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<title>Kidney Stones</title></titleStmt>

<publicationStmt><distributor>BASE and Oxford Text Archive</distributor>


<availability><p>The British Academic Spoken English (BASE) corpus was developed at the

Universities of Warwick and Reading, under the directorship of Hilary Nesi

(Centre for English Language Teacher Education, Warwick) and Paul Thompson

(Department of Applied Linguistics, Reading), with funding from BALEAP,

EURALEX, the British Academy and the Arts and Humanities Research Board. The

original recordings are held at the Universities of Warwick and Reading, and

at the Oxford Text Archive and may be consulted by bona fide researchers

upon written application to any of the holding bodies.

The BASE corpus is freely available to researchers who agree to the

following conditions:</p>

<p>1. The recordings and transcriptions should not be modified in any


<p>2. The recordings and transcriptions should be used for research purposes

only; they should not be reproduced in teaching materials</p>

<p>3. The recordings and transcriptions should not be reproduced in full for

a wider audience/readership, although researchers are free to quote short

passages of text (up to 200 running words from any given speech event)</p>

<p>4. The corpus developers should be informed of all presentations or

publications arising from analysis of the corpus</p><p>

Researchers should acknowledge their use of the corpus using the following

form of words:

The recordings and transcriptions used in this study come from the British

Academic Spoken English (BASE) corpus, which was developed at the

Universities of Warwick and Reading under the directorship of Hilary Nesi

(Warwick) and Paul Thompson (Reading). Corpus development was assisted by

funding from the Universities of Warwick and Reading, BALEAP, EURALEX, the

British Academy and the Arts and Humanities Research Board. </p></availability>




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<item n="speechevent">Lecture</item>

<item n="acaddept">Medicine</item>

<item n="acaddiv">ls</item>

<item n="partlevel">UG2/PG</item>

<item n="module">Urinary System</item>





<u who="nm0370"> you're not going to get any <pause dur="1.5"/> I-T aids for this talk you're not going to get any slides <pause dur="0.3"/> you can take notes if you want to <pause dur="0.5"/> # i've prepared some handouts for you with everything i'm going to say on here so feel free <pause dur="0.3"/> not to take any notes it's all on there <pause dur="1.4"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> the reason i teach this way is <trunc>t</trunc> <pause dur="0.2"/> to get your attention <pause dur="0.6"/> and # to hopefully prevent you from falling asleep for this talk <pause dur="0.6"/> so <pause dur="0.2"/> the subject of today's talk <pause dur="0.2"/> is kidney stones <pause dur="0.5"/> <kinesic desc="writes on board" iterated="y" dur="10"/> but first of all i'd like you to tell me what this is <pause dur="0.9"/> i'm i can assure you i'm not a very good </u><pause dur="1.8"/> <u who="ss" trans="pause"> train </u><u who="nm0370" trans="latching"> it's a train <pause dur="0.2"/> okay <pause dur="0.6"/> and <vocal desc="laughter" iterated="y" n="ss" dur="2"/> # <pause dur="0.2"/> so <pause dur="1.2"/> you're all trainspotters <pause dur="0.2"/> # i can tell <pause dur="0.7"/> because you know what a train looks like <pause dur="0.7"/> # <pause dur="0.6"/> and <pause dur="0.2"/> the theme of this morning's talk is to try to <pause dur="0.3"/> persuade <pause dur="0.2"/> those of you who are not trainspotters to become trainspotters actually it's very interesting the whole subject of trains <pause dur="0.6"/> and why do you think that <pause dur="0.4"/> kidney stone

disease has got anything to do with trains and trainspotters <pause dur="1.1"/> anybody <pause dur="3.5"/> think laterally <pause dur="1.7"/> speak up </u><pause dur="1.6"/> <u who="sm0371" trans="pause"> movement of urine the flow of <trunc>u</trunc> </u><u who="nm0370" trans="overlap"> no no it's a trick question </u><u who="sm0372" trans="latching"> we need trains to spot them </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> sorry </u><u who="sm0372" trans="latching"> we need <pause dur="0.2"/> trains to spot them </u><u who="nm0370" trans="overlap"> very good very <shift feature="voice" new="laugh"/>good <shift feature="voice" new="normal"/> i didn't think of that one <pause dur="0.3"/> # <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="3"/> i i think that <pause dur="0.3"/> the reason why <pause dur="0.2"/> it's similar to trainspotting is that most people think trainspotting is rather dull <pause dur="0.5"/> and # <pause dur="0.2"/> most people also think kidney stone disease is rather dull <pause dur="0.4"/> <trunc>n</trunc> but i happen to find it very interesting and i'm trying to get convince you this morning that it is interesting and <pause dur="0.2"/> trains are interesting <pause dur="0.4"/> # <pause dur="0.3"/> why do you think that trainspotting is dull </u><pause dur="1.8"/> <u who="ss" trans="pause"> <gap reason="inaudible" extent="1 sec"/></u><u who="nm0370" trans="overlap"> speak up </u><pause dur="0.7"/> <u who="sm0373" trans="pause">

it's monotonous </u><u who="nm0370" trans="latching"> it's monotonous isn't it <pause dur="0.4"/> it's very common there are a lot of trains about <pause dur="0.6"/> and it seems quite easy doesn't it trainspotting but <pause dur="0.3"/> you try sitting there on Crewe station all day long <pause dur="0.2"/> writing those little numbers down <pause dur="0.4"/> and # in fact it's a lot harder than most people think trainspotting and <pause dur="0.4"/> and it's perhaps more interesting <pause dur="0.2"/> than many people think and i'm going to try to convince you that <pause dur="0.6"/> kidney stones # <pause dur="0.4"/> are harder than you think <pause dur="0.2"/> and perhaps more interesting than you think <pause dur="0.4"/> why why are <trunc>k</trunc> why is kidney stone disease important tell me something about the <pause dur="0.3"/> epidemiology of <pause dur="0.2"/> kidney stone disease </u><pause dur="2.3"/> <u who="sf0374" trans="pause"> # </u><u who="nm0370" trans="overlap"> if you've got no idea say so </u><u who="sf0374" trans="overlap"> 'cause it causes an obstruction </u><u who="sf0375" trans="overlap"> no idea </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> okay so it's a cause of obstruction yes <pause dur="0.7"/> anybody else </u><pause dur="1.7"/> <u who="sm0376" trans="pause"> painful <pause dur="0.2"/> it's <unclear>painful</unclear></u><u who="nm0370" trans="latching">

painful <pause dur="0.5"/> and in fact and that's the key and that's one of the similarities with trainspotting <pause dur="0.4"/> # <pause dur="0.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> it's painful <pause dur="0.5"/> and it doesn't really matter <pause dur="0.8"/> and why doesn't it really matter <pause dur="1.8"/> why does kidney stone disease not really matter <pause dur="5.2"/> it doesn't kill you <pause dur="0.6"/> so people don't care about diseases that don't kill you <pause dur="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 <pause dur="0.3"/> which is perhaps why nobody's interested in fact there isn't a single <pause dur="0.2"/> group of kidney doctors in the U-K looking into kidney stone disease at the moment so <pause dur="0.3"/> if one of you wants to become famous do a <pause dur="0.2"/> PhD on the pathophysiology of stone disease <pause dur="0.5"/> so it doesn't kill you <trunc>h</trunc> how common is it <pause dur="0.9"/> anybody </u><pause dur="1.2"/> <u who="sf0377" trans="pause"> very </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> very <pause dur="0.8"/> do you want to put some numbers on that </u><pause dur="0.4"/> <u who="sf0377" trans="pause"> no <vocal desc="laughter" iterated="y" n="ss" dur="1"/></u><pause dur="1.4"/> <u who="nm0370" trans="pause"> anybody want to put some numbers on that </u><pause dur="0.8"/> <u who="sf0378" trans="pause">

ten per cent </u><pause dur="0.4"/> <u who="sf0379" trans="pause"> <unclear>twenty-five</unclear> </u><pause dur="0.8"/> <u who="nm0370" trans="pause"> it's yeah nearly actually twelve per cent of men five per cent of women have a stone <pause dur="0.4"/> at some stage in their lives <pause dur="0.3"/> and <pause dur="0.2"/> kidney stones are a bit like trains they just keep coming they keep recurring <pause dur="0.5"/> # and in fact fifty per cent of people of <pause dur="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 # <pause dur="0.3"/> or are about to perhaps today <pause dur="0.8"/> and <vocal desc="laughter" iterated="y" n="ss" dur="2"/> # <pause dur="0.4"/> and fifty per cent of those people have another attack in the next five years <pause dur="0.5"/> so it's suddenly becoming a bit more interesting it and what's interesting about it is it's <pause dur="0.3"/> one of the commonest chronic diseases <pause dur="0.3"/> but it's one of the diseases we know least about and it's one of the diseases that seems simple <pause dur="0.7"/> but perhaps isn't so <pause dur="1.3"/> perhaps this X-ray is <kinesic desc="turns on overhead projector showing transparency" iterated="n"/> <unclear>really</unclear> <pause dur="1.1"/> a primary example of why <pause dur="0.2"/> you think it might be simple what what does that X-ray show <pause dur="2.6"/> gentleman in the front here <kinesic desc="indicates member of audience" iterated="n"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> </u><pause dur="2.5"/> <u who="sm0380" trans="pause">

two kidney stones </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> 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 <pause dur="0.2"/> you see the spine you see the hips <pause dur="0.2"/> and you see a couple of kidney stones <pause dur="0.3"/> and what why do you think they're kidney <trunc>sto</trunc> what makes you say they're kidney stones </u><u who="sm0380" trans="latching"> they're calcified <gap reason="inaudible due to overlap" extent="1 sec"/> </u><u who="nm0370" trans="overlap"> okay <pause dur="0.2"/> so they're calcified <pause dur="0.4"/> in fact most kidney stones are calcified <pause dur="0.2"/> how many <pause dur="0.3"/> kidney stones are calcified <pause dur="2.6"/> guess calculate a guess if you don't know </u><pause dur="1.0"/> <u who="sm0381" trans="pause"> eighty per cent </u><u who="nm0370" trans="latching"> eighty per cent eighty per cent are calcified and therefore you can see on a plain X-ray <pause dur="0.2"/> but twenty per cent aren't <pause dur="0.8"/> there are twenty per cent of trains you can't see <pause dur="0.6"/> so it's suddenly becoming a more interesting disease so tell me about the <pause dur="0.2"/> stones you can't see these two ladies <pause dur="1.6"/> <kinesic desc="indicates members of audience" iterated="n"/> what are they made of stones you can't see <pause dur="0.6"/> on a

plain X-ray </u><pause dur="0.9"/> <u who="sf0382" trans="pause"> urate </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> urate yeah what percentage of stones are urate stones </u><pause dur="1.4"/> <u who="sf0382" trans="pause"> two per cent </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> about seven per cent <pause dur="0.2"/> okay <pause dur="1.3"/> and <pause dur="0.3"/> there are a lot of causes of stone disease <pause dur="0.3"/> and <pause dur="0.6"/> in the first stage of this talk i'm going to talk about <pause dur="0.3"/> the aetiology of stone disease <trunc>c</trunc> causes of stone disease and then we'll go on to <pause dur="0.4"/> the treatment what we're going to do about it <pause dur="0.6"/> so first of all <pause dur="0.3"/> tell me somebody <pause dur="0.2"/> the <pause dur="0.3"/> most likely composition of that stone <pause dur="4.1"/> i'll give you a clue <pause dur="2.1"/> <kinesic desc="writes on board" iterated="y" dur="2"/> calcium </u><pause dur="1.1"/> <u who="sf0383" trans="pause"> phosphate </u><u who="sm0384" trans="latching"> <trunc>phos</trunc> </u><u who="nm0370" trans="latching"> sorry </u><pause dur="0.6"/> <u who="sm0384" trans="pause"> phosphate </u><u who="nm0370" trans="latching"> no </u><pause dur="0.3"/> <u who="sm0385" trans="pause"> oxalate </u><pause dur="0.3"/> <u who="nm0370" trans="pause"> oxalate okay <pause dur="2.6"/> <kinesic desc="writes on board" iterated="y" dur="3"/> so about <pause dur="0.7"/> seventy-five

per cent <pause dur="0.4"/> of the calcium containing stones which are eighty per cent of all stones contain calcium oxalate <pause dur="0.5"/> and in fact <pause dur="0.2"/> the pathogenesis of these stones is ill understood <pause dur="0.4"/> one of the <pause dur="0.2"/> oldest operations in the history of mankind is what <pause dur="1.2"/> what did the Egyptians <pause dur="0.2"/> do <pause dur="1.2"/> to people with stone disease <pause dur="3.2"/> schistosomiasis the Nile <pause dur="0.4"/> papyrus rolls tell me about the Egyptians <pause dur="3.6"/> you're not a group of medical historians here <pause dur="1.4"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> but one of the earliest operations recognized by mankind is cutting for stone and Egyptians <pause dur="0.3"/> used to cut for stone by putting a cut through there <kinesic desc="indicates point on stomach" iterated="n"/><pause dur="0.3"/> so <pause dur="0.2"/> bit of wine bit of beer and they used to cut into the patient's abdomen to remove stones but this is <pause dur="0.3"/> one of the oldest diseases <pause dur="0.5"/> in the history of mankind and one of the oldest operations in the history of mankind <pause dur="1.4"/> okay <pause dur="0.2"/> so would anybody like to be brave <pause dur="0.4"/> and tell me <pause dur="0.3"/> # about the pathogenesis <pause dur="0.4"/> of <pause dur="0.6"/> kidney stone disease in other words <pause dur="0.4"/> the common causes of the common stones we've been talked about who's going to be brave and <pause dur="0.3"/> tell me about some risk factors </u><pause dur="2.5"/> <u who="sm0386" trans="pause">

infection </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> infection yes </u><pause dur="2.6"/> <u who="sm0387" trans="pause"> dehydration </u><u who="nm0370" trans="latching"> dehydration yes more common in hot countries </u><pause dur="2.0"/> <u who="sf0388" trans="pause"> is it more common in men </u><pause dur="0.5"/> <u who="nm0370" trans="pause"> more common in men nobody knows why but almost all kidney disease is more common in men <pause dur="0.4"/> i personally think it's because we don't get pregnant and women <pause dur="0.3"/> # get all this lovely twenty-four-thousand mile service when they're pregnant and <pause dur="0.3"/> all these diseases are found out and us men are left to rot <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="4"/> in our forties and fifties and then we get stone disease and heart attack <pause dur="0.5"/> and we leave our young wives <pause dur="0.8"/> # <pause dur="0.3"/> okay <pause dur="3.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="3"/> so who's going to help out the people at the back tell me <pause dur="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 <pause dur="0.3"/> predispose to stone disease </u><u who="sm0389" trans="overlap">

diabetes </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> diabetes no <pause dur="0.7"/> well yes and no yes via papillary necrosis yes but <pause dur="0.2"/> yes and no <pause dur="3.7"/> let's see how much reading you've been doing </u><pause dur="0.2"/> <u who="sm0390" trans="pause"> <unclear>urate</unclear> crystals </u><u who="nm0370" trans="latching"> okay so there are certain abnormalities in the urine <pause dur="0.3"/> that predispose to stone disease and what the urine is <pause dur="0.4"/> is <pause dur="0.2"/> a solution <pause dur="0.3"/> of <pause dur="0.3"/> salts <pause dur="0.7"/> and most of those salts are at a near supersaturation level <pause dur="0.5"/> so in other words you don't have to do much to the urine for the salts to come out of solution <pause dur="0.7"/> and some of the salts are as follows <pause dur="0.3"/> urate at the back <pause dur="0.2"/> anybody else like to offer any others </u><pause dur="0.5"/> <u who="sm0391" trans="pause"> cysteine </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> cysteine that's <trunc>y</trunc> yes that's more of a specific you're right but more of a specific cause of stone <pause dur="0.6"/> urate <pause dur="0.4"/> calcium oxalate <pause dur="0.3"/> if you have high levels of those in your urine that predisposes

you to stone disease and low levels of cysteine <pause dur="0.6"/> again how these factors interact we don't really understand <pause dur="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 <pause dur="0.4"/> it doesn't say it's a cause it's a risk factor <pause dur="0.4"/> tell me about some more specific causes gentleman at the front cysteine anybody else <pause dur="0.9"/> give me some rare stuff <pause dur="0.7"/> infection what type of stones do they produce <pause dur="5.1"/> it's going to be a long morning isn't it <pause dur="1.9"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> you weren't expecting questions fired at you were you <pause dur="0.6"/> you just <gap reason="inaudible" extent="1 sec"/> lecture <pause dur="1.1"/> don't want to be embarrassed at the front <pause dur="1.3"/> struvite stones so-called infection stones <pause dur="0.3"/> interestingly more common in women why do you think that is so </u><pause dur="0.7"/> <u who="ss" trans="pause"> <gap reason="inaudible" extent="2 secs"/> </u><u who="nm0370" trans="latching"> speak up <pause dur="4.1"/> it's 'cause women <pause dur="0.2"/> are more likely to get U-T-Is it's as simple as that so <pause dur="0.2"/> some stones most stones are more common in men but a few stones are more common in women <pause dur="0.2"/> okay <pause dur="0.3"/> there

are some rarer causes of stones that i don't intend to go through today in great detail <pause dur="0.3"/> there's something called a xanthine stone a dihydroxyxanthine stone <pause dur="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 <pause dur="0.2"/> mainly talk about the common causes of stone <pause dur="0.6"/> okay <pause dur="1.2"/> # <pause dur="0.3"/> if you were going to choose one of those urinary abnormalities <pause dur="0.9"/> as a problem which you can sort out in a patient with recurrent stones <pause dur="0.2"/> what would it be <pause dur="0.5"/> what do you think's the most common <pause dur="0.3"/> of the things <pause dur="0.2"/> that i've described so far </u><pause dur="0.3"/> <u who="sm0392" trans="pause"> low urine volume </u><pause dur="0.5"/> <u who="nm0370" trans="pause"> 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 <pause dur="3.2"/> probably the calcium <pause dur="0.4"/> of of the <pause dur="0.2"/> risk factors for renal stone disease hypercalcuria <pause dur="0.2"/> is probably the most important <pause dur="0.3"/> in fact sixty per cent of people <pause dur="0.2"/> who have <pause dur="0.4"/> classical calcium oxalate stones <pause dur="0.3"/> have <pause dur="0.2"/> so-called idiopathic hypercalcuria so many of you in this room will

have it <pause dur="0.4"/> has anybody would anybody like to volunteer any normal ranges of urinary calcium excretion <pause dur="1.6"/> this is a hard one isn't it <pause dur="0.9"/> tell me the normal calcium there you go that's an easier question gentleman at the front <kinesic desc="indicates member of audience" iterated="n"/> you're going to get <pause dur="0.4"/> poor chap's <vocal desc="laughter" iterated="y" n="ss" dur="2"/> going to get picked on <pause dur="0.3"/> chap behind him <pause dur="0.3"/> normal calcium level </u><pause dur="1.4"/> <u who="sm0393" trans="pause"> two-point-five <pause dur="0.6"/> in plasma </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> okay not bad okay two-point-two to two-point-six so you should know the <trunc>l</trunc> the normal levels <pause dur="0.3"/> of all basic bioclinical parameters by now <pause dur="0.4"/> and if you don't <pause dur="0.3"/> i'd like you to learn them <pause dur="0.5"/> because you're going to need them by the time you hit the wards <pause dur="0.3"/> # <pause dur="0.2"/> and you don't need to know the normal twenty-four hour urine excretion <pause dur="0.2"/> i'm # i have to look it up <gap reason="inaudible" extent="1 sec"/> <pause dur="0.4"/> and # one to four millimole per twenty-four hours <pause dur="0.5"/> of urine <pause dur="0.5"/> and there's an arbitrary line of over seven-point-five for men and

<trunc>six-f</trunc> <pause dur="0.3"/> point-two-five for women <pause dur="0.3"/> but interestingly <pause dur="0.3"/> # eight per cent of normal people <pause dur="0.5"/> # who don't have stones <pause dur="0.2"/> have so-called pathological hypercalcuria <pause dur="0.2"/> what what does that tell you <pause dur="1.2"/> if eight per cent of normal people have high levels of calcium in their urine </u><pause dur="1.7"/> <u who="sm0394" trans="pause"> there's something else there </u><u who="nm0370" trans="latching"> yeah there are other factors involved and clearly this is only one factor <pause dur="0.3"/> but it also tells you how we get normal ranges <kinesic desc="writes on board" iterated="y" dur="2"/><pause dur="0.3"/> how do you think <pause dur="0.3"/> just as a slight aside how do you think <pause dur="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 <pause dur="1.2"/> where do they come from </u><pause dur="3.0"/> <u who="sm0395" trans="pause"> a statistical average </u><u who="nm0370" trans="latching"> statistical average but where do we get the data </u><pause dur="1.8"/> <u who="sm0395" trans="pause"> patient data </u><u who="nm0370" trans="latching"> patient data where do we get that from </u><u who="sm0395" trans="latching">

hospitals </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> hospitals <pause dur="0.2"/> which hospital where when </u><pause dur="0.7"/> <u who="sm0437" trans="pause"> renal wards </u><u who="sf0396" trans="overlap"> renal wards </u><pause dur="0.3"/> <u who="nm0370" trans="pause"> renal wards no not particularly i mean a lot of our normal ranges are taken from old studies of vast numbers of <pause dur="0.5"/> # white <pause dur="0.2"/> American males entering the army fifty years ago <pause dur="0.2"/> and <trunc>ma</trunc> many of our normal ranges are completely wrong <pause dur="0.4"/> # <pause dur="0.2"/> but even if they are right <pause dur="0.2"/> we still have to develop a normal range and what we do is <kinesic desc="writes on board" iterated="y" dur="5"/> we screen a vast <pause dur="0.6"/> number of the population several thousands <pause dur="0.2"/> and we say the normal range is within two standard deviations of the mean <pause dur="0.9"/> and what's wrong with that <pause dur="0.2"/> as a method of describing a normal range </u><pause dur="8.3"/> <u who="sm0397" trans="pause"> there's another five per cent of the population outside of that </u><u who="nm0370" trans="latching"> very good okay so there's five per cent of normal people <pause dur="0.8"/> <trunc>se</trunc> people who are seven foot

tall aren't necessarily ill neither are people who are four foot tall <pause dur="0.7"/> and it may be that people <pause dur="0.2"/> either end of the normal range <pause dur="0.4"/> <kinesic desc="writes on board" iterated="y" dur="1"/> # <pause dur="0.2"/> <kinesic desc="makes quotation mark gesture" iterated="n"/>the normal range are perfectly normal <pause dur="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 <pause dur="0.3"/> so the fact that as i told you eight per cent of people who don't have stones <pause dur="0.2"/> have hypercalcuria <pause dur="0.3"/> means <pause dur="1.6"/> nothing <pause dur="0.6"/> means absolutely nothing <pause dur="0.2"/> it may be these are just normal people <pause dur="0.3"/> <kinesic desc="writes on board" iterated="y" dur="2"/> tail end Charlie four foot people or seven foot people <pause dur="0.3"/> so you should analyse <pause dur="0.4"/> # at the end of this talk i'm going to give you a list of fifty facts and i want you to <pause dur="0.3"/> analyse these facts <pause dur="0.3"/> with # some degree of caution <pause dur="0.9"/> okay <pause dur="0.6"/> # <pause dur="0.3"/> tell me a little bit now about some more specific causes of <pause dur="0.2"/> kidney stones right so we've had cysteine at the front <pause dur="0.5"/> # <pause dur="0.3"/>

<trunc>wh</trunc> we've had infection and <pause dur="0.3"/> a variety of other things at the back <pause dur="0.4"/> what <pause dur="0.2"/> anatomical problem might predispose you to stones </u><pause dur="1.2"/> <u who="sm0398" trans="pause"> <trunc>stric</trunc> </u><u who="sm0399" trans="overlap"> stricture </u><pause dur="0.5"/> <u who="nm0370" trans="pause"> strictures okay pelvic utero junction obstruction yeah <pause dur="0.2"/> anything else <pause dur="3.9"/> i'll give you a clue <pause dur="0.9"/> this is a kidney <pause dur="0.2"/><kinesic desc="writes on board" iterated="y" dur="2"/> kidney-shaped thing <pause dur="1.5"/> just for my own interest how big is a kidney <pause dur="0.9"/> roughly <pause dur="3.8"/> <kinesic desc="indicates members of audience" iterated="n"/> these two ladies <pause dur="0.7"/> how big is a kidney <pause dur="1.5"/><kinesic desc="holds up fist" iterated="n" n="sf0438"/> it's about the size of your fist okay <pause dur="0.4"/> it's twelve by six by three <pause dur="0.6"/> # with a minimum <pause dur="0.3"/> # <pause dur="0.2"/> height vertical distance of ten centimetres <pause dur="0.2"/> about a hundred-and-fifty grams one of the smallest <pause dur="0.4"/> organs in the body it takes <pause dur="0.5"/> a <pause dur="0.2"/> fifth of the cardiac output so it's very important it's very small and i like it <pause dur="0.6"/> # <pause dur="0.5"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> so <pause dur="1.2"/> now i've given you a few clues so <pause dur="0.9"/> what

other anatomical problems might <kinesic desc="writes on board" iterated="y" dur="1"/> predispose to stones we've said strictures <pause dur="10.2"/> okay <pause dur="0.9"/> well what do you think <pause dur="0.7"/> these <kinesic desc="writes on board" iterated="y" dur="10"/> bits of the kidney are called # <pause dur="3.3"/> you've done lots of anatomy what are they called </u><pause dur="3.8"/> <u who="sf0400" trans="pause"> calyces </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> calyces okay <pause dur="0.3"/> can the calyces fall off <pause dur="3.3"/> yeah what process leads to the calyces falling off </u><pause dur="1.2"/> <u who="sm0401" trans="pause"> <gap reason="inaudible" extent="1 sec"/> </u><pause dur="0.6"/> <u who="nm0370" trans="pause"> sorry <pause dur="4.4"/> oh dear <pause dur="1.1"/> okay anybody <pause dur="0.2"/> what process do you think could lead to the calyces falling off <pause dur="0.2"/> i mentioned it already <pause dur="3.5"/> <kinesic desc="writes on board" iterated="y" dur="2"/> okay papillary necrosis so there's <pause dur="0.3"/> which has # <pause dur="0.3"/> a variety of causes between diabetes sickle cell disease and lots of other causes <pause dur="0.3"/> and these can fall off <pause dur="0.7"/> block the drainage <kinesic desc="writes on board" iterated="y" dur="1"/> system stones can form behind it <pause dur="0.3"/> cancers

any obstruction <pause dur="0.3"/> to the urinary tract anywhere where there's stasis <pause dur="0.3"/> it can lead to <pause dur="0.2"/> worsening in the supersaturation of the urine <pause dur="0.6"/> so as well as having <pause dur="0.2"/> the <pause dur="0.5"/> biochemical <pause dur="0.3"/> risk factors that we've talked about so far there are also anatomical risk factors to kidney stone disease <pause dur="0.8"/> okay <pause dur="1.7"/> # <pause dur="2.3"/> cystinuria just slight aside <pause dur="0.6"/> gentleman mentioned it # at the front there <pause dur="0.4"/> # <pause dur="0.3"/> coming back to cystinuria <pause dur="6.4"/> if you don't know <unclear>anything</unclear> <pause dur="0.5"/> say you don't know <pause dur="0.7"/> it's all right not to know <pause dur="0.7"/> does anybody want to help him out <pause dur="1.0"/> why is it important <pause dur="8.9"/> no <pause dur="1.0"/> anybody <pause dur="0.8"/> tell me a sentence about cystinuria </u><pause dur="0.6"/> <u who="sm0401" trans="pause"> it's hereditary </u><u who="nm0370" trans="latching"> hereditary very good okay and that's why it's important <pause dur="0.7"/> and a few causes of stones are hereditary <pause dur="0.4"/> and therefore <pause dur="0.5"/> if you find a patient with cystinuria <pause dur="0.4"/> you might do what </u><pause dur="0.7"/> <u who="sm0402" trans="pause"> <unclear>do an intensive history</unclear> </u><u who="nm0370" trans="latching"> yeah look at the rest of the family <pause dur="0.3"/> you know look at the parents look at their children <pause dur="0.2"/>

warn them that they're going to develop kidney stones <pause dur="0.6"/> they don't kill you but they're bloody irritating <pause dur="0.5"/> they're very common <pause dur="0.3"/> cystinuria <pause dur="0.2"/> some studies up to three per cent of stones are <pause dur="0.2"/> undiagnosed cysteine stones <pause dur="0.6"/> and so this is important inherited cause <pause dur="0.3"/> of kidney stones and there is very effective treatment for it <pause dur="1.5"/> okay <pause dur="1.0"/> # <pause dur="0.7"/> now then <pause dur="0.3"/> let's talk about how kidney stones present <pause dur="0.6"/> let's # <pause dur="0.3"/> pick on somebody else now <pause dur="0.2"/> this gentleman here <kinesic desc="indicates member of audience" iterated="n"/><pause dur="0.2"/> how do you think kidney stones present </u><pause dur="0.3"/> <u who="sm0403" trans="pause"> pain </u><pause dur="0.5"/> <u who="nm0370" trans="pause"> pain </u><u who="sm0403" trans="overlap"> you can have <unclear>pain in</unclear> <pause dur="0.7"/> <gap reason="inaudible" extent="1 sec"/> even </u><u who="nm0370" trans="latching"> okay very good so pain pain is the hallmark of kidney stone disease <pause dur="0.5"/> okay <pause dur="0.2"/> tell me about the pain of kidney stone disease </u><pause dur="0.4"/> <u who="sm0404" trans="pause"> # acute <pause dur="0.3"/> sharp pain </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> yes </u><u who="sm0404" trans="overlap"> in the flanks </u><u who="nm0370" trans="latching"> very good anything else about it <pause dur="0.8"/> you're right </u><pause dur="0.9"/> <u who="sm0404" trans="pause"> # i don't know </u><pause dur="3.8"/> <u who="nm0370" trans="pause"> anybody want to help him out </u><pause dur="0.4"/> <u who="sm0405" trans="pause"> it moves </u><pause dur="0.6"/> <u who="nm0370" trans="pause">

it moves <pause dur="0.3"/> particularly it radiates through the </u><u who="sm0405" trans="latching"> <unclear>spine</unclear> to groin </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> yeah loin to the groin <pause dur="0.2"/> to the testicles in a man </u><pause dur="1.1"/> <u who="sm0404" trans="pause"> is it spasmotic as well </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> yeah tell me more about the spasmodic nature of renal colic <pause dur="0.8"/> what you're getting at </u><pause dur="1.4"/> <u who="sf0406" trans="pause"> # <gap reason="inaudible due to overlap" extent="1 sec"/></u><u who="nm0370" trans="overlap"> what is a colic </u><u who="sm0407" trans="overlap"> <gap reason="inaudible due to overlap" extent="1 sec"/> contraction </u><u who="sm0405" trans="latching"> the contraction's quite like an obstruction </u><u who="nm0370" trans="overlap"> very good okay <pause dur="0.4"/> so the three main forms of colic <pause dur="0.3"/> are <pause dur="0.2"/> gallbladder colic kidney colic interstinal colic <pause dur="0.3"/> when do you get interstinal colic <pause dur="0.6"/> when you want to go for a poo <pause dur="1.2"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> you have faeces obstructing <pause dur="0.4"/> your bowel <pause dur="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 <pause dur="0.3"/> you're sitting there you're dying to get out of this lecture you really want to have a poo <pause dur="0.3"/> it's a <vocal desc="laughter" iterated="y" n="ss" dur="4"/> big poo

you've been building up to it <pause dur="0.5"/> you had a curry last night <pause dur="0.5"/> this is an important poo <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="3"/> and you feel pain <pause dur="1.0"/> in the tummy <pause dur="0.3"/> and that's colic that's interstinal colic <pause dur="0.2"/> and renal colic <pause dur="0.2"/> is exactly the same type of pain <pause dur="0.2"/> but much much worse and it's said to be <pause dur="0.2"/> one of the worst of all pains <pause dur="1.5"/> but there is a group of people that know it's one of the worst of all pains <pause dur="0.5"/> who traditionally likes to mimic <pause dur="0.6"/> renal colic and why </u><pause dur="0.8"/> <u who="sm0405" trans="pause"> drug addicts </u><u who="nm0370" trans="latching"> drug addicts okay <pause dur="0.2"/> it's very common for drug addicts to present to A and E <pause dur="0.4"/> # with renal colic <pause dur="0.3"/> and # there's probably a couple <pause dur="0.2"/> # in this lecture at the moment <pause dur="0.3"/> # trying to <pause dur="0.2"/> # get some hints how to pretend to have renal colic <pause dur="0.4"/> # <pause dur="0.2"/> and when you're <pause dur="0.2"/> housemen and S-H-Os it's important to look for people <pause dur="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 <pause dur="0.4"/> and # it's one of the classic catches <pause dur="0.5"/> # <pause dur="0.2"/> so renal colic is

like all colics it's a spasmodic pain in other words <pause dur="0.2"/> you have no pain you have terrible pain you have no pain you have terrible pain <pause dur="0.5"/> and classically when there is no pain there is zero pain <pause dur="1.0"/> so you go from complete absence of pain to severe pain <pause dur="0.5"/> and a patient with renal colic <pause dur="0.3"/> usually writhe around while they're having an attack <pause dur="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 <pause dur="0.7"/> but unfortunately it's not that easy <pause dur="0.9"/> # <pause dur="0.2"/> pain is not the only way in which kidney stone disease presents <pause dur="0.3"/> <trunc>wh</trunc> why do you think pain is <pause dur="0.2"/> not the only way in which kidney stone disease presents </u><pause dur="5.0"/> <u who="sm0408" trans="pause"> you're obstructing urine output </u><u who="nm0370" trans="overlap"> yeah <pause dur="0.5"/> in other words the stones may have appeared <pause dur="1.7"/> finish my sentence <pause dur="2.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> it's like Blankety Blank this <pause dur="1.6"/> the stones may have appeared <pause dur="0.7"/> adverb <pause dur="1.3"/> two syllables <pause dur="0.9"/> <vocal desc="laughter" iterated="y" n="sl" dur="1"/> </u><pause dur="0.4"/> <u who="sm0409" trans="pause">

in the <pause dur="1.0"/> <unclear>#</unclear> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> </u><pause dur="0.3"/> <u who="nm0370" trans="pause"> slowly <pause dur="0.9"/> so if things happen slowly in the human body <pause dur="0.3"/> classically the pain <pause dur="0.3"/> acquired related to that particular problem <pause dur="0.3"/> # is non-existent <pause dur="0.3"/> in other words there is no pain <pause dur="0.6"/> # and this is true of many systems of the body if something grows slowly <pause dur="0.4"/> the body becomes accustomed to it <pause dur="0.4"/> and so it is possible to have severe <pause dur="0.9"/> kidney stone disease <pause dur="0.3"/> without causing obstruction nephropathy which can lead to dialysis transplants and everything horrible <pause dur="0.3"/> meeting Dr <gap reason="name" extent="1 word"/> <pause dur="0.6"/> # <pause dur="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 <pause dur="0.5"/> what are # some other atypical presentations of stone disease </u><u who="sm0410" trans="latching"> haematuria </u><u who="nm0370" trans="latching"> yeah haematuria <pause dur="0.3"/> very good <pause dur="0.3"/> macroscopic haematuria <pause dur="0.4"/> # again it's pretty unusual pain is much

more common anything else </u><pause dur="2.8"/> <u who="sm0411" trans="pause"> unconsciousness </u><pause dur="0.6"/> <u who="nm0370" trans="pause"> yeah yeah no true you know it <pause dur="0.3"/> possible if you <pause dur="0.3"/> # if you ruptured one kidney completely went into acute renal failure eventually you'd become unconscious and i've seen that happen <pause dur="1.3"/> well <pause dur="0.2"/><kinesic desc="writes on board" iterated="y" dur="3"/> infection caused by the stasis behind the stone <pause dur="0.9"/> can be a presentation <pause dur="0.2"/> of kidney stone disease <pause dur="0.4"/> and they say that <pause dur="0.3"/> a single urinary tract infection in a man should always be investigated <pause dur="0.2"/> women <pause dur="0.3"/> don't matter too much you're always having U-T-Is <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> soon as you become sexually active you start having U-T-Is perfectly normal <pause dur="0.6"/> that's <pause dur="0.3"/> # the name of the game can't do anything about it have one a year <pause dur="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 <pause dur="0.9"/> but sometimes <pause dur="0.5"/> if a woman changes her pattern of U-T-Is from one a year or whatever <pause dur="0.5"/> # 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 <pause dur="0.6"/> okay <pause dur="0.4"/> so there are differences in the way we investigate men and women <pause dur="0.9"/> # who do you think these <pause dur="0.2"/> # patients present to <pause dur="0.9"/> lady with the <kinesic desc="indicates member of audience" iterated="n"/> brown jumper there <pause dur="0.5"/> who </u><u who="sf0412" trans="overlap"> G-P </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> G-P yeah <pause dur="0.2"/> quite often they'll go to their G-P first <pause dur="0.3"/> and if they're not too bad <pause dur="0.3"/> if they're bad where do they go </u><u who="ss" trans="latching"> A and E </u><u who="nm0370" trans="overlap"> yeah they'll probably go up to A and E <pause dur="0.2"/> and this is a problem 'cause they're <gap reason="inaudible" extent="1 sec"/> are coming up <pause dur="0.2"/> and the pain is pretty bad so if you genuinely have it you also tend to go <pause dur="0.3"/> fairly rapidly to A and E <pause dur="0.8"/> and <pause dur="0.3"/> they <pause dur="0.2"/> go through a nice system <pause dur="0.2"/> you see a triage nurse <pause dur="0.3"/> Tony Blair ticks his boxes <pause dur="0.2"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> the patient is seen between four hours <pause dur="0.3"/> you know all

about that game don't you there'll be <unclear>there'll be</unclear> triage nurses and as soon as you see them we tick the box <pause dur="1.4"/> and then we falsify all the data <pause dur="0.3"/> to make us oh oh <trunc>sh</trunc> i'm on camera <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="3"/> # <pause dur="0.5"/> the # <pause dur="1.1"/> to make sure that our hospital gets enough stars <pause dur="0.4"/> anyway <pause dur="0.2"/> # that's another story <pause dur="0.8"/> so the patient comes up to A and E they're seen by a triage nurse <pause dur="0.2"/> oh dear this might be renal colic and who who are they <pause dur="0.9"/> pushed towards </u><pause dur="3.6"/> <u who="sm0413" trans="pause"> X-ray </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> X-ray so they have an X-ray then what happens <pause dur="0.3"/> who who who <pause dur="0.4"/> who are they then next seen by </u><pause dur="0.3"/> <u who="ss" trans="pause"> surgeon </u><u who="nm0370" trans="overlap"> a surgeon <kinesic desc="puts hands on head" iterated="n"/><pause dur="0.5"/> and this is a disaster <pause dur="0.6"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> when they see a surgeon <pause dur="0.3"/> why is it a disaster they see a surgeon </u><pause dur="3.6"/><u who="sf0439" trans="pause"> <gap reason="inaudible" extent="1 sec"/></u><pause dur="0.9"/> <u who="nm0370" trans="pause"> <kinesic desc="puts hand to ear" iterated="n"/>

'cause they're completely non-thinking people who couldn't be physicians <vocal desc="laughter" iterated="y" n="ss" dur="1"/> is that what you said </u><u who="sf0414" trans="latching"> yeah </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> okay <pause dur="0.3"/> <unclear>okay</unclear> sorry i don't i don't don't let me put words in your mouth though <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> # <pause dur="1.7"/> oh that's on camera as well <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> # <pause dur="1.7"/> no surgeons are good <pause dur="0.5"/> because <pause dur="0.5"/> they know how to get rid of the pain and they can spot white things <pause dur="0.3"/> and they can spot it when they don't come out and then they know <pause dur="0.9"/> what they have to do next <pause dur="0.4"/> why are surgeons bad for kidney stone disease bearing in mind the epidemiology which we've talked about </u><pause dur="0.6"/> <u who="sf0415" trans="pause"> they only treat the problem </u><pause dur="0.3"/> <u who="nm0370" trans="pause"> sorry they don't look for the cause <pause dur="0.5"/> and in many patients there is an identifiable cause <pause dur="0.8"/> but there's one famous <pause dur="0.2"/> American study where ninety-seven per cent of people in this study were

found to have some form of biochemical abnormality <pause dur="0.3"/> which some people wouldn't consider a cause <pause dur="0.8"/> and are ninety-seven per cent of stone form <unclear>is</unclear> investigated course they're not <pause dur="0.5"/> who <pause dur="0.2"/> who do you think that the thinking surgeon tends to investigate <pause dur="3.5"/> let's have some <pause dur="0.4"/> # comments from the back so <pause dur="0.3"/> two ladies with the scarves there <pause dur="0.5"/> who's the thinking are you going to be a thinking surgeon <pause dur="1.2"/> don't know yet <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> okay <pause dur="0.3"/> who do you think the thinking surgeon investigates <pause dur="3.9"/> hundred-thousand people having stones every day <pause dur="0.8"/> can't investigate them all <pause dur="2.0"/> who do you think they who would they focus on <pause dur="1.8"/> lady with the pink scarf </u><pause dur="0.4"/> <u who="sf0415" trans="pause"> no idea </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> no idea lady next to her </u><pause dur="0.8"/> <u who="sf0416" trans="pause"> anyone with a family history </u><u who="nm0370" trans="latching"> yeah good so if they've got a family history <pause dur="0.2"/> they'll spot that <pause dur="0.8"/> if they're asked the question <pause dur="1.3"/>

but if they don't <pause dur="0.7"/> oh yeah my mum had stone my grandmother <pause dur="0.5"/> we've all got stones but don't know why <pause dur="0.4"/> and # <pause dur="0.2"/> so they don't particularly <pause dur="0.2"/> # investigate the people who should be investigated <pause dur="0.4"/> # what most surgeons do is that they can count they can count up to <pause dur="0.5"/> two <pause dur="0.7"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> and that's very important <pause dur="0.4"/> for kidney stone disease because <pause dur="0.6"/> on the second stone which is the number <pause dur="0.4"/> after one <pause dur="0.2"/> <vocal desc="laughter" iterated="y" n="ss" dur="2"/> they know to investigate it and that's <pause dur="0.2"/> what most surgical practice is <pause dur="0.3"/> they investigate people after the second episode of stone <pause dur="0.3"/> unless the stones are particularly horrendous like <kinesic desc="indicates point on board" iterated="n"/> those ones <pause dur="0.2"/> or they have a staghorn calculus or something like that <pause dur="0.3"/> what's a staghorn calculus okay it looks like a staghorn but <pause dur="0.3"/> <kinesic desc="indicates member of audience" iterated="n"/> lady there <pause dur="0.2"/> what do you think causes staghorn calculi </u><pause dur="2.2"/> <u who="sf0417" trans="pause">

i don't know </u><pause dur="0.9"/> <u who="nm0370" trans="pause"> anybody </u><pause dur="1.2"/> <u who="sm0418" trans="pause"> is that just still in the kidney </u><u who="sm0419" trans="overlap"> <gap reason="inaudible" extent="1 sec"/></u><u who="nm0370" trans="overlap"> sorry </u><u who="sm0420" trans="latching"> is it still in the kidney </u><pause dur="0.3"/> <u who="nm0370" trans="pause"> still in the kidney <pause dur="1.2"/> it's called staghorn because it looks like a staghorn <pause dur="0.3"/> because it fills up the <kinesic desc="writes on board" iterated="y" dur="10"/> whole of the pelvic-caliceal system <pause dur="0.4"/> and some people would say that what i'm <trunc>a</trunc> what i'm trying to draw here is vaguely like the staghorn <pause dur="3.2"/> what predisposes to staghorn calculi <pause dur="0.4"/> which interestingly often don't present as pain <pause dur="1.6"/> infection infection stones <pause dur="0.5"/> # <pause dur="0.3"/> so these are particularly common in women <pause dur="0.4"/> and <pause dur="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 <pause dur="0.9"/> and now <pause dur="0.7"/> okay i've stood here as a physician slagging off my surgical colleagues who i work with on a daily basis <pause dur="0.5"/> and <pause dur="0.3"/> # <pause dur="0.6"/> why do you think it's actually a good idea that they don't investigate <pause dur="0.6"/> everybody <pause dur="0.3"/> with a single stone <pause dur="2.2"/> gentleman here <kinesic desc="indicates member of audience" iterated="n"/><pause dur="0.2"/> why is it a good idea not to investigate <pause dur="4.3"/> we talked a bit about the epidemiology at the start </u><pause dur="1.5"/> <u who="sm0421" trans="pause">

because it's so common </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> it's so common <pause dur="0.8"/> and we can't possibly be investigating five-million people <pause dur="0.6"/> because it's too expensive <pause dur="0.3"/> and you could argue <pause dur="0.3"/> that # it doesn't really matter anyway 'cause they don't kill you and most people have one episode maybe two in their lives <pause dur="0.2"/> it doesn't cause kidney failure <pause dur="0.2"/> it doesn't cause obstruction <pause dur="0.2"/> it doesn't cause any major problem <pause dur="0.2"/> so it may be yet another way in which the N-H-S cuts corners by <pause dur="0.2"/> only investigating people with <pause dur="0.2"/> two or more stones <pause dur="0.8"/> okay <pause dur="0.3"/> who do who do you think <pause dur="0.2"/> in most # <pause dur="0.7"/> # <pause dur="0.5"/> centres centres of excellence like Coventry actually <pause dur="0.2"/> sets up kidney stone disease clinics <pause dur="1.5"/> it's a trick question </u><pause dur="1.3"/> <u who="sm0422" trans="pause"> nobody </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> nobody absolutely <shift feature="voice" new="laugh"/>nobody <shift feature="voice" new="normal"/><pause dur="0.2"/> there is no specialist <pause dur="0.3"/> kidney stone disease clinic in Coventry in fact many of <pause dur="0.3"/> the the big cities in the U-K unless a doctor has a particular interest in kidney stones <pause dur="1.6"/> one of our surgeons does have <pause dur="0.6"/> some

interest in kidney stones <pause dur="0.2"/> but it's not his primary interest <pause dur="0.6"/> and none of the six nephrologists here have a particular interest in kidney stones so one of the commonest diseases <pause dur="0.3"/> of all time <pause dur="0.3"/> is <pause dur="0.2"/> not looked at by anybody in particular just by a mishmash of people <pause dur="0.6"/> and therefore mistakes are made <pause dur="0.3"/> there is nobody to refer to <pause dur="0.3"/> and in fact in the U-K there are almost <gap reason="inaudible" extent="1 sec"/> centres with an interest <pause dur="0.3"/> in kidney stone disease there was one <pause dur="0.3"/> at U-C-L in London i don't know if it's still going <pause dur="1.2"/> # so there you go do your PhD the pathophysiology of stone disease become famous <pause dur="0.4"/> go on world tours set up a clinic in <gap reason="name" extent="1 word"/> <pause dur="0.3"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> and you might do some good <pause dur="0.2"/> okay <pause dur="0.8"/> so <pause dur="0.6"/> we've talked a bit about their presentation <pause dur="0.2"/> what about their investigation <pause dur="0.4"/> okay let's pick on somebody else gentleman with the <pause dur="0.4"/> Nike black top tell me <pause dur="0.2"/> how you'd like to investigate somebody who presents with a kidney stone simplest test first remember <pause dur="0.3"/> <unclear>bit of a</unclear>

touchy-feely <gap reason="name" extent="1 word"/> students we do nice simple things first <pause dur="0.4"/> <vocal desc="laughter" iterated="y" n="ss" dur="1"/> we don't go for M-R-Is </u><pause dur="0.4"/> <u who="sm0423" trans="pause"> X-ray </u><pause dur="0.3"/> <u who="nm0370" trans="pause"> X-ray <pause dur="0.3"/> wrong <pause dur="0.3"/> okay <pause dur="0.2"/> it's simpler than that <pause dur="0.4"/> anybody else </u><u who="sm0424" trans="latching"> U-neg </u><pause dur="0.8"/> <u who="nm0370" trans="pause"> wrong simpler than that </u><u who="sm0425" trans="latching"> palpate </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> sorry </u><pause dur="0.4"/> <u who="sm0425" trans="pause"> palpate </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> palpate well we've moved <pause dur="0.2"/> you're right we would do that but we've moved on from <gap reason="inaudible" extent="1 sec"/> <pause dur="0.5"/> simple very simplest the most simple test of wee wee </u><pause dur="0.2"/> <u who="sf0426" trans="pause"> give us some <unclear>clue</unclear> </u><pause dur="0.6"/> <u who="nm0370" trans="pause"> giving you a clue </u><pause dur="0.3"/> <u who="sf0427" trans="pause"> a dipstick </u><pause dur="1.0"/> <u who="sm0428" trans="pause"> <shift feature="voice" new="laugh"/>speaking of what are we testing for <shift feature="voice" new="normal"/><vocal desc="laughter" iterated="y" n="ss" dur="1"/> </u><pause dur="0.6"/> <u who="nm0370" trans="pause"> a urinary dipstick <pause dur="0.2"/> okay <pause dur="0.2"/> possibly the simplest test of urine and possibly one of the most important <pause dur="0.5"/> # <pause dur="0.2"/> it can tell you lots of things <pause dur="0.5"/> lots of things like whether there's protein in the urine <pause dur="0.2"/>

blood in the urine which would be consistent with stones <pause dur="0.3"/> or is it <pause dur="1.0"/> what is the blood <pause dur="0.6"/> on a urinary dipstick caused by <pause dur="1.7"/> <kinesic desc="makes quotation mark gesture" iterated="n"/> the blood in inverted commas </u><pause dur="1.1"/> <u who="sf0429" trans="pause"> # lysis of red blood cells </u><pause dur="0.3"/> <u who="nm0370" trans="pause"> very good <pause dur="0.3"/> so if you forget everything i say this morning <pause dur="0.5"/> just remember this that the blood on a urinary dipstick <pause dur="0.3"/> is not due to blood cells <pause dur="0.4"/> it's due to haemoglobin in other words the lysis of blood cells <pause dur="0.3"/> and why is that so important <pause dur="0.2"/> and why do so many surgeons therefore <pause dur="0.3"/> put people into acute renal failure <pause dur="0.5"/> you've got to think laterally now <pause dur="0.5"/> lady with the blue headband there <pause dur="1.2"/> so why is that so important that the urinary dipstick does not measure blood cells <pause dur="0.6"/> it <pause dur="0.2"/> measures a component of blood why does that lead to so many clinical errors <pause dur="1.4"/> which you're not going to make 'cause you're never going to forget this 'cause i've picked on you <pause dur="1.2"/> right

anybody help her out </u><pause dur="0.8"/> <u who="sm0430" trans="pause"> all the remaining debris from the cell is stuck in the kidney </u><u who="nm0370" trans="latching"> yeah and <pause dur="2.3"/> there are many other causes of haemoglobinuria other than <pause dur="0.8"/> diseases where there is haematuria <pause dur="0.5"/> so there are many causes of haemoglobinuria myoglobinuria <vocal desc="sneeze" iterated="n" n="sm0431"/><gap reason="inaudible due to audience noise" extent="1 sec"/> et cetera all of which will give you a false positive blood inverted commas on <pause dur="0.2"/> the urinary dipstick <pause dur="0.4"/> so it is it is a good test and it's a bad test <pause dur="0.3"/> and the reason it needs surgeons to call if you've an acute renal failure <pause dur="0.2"/> is somebody presents with a stone <pause dur="0.2"/> what do they do history examination blah blah blah lots of blood tests yah-dah-dah <pause dur="0.2"/> X-ray I-V-Ps their standard first line investigation <pause dur="0.3"/> which contains nephrotoxic dye <pause dur="0.5"/> and therefore somebody who's <unclear>dyed</unclear> about every rhabdomyolysis because some other <pause dur="0.5"/> cause <pause dur="0.2"/> is having an unnecessary investigation which will make them worse <pause dur="1.0"/> and i have in my time saved a few people from <pause dur="0.2"/> acute renal failure by <pause dur="0.2"/> stopping surgeons do I-V-Ps </u><pause dur="1.5"/> <u who="nf0432" trans="pause">

<gap reason="inaudible" extent="1 sec"/> five minutes </u><u who="nm0370" trans="overlap"> okay <pause dur="0.7"/> so if you forget everything else i say today just remember that <pause dur="0.9"/> that the blood on a urinary dipstick <pause dur="0.3"/> is not <pause dur="0.3"/> made positive by blood cells it may be <pause dur="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 <pause dur="0.4"/> the other simple test of the urine <pause dur="3.2"/> other than putting a dipstick in <pause dur="1.1"/> what would <pause dur="0.5"/> twenty years ago if you were my houseman i was your consultant what would i be expecting you to do for my <gap reason="inaudible due to overlap" extent="1 sec"/> </u><u who="ss" trans="overlap"> taste it </u><pause dur="0.7"/> <u who="nm0370" trans="pause"> taste the urine possibly <vocal desc="laughter" iterated="y" n="ss" dur="2"/> </u><pause dur="1.9"/> <u who="sm0433" trans="pause"> sieve it </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> sorry </u><u who="sm0433" trans="latching"> sieve it </u><pause dur="0.5"/> <u who="nm0370" trans="pause">

sieve it and microscope it <pause dur="0.7"/> because many causes of kidney stone disease can be diagnosed on microscopy unfortunately <pause dur="0.3"/> it's a skill that most of us have now lost or forgotten <pause dur="0.3"/> and <pause dur="0.8"/> maybe i'm harking back to the good old days <vocal desc="laughter" iterated="y" n="ss" dur="1"/> when things were better when we had leprosy and T-V and <vocal desc="laughter" iterated="y" n="ss" dur="1"/> social deprivation but it was quite good fun to be able to make diagnoses by microscoping the urine which we no longer do and <pause dur="0.2"/> some disease particularly <trunc>s</trunc> cysteine disease <pause dur="0.3"/> where there's a classic type <pause dur="0.3"/> of benzene ring crystals can be diagnosed from simple microscopy of the urine you don't need any fancy tests <pause dur="0.7"/> so yes <pause dur="0.5"/> we go to do blood tests yes we go to do X-rays but we do simple tests first <pause dur="0.3"/> an M-S-U probably <pause dur="0.3"/> basic blood tests including <pause dur="0.2"/> a serum <pause dur="2.4"/> what </u><pause dur="0.2"/> <u who="ss" trans="pause"> calcium </u><u who="nm0370" trans="overlap"> calcium why </u><pause dur="0.8"/> <u who="sm0434" trans="pause">

<gap reason="inaudible" extent="1 sec"/> </u><pause dur="0.3"/> <u who="nm0370" trans="pause"> yeah well it's one of the commoner rare causes <pause dur="0.3"/> so but most people with hypercalcuria are not hypercalcaemic so <pause dur="0.2"/> everybody does the count and it's almost always normal and i think this is one of the reasons why <pause dur="0.2"/> surgeons get fed up with investigating people with stone disease 'cause everything's always normal <pause dur="0.3"/> but if they look for the things which were there they would find them to be abnormal in a lot of people <pause dur="1.0"/> so we do those simple tests <pause dur="0.3"/> # we do it twenty-four hour urine looking for calcium urate oxalate citrate all the other things <pause dur="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 <pause dur="0.2"/> one of the reasons why most of these patients are not investigated <pause dur="1.6"/> so plain X-rays are probably <pause dur="0.2"/> the single most useful test in eighty per cent of people with greater instance of stones which is why <pause dur="0.2"/> i brought that one up today <pause dur="0.4"/> but most surgeons would do an

I-V-P <pause dur="0.3"/> as well as a plain X-ray why would they want to do an I-V-P give horrible nephrotoxic dye <pause dur="0.4"/> with significant mortality </u><pause dur="0.4"/> <u who="sm0435" trans="pause"> want to check behind the stone </u><pause dur="0.8"/> <u who="nm0370" trans="pause"> yeah <pause dur="0.2"/> to see if there's any obstruction behind the stone <pause dur="0.7"/> # to see if they they need to do anything quickly <pause dur="1.3"/> what size stones pass naturally <pause dur="3.9"/> calculated guess if you don't know </u><pause dur="0.9"/> <u who="sm0436" trans="pause"> couple of millimetres </u><pause dur="0.4"/> <u who="nm0370" trans="pause"> sorry </u><u who="sm0436" trans="latching"> couple of millimetres </u><pause dur="0.2"/> <u who="nm0370" trans="pause"> yeah less than four and we would watch a patient with a stone of less than four <pause dur="0.2"/> millimetres <pause dur="0.2"/> four above usually requires some form of intervention <pause dur="0.4"/> how can we intervene how can we <pause dur="0.2"/> extract stones <pause dur="0.2"/> lady with the brown top on again </u><pause dur="1.2"/> <u who="sf0412" trans="pause"> # <pause dur="4.4"/> blocked by the # <gap reason="inaudible" extent="1 sec"/> </u><u who="nm0370" trans="overlap"> <trunc>ex</trunc> speak up sorry shush everybody listen </u><pause dur="0.3"/> <u who="sf0412" trans="pause">

<vocal desc="laugh" iterated="n"/> <pause dur="0.4"/> # i don't know </u><pause dur="0.5"/> <u who="nm0370" trans="pause"> this <gap reason="inaudible" extent="1 sec"/> again we sometimes shout at the stones we can use sound waves to shout at the stone <pause dur="0.5"/> sometimes we can go up there pull them out and various <pause dur="0.5"/> # <pause dur="0.4"/> horrible instruments <pause dur="0.2"/> # usually done under G-A though not always <pause dur="0.3"/> # <pause dur="0.2"/> we can use a Foley basket we can shatter them we can get them out there are various ways of doing that <pause dur="0.3"/> the last resort is an open operation doing what the Egyptians did it does work <pause dur="0.5"/> # <pause dur="0.2"/> but # it does leave quite a big scar <pause dur="1.0"/> okay <pause dur="1.1"/> so they're the investigations we tend to do <pause dur="0.2"/> on patients with <pause dur="0.2"/> recurrent kidney stone

disease and perhaps we should investigate them all <pause dur="1.0"/> # <pause dur="0.4"/> finally <pause dur="1.0"/> # <pause dur="0.4"/> i'd like to now convince you <pause dur="0.3"/> that this disease which you all thought was boring <pause dur="0.3"/> # unimportant and like trainspotting is not such a boring trainspotting disease <pause dur="0.2"/> first of all 'cause about ten per cent of you roughly are going to have one of these in your lifetime <pause dur="0.4"/> it's going to hurt <pause dur="0.4"/> it's going to <pause dur="0.5"/> stop you from going to work and is likely to happen again <pause dur="0.9"/> and <pause dur="0.3"/> if we did make some effort to get interested in a disease which is about as interesting as trainspotting <pause dur="0.3"/> we might be able to stop some of these attacks from happening <pause dur="0.7"/> okay thank you very much <kinesic desc="applause" iterated="y" n="ss" dur="6"/>