Monday, October 31, 2011

The challenge of Dementia

Dementia is not a pretty disease and there is still so much that the experts have to discover about it before we can ever contemplate talking about cures. So if there is anything simple and practical that we can do to prevent, or reduce the risk of developing dementia, then we should take it seriously.

But first, let me tell you a story: a story of hope. In 2001 a Dr Snowden convinced a congregation of Catholic Nuns to take part in an ongoing study into Alzheimers dementia, and he also convinced them to donate their brains …. after they died!

At the start of the study most of the Nuns were already elderly, between the ages of 75 and 94, 20 years later the researchers already have over 500 of the Community’s brains to study. For the scientists, this is a gold mine of information as in most studies there are so many “variables” that they have to take into consideration. Here, the Nuns didn’t smoke, rarely drank alcohol, followed the same diet and lived in the same environment. But the big plus was that they recorded their histories that were kept at the Convents from the time that they had signed up as postulants, and these were made accessible to the researchers.

So what have been the results? In a nutshell, those who had a positive spin on life lived, on average, 10 years longer than their gloomier confreres! Also, those with a positive spin on life were also less likely to show signs of Alzheimer’s disease in post mortem findings. And interestingly, there were 15 brains that showed the classical, pathological signs of Alzheimer’s disease, but the Nuns whose brains they were had not exhibited dementia in their lifetime. These were amongst those Nuns who had a positive, active perspective on life.

Dr. Snowdon hopes his study will encourage people to do things to ward off the disease, like quit smoking and other stroke-causing behaviors, and read to children to stimulate language development.
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Thursday, October 27, 2011

Thomas Jefferson, Joseph Lister and William Halstead

It's always good to see your "rellies" name in the headlines, even if the link is extremely tenuous!

I saw a headline labeled Thomas Jefferson University, and was immediately drawn to it, both for the name and the fact that someone had reduced wound infections by nearly 50%! It was serendipitous really that I had just finished reading a book about the introduction of painless surgery in the 19th Century. The death rate due to infection following surgery during this period was an astonishing 70 to 90%,  in fact "Laudable pus" was seen to be a healthy sign and a natural progression to normal wound healing!

Remember, prior to 1846 when Dr Joseph Lister introduced his aspectic techniques with carbolic acid, surgeons wore the same frock coats to each operation, and when surgery was over, they wiped their instruments on them to clean them. And it wasn't until 1889 (the year that my grandfather was born!) that Dr William Halstead in the US, introduced the wearing of rubber gloves during surgery. Actually, according to legend, he didn't introduce them to help reduce wound infections, but because the theatre nurse he "fancied" had terrible skin reactions to carbolic acid, and so he had them custom made for her as a "surprise" to protect her skin. It obviously worked so well that everyone started wearing them and the rest is history!

But back to Thomas Jefferson (not related sadly)  and the hospital named after him. Apparently by introducing a check list of 12 things to do to reduce infection rates, they had an astounding 50% reduction in wound infections after a surgical procedure known as a Whipple's operation. This is an operation that is performed for growths on the pancreas, both benign and malignant. The actions they took weren't big things either, amongst others they included:

  • smoking was banned at least 2 weeks prior to surgery
  • they clipped hair from the skin pre-op instead of shaving it off.
  • they used Chlorhexidine-alcohol skin preparation instead of iodine
  • they protected the skin edges meticulously during surgery
  • they changed gloves and gowns before closing the abdominal wound.
Historically, medicine progresses in small steps, and it's attention to the small things that often make the biggest difference.
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    Monday, October 24, 2011

    A new Nemesis for Nits?

    When our eldest offspring came home from Kindy a few decades past, I vividly remember her announcing that her teacher had told the class to tell their parents that their precious infants "may have visitors" with them! After a bit of head scratching ourselves, we "twigged" that she was talking about nits!

    Head lice infestations are a common event in the lives of every parent of school aged children. I have always found it amazing that within minutes of hearing of the possibility of head lice being present, my own head starts to itch too!Not that Nits actually cause any harm, and are merely extremely efficient at moving from one young child to another. Once found, then a suitable unguent or lotion is applied, followed by days of fine combing and picking eggs from the roots of hairs!

    Well, I was interested in reading the other day about a "new" product that has been cleared by the FDA in the US and was discussed at a large Meeting of Paediatricians on October 17th. This "new" product is derived from a naturally occurring soil bacterium, and is effective after just one 10 minute application. It's official name is Spinosad, and according to the experts, it will consign fine combing to the annals of history, which is a most welcome event!

    With all things "new" in the medical profession, I am always amazed by the fact that Veterinarians have usually been using these products for years, prior to the pharmaceutical company concerned releasing these "brand new" treatments onto the general public. For your information, Spinosad was released in 2007, for use on Sheep that were infected with a lice called Bovicola ovis!

    It has also been used for the control of leaf-miner, lesser mealworm and is the active ingredient the spray Success that I use to spray on my caterpillar affected lettuces! 

    What's good for the greens is great for the "grandies"

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    Thursday, October 20, 2011

    Screening for Ovarian cancer - experts still looking!

    Many years ago a good friend of ours (also a patient at the time) was diagnosed with ovarian cancer. Like most women with this disease, the tumour was well advanced before she had any symptoms,  and in these cases the 5 year survival rate remains at 30%. She was one of the most optimistic and cheerful ladies we have ever known, even as the disease progressed and she struggled with all the impotent therapy that she was given.

    Times, sadly, haven't moved on too far in all those years and so researchers are constantly on the look out for a screening tool that can pick up these "difficult to find" tumours at an early stage when treatment is so much more effective - a Stage 1 cancer has a 92% five year survival rate! There is a marker protein - CA125 - that is "associated" with these sorts of tumours, however it is not specific for the tumour and by itself it is not a good screening tool. It was thought that by adding Trans-vaginal Ultrasound to checking the level of CA125, that together they might be able to detect cancers at an early stage.

    The news is not good. A 13 year study following 80,000 women in the US and just published in the Journal of the American Medical Association, reported that those in the "screened" group - CA125 plus transvaginal ultrasound - fared no better than those in the "not screened group" who did not have an ultrasound plus CA125. In fact the screened group underwent more interventions and had more ovaries removed and had more surgical complications.

    Sometimes science does appear to move at a glacial pace, and when negative results come out it is always disappointing. But the upside is that now we know that this sort of screening is not valid, we can move on and redirect our energies and resources towards more fruitful ideas and solutions.

    Here's hoping!
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    Wednesday, October 19, 2011

    Let your Kids play, ration the electronic stuff!

    I have just read a report from the American Academy of Paediatrics, and one of the facts nearly knocked me off my chair. In a recent survey they performed, 90% of children under 2yrs watched some form of electronic media: OK I can understand that the TV may be on in the house and sometimes it is a useful distraction to sit them in front of a screen whilst you go to the "rest room". But then it reported that by aged 3, almost one third of children have a TV in their bedroom!!! I have to admit to being still stunned by this fact! What are we doing to our children?

    I think that AAP must be thinking along the same lines because they too don't think that children under 2 should be watching TV either, as the developing brain needs more than an electronic screen to help it learn and problem solve. Here's a list of their suggestions:
    • Set media limits for children before age 2, bearing in mind that the AAP discourages media use for this age group. Have a strategy for managing electronic media if they choose to engage their children with it.
    • Instead of screens, opt for supervised independent play for infants and young children during times that a parent cannot sit down and actively engage in play with the child. For example, have the child play with nesting cups on the floor nearby while a parent prepares dinner.
    • Avoid placing a television set in the child's bedroom.
    • Recognize that their own media use can have a negative effect on children.
    My advice would echo to the sound of TVs crashing to the ground having been ejected through windows! But although there is a tendency to 21st century Luddite-ism in my reaction, I have to admit that the electronic media does have just a few tiny benefits, although they pale into insignificance when compared to the  unstructured playtime and interacting with family members that helps the developing child understand and thrive in their small worlds.
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    Sunday, October 16, 2011

    Preparing for summer

    Today, here in Perth, the mercury shot up the scale and reached about 35C, which is unusual for October, but fairly standard for the summer months. In our house, we respond like prodded sea anemones - windows closed, curtains drawn and furtive glances out the window to see if the sea breezes "has come in yet"! As I look out of the window I can also see a vast plume of smoke on the horizon which reminds me of another terrible danger that can threaten in the searing Aussie heat, and that's bush fires!

    On a global scale Governments are looking to harness the sun's power to help reduce our reliance on fossil fuels, and in doing so we acknowledge the incredible power of the sun and the energy that it produces via it's massive nuclear fusion reactions. So in some respects, we are already using nuclear energy - AKA renewable energy - via solar panels, wind farms and tidal power. But I'm not heading toward a Green/Nuclear dissertation, but rather towards the fact that the UV radiation from the sun impacts on our skin and our eyes, and it's that time of year when we should be thinking about protecting both of them from the harmful effects of the sun: and in particular we should be training the next generation of little people on how to reduce their exposre to strong sunlight.

    • Don't go out into the sunshine between the hours of and 4pm unless you're wearing sun protection.
    • Use an appropriate 30+ sunblock on exposed skin.
    • Where possible wear long sleeved shirts and long legged pants.
    • Wear a wide brimmed hat
    • Wear effective UV protective sunglasses
    • Sit in the shade where possible
    • Maintain your, and your infants hydration on hot days

    The de-cision to protect your skin will reduce the risk of having an ex-cision to remove a cancer later in life!
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    Wednesday, October 12, 2011

    Greens, Genes and Heart Disease

    Over the years I've often said to patients, you can stop smoking, you can exercise more, you can even lose weight but you can't change the Genes you were given! Well, I may be proved wrong, at least if the researchers at McMaster and McGill universities in the US are proven to be correct in their findings. They have just reported that the gene that is the strongest marker for heart disease can actually be modified by a diet rich in fruit and raw vegetables.

    They performed a very large study on over 27,000 people of various ethnic origins and found that those who had a high intake of fruit and raw vegetables and who carried the high risk gene known as 9p21, reduced their risk of heart attacks to the level of those who did not carry the gene. "Our research suggests there may be an important interplay between genes and diet in cardiovascular disease," says the study's lead author Dr. Ron Do. Obviously there is still much more work to be done to find out the mechanisms of how this happens, and no doubt it will take many years before all the mysteries are resolved.

    In the meantime, it's back to the Hunter Gatherer scene of eating nuts, berries and raw veggies: now does that sound familiar?

    Source: PLoS Medicine
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    Tuesday, October 11, 2011

    Warts and all

    I was cleaning out some cupboards and came across an old copy of Mrs Lavendars Herbal Book which was probably published about 1920! It's a delicious dip back into time to see what folk were thinking in the time before antibiotics, and when modern medicine was in its infancy.

    Regarding warts she writes, " Warts, however, come and go in quite mysterious fashion, really I do not believe that anyone knows the exact causes excepting that often they come from the splash of egg water on the skin"! Well, times have moved on and the electron microscope has shown us that warts are caused by on of the Human Papillomaviruses ( there are over a 100 of them including the ones implicated with cancer of the Cervix), but she was absolutely right when she wrote that they come and go in quite a mysterious fashion.

    Papillomaviruses are quite contagious, and yet some people catch them and others don't. For those who do get them, eventually they will disappear of their own accord and will not need any treatment: mind you this can take a couple of years! I use the analogy of a Stealth Bomber: the virus flies under the radar of the body's immune system and causes a thickening of the base layer of the skin to cause the  skin eruption we recognize as a wart - this can take from 2 to 6 months -. Then, for some unknown reason, the virus loses its invisibility and is noticed by the body's immune cells which do their job and destroy it. Hence the reason why people often will say that their wart disappeared over night.

    If a wart is thought to be unsightly, then there are various options to removal: although, be warned, they will often return in a nearby location after removal!

    First there is the slow, painless errosive method using creams containing corrosive chemicals such as salicilic acid. The key is to persist until a hole has been made in the skin: too many people stop too early and the wart happily returns to its former glory.

    Destructive therapy: this can be by electro-cautery, which literally burns them out (under local anaesthetic of course): cryotherapy is another popular alternative when the liquid nitrogen causes a freeze burn to destroy the wart; and laser therapy which vaporizes them.

    Topical Immunotherapy is also becoming more popular, but is more expensive and does require prescription medication.

    What did Mrs Lavender recommend? She was a great believer in "the juice from the ordinary Dandelion". You had to use it until the wart turned black, and then it was said to drop off. Ah, those were the good old days eh?

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    Friday, October 7, 2011

    Kidney Transplants withouth the Immuno drugs?

    I love smart thinkers!

    Kidney transplants were such a big breakthrough for all those with end stage kiidney failure, but the chances of getting an identical match - unless you had a generous twin - were remote. That meant that even with the closest of matches, patients were/are left with the need for life long anti-rejection therapy to protect the donor kidney. But perhpas that all may change!

    Researchers at Stanford University School of Medicine have developed a novel protocol for those receiving a donor kidney which may allow them to go "drug free" after a few weeks. What they do is to weaken the recipients immune system with some well directed radiation therapy to the spleen, certain lymph glands and the thymus, and they inject Stem cells from the donor into the recipient at the same time. This results in a sort of "combined" immune response from the recipients "tweaked" immune system that makes it look at the new kidney and say "I see you, but I'm not going to get upset about you being here", and as the lead researcher, Samuel Strober, MD says, "... it casts a blind eye on the foreign tissue of the graft."

    Like all good things, this was not an overnight discovery: it took 30 years of mouse research before human trial were started. It's still very early days, but the results are certainly very encouraging.

    Why try and avoid immuno-suppressant medications? Well, they are very good at what they do, but they are not a cure and can have very powerful side-effects too such as Diabetes, high blood pressure and cancer!!

    As I said at the beginning, I love smart thinkers: but what I admire even more are determined, persistent smart thinkers,

    reference material October issue of New England Journal of Medicine
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    Wednesday, October 5, 2011

    Diet, exercise and sex!

    Now that I've got your attention, I should warn you that women over the age of 50 might like to read a good book or have a hot bath now, because this relates to older men with known cardiovascular who adopt a healthier lifestyle! 

    Those who do adopt healthier exercising and eating habits will have a 30% reduction in their risk of developing mild to moderate erectile dysfunction. These finding were reported after a literature review by Dr Stephen Kopecky from the Mayo Clinic in America who was looking at why both Cardiovascular disease and Erectile Dysfunction had a similar risk profile.

    Dr Kopecky said: "If you start lecturing a man about his risk of heart disease, his eyes start to glaze over. Everyone knows someone who's had a heart attack, has had a stent, and is back on the golf course in a week or two. But when you tell them the risk factors for heart disease are the same as those for erectile dysfunction and dementia, they are immediately interested. Men don't sit around worrying about heart disease, but they do worry about not being able to have sex and getting Alzheimer's."

    So for the older male of the species, this is a real "win win" situation: a reduced risk for heart attacks and an improved sex life! Perhaps the partners of these rejuvenated males may need to spice up more than their their recipes or else offer their spouses a healthy cold bath!

    Ref: September 12, 2011 in the Archives of Internal Medicine.
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    Monday, October 3, 2011

    In the Mood

    In the past week there have been a couple of events that have reminded me of how people are so important in our lives.

    My senior offspring alerted us to a situation where a husband had recently been diagnosed with cancer, their children being of primary school age. His spouse is naturally devastated, and by all accounts not coping too well with daily life. Enter the female psyche - which in these occasions is often far superior to the male variety - with the very basic observations of "Are you eating properly? Do the kids need anything for their school lunches?" Within 24 hours there was a meal roster established to deliver food, and "Mums Mafia" was clicking into gear at the school level to cover for lifts and after school activities.

    The other event that moved me was the reporting in the local paper of how Glen Mitchell, an ABC media legend in this part of the world, revealed that he was suffering from Bi-polar disorder and that on one occasion he had driven to a remote area, with a hose pipe, with serious self-harm thoughts in his mind. What changed his mind, and in fact changed his life, was the fact that the local Ranger spotted his car and came over to see what he was up to. He obviously spotted the hose in the back of the car and stayed on to chat to Glen. The two carried on a seemingly normal conversation and eventually Glen went home to his amazing wife Karen. She too spotted the hose and was frantic with worry. The great news is that with a change of medication, Glen has now had one of the best periods of his life for some years, and is now reaching out to help others with similar problems.

    It would be wonderful to think that the answer is to simply diagnose a person with a mood disorder and give the right medication, then "Hey presto" all is stable and well and everyone lives happily ever after. But the neuro-biochemistry of the the brain is somewhat more complicated than that, and there are so many variables at play in anyone's life at any one time, that although medication can be a part of the solution, in reality, there are so many other issues to address to ensure that consistent progress is  sustained.

    That's where we come back to the common denominator here: PEOPLE.

    We need people in our lives who are sensitive to our moods and our needs. My senior offspring was sensitive to the needs of a friend and did something. The Ranger in the park was sensitive to the needs of a struggling stranger and listened: Glen's wife was sensitive all the time and had kept a journal that alerted his treating doctor to Glens real situation - that's what love does: it cares. And I'm not just talking about family and friends being alert to the needs of a mate: the Ranger might have just been doing his job, but he in fact did far more: he showed the rest of us how to be good humans by taking time, by listening and by being a sign that goodness does exist in this often crazy world and thereby offering hope to someone who was lost. There's a lesson there for all of us.
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