Australia to adopt INNs

The Therapeutic Goods Administration (TGA) has announced that it will proceed with international harmonisation of drug names used in Australia from April 2016. For the past decade or so, since the United Kingdom moved to the World Health Organization’s International Nonproprietary Names (INNs), we’ve been in the anomalous situation of using former British Approved Names despite these no longer being used in the UK (nor listed in the British Pharmacopoeia). The TGA website has a list of affected drugs.

Some changes are trivial:

  • Substitution of “ph” with “f” (e.g. cefalexin, guaifenesin)
  • Substitution of “y” with “i” (e.g. amoxicillin, ciclosporin)
  • Substitution of “th” with “t” (e.g. indometacin)

Others are more significant (and will require dual-labelling for 3 years), for example:

  • Dosulepin (dothiepin)
  • Formoterol (eformoterol)
  • Furosemide (frusemide)
  • Glycopyrronium bromide (glycopyrrolate)
  • Hydroxycarbamide (hydroxyurea)
  • Lidocaine (lignocaine)

On the contentious subject of adrenaline vs epinephrine, the TGA has followed the UK practice where dual-labelling “adrenaline (epinephrine)” will be used indefinitely.

Biotechnology descriptors

Whilst giving a presentation at grand rounds recently, I noted that approved names for biological medications in Australia are suffixed with a three-letter abbreviation – the “biotechnology descriptor” – to indicate the biotechnology production system used, e.g. insulin lispro (rbe).

The most common biotechnology descriptors are:

  • ghu – gene-activated human cell line
  • rbe – recombinant bacteria Escherichia coli
  • rch – recombinant Chinese Hamster ovary cell line
  • rmc – recombinant mouse cell line
  • rys – recombinant yeast Saccharomyces cerevisiae

Incidentally, I cringe whenever someone refers to this group of medications as “biologics” – an Americanism that has crept into the Australian medical lexicon. Australian English still retains the “-ical” ending (rather than shortening to “-ic” in American English), therefore we should continue to refer to these medications as “biologicals”.

My colonial medical elective

Now that I’ve finally completed the Sydney Medical Program, it’s about time that I finally post some long-overdue reflections on my elective terms in London and Hong Kong at the start of the year.

The Royal London Hospital (Barts and The London, QMUL)

The Royal London Hospital

My first elective term was spent at The Royal London Hospital under Barts and The London School of Medicine and Dentistry (Queen Mary, University of London). The Royal London Hospital is a 650-bed tertiary hospital and the principal facility of the Barts and The London NHS Trust. It is particularly known as one of London’s major (level one) trauma centres and the home of the London Air Ambulance (Helicopter Emergency Medical Service), however a full range of medical and surgical specialties are represented.

Drs Po and Preston

I was assigned to the gastroenterology team under consultant gastroenterologist Dr Sean Preston. He was an excellent supervisor and I was lucky to have spent quite a lot of time under his guidance during my elective. Dr Roocroft (the F1 house officer) was also a great mentor, teaching me the ins and outs of being a house officer in the NHS.

Work casual

Work attire in NHS hospitals is very appropriately guided by infection control considerations. In summary:

  • no tie
  • sleeves rolled-up to elbows
  • no watch (most male doctors wear their watch on their belt)

The Royal London Hospital

The logic (and comfort) of this policy was such that I continued with this after returning to Sydney, where it was still convention for male doctors to wear ties.

Speaking English

There were a few differences in the medical vocabulary used in the UK, which took a little while for me to get used to. The most prominent ones during my elective were:

bleeper – pager
phlebotomy – venepuncture
OGD (oesophageogastroduodenoscopy) – endoscopy
TTA (to take away) – discharge summary

EastEnders

I alluded in a previous post that I lived in hospital accommodation. Indeed I found myself living in John Harrison House, The Royal London Hospital, Whitechapel E1 2DR for the duration of my stay in London. Whilst relatively cheap (approx. £100/week), it was rather spartan. One of the other JHH residents described living there as punishment for his sins, whilst more colourful language was employed by one of the senior registrars.

One of the unexpected consequences of living in Whitechapel, with its majority non-white population, was the difficulty I had in trying to find a decent full English breakfast. Despite there being half a dozen (halal) fried chicken shops on Whitechapel Rd alone, there were very few decent cafés in the area. Spotting a modern-looking café on New Rd advertising that they served “English breakfast”, I stepped into Zaza’s Café (E1 1HJ)… only to realise that they served a halal version of English breakfast: smoked turkey, beef sausage, egg, baked beans, mushroom & toast. It wasn’t bad, but it’s just not the same! Thereafter I quickly learnt the Arabic characters for halal (حلا).

Queen Mary Hospital (HKU)

My second elective term was spent at Queen Mary Hospital under the Faculty of Medicine, The University of Hong Kong. Queen Mary Hospital (est. 1937) is a 1400-bed tertiary hospital and the principal facility of the Hong Kong West Cluster, with a catchment area population of over 500,000 people.

Queen Mary Hospital, Hong Kong

I was attached to a final-year group undertaking their Specialty Clerkship rotation. This works rather differently from the way our attachments work during clinical years – instead of being attached to a specific medical/surgical specialty team for the duration of a clinical attachment, each group of HKU students is allocated to one general medical ward where they’re expected to clerk patients (with seemingly little direct role in patient care). They take part in case discussions, PBL tutorials, and clinics with consultants from different specialties over the course of the term. Often ward-based tutorials were quite crowded, particularly with the confined spaces inside most hospital wards in Hong Kong (see pic below – I wasn’t standing at the back).

Ward tutorial, QMH

Masquerade

I was in Hong Kong during the 2009 influenza H1N1 “swine flu” pandemic. Following their experience during the SARS epidemic, all Hong Kong hospitals had activated what they termed “pandemic emergency response level E2”. One of the E2 requirements was that a surgical face mask was required in all clinical areas – effectively meaning that staff/students had to wear surgical masks all day!

Emergency E2 clinical attire

White coat syndrome

In total contrast to NHS policy, Hong Kong clinical attire convention was still very conservative and included the wearing of a “clean, white laboratory coat”. I’d never previously worn a lab coat in the clinical setting, but noticed two advantages: (i) it was handy having large pockets in which to put my stuff (e.g. Oxford Handbook of Clinical Medicine), and (ii) I got my student/staff discount at the hospital cafeteria and Starbucks without having to show any ID. Nevertheless, once I returned to Sydney I greatly appreciated not having to wear a lab coat.

HKU Specialty Clerkship group a/b, 2010 rotation 1

Finally, I’d like to take this opportunity to acknowledge and thank the Specialty Clerkship group to which I was attached – Fifian, Jimi, James, Vincent, Rosemary, Edgar and Sha Sha – for helping me to fit-in and manage the language barrier.

Caerdydd

My first “international” trip within Europe was to Cardiff (Caerdydd), capital city of Wales (Cymru). Although part of the United Kingdom, Wales retains a distinctive cultural identity (see Ali G’s take on Wales)… and it’s only a 2 hours away from London by train! And so it was that I found myself aboard a First Great Western InterCity 125 diesel train making the journey between London Paddington and Cardiff Central (Caerdydd Canolog) via the Great Western Main Line. It was a pleasant journey, though I was a little disappointed at not getting to see the Severn Estuary due to the Severn railway crossing being a seven-kilometre tunnel underneath the river. Photo highlights from Cardiff available on my Flickr photostream.

Welsh / Cymraeg

Prior to this trip I’d never really encountered the Welsh culture/language (a little ironic given that I live in a place named “New South Wales”) besides the curious adoption of “eisteddfod” into the Australian vernacular. The Welsh and English languages are remarkably different considering the geographical proximity (although the reasons for the Celtic vs Germanic/Romance origins are fairly self-evident from British history). For example, this typical specimen of Welsh: Nid wyf yn y swyddfa ar hyn o bryd. Anfonwch unrhyw waith i’w gyfieithu. (translation)

Cardiff Central / Caerdydd Canolog

Cardiff Bay / Bae Caerdydd

Cardiff Bay is perhaps the best example of the city’s urban renewal since the 1990s. Recent developments around the picturesque bay area include: the Wales Millennium Centre (Canolfan Mileniwm Cymru), the National Assembly of Wales Senedd, Roald Dahl Plass, Mermaid Quay precinct, &c.

Roald Dahl Plass, Water Tower and Wales Millennium Centre
Roald Dahl Plass, The Water Tower, and Wales Millennium Centre; Cardiff Bay

Then, of course, there’s the Doctor Who Up-Close Exhibition in the Red Dragon Centre, Cardiff Bay. The current series of Doctor Who (2005– ) is filmed and produced in Cardiff and so it’s only fitting that there’s a permanent Doctor Who exhibition located there.

Doctor Who Up-Close Exhibition, Cardiff

Welsh food

Although the humble leek is a national symbol of Wales, there’s a whole lot more to Welsh cuisine (plus I don’t really like leeks). Two traditional Welsh dishes I tried for the first time whilst I was there were Welsh cakes and Welsh rarebit…

Welsh cakes (picau ar y maen)

Welsh cakes are kind of like a cross between scones and pikelets, usually containing sultanas. The best ones that I tried were freshly made at Fabulous Welshcakes (Mermaid Quay, Cardiff Bay). I also bought a pack from one of the stalls at the Riverside Market for the train ride back to London, which were also rather good and left me with a craving for Welsh cakes when I got back to to the capital. Back in London, however, it proved surprisingly difficult to find Welsh food – I eventually managed to find some hidden away in the baked goods section at Waitrose, an upmarket supermarket chain.

Welsh cakes from Fabulous Welshcakes, Cardiff Bay

Welsh rarebit

Welsh rarebit is essentially glorified cheese on toast… usually with beer (ale) mixed into the cheese! The rather odd name, a corruption of the original “Welsh rabbit”, for a dish that doesn’t actually contain rabbit apparently originates from the days when rabbit was the poor man’s meat in Britain – the Welsh were reputedly so poor that they couldn’t even afford rabbit and had to make-do with cheese. I tried a rather posh variant of Welsh rarebit at Mimosa Kitchen & Bar (Mermaid Quay, Cardiff Bay), which incorporated mushroom and pancetta into the cheese with a very tasty result!

Welsh rarebit, Mimosa Kitchen & Bar, Cardiff Bay

I didn’t get the chance to try any cawl unfortunately, although given how much I enjoyed scouse in Liverpool it’ll be high on my to-do list next time I visit the UK.

Panto-time!

Looking for something to do in the evening, I went to see Robin Hood: The Pantomime Adventure starring John Barrowman (of Doctor Who and Torchwood fame) at New Theatre. Pantomimes are a type of musical-comedy theatrical production and a Christmas/New Year tradition in Britain. It was another interesting new experience as I’d never been to a panto before. Some of the highlights included: the way audience participation was integrated into the performance, the innuendo (particularly around Barrowman’s orientation), numerous Welsh/British in-jokes and the Doctor Who references. It turned out to be a very entertaining night!

Robin Hood pantomime, New Theatre, Cardiff
Programme cover from Robin Hood, New Theatre, Cardiff

Merseyside

I ended up visiting Liverpool (Merseyside county) twice during my time in the United Kingdom. I decided well before I arrived in the UK that I would make a trip to Liverpool at some stage. My friend Martina described it as a “pilgrimage” (due to my football allegiance), but after the first few days of hospital accommodation austerity in crowded and polluted Whitechapel, the idea of escaping to Merseyside for a few days before starting my elective sounded rather agreeable. The second trip was the result of serendipity (see below). I came away loving the great culture of the city… even the Scouse dialect! Photo highlights available on my Flickr photostream.

Travelling Virgin

Despite the relative expense, compared to discount coach services, I decided to catch a fast train service to Liverpool on both occasions (the price of an Off-Peak Return ticket using my 16–25 Railcard was quite reasonable anyway). Virgin Trains, the franchisee for the West Coast Main Line on Britain’s privatised National Rail system, runs an hourly direct service from London Euston station to Liverpool Lime Street station (via Stafford and Runcorn). Virgin operates a modern fleet of Pendolino electric tilt trains on the route at speeds of up to 200 km/h for a typical travel time of 2 hours 8 minutes to cover the approximately 330 kilometres. This was the fastest land vehicle I’d ever travelled on and I was very impressed – there’s something very satisfying about whizzing through the beautiful English countryside at 200 km/h in relaxed comfort. Strangely though, Virgin Cola wasn’t available onboard (despite it being the only cola drink available on Virgin Atlantic services to/from Sydney).

Virgin Trains Pendolino at Liverpool Lime Street station
Virgin Trains Pendolino “Virgin Warrior” at Liverpool Lime Street station

Capital of culture

Liverpool is a city full of culture, from the listed historical buildings dating from the city’s heyday during the peak of the British Empire to the ever-present reminders of its four most famous musicians (e.g. Liverpool John Lennon Airport) to its two famous football teams (Liverpool FC and Everton FC) &c. – it was no surprise to discover that the city was named 2008 European Capital of Culture.

The Three Graces, Liverpool
“The Three Graces” – Royal Liver, Cunard, and Port of Liverpool buildings

Of course, the heart of Liverpool is its people and the Scousers (as they’re popularly known in Britain) I encountered were a great bunch. I even came to grips with the distinctive Scouse dialect (it’s not just an accent), however there were a number of occasions when I needed to (somewhat embarrassingly) ask people to repeat themselves. This apparently worked both ways – some of the locals had some trouble with my adopted Received Pronunciation accent. My favourite quote on this matter came from the owner of Kavanagh’s II coffee shop after I mentioned that I was Australian, “You don’t sound like an Aussie… Your accent sounds more ‘proper English’ than us!”.

Another Place

Another Place is a public art installation by British sculptor Antony Gormley. The work consists of 100 life-size cast iron figures (modelled after Gormley himself) facing out to sea, spread across 3 kilometres of coastline. After first being displayed in Germany, Norway and Belgium; its final permanent location is Crosby Beach, near Liverpool (actually in the Metropolitan Borough of Sefton, which is adjacent to the City of Liverpool). Although not in central Liverpool, it’s quite easy to reach Another Place – simply a matter of taking a Merseyrail train to Blundellsands & Crosby station and walking 500 metres along Blundellsands Road West to Crosby Beach. It’s a very interesting work – whilst each figure individually has quite limited artistic value, seeing dozens of them staring silently out to sea is a strangely mesmerising experience. Gormley’s official line is that the work represents “a response to the individual and universal sentiments associated with emigration, sadness at leaving but the hope of a new future in another place”.

Another Place by Antony Gormley
Another Place by Antony Gormley, Crosby Beach, Merseyside

You’ll never walk alone

The more famous and successful of Liverpool’s football teams is Liverpool Football Club, based at Anfield football stadium. As a Liverpool supporter, a stadium tour was practically a requisite during my time in England. Considering the notorious difficulty of getting tickets to matches at Anfield, I also thought the tour would be my only chance to see the inside of the legendary stadium.

Anfield stadium, Liverpool
Anfield stadium, Liverpool

Little did I know that a few weeks later I would manage to score tickets to an FA Cup 3rd round replay match between Liverpool and Reading (and the reason I returned to Liverpool). The atmosphere at Anfield on match night was amazing. Unfortunately the Reds played rather poorly that night (and both Steven Gerrard and Fernando Torres sustained injuries) and ultimately lost the match 2–1.

Liverpool v Reading, 13 Jan 2010
Liverpool v Reading, Anfield, 13 January 2010

The Baltic Fleet

I couldn’t leave Liverpool without trying some scouse, the local dish. Indeed scouse is so synonymous with Liverpool that the term came to refer to the people of Liverpool (Scousers) and their dialect (Scouse). Scouse is a meat stew containing lamb/mutton, potatoes, onions, carrots and potatoes; traditionally served with picked red cabbage and bread.

Scouse

I first tried scouse at The Baltic Fleet a pub on Wapping, near Albert Dock. The Baltic Fleet is also a microbrewery, so I tried their eponymous Wapping Bitter ale. Both were excellent. There’s nothing like a good bowl of scouse washed down with ale to lift the spirits on a (literally) freezing night.

The Baltic Fleet
33 Wapping
Liverpool
L1 8DQ
United Kingdom
wappingbeers.co.uk

Saying British place names

The United Kingdom, no doubt due to its rich cultural and linguistic history, has rather a lot of place names that are pronounced differently from what a non-Briton might expect from the spelling. Here are some examples I’ve encountered, along with the actual pronunciations given in the International Phonetic Alphabet (IPA). Some of these will no doubt already be familiar to readers because of similarly or identically named places scattered through the English-speaking world.

Thames /ˈtɛmz/
Islington /ˈɪzlɪŋtən/
Southwark /ˈsʌθək/
Borough /ˈbʌrʌ/
Marylebone /ˈmɑrlɪbən/
Holborn /ˈhoʊbərn/
Slough /ˈslaʊ/
Reading /ˈrɛdɪŋ/
Leicester /ˈlɛstə/
Gloucester /ˈglɒstə/
Salisbury /ˈsɔlzbri/
Willesden /ˈwɪlzdən/
Greenwich /ˈgrɛnɪtʃ/
Woolwich /ˈwʊlɪtʃ/
Norwich /ˈnɒrɪtʃ/
Chiswick /ˈtʃɪzɪk/
Lewisham /ˈlʊwɪʃəm/
Fulham /ˈfʊləm/
Ruislip /ˈraɪslɪp/

Regional accents can influence the pronunciation of certain place names.

Newcastle /ˈnjukɑsəl/ (Received Pronunciation)
Newcastle /njuˈkæsəl/ (Geordie)

Consequently, identically-named places in different parts of the country may be pronounced differently.

Wapping (London) /ˈwɒpɪŋ/
Wapping (Merseyside) /ˈwæpɪŋ/