As it was a more serious procedure, I reduced my INR to a requested 1.0.
Interestingly, I still have my gall bladder, but the surgeon put it on notice to behave.
Conclusion
I would totally agree with the conclusion given in the PERSONAL‐CovidBP Trial.
Personalized dose titration with amlodipine was safe, well tolerated, and efficacious in treating primary hypertension. The majority of participants achieved BP control on novel doses, and with personalization of dose there were no trial discontinuations due to drug intolerance. App‐assisted remote clinician dose titration may better balance BP control and adverse effects and help optimize long‐term care.
I would add some conclusions of my own.
- The app used in the PERSONAL‐CovidBP Trial, seems to have had a good algorithm.
- I suspect the app could also be Internet-based.
These are some general conclusions.
- If you are on Warfarin and have access to a Roche meter, it is possible to lower your INR to the value required by a surgeon for an operation or a procedure.
- Since starting to take Warfarin, I have had four operations or procedures, where others would have had anaesthetic or a sedative.
- In those four operations, I was able to go home on public transport. If I still drove a car, I could have driven home afterwards.
- Private hospitals like to use an anesthetist, as it pumps up the bill.
- Avoiding anaesthesia must save hospitals money.
Well designed apps, based on Control Engineering principles, that help the patient take the best dose of a drug will become more common.
£20 Per Hour Is A 43 % Pay Increase Over £14 Per Hour
The BBC has just reported on the Junior Doctors Strike from outside University College Hospital.
- Banners were showing that their current pay rate is £14 per hour.
- In an interview, a strike leader said that junior doctors need an offer of £20 per hour.
That would be a pay increase of forty-three percent.
I’m sure we’d all like a pay or pension increase of that amount.
Possible Coeliacs Should Get Tested
I was diagnosed as a coeliac by both the quick genetic test and the gold standard of endoscopy.
The genetic test is no more painful than any other blood test, but many people are afraid of endoscopy.
I have had four endoscopies.
- Two to check I had coeliac disease.
- One to investigate a problem in my gut with an ultrasound probe, which turned out to be gallstones.
- One to remove the gallstones, by punching a hold in my gut and then inserting and inflating a balloon to force them out.
Only for the last procedure, did I have any form of sedative. I was game, but the surgeon wasn’t!
Note that gallstones are often associated with coeliacs! As are cataracts, which I’ve also had removed from both eyes.
Yesterday in Liverpool, I had chats with two possible coeliacs, one of whom actually had a coeliac mother and the other a gluten-intolerant daughter.
This page on the NHS web site is an overview about Coeliac Disease.
Under Diagnosis Of Coeliac Disease, this is said.
First-degree relatives of people with coeliac disease should be tested.
My three sons didn’t get tested, despite both my late wife and myself insisting after my diagnosis.
Conclusion
If it’s ever suggested you be tested for coeliac disease, you should get tested.
It’s not a big deal these days.
The Anonymous Widower 