Medicine science, emotion, politics and money

Tweet The saga of Avastin, a drug used to help in end stage breast cancer, is a salutary warning on the pitfalls that can arise when a promising new "breakthrough" in cancer treatment collides with the reality of hard science, economics, politics and emotion.

Avastin is a relatively new medication for the treatment of solid tumours and is quite successful, in combination with other forms of treatment, when dealing with colon cancer. Avastin is in a unique class of medications, and targets the blood supply that these solid cancers "hijack" and stimulate as they grow and spread around the body.  It is also a very expensive drug and costs around $100,000 per year to treat patients.

The research was initially trialled, as usual,  on mouse models and was dramatically successful: however, when tried out in humans the results were not quite as spectacular - in fact, experts now tell us that the overall survival of people treated with Avastin is not increased at all; and the side effect profile of the drug is not patient friendly either.

Because of its initial promise in prolonging life in stage IV breast cancer, the FDA in America fast tracked it, and it has become widely used for these patients. Now, the FDA has reversed that decision in a 6 - 0 verdict, despite the drug maker and patients making a last ditch attempt to sway the verdict. This decsion has come at a time in US politics where one side is trying to introduce universal Health Care, and the other is saying that the Government is withdrawing a drug based on cost with comments such as "I shudder at the thought of a government panel assigning a value to a day of a person's life,"

Medicine can be quite messy and is not the clean cut, black and white process many of us would like it to be. When money, emotion, politics, power, and science collide, then yet again it is often the weak and the vulnerable who get crushed. My advice: make sure that the person who looks after your health is a good person who is on top of his or her game: and trust them! Your job is to live every moment of your life as well as you can until you draw your last breath: and don't die wondering.

Exercise and the lumbar spine

Tweet Having suffered from sciatica in the past, I can seriously assure you that I never want to have it again. It is a searing pain that shoots like a bolt of electricity down the back of your leg and into your foot. Even the strongest of painkillers only manage to dull  the pain, and their side effects of drowsiness and constipation often make sciatica sufferers reluctant to use them.

I underwent surgery to relieve the pain of my sciatica, and in the process lost a healthy chunk of one of my lumbar discs that had broken off and was pressing on the nerve - hence the severe pain! The good news is that I got over it all without complication and am now back jogging and cycling, but always at the back of my mind was the concern that exercise may not be helping my dodgy discs.

Well recent news out of the University of Gothenburg, presented at the annual meeting of the International Society for the Study of the Lumbar Spine (ISSLS), strongly suggests that exercise is good for the cells in those discs, at least if your a rat on a treadmill!! They have shown that rats that exercise have healthier discs than those rats that were left to their own devices and just ran around their cages! The hope is that they can repeat their findings in humans.

So, for for all of those "rats" out there, the answer is that if you want a healthy lumbar spine, get back on the treadmill, it's doing you the world of good. As for me, well, I'm going for a jog when it stops raining!

Whooping cough

Tweet I suspect that everyone of you who reads this article will never seen, or experienced whooping cough, which is why many parents in the western world are taking it less seriously than they should. This fact was brought home to me by an article in the morning paper which gave the following description of the illness as: "Whooping cough, also known as Pertussis, is an acute respiratory infection that is transmitted from person to person through respiratory droplets when an infected person talks, sneezes or coughs." Which when I read that, sounded like getting a mild cold. It did go on to state that "in young babies, infection can lead to severe health problems including pneumonia seizures and in some cases permanent disabilities or death", which did appear to give it an "edgier" feel.

But whooping cough is far nastier than these words make it appear.

Whooping cough still kills around 300,000 infants around the world each year and is one of the leading avoidable causes of death in children. The vast majority of those deaths occur in populations with poor, or non existent vaccination programs.

I have cared for patients with whooping cough, and it's a terribly debilitating disease. One family of five suffered miserably with pertussis for SIX months! They didn't have the energy to go upstairs to their bedrooms, so neighbours had dragged the mattresses downstairs for them to lie on. They were exhausted from the intractable coughing and feeling unwell: antibiotics were of no use to them, and all they could do was wait for full recovery, which eventually happened.

Because of the unfounded scare regarding the whooping cough vaccine, many people were confused and stopped vaccinating their children: children are at far greater risk of harm being driven to the supermarket in their parents car! Having our precious children protected against these "Childhood", yet killer diseases is something we should all do. If you do have genuine concerns, then talk to an expert, and, as my Mum always told me,  don't always believe everything you read in the newspaper!

Inappropriate use of antibiotics

Tweet A good friend of mine has just come back form overseas, and like a lot of international travelers, she has brought home more than just her luggage and some duty free! She has had a terrible time since she got back with a chest infection, and told me over the phone that she was "just finishing her third course of strong antibiotics".

As a doctor, I hate to hear things like that: and I'm not just talking about my compassion for a dear friend who is suffering, but more so for that fact that three different "strong" antibiotics have been used to no effect and probably for the wrong reason. Just as many chest infections are caused by viral infections as bacterial infections, and antibiotics have absolutely no effect on viruses!! In fact, giving antibiotics for the wrong reason can have completely the opposite intended effect - by that I mean that the effect of the unnecessary antibiotic is to wipe out all the bacteria sensitive to it, and leave behind all those that are resistant to it.

If you have a chest infection and are coughing up sputum, the first thing to do is to collect a sample of that sputum in a sterile container, so that it can be sent off to the Lab for analysis and to determine the sensitivity of any bacteria present to potential antibiotic treatment. These days this is a relatively quick process, but even if it takes a couple of days, your treating Doc can start you on a treatment that is likely to be successful, and once the "sensitivities" have come back, can then continue, or change medications, depending on the laboratory findings.

Trying three antibiotics in a row to see if they work is not smart medicine, and will often do more harm than good.

I sent my friend round a jar of Vicks (as a joke because laughter gets the lungs moving vigorously and helps shift sticky mucous) and suggested she try a gentle walk down the street. Today I hear that she is starting to recover, not, I am sure because it's anything to do with my suggestions, more that her own body is finally coping with the infection and almost certainly not because of any benefit from those "strong antibiotics."

"Dog eats sleeping owner's toe"

Tweet Now that's a headline to grab anyone's attention! However, it's not to be found as a banner headline on a tabloid newspaper, but in the more obscure Journal of the American Podiatric Medical Association. And it's a salutary lesson about the dangers of poorly controlled Diabetes, a disease that can be complicated by damage to the peripheral nerves and blood vessels, ultimately leading to loss of sensation and numbness.

The poor patient to whom this happened, had a pet Jack Russell who slept with her. The women awoke in the morning as usual, quite unconscious of the fact that half of her diabetic digit had been chewed off by her favourite pet. At first, all she noticed was blood on the sheets and the floor! As a consequence of her puppies night time snacking, she ended up in hospital where the long term consequence was that she underwent a lower limb amputation, which actually left her a double amputee.

This is a tragic story as well as a bizarre story. I know many people who let their small dogs sleep in their beds with them, and for the fit yet lonely, they are wonderful companions whose benefits far outweigh the negatives. But for Diabetics with altered sensation in their legs, this is a timely warning that:

       Pet dogs are still animals.

       Dogs lick things and can be a source of potentially nasty infections to open cuts and ulcers.

       Dogs chew things, and you shouldn't sleep in the same room as them.

According to the National Health Statistics for 2004/5 the prevalence rate for Diabetes was estimated to be 3.6% (or around 700,000). There is no doubt that there are more Diabetics now in 2011, so we're not talking about a small risk. Although the poor women reported in this article was a bizarre example of what can go wrong, the real issue is that Diabetes is not just a simple disease and "something to do with too much sugar": it has the potential to cause blindness, kidney failure, heart attacks and can lead to amputation of limbs and digits. We must take the major underlying causes - obesity and lack of physical activity - very seriously if we are not to be overwhelmed with the impact that this disease threatens to have on the whole of society.

Man on Fire - the disease, not the film!

Tweet My train of thought was distracted recently whilst reading about a very distressing condition called Peripheral Neuropathy. What caught my attention was the phrase "Man on Fire", which, if my memory serves me well was an action-thriller staring Denzil Washington, and what a very fine actor he is!

Firstly, more on peripheral neuropathy: this is a descriptive term that means damage to the nerves out in the "periphery" - usually the legs, and is often found as a complication of long standing Diabetes, alcoholism and exposure to toxins. However, in many cases there is no known cause, and consequently it is sometimes described as idiopathic (unknown) peripheral neuropathy. Despite all the medical jargon, what the sufferer experiences is unrelieved, excruciating burning pain in the affected areas, that may eventually lead on to complete loss of sensation. Now the loss of sensation may seem like a relief, but the problem then is that the patient can cut or graze themselves without knowing it, and this will often  lead on to infection and ulceration: and in the case of a Diabetic or an alcoholic, these two things are not conducive to improving ones health!

In the case of Diabetes, the damage to the peripheral nerves is thought to be due to damage to the tiny blood vessels that provide nutrition to the nerves themselves. In the case of Idiopathic peripheral nerve damage, we obviously don't know what the cause is. But Professor Stepehn Waxman MD PhD and his colleagues at the Yale School of Medicine have found that in about 30% of these cases there may be a defective gene involved: and this is where Denzil Washington comes in! There is a very rare medical condition called "Man on Fire" syndrome, where those afflicted sufferer life long, excruciating pain that so far has only been numbed by a cocktail of strong narcotic painkillers and antidepressants. Patients with Man on Fire syndrome have a defect in a single Gene , SCNA9 – which is expressed in sensory nerve fibers, and this is the same Gene defect identified in Dr Waxman's peripheral neuropathy patients.

The work they are doing with this damaged gene will lead to better understanding of peripheral neuropathy and holds out hope for far better management for those who suffer from it. What makes my occasionally cynical mind think that there must be a light at the end of the tunnel for those with this condition, is a press release from May 2011 which said:

" Yale School of Medicine has entered into a collaboration with Icagen, Inc. and Pfizer to explore the potential efficacy of investigational compounds as novel treatments for pain. These compounds, which were identified from an existing collaboration between Icagen and Pfizer may be useful in treating pain in people with a rare genetic disorder called ......... the “man on fire syndrome.”

Coffee the Wunderbean!

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"With pharmaceutical companies spending millions of dollars trying to develop drugs against Alzheimer's disease, there may very well be an effective preventive right under our noses every morning – caffeinated coffee," said Dr. Arendash  lead researcher at the University of South Florida in an article to be published on June 28 in the Journal of Alzheimer's Disease

Now we’ve all seen these sort of headlines over the years, of new drug breakthroughs that offer “so much hope” when used in animal models, only to be let down years later by unexpected side effects when  “trialled” on humans: but, hey, we’re talking about coffee here, and it’s been part of the human way of life for centuries, so the “side effect” profile is already well documented. So what is new about coffee?

Firstly, they’re talking about caffeinated coffee, and being an American study, they used “drip feed” coffee, so we’ll have to wait for an Italian study to let us know if the same applies to Cappuccino or espresso coffee! But it appears that there is a “secret” ingredient in coffee that helps the caffeine stimulate a growth factor called GCSF (granulocyte colony stimulating factor): GCSF is a substance greatly decreased in patients with Alzheimer's disease and has experimentally been shown to improve memory in Alzheimers mice! It appears to work in three ways:

·      First, GCSF recruits stem cells from bone marrow to enter the brain and remove the harmful beta-amyloid protein that initiates the disease.

·      GCSF also creates new connections between brain cells and

·      It increases the birth of new neurons in the brain.

All good so far: but you have to drink coffee in a “moderate” amount, and that means 3 to 4 cups a day. It doesn’t work with de-caffeinated coffee and it is not known whether this research is valid for instant coffee or other forms of our favorite beverage.

It also appears that coffee is a pretty amazing soup of all things that might be good for you: it is rich in anti-oxidants and contains compounds that are effective anti-inflammatory agents too. Recent research has shown coffee consumption decreases the risk of other nasty chronic health problems such as Parkinson’s Disease, Type II Diabetes and stroke too! It may also reduce the risk of prostate cancer and breast cancer!! Not a bad CV for a humble cup of coffee!!