Hippocrates Prize NHS shortlist discussed on BBC World at One

Shortlists and results for commended poets in the Open, NHS and Young Poet sections have just been released for the 2014 Hippocrates Prize for Poetry and Medicine.

With a 1st prize for the winning poem in the Open and in the NHS category of £5,000, and £500 for the Young Poet award, the Hippocrates prize is one of the highest value poetry awards in the world for a single poem.

Listen to discussion about Hippocrates NHS shortlist between Hippocrates judge, Robert Francis QC, and the BBC’s Martha Kearney on the World at One on Thursday 10^th April.

Competing for the UK NHS 2014 Hippocrates £5000 first prize are dentist Paula Cunningham from Belfast, Valerie Laws from Whitley Bay, who has worked as a poet with pathologists and neuroscientists, and Ellen Storm, a trainee in paediatrics and child health in the Mersey region.

The 2014 Hippocrates Awards will be presented at the close of the 5th International Symposium on Poetry and Medicine in London on Saturday 10th May.

Press release about the Hippocrates Young Poet Award
http://hippocrates-poetry.org/news/press-releases-2/extraordinarily-assured-and.html

Press release about the Hippocrates International Open and NHS Awards
http://hippocrates-poetry.org/news/press-releases-2/the-personal-and-the-beauti.html

What next for treating flu?

Listen to my interview about anti-flu drugs with broadcaster Andrew Easton on BBC local radio.

Pandemics of flu in past decades have caused serious complications and high death rates, with the 1918 'Spanish flu' the most serious example. This has lead to major efforts by the pharmaceutical industry to develop effective antiviral treatment for flu, to complement prophylaxis from immunisation.

Efforts to find drug treatments are important as flu mutates regularly so that immunisation may not protect from new strains of the virus.

During the 2009 swine flu pandemic, large amounts of antiviral drugs were prescribed and stockpiled. 
A Cochrane review has now reported marked variability in the quality of data of clinical trials of drugs used to prevent and treat influenza and disappointing outcomes from higher quality studies. Many studies were reported to include important potential bias. Reasons included obvious differences in colour between placebo and active treatments in randomised controlled trials.

Serious outcome measures were often based on self-reporting, for example not using X-rays to confirm a presumptive diagnosis of pneumonia. And unpleasant side-effects of the treatment occurred in from ~1 in 25 to 1 in 90 patients, in particular headaches, vomiting and psychiatric abnormalities.
For the serious complication pneumonia, for studies in which X-ray confirmation was used, there appeared to be no benefit from active anti-viral treatment on pneumonia severity.

Although there was a reported ~10% reduction in severity of symptoms in adults and 1 in 6 shorter symptoms in children when drugs were given after the diagnosis, higher risk children - those this asthma, did not appear to experience this benefit on duration of symptoms.

There is now a presumption that alternative simpler and cheaper remedies such as paracetamol (acetaminophen) might be just as effective for symptom relief. The international incidence of flu is so high that trials to confirm that important question would not be difficult to complete rapidly.
Any such trials should use robust outcome measures, including recording admissions to hospital, confirming that flu diagnosis is correct (ie illness not due an infection such as RSV which is resistant to current flu antiviral agents), and serious complications are confirmed using tests such as X-rays.

A serious underlying issue arising from work by these Cochrane authors, and other assessments of safety and effective of drugs, was a delay of around 5 years in provision of trial data by one of the companies involved. Prompt access to all data is vital to ensure that the clinical and cost-effectiveness of drugs can be validated.

There are now important efforts underway from NGOs such as AllTrials, regulatory agencies and professional societies to improve transparency of access to company data by independent researchers.

BBC report

Guardian report

Sharpening memory and cocoa - how interested should you be?

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

Listen to interview on the story on BBC local radio
 
The theme of the interest - from the LA Times to the Belfast Telegraph - is that cocoa "not only soothes the soul, but might also sharpen the mind'.

Fruit of the theobroma cocoa tree: Corti et al. Circulation 2009 

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

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