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Thursday, 8 August 2013

Leprosy, from old Spittals to modern times

The Berwick-on-Tweed leper hospital (Spittal) is said to have been established in 1234, at what is now called Spittal Beach. This coincides with the middle of the peak of reported leprosy in Great Britain as being 12th and 13th centuries. London eventually had 10 hospitals for lepers on main routes out of the city. The last recorded case of leprosy in London was said to be in 1559. St Bartholomew was associated with lepers in medieval times, with associations between leper hospitals and churches named after the saint both in Berwick and near London. The name leprosy is derived from the Greek word for scales (lepra), the disease discussed by Hippocrates, with evidence that it was known in Ancient Egypt at least 6000 years ago.

What was like to be leper in medieval times? Lepers lost their rights under common law, including property rights. They were excluded from places where people gathered. They had to carry a bell to warn others of their presence. They were isolated, typically sent away to remote hospitals with chapels, as lepers were expected to follow Christian rule. Hospitals were usually run by religious orders. The reportedly well-funded Berwick hospital was later by Royal Charter of James 1 of Scotland in the charge of the King's Chaplain, Thomas Lauder.

RC St Clemens, ex Benedictine Cloisters, Bad Iburg

Squints or hagioscopes allowed people with leprosy and other infectious diseases to view the sacraments from outside a church of without coming into contact with the healthy members of the congregation.

Historically people with leprosy were recognized because of resulting deformities and were shunned because of fear of contagion. Untreated, leprosy could progress, causing serious disease and deformity to nerves, skin, nerves, limbs and face, including flattening of the nose due to destruction of underlying cartilage, and associated changes in the quality of speech.

A stone tower was erected at the Spittal in Berwick in 1369 as look-out point and protection from raids over the nearby border by the Scots. The buildings were demolished and nothing above ground remains.

Red staining of organism that causes leprosy
We now know that the disease is caused by a bacterium similar to the one that causes tuberculosis: the leprosy version - mycobacterium leprae - discovered by Paul Hansen, leading to the eponymous name Hansen's disease for leprosy. There is a wide spectrum of clinical features of leprosy. The main route of spread to susceptible people considered to be by nasal droplets (from coughing and sneezing). Risk of acquiring the infection appears linked to causes of impaired cell-mediated immunity, prolonged exposure to infected patients, and to malnutrition. Although infants may develop the disease, the incubation period may be as long as 30 years.

Does leprosy still exist? The World Health Organization  records official data on leprosy from up to 120 national programmes in Member States, results published in  the WHO's Weekly Epidemiological Record. From this data, the WHO estimates that one person in 10,000 is affected by the disease (prevalence). New case detection is estimated to have decreased from around 760,000 in 2002 to around 200,000 in 2011 . With early combination drug treatment before deformity (usually for 6-12 months), outcome of the disease is much improved. However, patients with treated leprosy may still be ostracised, especially in rural communities, even if patients are known to have been treated,  because of ignorance about the low risk of disease transmission and about the success of treatment: people are considered no longer infectious after around one week of treatment and it is estimated that over 10 million people estimate cured of leprosy in past 2 decades.

Professor Carole Rawcliffe, Medieval History, University of East Anglia
Leprosy in Medieval England, 2006.

Sharpening memory and cocoa - how interested should you be?

Farzaneh Sorond and colleagues from Harvard and the Mass. General Hospital have attracted worldwide interest in their study published in the US journal Neurology "Neurovascular coupling, cerebral white matter integrity, and response to cocoa in older people". 

Listen to interview on the story on BBC local radio
The theme of the interest - from the LA Times to the Belfast Telegraph - is that cocoa "not only soothes the soul, but might also sharpen the mind'.
Fruit of the theobroma cocoa tree: Corti et al. Circulation 2009 
Why even think that it might? The authors drew on two background concepts:
- Earlier research using sophisticated brain imaging had reported that cocoa intake is associated with an increase in blood flow to the brain; and brain blood flow is linked to intellectual capacity.
- And cocoa contains flavonols, bioactive chemicals present in many foods associated with measures of healthy cardiovascular health, including increasing blood flow to the gray matter of the brain.
The question asked by the researchers was whether previous interest in chocolate containing products and better brain function might be explained by flavonol effects. 
To address this they carried out a study in which the design was high quality with regard to a possible effect of flavonols on 2 measures - brain blood flow and a test they used to assess memory.
What did they find? No difference in the effects of flavonol-rich vs low in flavonol cocoas as 2 cups per night for 30 days.
However, they reported a significant improvement in blood flow and in the intellectual function test by 30 days.
Should we all now start drinking large amounts of cocoa? Not yet based in this interesting but small study. To consider my question in a different way, key points arising from this work are:
- does cocoa sharpen the mind?
- does it protect from dementia?
- does it help people with dementia?
With these points in mind:
- the study was small - only 60 participants included and only 18 of these were noted to have improvements with regular cocoa
- the study was only for 30 days - more work would be needed to show whether these apparent benefits would be sustained
- the study was performed in older people - average age 73, who already had risk factors for cardiovascular disease - not safe to generalise study findings to other age groups and to people without cardiovascular risk factors.
- the 70% of volunteers who had normal blood flow and managed the test well at baseline should no improvement with cocoa
- the study was designed to test an effect of flavonols. However there was no time control for the effect of cocoa - e.g. vs other hot drinks. The authors cannot therefore rule out a time effect on their results e.g. people not managing the test well at the start doing better simply through  the initial practice
- the tests of brain function were 'Trailing Making Tests' ie involved a timed 'joining the dots' test. It would be important to confirm that more real world aspects of brain function were also improved
- no patients with dementia were included - further studies would be needed to show whether patients with dementia would also benefit and that any benefits were helpful for activities of daily living 
Thus results of the study could be explained as an artefact of the study design - ie not be due to the cocoa. At best they only applied to people with identified cardiovascular factors who also already had impaired brain blood flow and difficulty in performing the type of mental activity tests used by the researchers. 
And the concern about large amounts of cocoa is the associated increase in dietary sugar and fat intake of typical Western milky cocoa drinks. Neither are good for cardiovascular health, as they increase risk of overweight, high cholesterol, diabetes and high blood pressure. To compensate for those risks, the researchers under the strict conditions of the study made sure their volunteers made appropriate adjustments in other parts of the diet to balance sugar and fat intake over the month. In real world use, even if cocoa were confirmed to be helpful for the brain, it would be very important that people increasing their cocoa intake were very careful to avoid these unintended consequences of increased cocoa intake. Of note the researchers were not studying cocoa with added cream and marshmallows - not good for the circulation.
What about different sources of chocolate in cocoa? Not addressed by the researchers - except that they appeared to show at least that any benefits were not related to the types of flavonol they studied.
And how about eating chocolate instead? Again - not studied by the researchers. And in previous observational research on chocolate, there was an apparent benefit on heart disease protection from very small amounts (chocolate 1-3 times per month) with larger amounts reported to be harmful for the heart.
As a final thought, one of the reported uses by ancient Aztecs and Incas of chocolate drinks was as sedatives in religious rituals. Another explanation for the study findings is that calming effects of cocoa ('soothing the soul') reduced anxiety during the tests as a contribution to the observed improvements in brain blood flow and test performance with the drinks.

Link to interview 8.8.13 with Shane O'Connor on BBC local radio

Sunday, 4 August 2013

Distinguished barrister Robert Francis QC joins 2014 Hippocrates Prize Judges

The judging panel for the 2014 Hippocrates Prize for Poetry and Medicine includes poet Philip Gross, a winner of the TS Eliot Prize, and distinguished barrister Robert Francis QC.

Philip Gross (Stephen Morris)
Photo of Philip Gross by Stephen Morris
Philip Gross’s The Water Table won the T.S.Eliot Prize 2009, I Spy Pinhole Eye Wales Book of The Year 2010, and Off Road To Everywhere the CLPE Award for Children’s Poetry 2011. Deep Field (2011) deals with voice and language, explored through his father’s aphasia, and a new collection, Later, is due from Bloodaxe in Autumn 2013. He has published ten novels for young people, including The Lastling, has collaborated with artists, musicians and dancersand since 2004 has been Professor of Creative Writing at Glamorgan University, where he leads the Masters in Writing programme.

Robert Francis QC is a distinguished barrister who specialises in the NHS and medical negligence. He has been a Queen's Counsel for 21 of his 40 years at the bar. He has been involved in many inquiries into the NHS, both as barrister and as chair, most recently chairing the inquiry into the Mid Staffordshire Hospital. According to Peter Walsh, chief executive of the patient safety charity Action against Medical Accidents, Robert Francis has a "passion for justice in healthcare and improving healthcare more generally".