Friday, March 30, 2012

Not everyone who goes to the Doc is sick!

Sometimes, people go to see the Doctor when they are quite well, for instance, when they need more tablets for their BP, or to check out some bloods that were done when they felt bad, but now they're over it thought they should do the right thing and just "check it out". Those times are good to get to know each other and maybe just "chew the fat" for a few minutes - just like in "real life". So today, seeing as you're all feeling so great, I'd just like to share a photograph I took this morning. It's at a special place known as the Palace Gardens of Versailles, France: and it's beautiful.

And seeing as how I am a Doctor, before you go I ought to give you some medical advice.

Make some space in your life for you, a time to nurture yourself: and start today.

Take a good look at the photo and then, using  your imagination, put yourself in the picture and dream what you'd like to do. Just to set the scene: it's a beautiful spring morning, there's still a freshness to the air but the sun in warm on your back. On the lake there are white swans and ducks feeding, and people walk, jog or cycle by. The trees are just showing their new leaves and spring flowers are littered underneath them.

Relax, and breath easily and slowly whilst you do this.

Have a happy day and see you next time.
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Monday, March 26, 2012

Here's something I never knew before...

When I first started my medical career, the management of terminally ill patients who were in pain involved using a concoction known as a Brompton Cocktail! This was a mixture that had been around for decades, just like "Mixt Abominatum" that was used as a Tonic. Mixt Abominatum relied on the well known medical adage that if it tasted foul, then it must be doing you some good. Nowadays, things have happily moved on.

But back to the Brompton Cocktail: this contained Heroin, Cocaine, Largactil and the alcohol of your choice which was often Brandy. For those of a sweeter tastes, a tincture of orange might be added to make it more palatable. The resultant pain relief was often good, but the hallucinations were pretty difficult to cope with.

Today, Palliative care is a science in it's own right and pain control has come on in leaps and bounds, but Heroin, Morphine and its Opioid derivatives are still regarded as the gold standard in pain relief.

However, several studies published since 2002 suggest that Opioids can stimulate the growth and spread of cancer cells. One study from a group led by Patrick Singleton, PhD, assistant professor of medicine at the University of Chicago Medicine, has shown that lung cancer cells have five to ten times more "opioid receptors" on their surface than do non-cancerous lung cells. Once triggered by opioids that the body produces naturally- endorphines - or by doses of opioids given to relieve pain, these cells then proliferate, migrate and invade at a greater rate.

In another study which used Naltrexone, a drug developed to block the unpleasant side effects of Opioids, it was noticed that terminally ill patients treated with this drug survived months longer than those who did not receive it.

This does not mean that Opioids should not be used to control pain. What it means is that more research needs to be done, and that those who have cancer related pain should talk to their pain specialist and discuss whether Opioids are necessary, and if so, should a Naltrexone-like drug be given to block it's side effects?

As in nearly every field in medicine, we cannot say we have the perfect treatment or the ideal outcome: we are still on the road to discovery, but we're improving all the time.
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Friday, March 23, 2012

If music be the food of love ..

When our children were going through their final year exams at school, the eldest used to listen to the radio - usually commercial pop - but by the time our youngest went through, he was plugged into an iPod and it was more difficult to assess his musical genre as it echoed out of his skull! My attempts to convince them to try to listen to Mozart failed miserably, even though back then it had been shown that listening to the great Master did improve ones memory and ability to study! Such are the trials of a parent.

But music is wonderful stuff, and classical music particularly so. Music therapy is used in various contexts in clinical medicine: it is used to reduce anxiety after heart attacks and is used by other clinicians when taking bone marrow samples in order to reduce the patients appreciation of pain. There are other clinical uses in helping with anxiety in general and for those undergoing chemotherapy, but now there appears to be another string to the musical bow - prolonging survival after Heart transplants.

Researcher in Japan used a mouse model and found that by playing Opera and classical music to recently transplanted mice, survival length was increased. Revealingly, this did not happen with "new age" music or single frequency monotones. Lead author Dr Masanori Niimi and his team looked for the reason for this and have proposed that the increase in survival is related to spleen related cells, CD4+CD25+ which control peripheral immune response - how the body reacts to foreign matter.

Most people would acknowledge that there is inherent beauty and "healing" in listening to classical music and (some) opera - (most)young people excluded of course! So it's good to see that there really is some science behind what most of us have inherently believed. One wonders when science will come around to other such "beliefs" and find that they too actually work/have a scientific basis!
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Monday, March 19, 2012

Injury prevention

I took some Sunday afternoon exercise with the young bride yesterday, in the form of a long walk into the countryside. But as we left the edge of the village where we are staying, a car shot past us on the wrong side of the road and nearly "took out" a driver peacefully driving in the opposite direction! There was much tooting of horns, and thankfully, no accident happened and no one was injured.

But injuries do happen, and far more frequently than we think, and I'm not just talking road traffic accidents, there are falls in the home and physical violence too. Here's some information from the CDC in the US:

  •     1 person dies every 3 minutes in the US as the direct cause of injuries received
  •     Injuries are the leading cause of death from age1 to 44.
  •     Injuries cost $406 Billion in medical costs and lost productivity!

That's a huge impact on our societies and we need to constantly review how we can reduce such injuries and promote injury reduction awareness. Simple things like wearing car seat belts, that the vast majority now take for granted have saved 100's of thousands of lives around the globe and reduced the injury toll more the same amount too: and yet people still "forget" to wear them, so the message needs to be constantly re-cycled.

In the elderly, by encouraging the older age group to be physically active and take part in programs such as Ti Chi has also been shown to reduce falls and injuries that the elderly often are much slower to recover from.

In the home, falls down stairs account for a significant percentage of emergency department care and even death. In many of those instances it was when someone was carrying a child down the stairs but tripped on "stuff" that had been left on them. The moral to that tale is that the home is not only a constant "battleground" with little ones, but there can be serious injuries taking place there too. Keep your stairs clear at all times, check the back yard for obvious danger points and with older kids look for signs of bullying that, if unchecked, may lead to physical violence and injury.

Being aware that things can go wrong should make us wiser, not better worriers: life is a wonderful challenge and our job is always to keep trying to do "it" better!
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Thursday, March 15, 2012

The secret is in your eyes!

Many years ago as a budding medical student I spent many a happy hour looking into eyes, both socially and as a part of my professional training: both scenarios often proved to be both frustrating and mysterious, but we'll stick with the professional side of things.

The front of the eye, or the cornea which is the transparent bit we look through to see the world, forms in the embryo from skin like cells. The back of the eye, or the Retina, is actually a part of the brain; so when we look into the eye and observe the back of the eye we are looking at a small representation of the brains normal environment. And it's a glorious sight! When I had GP trainees at my surgery I used to delight in getting them to look at the back of the eyes and seeing the look of wonder and amazement of how beautiful it is. What the expert sees is a red surface that has tiny blood vessels running over the surface and converging to"drain out" through the same exit point, like some imaginary Martian landscape.

From a technical point of view it is quite tricky to get a patient to sit still whilst you shine a bright light in their eyes and "coo" over their retina! In all classical observations of the retina, the pupil of the eye needs to be dilated with special eye drops which gives much improved views; but the downside is that when the patient goes out into bright sunlight, because the pupil may still be wide open, the light can appear very bright indeed!

But apart from being amazed by the structure of the retina, being able to see these tiny blood vessels has given useful information on the state of the blood vessels in the wider circulation which is of particular importance for people with Hypertension and Diabetes. Now researcher have added another association to the health of retinal blood vessels - thinking and memory skills.

According to the author of a report in the online journal Neurology Dr Mary Haan,  of the University of California, San Francisco. "This could be very useful if a simple eye screening could give us an early indication that people might be at risk of problems with their brain health and functioning."

So the next time someone looks into your eyes and sighs, it might not be quite as romantic as you thought! 
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Tuesday, March 13, 2012

Hand foor and mouth disease

There I was as usual last week browsing through my medical journals and webpages when I came across a lovely picture of a virus - it's the one illustrated. It shows the actual structure of the EV71 virus that is responsible for outbreaks of Hand Foot and Mouth -HF & M - disease. This is a virus from the family known as Entero-viruses, and other viruses included in this group are the better known viruses of Polio viruses, ECHO viruses and Coxsachie viruses.

Well a few days later my son informed me that our youngest grandson has been unwell for a few days and he thought it could be HF &M virus! What a coincidence I thought:  and so here are a few facts about it.

Hand foot and mouth is very contagious and very common in the under 5 age group.

It has nothing at all to do with the Foot and Mouth virus that ravages cattle and which crops up in the world news every few years: that is a completely different virus and it doesn't occur in humans, just as "our" HF & M virus doesn't appear in cattle.

It can be very, very painful to the point where just swallowing saliva is impossible. Some infants need to go on IV as they refuse to have any fluids in their mouths and even dribble out all their saliva.

The classical findings are of a fever which is followed after a few days with small blister lesions on the palms of the hands and soles of the feet. They can also occur in other areas, but hands and feet are most common. The mouth is affected too with these blister lesions, and when they burst the raw surface produces a shallow ulcer that is very painful but heals well without any long term consequence.

Complications are rare but can include meningitis and encephalitis.

If your child has HF & M then keep them home from Kindy or pre-school to break the cycle of transmission.

In most cases all you need to do is give fluids and simple pain-killers until the rash disappears.
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Friday, March 9, 2012

Body Piercing: some thoughts and advice.

There was a song from "way back when" which had the line: girls are getting younger and prettier each day. The trouble is that when you get close to many of them, they have pieces of shrapnel stuck in various parts of their faces. I know that I'm allowing my prejudices to show, but why do they do it?

Here's a few things that they might have to deal with:

1. Infection at the site of piercing. Luckily this is not a big problem, thanks to the body's amazing ability to fight off infection, but it can and does occur.
2. Allergy to the material used. Cheap inserts that contain nickel are well known to cause a local allergic response and the only way to get rid of it is to remove the offending object.
3. Chipped teeth. For those who choose  a lip, cheek or tongue piercing, then beware of damaging your teeth.
4. Unsightly scaring. Some people are prone to Keloid scars which are thick, red and unsightly: if you have this tendency to produce keloid scars, then having a piercing will cause a keloid at the site of puncture.
5. Blood born infections. This is far more common when the piercing is done by un-skilled individuals with poor hygiene - and alcohol plays a big part here. Hepatitis B and C, Tetanus and HIV are the major serious infections that can be introduced by amateur, insanitary operators.
6. Sometimes the inserted jewelry can catch in clothes and tear the skin: that's not only painful but makes any scars bigger.

Most of the young people I know who had piercings 5 years ago have now removed them, but the telltale signs are still there in eyebrows, lips, noses, cheeks and probably elsewhere too! Unfortunatley, I think that this fashion trend still has some way to run yet, and so for all of those who may consider having it done - or for families of those who have a loved one who is considering it - here are a few suggestions.

    Never, ever, ever have a piercing under the influence of alcohol: you not only might regret you decision, but you might be getting more than you bargained for - see 5 above!
    Consider the possible implications on your future employment - will you be able to cover the piercing?
    Who is doing the piercing? Check them out before committing and look at the hygiene employed at their place of work. Do they have an autoclave to sterilize "non-disposables": do they wear gloves: do they wash their hands thoroughly between procedures?
    What sort of jewelry is going to be inserted? Does it contain nickel?

After insertion, most wounds will heal within 6 weeks though some in more moist spots may take longer. Make sure you follow the recommendations for correct wound care in the post-insertion period to avoid contamination and infection. If signs of an infection appear - redness, swelling, soreness or discharge - then see a Doctor.
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Wednesday, March 7, 2012

A resource we hope we never need ....

But as we all know, when things go wrong, we need lawyers to help us through the legal maze that is litigation. But who do you turn to if something goes badly "pear-shaped" in medicine? Who can you trust? I've asked Medical Malpractice Lawyers, a not-for-profit organization, to tell us how to go about looking for the right lawyer to advise you should the occasion ever occur.


"Working in the medical field is high intensity stuff; nurses, doctors, and paramedicals work long hours and considering that a single mistake can mean someone’s life, stress levels are high.  Although doctors have the best interests of their patients at heart, things can and do go wrong; they’re human and capable of mistakes, just like us.  Unfortunately, because mistakes in the medical field can mean long-lasting, life-changing injuries or, worse, death, injured patients need to know what their options are after suffering an injury. 

Due to this need, Medical Malpractice Lawyers, a not-for-profit organization, was founded by lawyers and lay professionals to fulfill 3 purposes. 

      First, provide laypersons with educational resources to help them determine legitimate legal professionals from illegitimate ones; we do this in an effort to stop laypersons from being taken advantage of by people like adjusters, inexperienced experts, or lawyers, who purport to have experience handling medical malpractice litigation but who, instead, financially benefit primarily from advertising or referring lawyers. 

     Second, provide educational resources to laypersons to help them throughout the process of their medical malpractice case, i.e. everything from choosing a lawyer to helping them calculate how much money they should take home from their case’s settlement or court judgment.

    Third, provide the general public with lawyers that not only specialize in medical malpractice, but who are successful in their field.  Lawyer ranking websites operate under flawed and subjective algorithms that are tainted by politics and the pursuit of financial gain.  Also, ranking sites do not legitimately check that the listed specialties of their rated lawyers are correct.  What this means is that the possibility of citizens seeking a medical malpractice lawyer ending up with a lawyer in an unrelated specialty is strong.  For instance, who would want motorcycle accident lawyers handling their medical malpractice case? 

To give citizens what is actually useful to them, Medical Malpractice lawyers has developed its “Top 1% Trail Counsel for Medical Malpractice Rating System.”  This rating system bypasses the flawed nature of lawyer rating sites by providing citizens with the annually computed top 1 percent of medical malpractice lawyers in the United States.  These are lawyers not only taking medical malpractice cases, but winning them; when you look at our rating system you will find the best medical malpractice lawyers in the country."
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Friday, March 2, 2012

Thoughts on the "lost" art of medicine.

I've been scanning the medical media for many years now looking for articles that I think might be of interest, and recently there's been something gnawing away at the back of my mind and I haven't been able to put my finger on it until today.

More and more of the information that we read is pure science, or "meta analyses" of previously released information, but analyzed under an even finer tooth comb. Thus, the pure science research coming out from the Lab tantalizes us with the promise of things to come in the next 10, 20 or 30 years: and the analyzers tell us such things as "Statins" might increase the risk of diabetes in women" and many other reports that promote interesting theories and trends - but at the same time can raise the level of anxiety too.

But when I sit with the dementing patient who is taking the requisite medications and tell them that this is the best we can do, apart from taking daily exercise: or when I listen to the middle aged, single, working Mum with 3 teenagers to "muster", and who is overweight with borderline diabetes and tell her that she needs to get out and exercise and eat healthy food - which her kids "hate": then I wonder where the scientists and meta-"analyzers" are?

I rejoice in the work that the scientists are doing, and it's great for the standard of medicine that we now have Cochrane reviews that provide measured suggestions as to what is current "best practice" for medical practitioners. BUT, have we forgotten the individual patient and how to apply this information to them? Each one of us is unique and hears different aspects of the information being supplied. This is the art of medicine - the hallmark of which is compassion - and perhaps something that is being neglected in our current "Age of Information".
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