DONALD SINGER: HEALTH, ART AND SCIENCE

What's in a medicine?

2012-02-28T23:38:00.001-08:00

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?

2012-02-28T22:06:00.001-08:00

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

2012-02-22T11:49:00.000-08:00

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'

2012-02-14T02:23:00.001-08:00

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 inself-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 successin 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

2012-02-11T09:47:00.000-08:00

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

2012-02-04T09:42:00.000-08:00

Entries are now closed for the 2012 Hippocrates Awards for Poetry and Medicine.
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 dates?
12th February 2012
Oral abstract submission deadline for 12th May International Symposium for Poetry and Medicine

31st March 2012
Poster abstract submission deadline for 12th May International Symposium for Poetry and Medicine

4th April 2012
Short-listing in London of 2012 Hippocrates Awards
Judged by BBC broadcaster and journalist Martha Kearney, Paris-based US poet and critic Marilyn Hacker and medical scientist Professor Rod Flower FRS

5th April 2012
Short-listed and commended entrants notified

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

4-6pm
Hippocrates awards announced by judges in London at International Symposium for Poetry and Medicine
Registration open

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

12th July
Entries open for 2013 Open International and NHS-related Hippocrates Awards for Poetry and Medicine

31st Jan 2013
Deadline for 2013 Hippocrates Award entries

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

2012-02-03T15:25:00.000-08:00

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

Hip fracture risk, smoking and anti-ulcer drugs (PPIs)?

2012-01-31T17:12:00.000-08:00

A report in the latest British Medical Journal by Chan and his team from the Gastro-enterology Department at the Massachusetts General Hospital in Boston, USA, suggests a small but potentially important higher risk of hip fracture in current or ex-smokers among post-menopausal women on treatment with the commonly used anti-ulcer drugs - proton pump inhibitors. The risk was small - one extra hip fracture per year for every 2000 women treated -but the risk was greater, the longer the treatment with a PPI.

The link is biologically plausible as both PPIs and smoking have actions on the body which could increase the risk of hip fracture. The authors were careful to state that the risk did not apply to non-smokers and for those at risk they were unable to attribute this to any specific type of PPI. Of note, there are several reasons why smokers are more at risk of causes of indigestion/dyspepsia which may make them more likely than non-smokers to be on PPI treatment.

This report is another example illustrating that drug choice and duration should be based on balancing clinical benefit against potential risk of adverse drug effects.
This was an older study among nurses in the US from data collected from 2000 up to 2008.
A weakness of the study is that it was not a randomised controlled trial. The report was based on following a cohort of people some of whom happened to be on PPI treatment : that means that the findings may be subject to bias ie there may be reasons unrelated to the PPIs to explain the hip fracture risk, although the authors made clear efforts to control for obvious sources of bias.
Patients who are concerned should consult their GP or pharmacist for advice.

See source reference
Khalili H, Huang ES, Jacobson BC, et al. Use of proton pump inhibitors and risk of hip fracture in relation to dietary and lifestyle factors: a prospective cohort study. British Medical Journal. Published online January 31 2012

Call for papers for 2012 International Symposium on Poetry and Medicine and Hippocrates Awards

2012-01-28T11:03:00.001-08:00

Registration is open for the 3rd International Symposium on Poetry and Medicine to be held on Saturday 12th May 2012 in London at the Wellcome Collection rooms on the Euston Road. The symposium will include poster sessions, lectures, round table discussions and poetry readings (by former President of the Poetry Society Jo Shapcott and 2012 Hippocrates Awards judge Marilyn Hacker) and the 2012 Hippocrates Awards will be announced at the end of the Symposium.

The programme includes contributors from the UK, USA, Denmark, Greece, Cyprus and France. There are 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 provisional programme of lectures, round table discussions, poetry readings and the Hippocrates Awards Ceremony is now published on the Symposium website.

Poster abstract submission remains open - deadline 31st March 2012.

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 now closed for the 2012 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.

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.

BBC broadcaster and journalist Martha Kearney has joined New York poet and critic Marilyn Hacker and medical scientist Professor Rod Flower FRS to complete the judging panel for the 2012 Hippocrates Awards for Poetry and Medicine.

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

New deadline midnight GMT 3rd February for 2012 Hippocrates entries

2012-01-24T16:49:00.000-08:00

Entries are now closed for the 2012 Hippocrates poetry & medicine awards for which there is a £50001st prize in each of 2 categories: an Open International Prize and UKNHS-related Prize for an unpublished poem of up to 50 lines written in English. Judging is anonymous.

For the 2012 awards there have been entries from 5 continents, from 32 countries from Argentina to Australia, Brazil to Burma, Italy to India, South Africa to Switzerland, Ghana to Germany, France and Switzerland, andwith poems submitted from 36 US states, 5 Indian states, 5 Canadian provinces, and from throughout the UK.

Hippocrates Prize winners will be announced by the judges, Marilyn Hacker,Martha Kearney and Professor Rod Flower, FRS, at the Awards Symposium in London,Sat 12th May at the end of our 3rdInternational Symposium on Poetry and Medicine.

A downloadableposter about the 12th May International Symposium on Poetry and Medicine is available.

There is more information about the Hippocrates Initiative in earlierpostings on this blog.

The Hippocrates initiativereceived a 2011Times Higher Education Award for Excellence and Innovation in the Arts.

For further information, seethe Hippocrates initiative websiteor email the organisers.

Smoking advice in literature

2012-01-23T16:53:00.000-08:00

In 'The beautiful and damned', F Scott Fitzgerald's novel of the East Coast 'smart set' during the period just before The Great War and published in 1922, mention of smoking by the superficially charmed young men and women is very frequent, including for Gloria (age '22'). However also striking is Gloria's comment on advice from reformers that '... if you smoke so many cigarettes you'll lose your pretty complexion!'
Further examples welcome of earlier literary offers of advice on risks of smoking, heeded or ignored?

See related previous blog on: Stopping smoking - why and how?

FPM to launch a new journal on Health Policy and Technology

2012-01-13T15:22:00.000-08:00

Health Policy and Technology (HPT), the new official journal of the Fellowship of Postgraduate Medicine (FPM), will be launched in March 2012 as a cross-disciplinary journal,which will focus on past, present and future health policy and the role oftechnology in clinical and non-clinical national and international healthenvironments. HPT will be published by Elsevier, a .major international publisher of scientific, technical and medical information

The FPM continues to publish its first international publication, the Postgraduate Medical Journal, launched in 1925. HPT provides a further excellent way for theFPM to continue to make important national and international contributions to developmentof policy and practice within medicine and related disciplines. The aim of theFPM in establishing this new international journal is to publish relevant, timely and accessible articlesand commentaries to support policy-makers, health professionals, healthtechnology providers, patient groups and academia interested in health policy and technology.

Topicscovered by HPT will include
- Health technology,including drug discovery, diagnostics, medicines, devices, therapeutic deliveryand eHealth systems
- Cross-nationalcomparisons on health policy using evidence-based approaches
- Nationalstudies on health policy to determine the outcomes of technology-driven initiatives
- Cross-bordereHealth including health tourism
- The digitaldivide in mobility, access and affordability of healthcare
- Health technologyassessment (HTA) methods and tools for evaluating the effectiveness of clinicaland non-clinical health technologies
- Health andeHealth indicators and benchmarks (measure/metrics) for understanding the adoptionand diffusion of health technologies
- Health andeHealth models and frameworks to support policy-makers and other stakeholders indecision-making
- Stakeholderengagement with health technologies (clinical and patient/citizen buy-in)
- Regulationand health economics

Professor Wendy Currie will leadthe journal as its founding Editor-in-Chief. Her research, consultancy and publications focus onpolicy-making for large-scale information and communications technology (ICT)projects in health, financial services and government.

The first issue of Health Policy andTechnology will focus on Electronic Health Records in the 21st Century, with papersdiscussing implementation targets for EHRs in healthcareorganizations, cross-border policies for EHRs, financial and non-financialcosts of introducing EHRs, clinical and patient engagement with EHRs, governmentpolicy for EHRs and country comparisons, security and governance practices inrelation to EHRs, and the role of EHRs in campaigns to improve citizens' healthand reduce health inequalities.

The first issue also includes a paper on the pioneeringnew Centre for Health Technology Assessment of Devices and Diagnostics withinthe UK’s National Institute for Health and Clinical Excellence (NICE). There isalso the first of a series of interviews with international leaders in thefield of health policy and technology, beginning with Sir Michael Rawlins,Chairman of NICE.

Theaim of the Fellowship of Postgraduate Medicine (FPM) is to promote internationalcalibre excellence in postgraduate medical education through its publications,clinical and scientific meetings, and other activities. The FPM is a British medical charitythat was founded at the end of World War I, when it pioneered development ofpost-graduate educational programmes in all branches of medicine.

Itsfoundation was the result of a merger between the Fellowship of Medicine andthe Postgraduate Medical Association, with Sir William Osler the first presidentof the new organisation. The FPM is supported by Fellows with expertise in thepractice of medicine, medical education and publishing, and research in medicineand related disciplines.

HPT website

FPM website

FPM contact email

Commended 2011 Hippocrates entry published in Br J Psychiatry

2012-01-03T15:14:00.000-08:00

'Street-wise' by Wendy French, one of 20 NHSentries commended in the 2011 Hippocrates Prize for Poetry and Medicine, hasbeen published in the December issue of the British Journal of Psychiatry.

Entriesare closed for the 2012 Hippocrates Awards. Witha 1st prize of £5000 for the Open International category and a separate 1st prize of £5000 for the UK National Health Service-related category, this is one of the best funded awards anywhere in theworld for a single poem.

Judges for the 2012 Hippocrates Awards are New Yorkpoet and critic MarilynHacker, medical scientist Professor Rod Flower FRS and BBC broadcaster and journalist MarthaKearney.

Awards will be presented in London on SaturdayMay 12th 2012, at the 3rdInternational Symposium on Poetry and Medicine, to be held at the Wellcome Collection rooms inLondon.

During the 2012 Symposium, there will be readings by JoShapcott, Past-Presidentof the Poetry Society, and US poet and 2012 Hippocrates awards judge, Marilyn Hacker.

From eternal fires to venom and personalised medicine

2012-01-02T17:00:00.001-08:00

Why should picnics, 'show and tell', and morning break be memorable for a small boy in the Middle East? The road for weekend family visits to the river Zab passed near rocky slopes, above which a heat haze marked scattered low flames. The existence of eternal fires was noted by Greek historian Herodotus, writing in the 5th century BC. A matter-of-fact article in the Pittsburgh Press, 14th May 1965, refers to these as 'seepage of natural gas in the Kirkuk oil field', part of the lands once ruled by Nebuchadnezzar, king of the Neo-Babylonian Empire from ca. 605 BC – 562 BC. The Kirkuk area is now part of northern Iraq. These 'eternal fires', due to natural gas escaping from the rocks, give a possible explanation for the biblical reference to Daniel's three friends, Shadrach, Meshach and Abednego being put to the den of fire. An obvious reason to survive the fires would be, at the right time, heavy rain temporarily extinguishing the flames. Other sites where self-igniting natural gas leaks occur include Central Java.
Primary school play was subject to interruption by sandstorms, and on one occasion spent indoors to avoid a plague of locusts, so dense as to make breathing difficult. Knowing then of locusts from stories of the plagues of Egypt, my memory is of surprise that hedge and tree leaves were largely uneaten. And 'show and tell' was made the more exotic because a friend's father had ready access to formalin - his son regularly bringing in a preserved scorpion or multi-coloured snake. Both may use in their venom sarafatoxin, a primitive form of endothelin, to immobilise pray through causing angina, due to severe coronary artery spasm. This knowledge about toxins arose from the discovery of endothelin by Yanagisawa, reported in 1988
The ancient town of Arapha, near the modern Kirkuk area oil field discovered in 1927, was an important centre in the time of the Babylonian King Hammurabi (fl. 1792 BC to 1750 BC), who provided the early legal Hammurabi Code, including rules for good medical practice, dating back to around 1772 BC. A historical connection to an early example of guidelines for 'personalising medicine'.

©DRJ Singer

A good time to get weight in trim

2011-12-30T17:23:00.001-08:00

New Year is a familiar time for people to make resolutions and aims to improve lifestyle.

Why bother about overweight?
Excess weight increases the burden of cardiovascular risk (high blood pressure, raised cholesterol and diabetes mellitus); causes premature ageing of arteries, leading to heart attacks, strokes and other serious disorders of the heart, brain and circulation; contributes to risk of sleep dusturbance and sleep apnoea syndrome; causes premature joint ageing with arthritis; non-alcholic fatty liver disease is the commonest cause worldwide of liver damage; and increased risk of cancers - weight gain and overweight estimated to be linked to 1 in 5 cancers.
People who have no difficulty in maintaining normal weight may find it difficult to understand the challenges. For those who are currently overweight, the challenges in regaining a more healthy weight include beating the psychological, physical and social addiction to causes of overweight, and resisting peer pressure.

Getting started
Importants steps on the path to reducing excess weight include being ready to think about action, to think about taking action and to prepare to take action. That might mean telling friends and family you are serious about losing weight, and to seek whatever help may work - e.g. family doctor or nurse or other health professional, and support groups for the overweight.

What works?
Smaller portion size, cutting down on processed foods and increasing exercise are the big 3 factors that help. Keep a weight chart and if possible find a friend with whom to lose overweight. Wear a belt. Pace your eating and drink water with your food. Eat regular small meals. Avoid snacking, Research evidence suggests that successful measures include recording weight regularly, knowing the approximate energy intake of what you eat, and regular activity.
It is also clear that insight into the personal health risks of overweight provide extra incentive to lose weight. Better of course to reduce excess weight before serious clinical effects of overweight occur.
There are many support groups and diet plans available to order, often at high cost.

Research evidence suggests that success in maintaining weight loss is associated with clear strategies for coping with life stresses and with 'continued adherence to diet and exercise strategies, low levels of depression and disinhibition, and medical triggers for weight loss'. In contrast, unsuccessful weight maintainers are erratic or inconsistent in recording their weight and being vigilant in keeping to healthy types and amounts of food and in continuing regular activity.
Once overweight people have maintained a weight loss for 2-5 years, the chances of longer-term success in maintaining a healthy weight are much greater.

Apps
There an increasingincreasing variety of 'apps' for smartphones and PCs, that reinforce the combined impact of healthier dietary intake and maximising exercise. Many are free, with myfitnesspal an excellent example. These and other free lifestyle apps are like your personal health bank. The more active you are, the more energy balance you have towards losing weight, the more you eat, the less reserves in your health bank.
I welcome comments in the box below on what has, or has not, been helpful for you in efforts to reduce overweight.

©DRJ Singer

Favourite poems on a medical theme from entries in the 2012 Hippocrates initiative poll

2011-12-29T16:32:00.000-08:00

To mark the launch of the 2012 International Hippocrates Prize for Poetry and Medicine, the organisers invited nominations of favourite poems with a medical theme. The top 5 favourites were:

Dylan Thomas – Do not go gentle into that good night
William Butler Yeats - When you are old
Dannie Abse - The Pathology of Colours
Jo Shapcott - Of mutability
Stevie Smith - Not waving but drowning

You can see examples of comments received and find links to many of the submitted favourite poems on the earlier blog on favourite poems on a medical theme.

'Medical' was to be interpreted in the broadest sense, with only one nomination may be made by any one person. Nominations were to be for poems written by a poet from anywhere in the world and in any language. The poem were to be contemporary or from any historical period.

The Hippocrates Prize of £5000 for the winning poem is one of the highest value awards in the world for an unpublished poem in English on a medical theme.

Entries for the 2012 Awards are now closed. 2012 Hippocrates Prize judges include New York poet and critic Marilyn Hacker and medical researcher Professor Rod Flower, Fellow of the Royal Society. Awards will be presented on Saturday 12th May 2012 at the 3rd International Symposium on Poetry and Medicine, to be held at the Wellcome Collection in London.

Stopping smoking - why and how?

2011-12-28T14:31:00.000-08:00

A time of year when resolutions are made and no better time than now for smokers to stop.

Why bother?
Apart from the obvious: cost, smell on clothes and breathe, and taste impairment and eventual loss of taste? Smoking is the single most preventable cause of disease and death.
For primary prevention, smokers and their advisers need to be well informed of the personally relevant risks of smoking and benefits of stopping. For younger smokers, risks include premature ageing of the skin, increased risk of impotence, risk to the developing baby in the womb, and increased risk in offspring of serious chest disorders. For older smokers, the more pressing risks are increased risk of cancer of the lung, mouth, throat, bladder and many other types of cancer; premature ageing of arteries, leading to heart attacks, strokes and other serious disorders of the heart, brain and circulation; and serious lung disorders including chronic obstructive lung disease and emphysema. And in the long-term, it is estimated that around half the smokers who do not give up smoking will die from one or more of these and other smoking-related diseases.
For non-smokers and confirmed ex-smokers the question has to be - why bother? Give up now to improve your medical and financial health.
For current smokers, the challenges are to beat the psychological, physical (nicotine), and social addiction, including resisting peer pressure. Useful ammunition to help smokers to stop smoking includes being aware that giving up tobacco can help you live longer, and that the risk of getting cancer is less with each year you stay smoke-free.

Help from friends and family
Now is a good time for smokers to be ready to think about stopping, to think about stopping and to prepare to stop. That might mean telling friends and family you are serious about stopping, and to seek whatever help may work - e.g. from pharmacist, family doctor or nurse, or other health professional, and smoking cessation support groups. The US National Institutes of Health recommend:
- 'Try not to view past attempts to quit as failures. See them as learning experiences'.
- 'Make a plan about what you will do instead of smoking at those times when you are most likely to smoke'.
- 'Satisfy your oral habits in other ways'.
Their website provides excellent advice on other ways to help to smoking including how to plan stopping, setting a stop date, and having alternative strategies for times you associate with smoking.

Stop smoking apps
There are now several free or low cost 'apps' which may be helpful. For example, the UK NHS mobile 'Quit smoking' app provides links for UK smokers to the NHS Stop Smoking helpline and other UK NHS Stop Smkoing Servces. 'My Last Cigarette' - MLC provides a dashboard with daily changing reminders of dangers of smoking, and updating estimates of effects of stopping smoking on risk of heart disease, lung disease and other serious medical problems, money saved since stopping, life expectancy gained, and number of smoking-related deaths since the time a smoker has stopped.

Benefits of training health professionals and funding nicotine replacement treament
A controlled study in Germany reported benefits from extra training for family doctors, and further benefit when costs of anti-smoking treatment are subsidized. However, for these over 10/day cigarette smokers, although very helpful for those who succeed in stopping, outcomes were very modest: by
12 months after intervention, 1 in 30 had stopped with usual support, 1 in 10 when their family doctor had received training and been paid a €130 incentive for each patient who stopped, and 1 in 7 where patients also had costs of treatments subsidized.

Unexpectedly rapid benefits from banning smoking in public placesMore recent encouragement for anti-smoking campaigns has come from evidence of the rapid time to benefit from stopping: around 1 in 5 fewer heart attacks within 1 year of stopping in countries which have moved to ban smoking in public places. That provides clear evidence to smokers that their cardiovascular risk reduces very rapidly after stopping smoking.

Avoiding temptation to smoke
A recent review of a large number of trials of ways to help people to stop smoking concluded that the evidence for success was 'strongest for interventions focusing on identifying and resolving tempting situations'.

I should be interested to know what you have found to work for you, or not to work in helping you to stop smoking.

©DRJ Singer

Notes on Leonardo da Vinci at the National Gallery, London

2011-12-19T17:25:00.000-08:00

Despite reports of a sell-out, good news for the visitor to London that morning queuing (and not too early) has at least up to mid-December been rewarded by entry to the Leonardo da Vinci: Painter at the Court of Milan exhibition' at the National Gallery in London, described by the organizers as ''the most complete display of Leonardo's rare surviving paintings ever held.'
What’s to see? Sketches in red crayon, chalk and ink, work by his pupils, paintings in evolution and finished, and a tantalising copy of La Cenacolo [‘The Last Supper’], supported by preparatory drawings of key figures at the supper. During my visit, the paintings were the main attraction, not many visitors showing interest in the sketches. Therefore although the rooms seemed very busy, by avoiding the crowds close to the walls, it was easy to have unhurried close views of all exhibits.

The drawings
There was a surprising contrast between drawings detailing accurate anatomy of human bone and muscle vs. cross-sections of human skull and brain, which, apart from the frontal sinus, are imagined from perceived wisdom of the time. Most striking were ventricles as a mid-line set of 3 chambers, reported in the gallery notes as attributed by Leonardo to locations for imagination, intellect, memory and the seat of the soul.
Close inspection of the sketches revealed how hatching brings out soft contours and boundaries, part of Leonardo’s sfumato style;- the hatching upper left to lower right, typical of the work of a left-handed artist. And little waste, several sheet showing not only many different figures or views from multiple angles but unrelated engineering drawings.
Thanks to colleague DS for alerting me to the 1977 exhibition at the Royal Academy of Arts of Leonardo's Drawing from the Royal Collection. Copies of the exhibition catalogue are still available with some detective work.

The paintings?
- their excellence even more evident by pairings with works by members of his workshop;
- the ‘Musician’ illustrating Leonardo’s interest in physiology, with eyes painted at different times reflected in asymmetric pupil size - the nearer right eye much larger, indicating that light was much lower than when the left eye was painted; and not explained by contrasts in room lighting – the darker background for the left side of the face would have caused left pupil enlargement;
- examples of later owners aiming to improve or sanctify Leonardo’s originals – for example, in the later National Gallery version of Virgin on the Rocks, addition of halos and a crucifix.
- numerous symbols explained, from the ermine for purity, to violets for humility, and the red-faced goldcrest, clutched by a breast-feeding Christ child, for torture, in ‘The Madonna Litta’.
- mood – wonderful examples of melancholy, adoration, serenity; and the sullen, in Beatrice d’Este, wife of the Duke of Milan, Ludovico Sforza.
And within the exhibition there is a mystery. Beatrice is described as ‘La Belle Feronnière’. However ‘The ‘Lady with an Ermine’, Cecilia Galerani, the ~16 year old mistress of the Duke of Milan has the phrase ‘La Bele Feroniere' in golden capitals at the top of the dark background. The curators leave this for observant visitors to decode: obvious explanations – a misattribution, or a view that the sitter was in common for both portraits. Upstairs part of the exhibition provides engaging insight into the Last Supper, all the better for passing a series of Titian portraits – including a 'Young man with quilted jacket', a more self-confident subject, painted around 20 years later than (c. 1510) and perhaps in homage to the more tense features of the sitter for Leonardo's ‘Portrait of a Musician’ (from c. 1490).
Access to the heavily restored ‘original’ Last Supper in Milan is now very restricted. Identified hazards include further pollution from the Milan air, volatile lipids from the skin of visitors and acid damage from carbonic acid generated by exhaled carbon dioxide. In the 1970s, when I first saw the fresco in the Refectory of Santa Maria della Grazie in Milan, with a pre-med student friend, other than by ticket, viewing was unrestricted. My recollections are of a large faded painting in poor state of preservation – and photographs from the Second World War recording the remarkable survival of a sandbag-protected Cenacolo, the other walls severely damaged by wartime bombing.

What next? The Prado has announced discovery after restoration a painting contemporary to the Mona Lisa, considered to be from his studio - either a copy or a simultaneous portrait of the same sitter, a similar Tuscan landscape revealed by removal of later black background. This to be displayed soon alongside the Mona Lisa at the Louvre, to be seen toogether for the first time in over 500 years.

Further sources:
Leonardo exhibition catalogue
The Louvre: all the paintings
Leonardo's Notebooks

Paper engineered Leonardo inventions

© DRJ Singer

US - European perspectives on potential impact of promoting cycling

2011-12-18T04:33:00.001-08:00

As a response to my summer notes on 'city cycling', I was sent a link by @jenicarhee to a graphic (see below) on potential impact of regional schemes to promote cycling. Projected advantages include for health, environment and financial benefit. This approach lends itself to regular update on actual outcomes and imaginative ways to assess impact. See for yourself via: 'How bikes can save us [infographic]'.

Hippocrates initiative wins national award for Excellence and Innovation in the Arts

2011-11-24T18:20:00.000-08:00

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

The awards will be announced on 12th May 2012 at a symposium in London at the Wellcome Collection rooms on the Euston Road.

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.

In its first 3 years, the Hippocrates Awards have attracted over 4000 entries from 44 countries, from the Americas to Fiji and Finland to Australasia.

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

Drugs don't work if patients don't take them

2011-11-19T06:44:00.001-08:00

A surprisingly common problem: WHO estimates published in 2003 and more recent studies suggest that in the developed world around 50% of patients with chronic medical disorders such as diabetes and asthma do not take their medicines regularly. Indeed, for example, for high blood pressure, around half the patients on drug treatment have stopped taking their tablets within the first year of starting treatment. Despite this evidence that many patients are not benefiting from prescribed medicines, these data may even be underestimates of prevalence of low adherence to medicines, as clinical studies are typically conducted in patients willing to participate, who have less co-morbidity and have fewer prescription medicines than is usual in the general population of patients.
There are multiple potential contributory factors, including costs of paying for medicines, lack of insight into medical conditions or awareness of ways in which medicines may help, perceptions that medicines are not working, and concerns about potential or actual adverse effects of medicines.
Personalising medicines using genetic and other companion diagnostics may help to improve adherence by avoiding drugs more likely to cause adverse effects.
Identifying and improving poor adherence is important to maximise disease control, improve quality of life, and to avoid unnecessary investigation, avoidable treatment escalation and avoidable adverse effects if treatments not normally taken are taken variably by a patient or are dispensed e.g. during acute medical admission.
Poor adherence can be recognized in a number of ways, including direct discussion with the patient, tablet counts, checking timeliness of prescription renewal, and both clinical and laboratory clues from expected biological effects of the medicines.
More studies are needed to identify ways to be more effective in helping patients to be more adherent to their medicines. Meantime the UK'S NICE recommends regular informed discussion with patients to improve adherence to their medicines.

©DRJ Singer

Broadcaster Martha Kearney joins judges for 2012 Hippocrates Awards for Poetry and Medicine

2011-11-12T03:22:00.000-08:00

In its first 2 years, the Hippocrates Prize attracted over 3000 entries from 32 countries, from the Americas to Fiji and Finland to Australasia.

The Hippocrates poetry and medicine initiative was co-founded by a team from the University of Warwick, supported by several external organizations interested in medicine and the arts.

The Hippocrates initiative was named winner of the Award for Excellence and Innovation in the Arts in the 2011 Times Higher Education awards, announced 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 now closed for the 2012 Hippocrates Prize for poetry and medicine, which is for unpublished poems in English.

Medicine may be interpreted in the broadest sense. Themes for prize entries may include the nature of the body and anatomy; the history, evolution, current and future state of medical science; the nature and experience of tests; the experience of doctors, nurses and other staff in hospitals and in the community.

Other topics might include experience of patients, families, friends and carers; experiences of acute and long-term illness, dying, birth, cure and convalescence; the patient journey; the nature and experience of treatment with herbs, chemicals and devices used in medicine.

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.

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.

Marilyn Hacker's book of poetry Presentation Piece (1974) won the National Book Award. In 2009, she won the PEN Award for Poetry in Translation for King of a Hundred Horsemen by Marie Étienne. In 2010, she received the PEN/Voelcker Award for Poetry.

Rod Flower is Professor of Biochemical Pharmacology at the WIlliam Harvey Research Institute^[21] in London. His main scientific research interests concern inflammation and anti-inflammatory drug mechanisms. He was formerly President of the British Pharmacological Society and is a Fellow of the Academy of Medical Sciences.

Martha Kearney is the main presenter for BBC Radio 4’s lunchtime news programme ‘The World at One’. She previously worked for Channel 4, presented the BBC’s Woman’s Hour, Today and PM and was political editor for Newsnight. She has been commended for her national and international reporting, including for work on child poverty. She has been a judge for the Webb Essay Prize and the Guardian First Book Award, and has chaired the judging panel for the Orange Prize for Fiction.

Marilyn Hacker said: ‘The enormous scope and the intense focus provided by this conjunction combine to entice and hold a reader's attention. The poems I read from the 2011 submissions touched basic and utterly complex human issues, with extreme attention and with admirable verbal bravura. I look forward to reading the new ones.’

Rod Flower observed that ‘poetry can reconnect us with ourselves, and with the outside world, in a way that promotes a feeling of well-being and acceptance…and in some mysterious way, poetry enables us to gain traction on the conflicting emotions stirred up by the suffering of disease or the triumph of the cure.’

He added that ‘As a professional pharmacologist with a deep interest in the discovery and use of new medicines to mitigate the ravages of disease, I am delighted to be amongst the panel of judges this year and am eagerly anticipating the challenge of enjoying – and assessing – this year’s entries.’

The 2012 Awards are supported by the Fellowship of Postgraduate Medicine and the Cardiovascular Research Trust.
The Hippocrates initiative for poetry and medicine was co-founded by clinician and medical researcher Professor Donald Singer and poet and translator Michael Hulse. The 2012 awards are co-organized by humanities researcher Sorcha Gunne.

- Register for the 12th May International Symposium on Poetry and Medicine

- Submit a paper for the 12th May International Symposium on Poetry and Medicine
- Nominate your favourite poem with a medical theme
- View and listen to podcasts from 2010 and 2011 Hippocrates Awards and Symposia
- Press and media reports on previous Hippocrates Awards
- Order Anthology for 2010 or 2011 winning entries for the Hippocrates Awards
- Hippocrates poetry and medicine initiative
- International Hippocrates Research Forum for poetry and medicine. This includes poets, academics and health professionals in the UK, Europe and the USA.

- Origins of the Hippocrates poetry and medicine initiative

Notes

Poems entered are to be of no more than 50 lines and submitted online, accompanied by an entry fee (£6 per poem).
Judging of submissions will be anonymised.
The deadline for submissions is 31^st January 2012.
For more details please visit the website www.hippocrates-poetry.org.

The Fellowship of Postgraduate Medicine is a national medical society founded in 1918 and publisher of the Postgraduate Medical Journal and Health Policy and Technology.

The Cardiovascular Research Trust is a charity founded in 1996, which promotes research and education for the prevention and treatment of disorders of the heart and circulation. The charity founded Healthy Heart Awards for schools and colleges.

Kew, angel's trumpet and artemisia - from dream plant and poison to herbal remedy.

2011-10-30T15:57:00.000-07:00

Guides to plants have a large number of entries labelled as 'medicinal use' and 'poison'.

The ancient Greeks recognized this overlap, in using the same word for drug, poison and magic charm: pharmakon. This remains in current use in the word pharmacology - the study of drugs of all types.
The Temperate House at Kew Gardens, the largest surviving Victorian glasshouse in the world, has a tantalising display of medicinal plants, for most the scientific name the only clue to properties. Nearby there are two examples of contrasting properties of plants.

Artemisia [in this case A. austriaca - Austrian wormwood] is there as scrawny, pale green, ground cover. This plant is thought to be named after 4th century BC queen of Persia and botanical expert Artemisia, or after Artemis, sister of Apollo and Greek goddess of the wilderness, the hunt, fertility and both bringer and treater of disease in women. This bitter herb is said to have been used by the ancient Greeks to treat parastic infestation by intestinal worms. A large number of medicinal properties are claimed for wormwood species. Artemisinin, the extract of Chinese Wormwood, is used as an anti-malarial however resistant strains of malaria are now being reported. Recent experimental evidence suggests that artemisinin may have anti-cancer effects through limiting proliferation and cause programmed cell death (apoptosis) in certain sub-types of cancer cell. Other research indicates that artemisinin may induce cancer cell resistance to other types of cancer treatment. Much more work is needed on effectiveness and safety of artemisia extracts in the clinic.

Angel's Trumpet [Brugmansia aurea] in contrast has more sinister properties. This tree, native to sub-tropical South America from Colombia to Ecuador, has delicate, orange, trumpet-shaped, hanging, lemon-scented flowers. All parts of the plant are considered poisonous through antagonism of muscarinic cholinergic receptors and other effects of tropane alkaloids, including the racemic mixture atropine, its laevo-stereoisomer hyoscyamine [M1-antagonist], and scopolamine. Actions include belladonna-like effects, hallucinations, sedation and pupil enlargement, which may be symmetrical or asymmetrical. Local shamans are reported still to use plant extracts to aid their ceremonies through inducing visual hallucinations. Historically it is believed that in the Americas extracts of this plant, combined with alcohol and tobacco, were used to induce sleep in slaves or wives before their immolation after the death of their king.

©DRJ Singer

The Tempest and Prospero's curse - magic, pleurisy, and other thoughts

2011-10-30T12:49:00.000-07:00

In response to Caliban's cursing in 'The Tempest', Prospero rewards him with a threatening prophecy:

'... tonight thou shalt have cramps,

Side-stitches that shall pen thy breath up ...'

This is a plausible symptomatic description of the intermittent, breath-restricting pain caused by pleurisy [earlier known as pleuritis], a suggestion at least as early as 1886. In contrast, as used by Shakespeare, the word pleurisy denoted a plethora, or excess of blood. This use is thought to have arisen from the idea that the word pleurisy was derived from plus pluris.
e.g in Hamlet Act IV, Scene 7:

"For goodness, growing to a plurisy
Dies in his own too much."

Pleurisy, local pain and difficulty in breathing, usually arises from inflammation of the pleura - the membranes that lines the lungs and inner walls of the thoracic cage. These inflammatory processes lead to adhesion of the visceral to the parietal pleura.

Dr Charles Buckmill, writing in 1860, was sceptical of the medical nature of Prospero's curse, seeing it as a blend, half health, half magical in character.

How could Prospero have predicted this would happen to Caliban? Were there poisons at the time [1610-11] that Prospero could have given to Caliban to cause reversible pleurisy? And how did doctors of Shakespeare’s day diagnose pleurisy? The pain of pleurisy is often knife like or cramp-like pain, and worse on inspiration. Pleuritic pain is typically altered by posture, eased in some positions, made worse in others.

These symptoms we now recognize as pleurisy were well-established in Tudor and early Jacobean times; and post-mortem examination was then in European medical centres a route to understanding (or misunderstanding) the nature of disease in retrospect. The Hippocratic writers were already diagnosing pleuritis from a cluster of symptoms: pain in the side, fever, shivering, rapid breathing, difficulty in breathing when lying flat [orthopnoea] and cough productive of pomegranate-peel coloured or blood-stained sputum. From 300BC, discussion moved to the pathology of pleurisy, with a distinction between disease in the lung (e.g. Herophilus: modern pneumonia) and pleuritis as a disease of the membrane that lines the inner part of the ribs [membrana hypezocota] and resulting in increased pain on lying on the unaffected side [because lung movements than are greater at the site of pleural inflammation], or in some greater when lying on the affected part.

Pleurisy results in abnormal lung sounds, which, if loud, would have been audible by a physician placing an ear against the chest [auscultation]. This medical diagnostic method is thought to have been used by Ancient Egyptian physicans. However the key early method of diagnosing pleurisy was ‘hardening of the pulse’.

On listening with a stethoscope, a pleural friction rub is heard. Laennec, the inventor in 1816 of the stethoscope, called this friction sound ‘frottement ascendant et descendant’ and ascribed it to emphysematous change in the lungs. Descriptions of the rub include - a scratchy sound similar to that of a door opening on a rusty hinge; or similar to the sound or two pieces of sandpaper rubbed together. Laennec also used described ‘aegophony’ in pleurisy - a sound like the bleating cry of a goat. Laennec considered that pleurisy was typically associated with modest accumulation of fluid in the pleural cavity (pleural effusion). However with too much pleural fluid, lung sounds disappear, including pleural rubs.

Recognition of pleural effusion goes back to early Babylonian medicine. Small lead tubes discovered in ancient Babylonian sites are considered to have been trochars – implements inserted through the chest wall to drain pleural fluid. With the benefit of modern imaging, it is now easy to be clear in life that both ‘wet’ and ‘dry’ forms of pleurisy may develop.

Contributors to the germ theory of disease range from Varro in 36BC, to microscope inventor Van Leeuwenhoek’s reports in the 17^th Century, and Semmelweiss and Pasteur in the 19^th Century. Modern medicine recognizes pleurisy, pleuritic pain and its other symptoms as part of a syndrome. Investigations aim to identify the cause of the pleurisy, which might include viral or bacterial infection, pulmonary embolism, immune-mediated disease, kidney failure and tumours. In addition pneumothorax may present wth pleuritic pain. Of note as early as the early 17^th Century, the Paduan Vincent Baronius recognized that patients with pneumonia can also develop pleurisy [pleuripneumony], a concept more widely disseminated by Morgagni a century later.

Back to Prospero’s curse. If not just author’s invention, here are some possible recurrent disorders symptoms of which Prospero could be predicting.

- Pleurisy is typical worse at night, when during attempts at sleep the sufferer may turn to adopt a posture likely to make pleurisy worse and thus awake in pain and breathless.

- Tuberculosis may not be fatal but may leave a patient with pleurisy.

- Malaria was endemic in Shakespeare’s day, including in Mediterranean islands such as Sicily. Attacks of malaria are known sometimes to present with cramping chest pains – and the anaemia of malaria could have made Caliban breathless, especially if were already anaemic. For example his inherited deformed appearance could have had a physical rather than imaginary basis. Thalassaemia – common in the Eastern Mediterranean setting of ‘The Tempest’ - may cause of chronic severe anaemia and is associated with facial deformity.

- And familial Mediterranean fever (FMF), a genetic disorder common in the Mediterranean, is a recurrent painful disorder of membranes, including the pleura. And FMF induced joint disease could contribute to a deformed appearance.

Prospero may thus simply have been reminding Caliban of previous or likely medical afflictions. Clearly the scientific details are modern, however these conditions were endemic at the time and present in the right geographical setting for the play.

More on history of pleurisy, stethoscopes and older treatments:

1. Hippocrates. Index of symptoms and diseases. vi. 33. Loeb edition. Translated by P. Potter. London, 1988.

2. Shakespeare's doctor son-in-law John Hall describes use of scabious as a herbal remedy for ‘pains and stitches in the side’.

3. Laennec, R. T. H. (1819) De l’Auscultation Médiate ou Traité du Diagnostic des Maladies des Poumons et du Coeur. Paris: Brosson & Chaudé.

4. The cyclopaedia of practical medicine: comprising treatises on the nature and treatment of diseases ... Volume 1 Edited by Sir John Forbes, Alexander Tweedie, John Conolly. Publishers Whitaker et al, Paternoster Row, London 1833.

5. The medical knowledge of Shakespeare by Sir John Charles Buckmill MD, Longman, 1860.

6. TCM. Notes from a physician's notebook. The Cincinnati Lancet. p75, January 16th, 1886.

7. Wilson, A. (2000) On the history of disease concepts: the case of pleurisy, History of Science, Volume 38 (3), 271 – 319.

Companion diagnostics - a new concept for safer medicines?

2011-10-15T08:28:00.000-07:00

Diagnostics can be used in several ways: to establish the nature, subtype and severity of disease; to monitor wanted response to treatment with lifestyle, drugs and/or devices; to monitor for disease progression and for adverse effects of treatment. The term 'companion diagnostics' describes coupling diagnostic imaging or laboratory investigations with selection and monitoring of treatment. Although a logical idea, its use in the medical setting appears surprisingly recent.

In the late and 1980s and 1990s, reports of the use of combination diagnostics appear largely applying to veterinary and dental practice.

The partner term 'companion therapeutics' was used in a 2003 commentary on the FDA "Draft Guidance for Industry: Pharmacogenomic Data Submission" issued on November 3, 2003, which noted that the [pharmaceutical and biotech] 'industry is now expected to accelerate its development of diagnostics and companion therapeutics towards the goal of personalized medicine'. Implicit in this evolution of a personalised approached to medicines is the recognition that diagnostics will not necessarily identify that a given patient may have a safe or effective treatment flagged as the result of testing.

An early example of a pharmacogenetic companion diagnostic is the UGT1A1 molecular assay for in vitro diagnostic use. This pharmacogenetic test was approved in 2005 by the FDA for use as a companion diagnostic to a specific drug therapy. The test was to be used to identify mutations in this gene in patients who may as a result be at increased risk of adverse reaction to the anti-cancer drug irinotecan.

2006 and 2007 discussion of companion diagnostics pointed both to more efficient patient selection for clinical trials and a more profitable approach for drug developers.

Current descriptions use narrower definitions of companion diagnostics as referring to tests to 'identify and detect genetic, protein, or gene expression markers to predict whether a drug works or causes adverse effect in patients'. However there is a long history of coupling tests with treatment choice and refinement, in every therapeutic area from cardiovascular disorders such as hypertension and raised cholesterol, to anaemia and treatment of lung, gastro-intestinal, renal and neurological disease.

To date there are only 75 publications in the PubMed research database with companion diagnostics as a key term, with a typical recent example from August 2011 in Nature Reviews on Clinical Oncology by La Thangue and Kerr applied to cancer chemotherapy: Predictive biomarkers: a paradigm shift towards personalized cancer medicine.

©DRJ Singer

Ahead of their time

2011-10-03T00:09:00.000-07:00

An example from this weekend's episode of the series 'Downton Abbey' of the challenges of historical accuracy in broadcast media. Set during the Great War, a keen enlister is turned down on medical grounds because of a heart murmur citing 'mitral valve prolapse' as the reason. This condition is often benign however was not recognised until the 1960s. The condition was first reported by John Barlow and colleagues in the American Heart Journal in Feb 1966 (Barlow's syndrome). The phrase 'mitral valve prolapse' was first used by Michael Criley and colleagues later that year in the July issue of the British Heart Journal.

Toll-like receptor on brain glial cells - a new target to reduce acute toxic effects of alcohol?

2011-09-29T18:34:00.000-07:00

Researchers in Adelaide, Australia led by Mark Hutchinson have attracted international media interest with headlines heralding a new treatment to protect from hazards of alcohol. How close is the research to human treatment? And is there a risk this could be a drug of abuse for people over-indulging in alcohol and hoping to avoid harmful effects? My discussion below complements two radio interviews, one with a Californian station, the other with BBC Radio Ulster. To listen to the interviews, use the podcast links at the foot of this blog.

This was an experimental study looking in mice at ways to prevent some of the harmful effects of a single large dose of alcohol. The authors were following up previous research suggesting a link between alcohol and the immune system. The Toll-like Receptor 4 is a member of a family of inflammation-inducing receptors, first described in the fruit fly. TLR-4 is present on immune defence white blood cells in the circulation. TLR-4 is also present on glial cells in the brain. Glial cells make up around 90% of cells in the brain and have an important defence role against brain infection.

The scientists used two approaches to find out whether TLR-4 is involved in unwanted effects of a large single intake of alcohol: animals with genetic absence of TLR-4 and its pro-inflammatory signalling pathway partner MyD88; and the drug (+)-naloxone. This is the mirror-image version of the (-)-naloxone in clinical use to treat an overdose of an opiate such as diamorphine (heroin) or morphine. (+)-naloxone blocks TLR-4 without blocking the enkephalin receptor through which opiates act.

Hutchinson and colleagues studied two adverse effects of alcohol overdose: sedation and unsteadiness. Their model of sedation was the time taken to regain normal posture (loss of righting reflex). Their model of unsteadiness was the mouse equivalent of keeping balance on a rolling log.

What did they find? The drug (+)-naloxone halved the duration of sedation after acute alcohol and shortened the recovery time for loss of balance. These effects could have been due to 'off-target' effects of the naloxone, however findings were similar in animals genetically deficient in TLR-4 and MyD88 - reduction in severity and duration of sedation and unsteadiness. The authors also showed that alcohol switched on inflammatory protein production by cells from the hippocampal part of the brain; and they ruled out differences in alcohol metabolism between models.

What do these results mean for people?

Firstly, they are important in raising the question whether genetic variation in activity of TLR-4 inflammatory pathways plays a role in explaining major differences in tolerance of alcohol.

These results provide an interesting complementary mechanism for protective effects of naloxone on alcohol-toxicity to those reported by Badawy and Evans 30 years ago using different experimental methods.

Secondly, these findings suggest that targeting TLR-4 in the brain may be a new way to reverse some of the serious adverse effects of major alcohol overdose in patients attending emergency departments.

What about (+)-naloxone as the drug to use? Studies would be needed to confirm that TLR-4 is also important in alcohol-mediated toxicity in humans, and if so to understand more about the wider range of adverse effects of alcohol which may be prevented or reduced.

What about cautions?

- This is experimental research which would need to be repeated in human subjects with TLR-4 blocking strategies which pose minimal toxic risk.

- Naloxone has to be given by injection - it is not sufficiently absorbed by mouth to be clinically active.

- Use (+)-naloxone is no exception to the rule that all drugs can have harmful effects. There is concern that risks of harmful effects from (+)- naloxone mean that is unlikely to be safe to use in general alcohol users.

- (+)-naloxone may block some of the wanted mood-altering effects of more moderate alcohol intake. For example, it is known to affect other brain pathways e.g. blocking stimulant effects of cocaine and amphetamines. This may well lead to loss with this drug of the wanted effects of alcohol.

- The published study showed reduction in severity and duration of alcohol's effects not their prevention: if confirmed in people, general hazards of alcohol, for example when driving, would remain.

- (+)- naloxone is unlikely to prevent the 'hangover' from alcohol, which is recognized to be due to many factors, including dehydration (alcohol is a diuretic), low blood sugar, and other chemicals (congeners) present in alcoholic drinks and contributing to colour and taste.

The most interesting aspects of this study are that:

- if confirmed in further research in humans, assessment of TLR-4 variability may be developed as a test for susceptibility to alcohol;

- safe, effective TLR-4 inhibitors for use in humans could be a treatment for some of the physical effects of a severe overdose of alcohol in people presenting to hospital.

See the article

Podcasts of radio interviews with Professor Donald Singer about research on alcohol, the immune system and new potential treatment:

Interview with Jon Bristow on San Francisco KGO Radio 12.17 PDT 29th Sep, 2011.

Interview with Seamus McKee on BBC Radio Ulster 16.15 GMT 28th Sep 2011.

San Francisco KGO Radio
BBC Radio Ulster

Companion diagnostics to personalise medicine

2011-09-25T17:45:00.000-07:00

What common link is there between confusion, dementia, dyspepsia, heart failure, hypertension, liver failure and stroke (apart of course from excess alcohol in some)? They are all syndromes - clusters of symptoms and physical signs with many possible causes, risk factors and co-morbidities.
Earlier approaches to treating these health-related conditions were largely based on trial on error until the most effective treatment(s) were identified. While pragmatic, in many that may lead to a delay in achieving effective disease control, while exposing some patients to unnecessary risk of adverse drug reactions.
The relatively new term 'companion diagnostics' describes the concept that coupling careful selection of biomarkers of disease and risk factor phenotype, of therapeutic response and early warning of risk of adverse reactions, will provide a more rapid route to safe and effective drug selection and monitoring.
Major current challenges include the relative immaturity of research evidence on cost and clinical effectiveness of combining companion diagnostics with specific therapeutic strategies. A major potential driver to improve systematic assessment of companion diagnostics will come from the extension of the activities of NICE (the UK's National Institute for Health and Clinical Excellence) from pharmaceutical and other treatments into assessment of diagnostic technologies (Diagnostics Assessment Programme), including companion diagnostics. This will be complemented by the role of NICE in commissioning new research where significant gaps are identified.
A further important challenge is the fragmentation of diagnostic services within clinical health services. There are practical reasons for having multiple local diagnostic capacity for serious acute illnesses for which very rapid access to sophisticated diagnostics is potentially life-saving or critical to minimise preventable complications, from early selection of effective treatment. Where there is the luxury of more than a few hours delay without significant risk to the patient, e.g. while using 'holding' empirical treatment, there needs to be more research on relative effectiveness of local compared with remote lab diagnostic strategies. There are also practical issues to be resolved among biotechnology companion diagnostic developers where joint licensing agreements are needed when multiple diagnostics are indicated from different source providers. And standardisation of testing is needed across national health service and private laboratories to ensure that results of these new diagnostic tests are validated.
And of course when there is a single test, implementation is more straightforward. However where multiple tests are needed within a companion diagnostics portfolio, there will need to be a regular programme of induction and refresher education for prescribers on how best to use and interpret results of this new testing strategy. This will be particularly important for interpreting the currently less familiar genotype based tests.

Ritalin and delayed puberty? More questions than answers.

2011-09-19T15:53:00.000-07:00

In the US medical journal Proceedings of the National Academy of Sciences by Mattison and colleagues reported September 19th 2011 that the ADHD treatment methylphenidate delays puberty in male non-human primates.

This experimental study suggests that continued use of methylphenidate hydrochloride (Ritalin) in young animals is associated with a delay in the pace of normal puberty, based on hormonal measurements and rate of testicular growth. Should this be a cause for concern for the use of this drug in humans? The eventual changes expected during puberty still occurred and the authors themselves note that ‘the effects were transient and no permanent deficits were found', including normal testicular size at the end of the study. They note the need for further studies in humans.

There are several important criticisms of this study. A major weakness in experimental design is the absence of a further treatment group given a chemically different behaviour altering treatment. This would have given insight into whether or not the changes observed are simply due to a change in behaviour pattern, as suggested by the observation that effects are transient, rather than to a harmful chemical effect of the treatment.

This possible effect of behaviour change alone was reported in the same journal [PNAS] the previous week [12th September, 2011] in a study by Gettler and colleagues noting that testosterone levels decrease in men who take part in child care. The authors also provide no information on important potential consequences of their findings. For example, it would have been important to know whether or not there was any impact on intellectual or psychological development or on fertility.

©DRJ Singer

Information on health and disease from the patient's perspective

2011-09-18T11:47:00.000-07:00

Where can patients and their family, friends and carers go for advice from the patient's perspective about health-related conditions? And how can health professionals gain insight into patients' perspectives on their health or illnesses. Individual disease-focused charities and patient associations are ever better at providing patient friendly advice.
A further excellent web resource is Health Talk Online, with over 60 serious and common diseases represented, based on the experience of over 2000 patients. Conditions and issues covered range from heart risk and disease to cancer and women's health. This resource was established by the Charity DIPEx, in collaboration with health scientists from the University of Oxford (the Health Experiences Research Group), and is coupled to the website Youth Health Talk, which is about 'young people's real life experiences of health and lifestyle'. Health Talk Online aims to use the real life experience of people to discuss health, health-related conditions and illnesses, including insight into tests and therapies (and their possible adverse effects), what outcomes to expect from treatment with drugs and/or devices, news, and updates on progress in medical research, patients' viewpoints about the impact on their life of the health conditions of interest, and discussion forums.
It is vital that information sources such as this are reliable. With that in mind it is noteworthy that the charity DIPEx has been selected by the UK's Department of Health to help to pilot an accreditation scheme using 'kite marking' to indicate reliability of organisations that provide information about health and social care.

Assessing prescribing skills

2011-09-15T15:32:00.000-07:00

Doctors and other prescribers internationally find prescribing challenging. To get this right at times of high pressure, including in the emergency medicine setting, it is vital that basic skills are as well developed as possible. Add to that the need for care in calculation, avoiding the distracting effects of multi-tasking, challenges in medicines reconciliation, and risks inherent in shift-working and other complex work patterns. And electronic prescribing systems alone are not a sufficient safeguard. For example, reporting from the USA indicates that error rates may increase following the move from paper to electronic prescribing. The complex range of skills needed for safe and effective prescribing includes sound core knowledge of basic mechanisms of drug action, drug use in the clinical setting, and the impact of patient genetics, age, gender, lifestyle, the disease to be treated as well as co-existing medical conditions and the impact of other drugs and remedies. Many of these principles are easier to put into practice by adopting a personalized approach to therapeutics, with the aim of prescribing the right drug or drugs at the right dose to the right patient for the right disease and at the right time.

To help to increase focus on early training in essential prescribing principles and practice, in the United Kingdom the British Pharmacological Society and the Medical Schools Council supported by a national team of experts, to develop a Prescribing Skills Assessment that will eventually allow all students to rehearse and demonstrate competencies relevant to safe and effective initiation, monitoring, review and, when needed change in route, dose, duration or type of medicines alone and in combination in clinical practice, along with skills in communicating key points about medicines to patients, their carers and to relevant health professional colleagues.

See related blogs on
- Improving prevention of serious adverse drug reactions
- Personalized medicine for better drug discovery

Advances in treating acute lung syndromes

2011-09-14T14:14:00.000-07:00

Although only described as recently as 1967, a range of important contributory factors have been defined for acute respiratory distress syndrome (ARDS), which is now recognized to be at the severe end of a spectrum of acute lung injury, which imposes high risk for patients and which confers a major burden on health services. Outcome of treating the syndrome has been much improved by developments in devices to treat lung and other organ failure, supported by advances in expertise in intensive care. However, other than treatments for underlying causes, there is still important unmet need with regard to effective specific pharmacological treatments.

A timely review of ARDS by Dushianthan and colleagues is the Editor’s choice article in the September issue of the Postgraduate Medical Journal. These experts from Southampton provide an update on knowledge of risk factors, including genetic biomarkers, for development of ARDS and other acute lung injury variants, and an up-to-date commentary on general and specific treatment options.

The authors note that ‘sepsis, pneumonia, and trauma with multiple transfusions’ account for most episodes. They highlight the importance for recovery of ‘general supportive measures such as appropriate antimicrobial therapy, early enteral nutrition, prophylaxis against venous thrombo-embolism and gastrointestinal ulceration’.

They discuss encouraging experimental evidence from trials of corticosteroids, nitric oxide, prostacyclins, exogenous surfactants, ketoconazole and antioxidants, however note that these findings have not as yet being translated into benefits for patients. They note as further treatment targets of interest, new approaches to modulating inflammation, and use of mesenchymal stem cells.

See the free full article for further details.

Stress and recovery in junior doctors

2011-09-13T15:29:00.000-07:00

This blog is the start of a series of occasional notes highlighting articles of note published in the Postgraduate Medical Journal, the Fellowship of Postgraduate Medicine's first journal, launched in 1925, with the continued aim of educating doctors and other health professionals.
In the September 2011 issue, Dr Elke Ochsmann and colleagues from Aachen in north-west Germany report on a study of almost 1500 junior doctors. The authors report that 'Overtime work seems to be the important work related factor concerning junior doctors' level of strain'.
They add that for recovery from work-related stress 'performance feedback from colleagues seems to be a major resource'.
The conclude that the 'findings have implications regarding work time regulations and the necessity of leadership skill development training' in developing a better support system for junior doctors.

See the article for further information.

Why have a National Blood Pressure Week?

2011-09-09T14:38:00.000-07:00

In the UK, over 1,500 venues are offering free blood pressure checks during National Blood Pressure Week (12-18 September 2011). Why all that effort? High blood pressure is a major preventable and treatable risk factor for serious heart diseases and stroke syndromes throughout the world. And even at the age of 20 around one in 20 people may already have high blood pressure, increasing to around 1 in 2 people by the age of 70.

An annual blood pressure week provides an important focus to remind the public and health professionals about risks of high blood pressure, how to prevent it, measure it accurately and use lifestyle and drugs in people in whom blood pressure is too high.

Blood pressure should be as low as possible, with, for adults, the upper level, when the heart has contracted, below 140mmHg and the lower level below 90mmHg, when the heart is relaxed between heartbeats. These thresholds should be much lower in people at increased risk of blood pressure complications, such as diabetics and people with kidney disease.

Provided people are otherwise healthy, the ideal blood pressure is now considered by international experts for the upper value to below 120, the lower below 80, recorded as ‘below 120/80mmHg’.

It is very important that patients help by following a healthy lifestyle. This is both helpful to prevent high blood pressure, and for patients with hypertension, to reduce its severity. People should aim for a healthy weight, using fresh foods as far as possible, keep salt intake low, and alcohol intake within healthy limits, be active and have regular good sleep.

This year it is timely the UK’s National Blood Pressure Week comes just after the launch of important new blood pressure guidelines prepared by the National Institute for Health and Clinical Excellence (NICE) advised by experts from the British Hypertension Society (BHS).

The NICE guidelines contain new advice on blood pressure measurement, including involvement of patients in their own management, supported by home blood pressure readings.

It is of course very important that any blood pressure monitor, whether for clinical or home use, should be accurate. A helpful list of accurate devices is on the British Hypertension Society's website.’

If you have high blood pressure, you should make sure that your doctor knows about any over the counter tablets or herbal remedies you are taking, as these can interfere with the actions of blood pressure tablets.

There are now seven major types of blood pressure treatments. For best blood pressure control, prescribers need to the right drug options for the right kind of patient, taking into account, for example, age, ethnicity and potential risks in pregnancy. If single drugs are not sufficient to control blood pressure, the NICE guidelines provide advice on which drug combinations are best to use.

Useful websites:
British Hypertension Society – includes information on which blood pressure monitors are accurate http://www.bhsoc.org
Blood Pressure Association – includes a list of venues for free blood pressure checks http://www.bpassoc.org.uk/
NICE guidance on hypertension for patients and carers: http://guidance.nice.org.uk/CG127/PublicInfo/pdf/English

Networks and personalized medicine for better drugs?

2011-09-08T15:48:00.000-07:00

For more on this theme see my article in the October 2011 issue of Public Service Review: Science and Technology Review.

For many individual patients treatments may not exist, may not be veryeffective, or may result in unpleasant adverse effects. How can prescribers improve drug selection andreduce the harmful effects of medicines? Are therebetter ways to develop drugs for patients who are difficult to treat? And what can we do to improve pooradherence to medicines? These elements underpin ‘personalized medicine’, incurrent use the concept that by considering differences among patients ingenetics, disease burden and other factors, more effective and safer drugs canbe developed. Personalizing medicine is a path to better disease prevention andcontrol where limited treatment options exist, such as for many cancers,resistant infections and dementia syndromes, and better drug development for newmedical challenges. These concepts have in recent years attracted interest from the Royal Society, the Nuffield Council on Bioethics and cognate international institutions.

It is clear that there needs to be consistent investment and support frompolicy makers and regulators to develop and sustain the academic and industry pharmacologyexpertise and activity needed for the long-term success of a personalizedmedicine strategy, so that we can continue to be able to improve the health ofthe public and individual patients.

NICE is an international leader in developing evidence-based treatment guidelines.Its reports increasingly recognize the need to refine drug choice based on patientcharacteristics. For example, updated national hypertension guidelines released in August 2011 advise drug selection guided by age, gender, ethnicity, andmonitoring, with treatment modified depending on clinical response. NICE alsorecognizes the need for research on ways, tailored to patient preference, to improvelong-term adherence to drug treatment.

Pharmacologists are developing two complementary approaches aimed atachieving “precision medicine” in as many patients as possible: better drugdiscovery combined with high definition biomarkers for drug selection andmonitoring. Network pharmacology brings together sophisticated databases ofgenetic mechanisms for disease, pharmacological pathways, candidate drugs, andpopulation data describing important variants among individuals in drughandling and responsiveness. These methods also allow ways to findpreviously unexpected “off-target” actions of existing or new drugs, which mayaccelerate discovery of new treatments for serious diseases.

Diagnostic methods are increasingly being used to improve drug selectionfor individual patients. For example growth tyrosine kinase receptors can beblocked using the biological agent imatinib to treat particular patterns of Philadelphia chromosome-positive chronic myeloid leukaemia,and rare gastro-intestinal tumours. Understanding genes and drugs thatinfluence enzymes that modify drugs in the body, improves accuracy in definingpatients who will not respond to a given medicine, or may develop adverseeffects. For example, to minimize risk of serious harm, pharmacogenetic testing isrecommended for variability in a specific liver enzyme before deciding whether or not toprescribe the anti-HIV drug abacavir. This knowledge also allows better predictionof a patient’s risk of harm from interactions between treatments, based onrecognition of medicines and other remedies that interfere with how drugs arecleared by the body.

See my previous blogs on
- preventing adverse drug reactions
- new UK guidelines on managing high blood pressure

City cycling: beyond the obvious benefits

2011-08-31T17:15:00.000-07:00

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

New UK guidelines on managing high blood pressure

2011-08-24T13:18:00.000-07:00

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.

Improving prevention of serious adverse drug reactions

2011-08-20T15:31:00.000-07:00

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.

Taboo tablets - beta-blockers and professional string players

2011-08-15T15:07:00.000-07:00

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 provides me with two perspectives explaining that feeling nervous about performing triggers 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. 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 also 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 disturbances, weight gain and GI upset. 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. 
See The Strad for the full article.

NICE guidance and treatment of Alzheimer's Disease

2011-08-15T14:37:00.000-07:00

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.

Ideas for maintaining variety in providing for multiple special diets

2011-08-14T16:00:00.000-07:00

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.

Provence, the Rhone estuary and the 'French paradox'

2011-08-11T15:05:00.000-07:00

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?'

2012 Hippocrates Prize for Poetry and Medicine

2011-08-08T03:38:00.000-07:00

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.

See also
- Enter online for the 2012 Hippocrates awards for poetry and medicine
- International Hippocrates Research Forum for poetry and medicine. This includes poets, academics and health professionals in the UK, Europe and the USA.

- Origins of the Hippocrates poetry and medicine initiative

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

2011-08-06T10:49:00.000-07:00

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.

New ideas on diet and cardiovascular health?

2011-08-02T00:58:00.000-07:00

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.

This Symposium followed the July 2011 event on Exercise and Cardiovascular Health, also organized by the Cardiovascular Research Trust.

Further Symposia planned by the Cardiovascular Research Trust:
- 2nd Symposia on Cardiovascular Health, Diet and Exercise: Thursday 6th December 2012

- 3rd Symposia on Cardiovascular Health, Diet and Exercise: Thursday 5th December 2013

See blog on the French healthy heart 'paradox' 20 years on.

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

©DRJ Singer

Origins of the Hippocrates Prize for Poetry and Medicine

2011-07-23T14:52:00.000-07:00

Entries for the 2012 Hippocrates Prize are now closed.

Co-organized with poet and translator Michael Hulse and new member of the team post-doctoral humanities researcher Sorcha Gunne, the 2012 Hippocrates Prize for poetry and medicine has been launched and plans are underway for the associated 3rd International Symposium on Poetry and Medicine, to be held at the Wellcome Collection rooms in London on Saturday May 12th 2012, when the 2012 awards will be presented. There is already strong international interest from potential contributors to the Symposium programme.

See the 2010 blog to find out more about the origins of this major prize, one of the best funded anywhere in the world for a single original poem, the first awards symposium in 2010, and comments from the first NHS and international winners, and from the inaugural judges, broadcaster and writer James Naughtie, doctor and poet Dannie Abse, and Medical Director of the NHS Sir Bruce Keogh.

Favourite poems on a medical theme

2011-07-22T16:27:00.000-07:00

The 2012 Hippocrates Awards are being judged by broadcaster Martha Kearney, US poet and critic Marilyn Hacker and medical researcher Professor Rod Flower, FRS.

2012 Awards will be presented by the judges at the close of our 3rd International Symposium on Poetry and Medicine on Saturday 12th May at the Wellcome Collection Rooms.

To mark the launch of the 2012 International Hippocrates Prize for Poetry and Medicine, the organisers are inviting nominations of favourite poems with a medical theme.

'Medical' can be interpreted in the broadest sense. Anyone in the world may nominate a poem. Only one nomination may be made by any one person. Nominations should be for poems written by a poet from anywhere in the world and in any language. The poem may be contemporary or from any historical period.

When you nominate a favourite poem on a medical theme, you can add a comment about why you like the poem and the poet.

Here are some examples of comments received:

On 'Patience Strong' by UA Fanthorpe: 'Here writes a poet about a poet, and about a lesson learnt from a gentleman living with epilepsy. Ursula Fanthorpe was a champion of the underdog, this poem is an epitome of both insight and humility and offers lessons to us all'.

On 'Hospital Waiting Room' by WH Davies: 'I love this poem. It was written in the early days of the NHS and is a fascinating look at class in British society from someone who put himself outside of it.'

On "The Pathology of Colours' by Dannie Abse: 'Abse is a master at combining the every day earthy detail with the mystical. He brings the world of medicine into the world of poetry in a way that speaks to all of us'.

On 'Seven Ages of Man' by William Shakespeare: 'A cameo of the whole of life from birth to frail, unknowing 'second childishness'.'

The online site for nominations of a favourite poem is now open.

The top 10 entries will be included in an international Anthology on Poetry and Medicine to be published in 2012 by the Hippocrates Press.

Submissions Dannie Abse - Song for Pythagoras and ThePathology of Colours

JoëBousquet - La pupille (… the half-opening of the swallow’s nest …) LaConnaissance du Soir, 1947, Gallimard

Simon Bridges - Tomorrows

Constantine Petrou Cavafy - The death ofthe Emperor Tacitus

Blaise Cendrars - Leventre de ma mère [My mother's womb]

WH Davies - HospitalWaiting Room

John Donne - No man is an island  UAFanthorpe - Patience Strong

Thom Gunn - Intime of plague

Oliver Wendell Holmes - The morning visit 

Jane Hirshfield - What binds us

Ted Hughes - Examinationat the Womb-Door

Victor Hugo - Les feuilles d'Automne - Ce siècle avait deux ans! [Autumn leaves - This century was 2 yearsold]

John Keats - Ode to a nightingale[... where palsy shakes a few, sad, last, gray hairs...]

Philip Larkin - Ambulances

Federico Garcia Lorca - El Lagarto Viejo (The Old Lizard)

Stéphane Mallarmé: Le tombeau de CharlesBaudelaire

Katherine Mansfield - A day in bed

Roger McGough - Wisdom TeethCzeslaw Milosz - So little

John Milton – On his blindness  and Lycidas

Merrill Moore - The noise that time makes Thomas Nashe - Alitany in time of plague Pablo Neruda - Oda ala tristeza (Ode to sadness)  

Sylvia Plath - The companionable ills 

Anna Piutti – Current 

Peter Porter - A Chagall postcard 

Peter Reading - C

Adrienne Rich – Power 

William Shakespeare - Seven ages of man [As you like it 2.3.139-167]  

Jo Shapcott - Hairless and Ofmutability

Stevie Smith - Not waving butdrowning

Robert Louis Stevenson - The land ofcounterpane

Dylan Thomas – Donot go gentle into that good night

Heather Wastie - Ping pong neonatal ICU William Carlos Williams - Thelast words of my English grandmother William Butler Yeats - When you are old

TheHippocrates Prize is one of the highest value awards in the world for anunpublished poem in English on a medical theme. 2012 Hippocrates Prize judgesinclude New York poet and critic Marilyn Hacker and medical researcherProfessor Rod Flower, Fellow of the Royal Society. Awards will be presented onSaturday 12th May 2012 at the 3rd International Symposium on Poetry and Medicine,to be held at the Wellcome Collection in London.

Healthy heart awards

2011-07-19T15:05:00.000-07:00

The results of the inaugural 2011 ‘Healthy Heart Awards’ were announced on Thursday 14th July 2011 at a Symposium on Exercise and Cardiovascular Health organised in London by the Cardiovascular Research Trust. The overall 2011 award and best secondary school award went to the Enterprise Club of the Joseph Leckie CTC, Walsall. Best primary school award went to Forsbrook Primary, Stoke-on-Trent. And a ‘highly commended' award went to Hill West Primary School, Sutton Coldfield.

The Cardiovascular Research Trust, supported by HTI, launched these new Healthy Heart Awards for schools and colleges in November 2010. The challenge for entrants to the 'Healthy Heart Awards' was to develop ideas for interactive educational ‘Healthy Heart’ programmes. The aim of the awards is to engage young and older school and college students from around the world in the health of their hearts. The aim of the award is to engage young and older school and college students in their health.

Entries were to consist of original material and could include: a logo; pictures and names for suggested characters; text and images for and about helpful messages about health and the heart, favourite sports and activities, healthy foods and how they can help the heart, unhealthy things to avoid, how unhealthy things can harm the heart, heart problems; questions and quizzes; outlines for moving picture sequences for games to link any of the above; other ideas which could add to an educational ‘Healthy heart’ game. The organisers hoped that participating children and students would enjoy taking part, and that the Awards would provide an innovative opportunity for teaching and learning relevant to the curriculum, both for science and health.

Ben Edge, teacher at Joseph Leckie Community Technology College, winner of the overall 2011 Healthy Heart Awards, was impressed by the science learning, team-working, interest in health, and development of enterprise and commercial skills that taking part in the Awards inspired in his school students. He observed that “The ‘Healthy Heart App’ challenge from the CVRT allowed the students the opportunity to work towards a common goal as part of a team.

He added: "the students really enjoyed designing games and characters for the App, as well as researching and developing educational materials that teenagers can use to educate themselves about maintaining a healthy heart. The Joseph Leckie CTC Enterprise Club were able to develop important Enterprise and Commercial thinking skills by working towards the criteria provided by The CVRT.”

Mrs Emma Hindmarch, Year 6 Teacher at Forsbrook in the West Midlands, winner of the Primary School category in the 2011 Healthy Heart Awards, said, "We are absolutely thrilled to have won the Healthy Heart Primary School Award. The children really enjoyed researching good and bad things about the heart. It was also a fun way for them to work together to revise the school's science curriculum."

Pupils from Hill West Primary also enjoyed taking part:

Khadeim, Year Six, said "I was really excited to be able to enter this competition which involved us developing an app that could help other children realise what is needed for a healthy heart."  Emily, Year Six, added: 'the whole experience was incredibly informative, I learnt a lot moreover I am happy to be educating other children in an exciting way via an app."  

From the teaching perspective, Mrs Diane Hardeman, the teaching Assistant who co-ordinated the Hill West entry, said: "the competition enabled our pupils to use their scientific knowledge in a fun and esciting way. It is wonderful to see their efforts have been acknowledged furthermore we all look forward to seeing the app once it has been developed."

Award winning schools and colleges will have their entries incorporated into an ‘app’ to help children and young people around the world to find out more about the heart and how to keep it as healthy as possible.

Entries for the 2012 Healthy Heart Awards open 1st October, 2011.

Winners of the The 2012 Healthy Heart Awards will be announced in Summer 2012 in London at a Symposium on Cardiovascular Health organized by the Cardiovascular Research Trust.

Exercise and cardiovascular health on Everest

2011-07-12T03:11:00.000-07:00

Jesuit priest Father Jose Acosta, wrote of his crossing the Andes in the late 16th century problems with sickness and vomiting which he attributed to the "thinne air", so "delicate as it is not proportionable wth the breathing of man". In 1865 the first man to climb the Matterhorn, Edward Whymper, recently commemorated in London by a blue plaque, was an early student of sickess at altitude. In recent modern times, climber Charles Houston made a major contribution to research into mountain sickness, his interest inspired by his episode in August 1953 of unconsciousness high on K2. He crystallised key ideas on mechanisms in his 1980 book "Going Higher: Oxygen, Man and Mountains". Speaking about his talk at the 14th July Symposium on 'Exercise and Cardiovascular Health’ organized by the Cardiovascular Research Trust, Professor Chris Imray commented: "increasing numbers of people travel to altitude for both leisure and work purposes. On ascent to altitude, there is a reduction in atmospheric pressure, and there is consequently a reduction in the inspired levels of oxygen. The resulting physiological challenge stresses the body both at rest and further during exercise.

The cardio-respiratory challenges and the subsequent responses of ascending to high altitude will be discussed in detail, as will the role of ‘altitude training’."

Professor Imray will present "unique data from the Caudwell Xtreme Everest expedition, including arterial blood gases and the response to exercise at extreme altitude ...".

These studies provide important messages for health and risk for climbers at high altitude. They raise interesting questions about impact on brain and heart function of working at high altitude for border guards who are not acclimatised to low oxygen levels. They also provide insight into the physiological challenges and pressure for emergence of survival genetic variants for populations historically living at altitude.

See the symposium website for the programme.

Exercise and cardiovascular health

2011-07-07T12:49:00.000-07:00

The good news is that even mild activity can be helpful in keeping healthy and in reducing risk of joining the pandemic of cardiovascular disease in the 'developed' world and emerging epidemic of heart attacks and strokes in less developed countries.

At the elite end of the exercise spectrum, internationally competitive athletes benefit from positive feedback effects of exercise on the heart and circulation.

And for patients with established clinical heart problems, exercise under medical supervision is now well recognised to help to complement medical and surgical treatments to aid recovery and reduce the risk of future heart disease.
Not a good idea though for the out-of-condition to go from none to extreme exercise. What advice should the health or sports professional consider ?
These themes form the programme for a symposium on 'Exercise and cardiovascular health' in London on the afternoon of Thursday 14th July 2011.

Of interest to a diverse audience - sports professionals and health professionals and students looking for an update on benefits and risks of exercise, from prospective to the elite athletes interested in benefits of exercise for their health and performance, to people with heart conditions wanting to find out more about exercise and the heart. And as an interesting case study on extreme athletes, surgeon and Everest researcher and mountaineer Professor Chris Imray will be discussing exercise at extreme altitude.

See the symposium website for the programme.

Anti-cholinergics, mortality and mental impairment

2011-07-06T10:16:00.000-07:00

A report by a team of UK and US researchers in the Journal of the American Geriatric Society has suggested increased risk of mortality and mental impairment in older people from some medicines used in combination. The study relies on events from almost 20 years ago. How helpful is the study for current clinical practice? Hear Donald's interview by Annie Othen on BBC radio about the report.

Painkillers and risk of heart rhythm disorders

2011-07-06T09:25:00.000-07:00

This week the British Medical Journal published a report by Schmidt and colleagues from Denmark, North Carolina and Boston, USA on "Non-steroidal anti-inflammatory drug use and risk of atrial fibrillation or flutter ..." This has lead to alarming print media and web headlines on risks of heart disease from these commonly used medicines. How worried should we be? On one level this is a general reminder that powerful medicines may have powerful harmful effects. Indeed previous studies have reported an increased risk of atrial fibrillation from NSAIDs and these medicines and the related COX-2 inhibitors have been implicated in increased risk of other types of heart disease. With that in mind, patients on these medicines who develop palpitations or other features of heart problems, including shortness of breath or ankle swelling, should consult their GP for advice. However there are some interesting aspects of the study showing the importance of looking critically behind headlines at the details of research reports. This includes considering potential sources of bias which may lead to undersestimation or exaggeration of effects; and being clear on the difference between absolute effect on risk (e.g. 17 vs. 10 per 1000) and relative risk (e.g. 70% increase). Here is a link to Donald talking about the study on BBC Radio