L'Amour, carotid and stroke

As cinema, Michael Haneke's l'Amour is a human drama about the effect of illness on family (partner and next generation), the reality of managing a progressively failing spouse at home, challenges of involving carers, perspectives of young protégé, of emergency services, of remote relatives ...
A subtext is personalising the question:why stroke(s) in this slim elderly woman, the mystery of the transient cerebral ischaemic attack - micro-emboli? transient local clot on a narrow artery? ...
And the human impact of the dilemma:what to do about severe carotid disease and minimising risk of surgery?

See recent blog on predicting and suppressing cerebral micro-emboli in patients with carotid disease.

Sleeping pills and risk of pneumonia

Research published in the journal Thorax has suggested that commonly prescribed sleeping tablets - benzodiazepines - are linked to increased risk of pneumonia, and to risk of 30 day and longer term mortality in patients diagnosed as having had community acquired pneumonia.  Reasons are unclear however these medicines may both impair immune responses and reduce the depth of breathing, thus making it more difficult for microbes to be cleared from the lungs. Reported risk of pneumonia was more evident with longer term use of sleeping tablets. 

Of note, this was a case control  study and thus at much greater risk of inadvertent bias as a reason for the findings than more reliable double blind, randomised controlled trials. It would be expected that patients with greater overall disease burden would be at higher risk of pneumonia if the relationship with treatment were due to 'cause and effect'. However the reverse was reported by the study authors. 

This work suggests the need for further studies to explore these potential risks in more detail. 
Meantime, there are risks to stopping these medicines suddenly. Patients with concerns should contact their medical advisor or pharmacist for advice. 

The original study

Expert comment

Media reporting

Progress on Personalized Medicine? Updates from Harvard.

@HealthMed The 8th annual Personalized Medicine Conference took place at Harvard this week - a joint venture of Harvard Medical School, Harvard Business School and Partners Healthcare, lead by Professor Raju Kucherlapati, from the HMS Department of Genetics. Worth checking the excellent archive of past programmes, presentations and podcasts.
Meantime, some of the highlights?
- An excellent narrative on the partnership between Plexxikon (Peter Hirth) and Roche Diagnostics (Suzanne Cheng) to create a companion diagnostic/therapeutic pairing for vemurafenib (Zelboraf), the first FDA approved pairing for BRAF V600E positive metastatic melanoma
- Further case studies illustrating successful drug development using genetic approaches
- Personal case studies on the impact, clinical value and ethical and clinical challenges of genomic screening: from Joe Beery, Life Technologies, on detecting unrecognised treatable serious early childhood disorders, to John Lauerman, Bloomberg News, on consequences of sequencing for asymptomatic adults - questions on penetrance and future screening for onset e.g.  of metabolic disease and cancers

Harvard Medical School: New Research Building - Avenue Pasteur.

- Clinical potential, and regulatory and reimbursement challenges to introducing molecular diagnostics into clinical care pathways
- Leadership award to Randy Scott, In Vitae, whose discussion points included the relevance of Moore's Law (technology advancing) and Metcalfe's Law (people factors: exponential increase in interaction as network expands) to developments in personalized medicine
- Business models and their governance for use of genetic information
- A North Virginia (John Vockley, Inova) pioneering series of projects aiming to assess outcomes of neonatal genomic sequencing: from insight into preterm labour to prospective longitudinal follow-up to adulthood, supported by multi-generation family member sequencing combined with clinical histories
- The US Air Force Programme on Patient-Centered Precision Care (Dr Cecili Sessions), in partnership with the Coriell Institute and Johns Hopkins University,  aims of which include understanding the impact on health-related behaviour of providing personal genetic information on remediable medical disorders and on drug responses.
- A business school case study led by Professor Richard Hamermesh, Director of the HBS HealthCare Initiative, on reactive and proactive responses for development of companion diagnostics (1).
- Pros and cons of liberal vs. restrictive approaches to IP for genetic and other molecular diagnostics
- Engaging the policy community and the public in ethical, clinical, reimbursement and adoption issues for new diagnostics and treatments aimed at personalizing medicine, including case studies from the American Medical Association and the American Assocation for Cancer Research.

Personalized Medicine Conference website 
Companion and coupled diagnostics

Boris Godunov

Boris Godunov

@HealthMed The RSC is currently running a new version by Adrien Mitchell of Pushkin's Boris Godunov - in which Godunov is accused of the murder of the young epileptic son of former Tsar Ivan the Terrible, following which he (Godunov) allows himself to be 'persuaded' to became the new Tsar. 

Tsar of Russia Boris Godunov is said to have died in mid-April 1605 after a lengthy illness, the cause of death attributed to a stroke. 

Hippocrates is considered to have been the earliest to describe stroke - then called apoplexy [for Gk for to strike down/incapacitate]. As insight into Roman views on the cause of apoplexy, the Latin translation (sideratio) indicates a disease caused by a constellation.  It wasn't until several decades after Godunov's death that Swiss pharmacologist and pathologist Johann Jakob Wepfer linked apoplexy both to bleeding within the brain and to blockage of a blood vessel in the brain. His work on strokes was published in 1658 as Historiae apoplecticorum. 

Depicted as well-fed, Godunov by the age of 54 would have been at risk of hypertension, diabetes and hyperlipidaemia. Other causes of apoplexy could have included a primary or secondary cerebral tumour, indolent brain infection/abscess such as tuberculosis, or indeed a ruptured congenital vascular anomaly. Poisoning was of course then an occupational hazard. Slow onset heavy metal or other toxins could have contributed to his reported long terminal illness.

Apoplexy has attracted fascination from historical reports (e.g. from Petrarch to Copernicus and Catherine the Great, surgeon John Hunter's suspected caused of death - reportedly during a meeting with the board of management, and President Woodrow Wilson) to fictional references - often with a hint of retribution (e.g. Villefort's father in the Count of Monte Cristo, Rip van Winkle's wife ... ). 

For more on general aspects of apoplexy, see History of Stroke by Maurizio Paciaroni and Julien Bogousslavsky.

Shakespeare's Medicine Cabinet discussed at the Dana Centre

@HealthMed: Shakespeare’s Medicine Cabinet was the theme of a packed evening session at the Dana Centre on 8^th November. The Dana Centre is funded as joint venture with the Science Museum and Imperial College London, with the aim of bringing together the public with academics and other experts to discuss a wide range of themes.

This evening explored, with the help of the excellent Dana Actors (directed by Silvia Ayguade), facts and fantasy underlying effects of plants as medicines, poisons and aphrodisiacs in Shakespeare’s plays.

Professor Rod Flower FRS selected examples from Macbeth, Midsummer Night’s Dream and Romeo and Juliet, asking the question whether botanical references were ‘merely dramatic license, or was there a scientific basis for the use of drugs in his plays?’ For example Juliet imploring the Friar:

“… Let me have a dram of poison, such soon-speeding gear 

As will disperse itself through all the veins 

That the life-weary taker may fall dead …”

And the Friar’s offer of a specific death-mimicking toxin to last ‘… two and forty hours …’

Love-in-idleness

The interval was spiced with the opportunity provided by the British Pharmacological Society organisers to sample some of the healthier plants mentioned, including an interesting Heartsease floral tea – the plant referred to as ‘love-in-idleness' by King Oberon in Midsummer Night’s Dream.

Dr Randolph Arroo, Head of Research at the School of Pharmacy in Leicester, went on to discuss the interface between plants and medicines in the second Elizebethan Age.

His comments on reliability of plant sources and earlier issues raised by Professor Flower were echoed in the discussion points raised by a very engaged and informed audience.

For more see the Dana Centre website

and the website of co-organiser the British Pharmacological Society.

More news on the Geneva EACPT 2013 Congress

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Around 10 months to go until the European Association for Clinical Pharmacology & Therapeutics 11th International Congress to be held in beautiful Geneva 28-31 August 2013. The image is one of a series on the congress website showing the best of the city.

Abstract submission is now open for the next EACPT Congress,

Over 900 participants are expected to attend including health professionals, scientists, policy makers, biotechnology and pharmaceutical professionals and others with an interest in basic and clinical pharmacology, pharmacotherapy, drug discovery and development, regulatory affairs and related areas.

Key themes at the congress will range from bedside pharmacology for special patient groups to pharmacology & toxicology, and pharmacology and society. 

Specific topics will include advances in personalised diagnostics to improve the safety and effectiveness of medicines, updates on new biological approaches to ocular disease, therapeutics of cardiovascular, cancer and inflammatory disease, clinical trial design and regulation, and drug safety and toxicology.

See here for more on key themes of the Congress. 

EACPT Geneva 2013 Congress website  

The European Association for Clinical Pharmacology and Therapeutics (EACPT) has its origins in a working party in the early 1980s under the auspices of the World Health Organisation (WHO-Europe). 

The EACPT's next biennial congresses after Geneva 2013 are in Madrid 2015 and in Prague 2017. The EACPT also arranges summer schools, and other scientific and professional activities.

Call for papers for 4th International Symposium on Poetry & Medicine, London: 18th May 2013

Registration is open for the 4th International Symposium on Poetry and Medicine to be held on Saturday 18th May 2013 in London at the Wellcome Collection rooms on the Euston Road. The symposium will include poster sessions, lectures, round table discussions and poetry readings (Hippocrates Awards judge Jo Shapcott) and the 2013 Hippocrates Awards will be announced at the end of the Symposium. 

The programme includes keynote lectures from Anne Hudson Jones from Texas, USA and Hugues Marchal from Basel, Switzerland.  

Listen to these speakers discussing poetry and medicine. 

There will be sessions on historical and contemporary themes, illness and poetry, poetry as therapy, poetry in the education of medical students, nurses and doctors, and poetry as an aid to health professionals. The programme of lectures, round table discussions, poetry readings and the Hippocrates Awards Ceremony will be published on the Symposium website. 

Oral abstract submission is open - deadline 28th February, 2013. 

 Poster abstract submission is open - deadline 31st March 2013.

The Hippocrates initiative was named winner of the Award for Excellence and Innovation in the Arts in the 2011 Times Higher Education awards, announced on 24th November 2011 in London. This award aims to recognise the collaborative and interdisciplinary work that is taking place in universities to promote the arts. 

Entries are open until 31st Jan 2013 for the 2013 Hippocrates Prize for poetry and medicine, which is for unpublished poems in English.  

The Hippocrates poetry and medicine initiative was co-founded by a team from University of Warwick, and has been supported by several external organizations interested in medicine and the arts, including the Fellowship of Postgraduate Medicine, the Wellcome Trust, the Cardiovascular Research Trust and Heads, Teachers and Industry. 

We are delighted that the National Association of Writers in Education is supporting the inaugural International Hippocrates Prize for Schools 

In its first 3 years, the Hippocrates Prize has attracted over 4000 entries from 45 countries, from the Americas to Fiji and Finland to Australasia.

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 each category there is also a 2^nd prize of £1,000, 3^rd  prize of £500, and 20 commendations each of £50.  

Judging panel for the 2013 Hippocrates Prize: 
- Jo Shapcott, winner of the 2011 Queen's Gold Medal for Poetry
- Theodore Dalrymple, doctor and writer
- Roger Highfield, science writer and Executive for the Science Museums Group.

For more on the 2012 Hippocrates Awards and the Hippocrates initiative see update. 

@HealthMed @HippoetPrize