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Wednesday, 31 August 2011

City cycling: beyond the obvious benefits

Cycling sounds an attractive approach to better personal health, reduced carbon footprint and therefore a generally healthier urban environment. Rojas-Rueda and colleagues in a British Medical Journal paper have recently modeled the health risks and benefits of the Barcelona bike sharing scheme (Bicing), based on the over 180,000 Barcelona residents using the Bicing scheme.  They conclude there are greater health benefits than risks in Barcelona, and a large reduction in annual carbon dioxide emissions.
For Barcelona and elsewhere, bike-sharing appears to offer the opportunity to introduce regular cycling as a way for many in the population to return to, or increase exercise, on a sufficient scale for both public health and environmental benefits.
After Milan's earlier efforts to provide affordable and enjoyable city centre cycling - yellow bikes disappearing around Europe to Geneva and beyond - Paris (launched 2007) and London (launched July 2010) are also addressing the challenge of encouraging exercise and reducing car travel on city centre streets - with some extra effects on healthy mind and body. This includes 'water-cooler' bonding as initiates explain how to use the cycle pay columns or how to free a tricky bike. And more than intended exercise in several forms. Cyclists often need to return for a fresh hire after realising too late that their chosen cycle is faulty - punctured, chain off, saddle collapse syndrome, sticky wheels and so on (a Paris code is to reverse the saddle and or collapse the saddle support on a faulty bike); or moving from full cycle rack to next cycle station looking for a post at which to return a cycle at busier city locations. For the less pressed, this is another opportunity to meet fellow cyclists while waiting, and to compare notes on nearby velib station options. A peak time problem at busier sites is of course there being no bike available; more exercise, locating then walking to the next available station. Paris is trying hard - from the velib website at the end of August, 1233 locations were declared - enough hire and return capacity for this to be more than a tourist or freetime gimmick. The Paris website includes a colour-coded webmap: green for stations with available spaces, red for full cycle stations. The Paris Velib system leads the way globally in number of sites and available cycles. Paris also has the advantage of many wide pavements, and, in some areas, proper cycle lanes - although partnering these with buses and taxis is a source of recurrent adrenaline surge.
A reporting option on the booking terminal at cycle stations would be a good addition, so that the next hirer does not have the same problem; also helpful would be a less sticky webmap for locating alternative Velib stations: not a very mobile phone friendly website. And a review in Paris is planned of the economics of the scheme, with 80-90% of cycles reported in need of repair or replacement due to damage or theft; much less respected than the earlier  Lyon scheme (established May 2005, now with around 340 bike stations, and as for Paris, run as a partnership with advertising company JCDecaux).

© DRJ Singer

Wednesday, 24 August 2011

New UK guidelines on managing high blood pressure

High blood pressure is a major preventable and treatable risk factor for heart disease and stroke syndromes both in the developed and the developing world.

In an innovative partnership between a UK government agency - the National Institute for Health and Clinical Excellence (NICE) - and a professional organisation - the British Hypertension Society (BHS), NICE guidelines for managing hypertension in primary care were first issued in 2006. Key elements to those guidelines included a stepped care approach starting with different first line options for younger vs. older patients with a 55 year age boundary, and for patients of black African or Carribean origin compared to other ethnic groups. The 2006 guidelines also highlighted risks of new onset diabetes mellitus from beta-blocker treatment.

On 24th August, five years on, NICE, again supported by experts from the BHS, has released updated hypertension guidelines which include several key developments of interest to prescribers and patients. These include adding blood pressure measurements away from the clinical setting to confirm the diagnosis for patients with mild to moderate increases in clinic blood pressure readings. With even higher office readings, advice remains to treat based on those office readings. There is detailed advice both on blood pressure measurement using ambulatory devices as well as more systematic involvement of patients in their own management, supported by home blood pressure readings. It is of course important that any blood pressure monitoring device, whether for clinical or home use, should be validated. A helpful list of validated devices is is listed on the British Hypertension Society's website.

As an update on treatment options, the new 2011 guidelines now suggest systematic use of calcium channel blockers as first line treatment in older patients, with now specific, named diuretics as alternative options for specified indications. The 2011 guidelines for the first time also highlight the clinical and cost effectiveness of evidence-based treatment of hypertension in older patients, and in particular the over 80s.

For more information, see the summary documents and more detailed reports on the NICE website.

Saturday, 20 August 2011

Improving prevention of serious adverse drug reactions

Around 1 in 20  admissions to hospital are due to adverse drug reactions in the UK and other countries with well-developed health services. There are multiple causes for this surprisingly high rate of adverse reactions to medicines: the patient might not have followed established guidelines, such as avoiding alcohol; the wrong drug or dose might have been prescribed; an interaction between two drugs might have been overlooked; the patient's genetic makeup might cause an anomalous reaction; the patient might be taking contaminated drugs bought from unregulated sources on the internet; an unknown adverse reaction to a new drug might have been missed in the development and safety testing of that drug.
Many of the adverse drug reactions are preventable. We need to make sure medical students and prescribers are aware of how to prescribe safely, know common and high risk drugs well and, importantly, to make sure adverse reactions are recorded on patients' records so that they don't happen again. Now that people are able to obtain  prescription drugs on the internet, systems also need to be improved in order to better regulate drugs that are accessed in this way. 
Today's national and international regulations on medicine safety have evolved over than a century. In 1906 came a major focus on medicine safety in the USA, with the Food and Drugs Act signed by President Theodore Roosevelt. The UK went on in 1941 with the Pharmacy and Medicines Act to force manufacturers to list active ingredients on drug packaging, and restrict manufacturers from general advertising about medical claims of their products. The thalidomide disaster of the late 1950s and early 1960s brought about further major improvements: previously drug testing was very limited. Now great care is taken in assessing possible risks of medicines during pregnancy.
Many serious adverse drug reactions happen in people with genetic reasons for reduced ability to handle drugs in the body. Drug leaflets now specify if there is any known 'pharmacogenetic’ information on a medicine. The potential seriousness of these differences between people is shown by the example that the Japanese regulatory authorities are unwilling to license drugs for use in their country unless they have been tested on Japanese people.
New pharmacogenetic provide the opportunity to reduce exposure of patients to potentially harmful medicines based on recognizing an increased genetic risk. And new chemical genomics methods allow ways to identify safer and more effective use of current and new medicines.
For further details on these themes, see my interview with Amy McLeod from Warwick's Knowledge Centre.

Monday, 15 August 2011

Taboo tablets - beta-blockers and professional string players

The following blog arose from contributing to an article in The Strad by Catherine Nelson on drugs and occupational stress amongst professional musicians.

As clinical pharmacologist and amateur violinist gives me two perspectives on performance or audition anxiety: this is due to the triggering of an extra release of
 adrenaline – and other fight-or-flight response hormones – which in turn can cause
 string players to feel anxious and suffer a shaking bowing arm. Beta-blockers can stop 
unwanted reactions to these hormones, such as an increased heart 
rate, and thus lessen detrimental effects of stress on the musician’s performance.

I had heard of a violinist who was so anxious and stiff during an audition that the bow simply flew out of his hands. Many professional musicians are worried by the stress of performance, and beta-blockers may help some players control the debilitating physical symptoms of this stress.
It is of course extremely important that musicians, for whom medical treatment of occupational stress may be indicated, work
 with a medical practitioner to ensure, if a beta-blocker appears worth a trial, that they take the right dose, provided it has been checked that this would be medically safe to do so. I am particularly concerned about anecdotal evidence of players sharing medicines - which may not be the right medicine, or a possible cause of severe and rapid onset harmful effects. People are increasingly turning to the internet to
 obtain drugs. At best these pills may be out of date – at worse 
they may be contaminated. Taking them without getting advice from a
 doctor can be very dangerous.
Beta-blockers slow the heart, helping to make people feel calmer, but they also make your heartbeat less forceful than it should be,
 so that even fit people may feel tired and short of breath, and some people may be tipped into heart failure. Players with certain pre-existing medical conditions may suffer worse adverse reactions. These
 drugs also make the airways less open, so are dangerous in asthma.
 Other side effects include sleep disturbance, weight gain and stomach upset, including increased stool frequency and urgency. There 
are also reports of people suffering depression while taking
 beta-blockers, though it may be that people with heightened anxiety are 
more prone to suffering depression. It is therefore better to avoid medicines if possible.
The message for beta-blockers should be that if they are worth a trial on medical grounds, to try a low
 dose under the advice of a medical practitioner; the dose may then be carefully increased if needed. If medically indicated, it is also very important always to 
try beta-blockers first under rehearsal conditions, as being made too relaxed or having unwanted effects could be harmful when performance really matters.

The implications of the broader issue of anecdotal widespread use of beta-blockers raise important occupational health and ethical concerns which deserve to be discussed nationally and internationally, both by the music profession and relevant medical organisations.

See The Strad for more on the article.

NICE guidance and treatment of Alzheimer's Disease

The following blog is based on a contribution to a Daily Telegraph article quoting from my Science and Media Centre response to new NICE draft guidance on Alzheimer's Disease.

'The proposal by NICE to extend its guidance to include access for 3 drugs (donepezil, galantamine and rivastigimine) to patients with much milder disease than previously eligible is excellent news for patients with Alzheimer's disease and their families. It is also very encouraging to have in the guidance a new treatment option (memantine) for patients with more severe disease. People with serious conditions such as Alzheimer's may naturally express concern about how long this has taken. However it is essential that health policy makers have convincing evidence both for effectiveness and risk before making a medicine available to people who could benefit. Consider the recent public concern about regulation of the diabetes drug rosiglitazone, for which an unexpected increase in cardiovascular risk appears to have occurred after it became widely available. It will still be very important to remain vigilant for possible unexpected risks of the Alzheimer's treatments, as these drugs will now be exposed to large numbers of people, who may also be medically more complex, and therefore more at risk of adverse effects, than in the clinical trials on which the NICE guidance has been based.'

There are many causes of dementia other than Alzheimer's. The following paper describes research on CADASIL, a genetic disorder for dementia: Hussain, MB, Singhal S, Markus HS, Singer DRJ. Abnormal vasoconstrictor responses to angiotensin II and noradrenaline in isolated small arteries from patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Stroke 2004; 35:853-8.

Sunday, 14 August 2011

Ideas for maintaining variety in providing for multiple special diets

What to do about special diets? It is possible with a little research to prepare an individual meal to cater for a cluster of guests each with different special dietary needs and preferences, for example allergy to gluten, diabetes mellitus and preference for vegetarian food. There are also now many recipe sources for individual special diets, for example in the UK the BBC website (separate listings for gluten-free, nut allergy, egg-free, dairy-free, 'healthy', pregnancy-friendly, shellfish-free, vegan and vegetarian), the Coeliac Society for gluten allergy and Diabetes UK and other international equivalent organisations for diabetic recipes. But when more than one allergy is present in the same family, maintaining daily variety is much more difficult.
Xavier Ternisien in today's Le Monde [Sunday 14th August] has highlighted a blogger for francophones who has risen to this challenge. Bordeaux 'blogueur' Anne Lataillade worked in financial services after graduating from business school. Struggling for inspiration for meals for separate gluten and egg allergy in her 2 children, she has been blogging on practical recipes since 2005. Her aim is to provide simple to make recipes that work, with ideas for savoury foods and desserts compatible with both these allergies. She accompanies her blogged recipes with photographs of the dishes and information on the sources and properties of the suggested ingredients. Her website also provides information on archived recipes and on publications arising.
A further website worth checking is 'Cooking Allergy Free'. This site, after free registration, allows access to a large menu of potential allergies and then to a limited range of suitable recipes compatible with a a very complex range of needs and preferences.
Attractive varied suggestions are a good approach to complement other measures to encourage adherence to special diets for medical allergies.
US actress Zooey Deschanel highlighted the challenges of catering for multiple food intolerances and preferences by appearing on a 2009 US television programme in which chefs were asked to provide food suitable for vegans intolerant to dairy, eggs, soya and gluten.

Thursday, 11 August 2011

Provence, the Rhone estuary and the 'French paradox'

The ‘French paradox’, coined in 1992, refers to apparent unexpectedly low cardiovascular disease rates despite reported high exposure to factors predisposing to increased cardiovascular risk such as alcohol, cheeses high in saturated fats, and the stereotypical Gitane cigarette or modern equivalent. Obvious explanations for such a paradox include protective genetic factors, cardioprotective factors in the French lifestyle, and ascertainment bias in recording cardiovascular disease.
What insights are evident to explain the French paradox from visiting the Mediterranean reaches of the Rhone valley? Unlike for some northern European populations, the southern French are not averse to leafy green vegetables (the Provencal variant - ‘mesclun’), tomatoes, or other salad ingredients. And garlic and other alliums are popular in local recipes.
Cheese intake appears relatively low and goat and sheep’s cheese are popular. That raises an obvious question: does the species source of cheese matter for cardiovascular risk? Alcohol intake in public appears modest. That combined with evidence from Roger Corder and others for possible cardiovascular protective effects of certain red wines may contribute to reduced cardiovascular risk.
The typical local build is lean. However increasing numbers of young and older French men and women are developing abdominal obesity.
Smoking outdoors is still very prevalent, particularly among young women and men. There remains scope both for active and passive smoking to be continuing risk factors for increasing risk of cardiovascular disease.
What about access to health prevention and medical treatment? Every variety of doctor is available, with rooms in large and small towns, brass or marble plaques advertising their specialty, diploma – especially when from Paris, or even the gift of ‘expertise’. This health provision is complemented by a large number of pharmacies, and the newer vogue for parapharmacies, providing expertise and/or access to conventional, as well as plant-derived and other complementary remedies.
Do these other ‘remedies’ work? Certainly herbal and other plant extracts can have potent medical effects. For example, St John’s wort can reduce the expected clinical effects of treatment both by reducing absorption of drugs through activation of drug transporters in the gut, and by increase drug breakdown through activation of liver enzymes responsible for drug breakdown.
And grapefruit juice may lead to potentially serious interactions with over 50 prescribed and over-the-counter drugs, through reducing their breakdown, therefore leading to greater than expected effects of these medicines. Pomelos and Seville oranges may have similar actions.
The afternoon promenade is popular and there is ample opportunity for outdoor activity, whether from walking, more relaxed or extreme forms of cycling, riding the ‘wild’ Camargue horses, or active engagement in the local bull-friendly pursuit of trimming the bull’s fringe. This involves rapid evasive action from the charging bull, by leaps over high wooden barriers by the bull-trimmers (razeteurs). There is also ample opportunity to release aggression as a spectator, or as a participant in local bull- or horse-related spectacles.
Taken together, there are obvious dietary and lifestyle opportunities available in Provence to reduce cardiovascular risk. These are potentially offset by smoking, development of abdominal obesity and the degree to which exercise and alcohol feature in an individual’s lifestyle. And, at least for cardiovascular mortality, ascertainment is increasingly difficult, as fewer post-mortems are performed to verify cause of death.
The best strategy for cardiovascular prevention is effective public health advice, combined with effective management of cardiovascular risk factors by lifestyle and drugs, with advisors and members of the public well-motivated to adopt effective evidence-based measures to reduce cardiovascular risk. That of course begs several questions on existence or strength of the evidence base for cardio-protective effects of dietary factors, including different regional wines. These questions are key themes included within a Symposium on cardiovascular effects of ‘healthy foods’ to be held in London on Thursday 8th December 2011, with discussants including Professor Roger Corder (Wm Harvey Institute, London) and Professor KT Khaw (University of Cambridge).
For further details see my recent blog on 'What foods protect cardiovascular health?'

Monday, 8 August 2011

2012 Hippocrates Prize for Poetry and Medicine

Entries are now closed for the 2012 Hippocrates Prize for poetry and medicine, which is for unpublished poems in English. 

Judges for the 2012 Hippocrates Awards are New York poet and critic Marilyn Hacker, medical scientist Professor Rod Flower FRS and BBC broadcaster and journalist Martha Kearney. Awards will be presented in London on Saturday May 12th 2012, at the 3rd International Symposium on Poetry and Medicine, to be held at the Wellcome Collection rooms in London. During the 2012 Symposium, there will be readings by Jo Shapcott, Past-President of the Poetry Society, and US poet and 2012 Hippocrates awards judge, Marilyn Hacker

The Hippocrates Awards

With a 1st prize for the winning poem in each category of £5,000, the Hippocrates prize is one of the highest value poetry awards in the world for a single poem. In its first 3 years, the Hippocrates Prize has attracted around 4000 entries from 44 countries, from the Americas to Fiji and Finland to Australasia. Awards are in an Open category, which anyone in the world may enter, and an NHS category, which is open to UK National Health Service employees, health students and those working in professional organisations involved in education and training of NHS students and staff.
Co-organizers are poet and translator Michael Hulse and post-doctoral humanities researcher Sorcha Gunne. 

Hippocrates initiative wins national 2011 THE award
On 24th November, the Hippocrates poetry and medicine initiative was presented with the 2011 Award for Excellence and Innovation in the Arts for the 2011 Times Higher Education awards. This award aims to recognise the collaborative and interdisciplinary work that is taking place in universities to promote the arts. Entries were open to teams and all higher education institutions in the UK. Major support for the Hippocrates initiative has come from the Fellowship of Postgraduate Medicine, with additional support from the Wellcome Trust, the Cardiovascular Research Trust, Heads, Teachers and Industry and the University Warwick's Institute of Advanced Study.

Favourite poems on a medical theme 
To gauge international interest in the nature and extent of interest in medicine as a theme in poetry, we are also inviting international contributions in any language of favourite poems which feature medicine and health in the broadest sense. More details are given in my recent blog on how to submit suggestions

Saturday, 6 August 2011

The parapharmacy: business, health, and safety of the patient and the public

Parapharmacie - a 'new' word noted on the streets of Arles, a lively, walled French town in south Provence, near the Camargue coast, and echoed in many variants in the medieval Besancon, within a tight meander of the Doubs, near the Swiss border. Parapharmacie sounds more professional than the English 'Health and Beauty' variant. This in fact not so new idea seems to go back at least to the early 1980s, with deregulation of certain aspects of French pharmacy sales. Instances of 'Parapharmacie' include local provision as stand alone stores, as well as sections of a conventional pharmacy or a designated area in a supermarket - as well as an international presence within online parapharmacie outlets.
Unlike for pharmacists, there is no formal specific qualification for the parapharmacist, whose shop window offers a range of health care and personal hygiene-associated provision, including phytotherapy and dietary supplements. Medicines, dressings and herbal remedies listed in the pharmacopeia require pharmacy training, however 34 plant extracts can be sold by parapharmacists - but not as combinations. These include extracts of bramble, camomile, violets and mauve. An attractive business model, with reportedly a 30-40% profit margin permitted - more attractive than the 15-20% for prescription only medicines; and without the training overheads of conventional pharmacies. But the concept raises similar concerns to OTC (over the counter medicine) outlets in general. And what about drug interactions between herbals and conventional medicines? And the problem that intake of nutrients above the recommended daily intake can be harmful? In practice a parapharmacy may work alongside a pharmacy, with professional pharmacist available. However even by 2009 around 250 parapharmacies were operating online. Hence this is now a well-established international approach to engaging the public in new ways to access health care and hygiene products. I'm sure that it goes without saying that the vast majority of parapharmacies are highly professional in their activities. The message for the public is to ask for professional advice when seeking health care products, and in particular to seek reassurance that remedies bought 'over the counter' from non-pharmacy sources, including parapharmacies, do not pose a risk from interactions with prescribed medicines or because of known medical problems. To paraphrase Benjamin Franklin (from another context) 'keep your eyes wide open', however professional sounding the source of aids to health and hygiene.

Tuesday, 2 August 2011

New ideas on diet and cardiovascular health?

What foods may actively help to promote the health of the heart, brain and circulation? And for people who have cardiovascular risk factors, heart disease or stroke syndromes, are there dietary factors that can reduce disease severity or prevent recurrent disease?

To address these and related questions outlined below, the CVRT organised an afternoon symposium on the 'Cardiovascular effects of ‘Healthy’ foods in London on Thursday 8th December, at the Medical Society of London rooms - 11 Chandos Street - 5 minutes walk from Oxford Circus. The symposium considered evidence and mechanisms for cardiovascular benefits (or not) of ‘healthy’ foods. A key message from KT Khaw was that healthy lifestyle actions are cumulative in protecting against serious disorders of the heart and circulation.

See weblink for the programme.

Too many calories, and high intake of saturated and transfats, are well recognised to increase risk of obesity, diabetes mellitus and accelerated vascular disease (atheroma) and low salt (sodium chloride) and potassium rich foods to confer cardiovascular protection.

Outstanding questions include whether particular types of macro-nutrient (protein, carbohydrate and fats) or micronutrients (vitamins, flavenoids, trace minerals) are protective. An association between dietary factor(s) and apparent cardiovascular benefit may be causative, due to 'reverse causation' [e.g. because healthier people believe in the link or are more likely to be able to afford particular dietary constituents]; or may be a coincidental association.

Speakers at the Symposium included Professor Roger Corder from the William Harvey Institute in London, Professor KT Khaw from the University of Cambridge and Associate Professor Naila Rabbani from the University of Warwick. KT Khaw  discussed current controversies, Naila Rabbani  bioactives in fruit and vegetables, and Roger Corder dietary polyphenols and potential vascular benefits of red wine and chocolate. And Jinit Masania outlined a new EU research programme, applying nutrigenomics to assess health claims made for foods.


See also Dr Carolyn Staton’s excellent blog on 'Food and microcirculation' on the British Microcirculation Society site. 

© DRJ Singer