What's in a medicine?

@HealthMed Most of the weight of a tablet or capsule consists of coatings and fillers to make the enclosed active ingredient is big enough to pick up. Some common medicines such as the heart tablet digoxin or thyroid replacement treatment may have an active ingredient weight of as low as one tenth of a gram - ie it might take around 50 doses to fill a level teaspoon.
That raises the obvious question: what other ingredients are present in medicines? The range of fillers includes usually harmless chemicals such as the sugar lactose. That could prove a problem with patients who suffer lactose intolerance - due to immaturity in or loss of the enzyme needed to break down lactose.
And liquids or tablet coatings may include animal extracts, in the form of gelatin. Although this should be clearly labelled on the package insert that should accompany all medicines, a paper in the latest issue of the Postgraduate Medical Journal has reported that many patients on restricted diets are unaware of this.
The study in the Postgraduate Medical Journal reported that a quarter of patients surveyed who were on restricted diets were unaware that they had been prescribed drugs containing gelatin, contrary to their wishes or beliefs as vegetarians, or for other cultural or religious reasons.
If not clear from the packaging, patients should ask their pharmacist for further information on the non-drug contents of medicines prescribed, or bought over the counter without a prescription.

See BBC report on the PMJ article                                                                                                                                                                                                                                            

Cancer risk, premature death and sleeping tablets?

@HealthMed A team of researchers from Scripps Institute and the Jackson Hole Center for Preventive Medicine in Jackson, Wyoming, in the United States has reported in a publication in the British Medical Open Journal that use of sleeping tablets is associated with increased risk of cancer (lymphoma or cancer of the lung, colon or prostate), and  premature death. Results were obtained by interrogating electronic case records within a large US health care service: the Geisinger Health System (GHS), the largest rural integrated health system in the USA. GHS serves a 41 county area of Pennsylvania with approximately 2.5 million people.
This report has been disseminated widely in the international media, including for example in the Los Angeles Times.
The 2 major questions raised by this work are whether findings are explained by effects caused by the sleeping tablets -  or are the kind of people who are prescribed hypnotics just more likely to develop cancer or premature death, as a result, for example, of genetic factors, lifestyle reasons or associated disease causing the sleep disturbance.
Obvious more specific questions include are whether this relationship is:
- caused by the sleeping tablets (hypnotics);
- a feature of 'reverse causation - ie resulting from the initial sleep disturbance having been caused by symptoms of at that stage undiagnosed cancer, or sleep disturbance caused by cancer risk factors such as smoking, excess alcohol or obesity - ie some cancer-related factor leading to patients seeking a prescription for hyponotics
- coincidental
- or spurious - the result of some bias in subject selection.
The short, ~2.5 year average treatment duration makes this possible early cancer effect important to exclude as an explanation.
The authors say they have made reasonable efforts to exclude other causes of increased cancer risk. A wide range of hypnotics were included in the study, making it unlikely that a direct chemical action of the tablets is responsible for the cancer risk.
An intriguing possibility is that the association is a marker of chemical changes in the brain arising from sleep disturbance: it is well recognized that disordered brain function leads to production by the brain of inflammatory mediators (cytokines). One consequence is the thought to be the increased risk of heart disease reported in patients who have depression. That has lead to interest in using new biological agents to inhibit the action of these cytokines as a new approach to treatment depression and other serious neurological disorders. Taking sleeping tablets, although prolonging sleep duration, may not be sufficient to induce a normal sleep pattern.
In the context of the Scripps study, this raises the question whether  inflammatory mediators
could modulate tumour formation or accelerate the growth of early stage cancers. This concept was discussed by Reiche and colleagues in a Lancet Oncology review in 2004. As an example, the chemical - tumour necrosis factor alpha - is a potent cytokine implicated in depression and - as the name indicates - with a role in tumour biology, for example in modulating tumour blood supply.
Although in the Scripps study the reported relative risk of cancer increased from 3.5 to 5-fold with the numbers of sleeping tablets used, there needs to be a clear description of absolute events rates. And the increase in premature death was from a very wide range for causes, from accidents to asthma, flu and diabetes.
Of note, this was an observational study controlled by the authors by aiming to find well-matched subjects not on sleeping tablets (cases: 10 529 patients who received hypnotic prescriptions;  23 676 matched controls). A randomised controlled trial aimed at assessing these particular outcomes would have been needed to test these findings with more confidence of lack of bias. 
If the relationship is confirmed as having a causative link, the study would illustrate yet again the importance of balancing benefit and risk when prescribing tablets, and ensuring that any prescription is  continued for the minimum clinically indicated time.

Clinical pharmacology theme for Spring 2012 WMPA conference

@HealthMed Registration is now open for members and guests for the Spring meeting of the West Midlands Physicians Association.
The next meeting of the WMPA has updates on Clinical Pharmacology as its major theme and will be held on Wednesday 16th May 2012 at the Clinical Sciences Building at the University Hospital Campus in Coventry. Key speakers will include Dr Andrew Kicman (King's College London) on drugs in sport, Professor of Psychiatry Femi Oyebode (Birmingham) on medicines in psychiatry, Dr Richard Fitzpatrick (Liverpool) on advances in pharmacogenetics and Dr Paul Newrick (Worcestershire Royal Hospital)on medical advances in managing diabetes mellitus.
In view of the large number of high quality abstracts submitted, an attended poster session will be included in the May 2012 meeting.
Registration is open to members and guests (subject to availability of places).
For further information, contact the WMPA organizers.
See the WMPA blog or the WMPA website for more on the WMPA 2012 Spring conference and on the history of this 62 year old medical society.

Romeo's 'Sick health'

@HealthMed One of Romeo's string of oxymorons [Romeo and Juliet Act 1, Scene 1: reflecting on his heart sickness for fair Rosalind], 'sick health' illustrates the challenge of preventing more conventional heart disease - with its long prodrome of apparent health masking the development of sub-clinical disease from unrecognized risk factors, which may however be reversible if identified and addressed.

Why don't more people engage? Many reasons, including fear of finding a problem if tested, difficulty accessing advice/health checks, lack of interest or knowledge of outcomes of 'treatment', lack of confidence in self-efficacy to achieve supporting or first-line life-style changes, in diet, exercise, weight, smoking cessation, alcohol intake ...

To find out more on challenges and solutions for success in behaviour change, look for sources on Theory of Planned Behaviour e.g. this referenced link from the University of Twente.

See my previous blogs on smoking and alcohol.

Stopping smoking: why and how?

Hip fracture risk and smoking

Smoking: literary warnings

Alcohol: literary warnings

Alcohol and the French paradox

The 'Magic of Medicine' at the Dana Centre

@HealthMed The Science Museum’s Dana Centre in South Kensington in London aims to provide updates for adults on contemporary science, technology and culture in an informative and innovative format. For those who can't make it in person the Centre makes its events available for interaction online or by smartphone.

The next event at the Dana Centre - on 16th February - is a sell-out session on the Magic of Medicines, organised jointly with the public engagement team at the British Pharmacological Society. Themes will range from drug discovery from Nature by the ancient Babylonians and Greeks such as that chewing meadowsweet or willow bark relieves pain, to new experimental approaches to drug discovery, latest advances in personalizing medicines, supported by companion diagnostics, to the need to maintain vigilant pharmacology and related expertise ready to combat new and unresolved disease challenges, in the face a declining pharmaceutical sector.

What's on at the Science Museum’s Dana Centre.

The Science Museum’s Dana Centre is a collaboration between the British Science Association, the European Dana Alliance for the Brain, and the Science Museum. It is part of the Wellcome Wolfson Building, which is supported by four principal donors - the Wellcome Trust, the Wolfson Foundation, The Dana Foundation and the Garfield Weston Foundation.

Next key dates for Hippocrates poetry and medicine initiative

31st January 2013

Deadline for 2013 Open International and NHS-related Hippocrates Prize for Poetry and Medicine

31st March 2013
Deadline for 2013 Hippocrates Prize for Poetry and Medicine for Young Poets

18th May 2013
4th International Symposium on Poetry and Medicine
Wellcome Collection, Euston Road, London

18th May 2013
Awards for the 2013 Hippocrates Prize for Poetry and Medicine
Wellcome Collection, Euston Road, London

21st - 22nd September 2013
Hippocrates in Venice workshop

Recent events

12th July 10am
Hippocrates Initiative Lecture at Lichfield Science Festival
Programme announced in April by Festival organizers

12th May 2012
9am-4pm
Wellcome Collection, London
International Symposium for Poetry and Medicine
Lectures, Q & A discussions, and poetry readings (Jo Shapcott and Marilyn Hacker)
Registration open

18th June 18.00 - 20.30
Hippocrates Initiative for Poetry and Medicine
Chandos House, 2 Queen Anne St, London
5 minutes from Oxford Circus.
Free subject to registration and availability of places:
To register: email hippocrates.poetry@gmail.com

18.00
Coffee

18.30
Hippocrates Initiative for Poetry and Medicine: the first 3 years.
Professor Donald Singer
Readings from Hippocrates Award-winning poets:
Michael Henry - Open Hippocrates Winner, 2011
Wendy French - NHS Hippocrates Winner, 2010 & NHS 2nd Prize, 2011
Tricia Torrington - Commended, 2012
Panel discussion

19.30
Reception

12th May 2012
4-6pm
2012 Hippocrates Awards for Poetry and Medicine announced by judges in London at International Symposium for Poetry and Medicine at Wellcome Collection Rooms, 183 Euston Road
Registration open

Downloadable flyer for Saturday 12th May Poetry and Medicine and Hippocrates Awards Symposium.

Latest programme for 12th May Poetry and Medicine Symposium and Hippocrates Awards

12th May 2012
Launch of 2012 Hippocrates Anthology in London on Saturday 12th May at 2012 Hippocrates Awards: Wellcome Collection Rooms, 183 Euston Road

On 4th April, the entries were shorted listed in London by the judges for the 2012 Hippocrates Awards for Poetry and Medicine, BBC broadcaster and journalist Martha Kearney, Paris-based US poet and critic Marilyn Hacker and medical scientist Professor Rod Flower FRS.

What happened this time, the 3rd year for the awards?
Over 1000 entries from 5 continents from around the world: 32 countries (12 European), 5 Indian and 36 US states. and 5 Canadian Provinces. In order, the largest number of entries have come from the UK, USA, New Zealand, Australia, Republic of Ireland, Canada, France, India, Switzerland, Greece, Singapore, Italy, South Africa, Germany ...

What next for key Hippocrates dates?

10th April 2012 Press release about short-listed and commended entrants.
Short version

Full version with list of top 6 short-listed entries and 40 commended poets

Alcohol and risk: surprising early warning from F Scott Fitzgerald.

F Scott Fitzgerald

@HealthMed More early 20th Century discussion in literary fiction of risks of over-indulgent lifestyle.
F Scott Fitzgerald addresses lifestyle risk twice in his 1922 novel 'The beautiful and damned': smoking as a risk for a young woman's complexion, and later in the book, risks of alcohol.
Usher girlfriend Georgina challenges Harvard man Anthony Patch on his drinking - both for the amount and as a daily habit, predicting serious disease. She comments: 'you and your friends keep on drinking all the time. I should think you'll ruin your health'. She then adds: 'Think what you'll be at 40'.
Anthony is dismissive, replying that 'I only get really tight once a week'. He is neither concerned about weekly binges nor about the long term. For him 40 is beyond his horizon.
Apparent insight, but not for him - for Fitzgerald - take heed of what he says, not as he does.
The book is remarkably prophetic in that the author himself did not live much beyond 40, dying aged ~44 after what was considered a second heart attack, with excessive alcohol considered a major health problem,  oesophageal varices suggested as the cause of a major illness. Retrospective risk factor ascertainment is of course problematic, however it is likely that his smoking contributed to his early demise, assuming the heart attack diagnoses are correct.

Notes on why and how to stop smoking. 

Smoking warnings in literary fiction

Smoking and hip fracture risk

Ideas for losing weight

French paradox