90 years for the Postgraduate Medical Journal

A Symposium is being organised by the Fellowship of Postgraduate Medicine to mark the 90th Anniversary of its first official journal, the Postgraduate Medical Journal. The Symposium will be held at the Medical Society of London on on 1st October 2015.
Speakers on the day will comment on what medicine was like in the 1920s, current progress in their field, and what is in prospect over the next 90 years.
Other speakers will include FPM Fellow Professor Peter Barnes FRS, London, who will speak on advances in respiratory medicine, Professor Dame Carol Black, Principal of Newnham College, Cambridge and Past-President of the Royal College of Physicians who will discuss opportunities to improve public health through a focus on health in the workplace, Professor Melanie Davies (Leicester) on progress in managing diabetes, vascular surgeon Professor Alison Halliday (Oxford) on carotid surgery to prevent stroke, FPM Fellow chemical biologist Andrew Marsh (Warwick) who will discuss advances in drug discovery, FPM Fellow cardiac surgeon Wade Dimitri (Coventry) who will discuss early development of heart surgery  Dr Paul Nunn (London), former Director of the WHO Tuberculosis Programme, on advances in managing tuberculosis, FPM Fellow Professor Munir Pirmohamed (Liverpool) who will discuss Progress in Personalised Medicine, Emeritus Professor Terence Ryan (Oxford) on Sir William Osler and Professor Karol Sikora (London) on cancer - a disease of our time.

The Postgraduate Medical Journal publishes topical reviews, commentaries and original papers on themes across the medical spectrum. It provides continuing professional development for all doctors, from those in training, to their teachers, and active clinicians, by publishing papers on a wide range of topics relevant to clinical practice.
Papers published in the PMJ describe current practice and new developments in all branches of medicine; describe relevance and impact of translational research on clinical practice; provide background relevant to examinations; and papers on medical education and medical education research.  The FPM is a British non-profit organisation founded in the autumn of 1919 as a merger of the Fellowship of Medicine and the Postgraduate Medical Association, with Sir William Osler as its first president. Its initial aims were the development of educational programmes in all branches of postgraduate medicine. 
The FPM organises clinical and research meetings and publishes two journals. The FPM has since 1925 published the international journal, the Postgraduate Medical Journal. In 2012 the Fellowship launched a new international journal, Health Policy and Technology, published on the Fellowship's behalf by Elsevier.

Digital Health: Catapulting Personalised Medicine Forward

In a new collaboration, on 27th November 2014 the UK’s Digital Catapult, the Fellowship of Postgraduate Medicine, IDEALondon, and Vital Transformation brought together leading experts working at the frontiers of research where personalised medicine and medicines, and health technologies intersect.

 

Round table sessions featured demonstrations of how next-generation technologies and social media will integrate with public health, thus facilitating the burgeoning market for personalised medicines. The symposium included disruptive start-ups and technology practitioners finding common ground in bringing secure personal health data to the public and advice on stratified medicines to prescribers and their patients.

 

The Digital Catapult, launched in November 2014, aims to place electronic and mobile technologies at the forefront of their future public health strategy. 

Publications arising from the symposium will be published in the FPM journal Health Policy and Technology.

 

See the meeting agenda and speakers. 

 

See conference report.

What's new on health matters from Australia?

@HealthMed Recent news concerns infection alerts, raising awareness of the risks of overweight, and ethics of using social networking to undermine efforts to combat drinking and driving.

'Grabbable gut' as clue to being overweight.

How do you engage the public in long-term interest in benefits of keeping weight in check? The recent ‘LiveLighter’ Australian anti-obesity campaign campaign, supported by the The Heart Foundation, aims to improve recognition of overweight as a personal problem. The campaign includes dramatic pictures of internal excess fat, accompanied by images of a man who does not appear realise he has a weight problem - with the reminder that if you can 'grab your gut' ie have enough spare loose abdominal flesh to grasp by the handful, there is a problem.  In other cultures, 'spare tyre', or the advice 'if you jump up and down and it bounces you're overweight' ... have similar resonance. 

Some critics have complained that the campaign further lowers self-esteem in those who already feel under psychological threat - or simply claim that these messages won't work. This overlooks the obvious - increasing failure to perceive that a given build is excessive, with overweight becoming the norm, both in developed and less developed countries.

  Key challenges are more about how to raise awareness that weight is even a problem, why that matters, and what initial and long term sustainable measures will help to keep weight in check and avoid preventable long-term cardiovascular and non-cardiovascular serious health risks.

Raising public awareness is all the more pressing with recognition, for example from recent data from the US NHANESIII study presented at the European Society of Cardiology Congress in Munich, that relative overweight [based on increased waist-hip ratio] is more important than raised weight based on body mass index, for predicting increased risk of serious heart disease and other causes of premature death.

Random roadside alcohol checks

In parallel with public health messages about the risk of drinking with any alcohol in the blood, random alcohol tests are being used in Western Australia to discourage drivers from drinking.

Several different initiatives have been used in other countries. In France, by a new 2012 law breathalyzer kits are compulsory for all cars. In Sweden and the USA, alcohol ignition interlocks have been used for drink drinking offenders, and several other countries have piloted these schemes involving a breathalyzer coupled to the ignition – if any alcohol is detected, the car’s ignition is inactivated. Elsewhere, a timed arithmetic test is used as barrier to starting the car, based on the adverse effects of alcohol on brain function of even modest alcohol intake. Rather than accepting help not to drive when potentially a danger to pedestrians and other road user, some drunk drivers have been reported to use a friend or even pay a sober contact to beat the tests.

In Australia, booze bus spotters have been posting messages on social networking sites to warn drivers of its location. Worrying not least from the question how and when drivers are accessing these messages.

Rise in ’Ross River cases’

RossRiver virus, an RNA alpha virus and member of the togaviridae family of viruses, is spread by mosquito  bites and is endemic in Australia and several South Pacific islands. The illness was first reported in 1928. The main reservoir animals appear to be kangaroos and wallabies.

The features include rash and flu-like syndrome, the acute features usually settling within 12 months, with however some of those infected by the virus reporting subsequent long-term ME like debility.

Why now provide an update on the virus? Public health reports indicate a rapid ~5-fold increase in numbers of cases of Ross River disease in Western Australia over the past 3 years from, 332 in 2009-2010 up to 1570 in 2011-2012. This rapid increase has been attributed to increased numbers of the vector - mosquitos - due to a series of La Niña events [coupling of Pacific Ocean currents with weather patterns].  This has lead to an increase in rainfall in parts of Australia, the resulting humid conditions and increase in ground-water favouring greater breeding by mosquitos. 

Teenagers, IQ risk and cannabis: cause and effect, bias or other explanations?

@HealthMed My first contact with study of the science of cannabis was as a medical student in Aberdeen undertaking a summer project in pharmacology: a new researcher, Roger Pertwee, was interested in the effects of bioactive ingredients of cannabis on brain regulation of temperature and muscle function.  Research since then by Pertwee and many others has identified the importance of endogenous chemicals, endocannabinoids, that are part of normal functioning of the brain and other parts of the body, for example in modulating mood and stimulating appetite. Abnormalities in endocannabinoid pathways have also been implicated in a wide range of medical conditions, including inflammation, obesity, cancer, cardiovascular disease as well as mood disorders. 

Now this week we have a report illustrating a new facet of potential harm from cannabis. In a long-term follow up study by scientists in Otago, at Duke University, USA and King's College London, lead by Madeline Meier (Duke), IQ and reported cannabis use was monitored over the 25 years from age 13 to 38 in the Dunedin Birth Cohort. Of particular interest, their study of over 1000 subjects included teenagers in whom IQ was checked before any cannabis exposure. Around 1 in 7 reported being regular cannabis users, 1 in 20 doing so at least weekly before the age of 18.

What did the investigators find? With no cannabis history, there was a small fall in IQ. However recurrent cannabis use was associated with an 8 point decline in IQ, comparable to that seen in early dementia. Importantly, this decrease in IQ was particularly marked when cannabis use began during teenage years. A further concern was that stopping cannabis use did not lead to recovery of the IQ loss. Commentary on the results has ranged from concluding that cannabis is harmful in teenagers but safe in adults, to more cautious notes that adolescent brains appeared more vulnerable to cannabis, without providing carte blanche for longer term safety of cannabis use in adults …

Are these fair interpretations? For further discussion of this long-term, prospective observational study, important caveats in its interpretation, and its potential implications, see my discussion posted on The Independent blogs site.

Shift work and cardiovascular risk

@HealthMed It is well-known that shift workers have increased risk factors for serious heart disease, for example as reported in Knuttson's 1986 Lancet paper on papermill workers. They are more likely to smoke and tend to have higher blood pressure, cholesterol and weight and be more likely to have diabetes than  workers whose work pattern is confined to the daytime. They are also more likely to have insomnia, itself an independent risk factor for cardiovascular disease. Clinical pharmacologist Daniel Hackem from Ontario and his colleagues from Norway, Sweden and the USA had now raised further public and health professional interest in this disease link in a paper published in the British Medical Journal.

They looked at 34 previous studies of over 2 million shiftworkers. Together, there were over 17,000 heart events, over 6000 heart attacks and almost 2000 strokes. They concluded that stroke risk was around 5% higher and coronary event risk 24% higher in the shift-workers. Surprisingly, despite their large dataset, the researchers found no associated increase in mortality.

They take care to point out, as with any other observational study, that this is not necessarily a cause and effect relationship. People who take on shift work may be different in some unconnected way that puts up risk of vascular disease. Lower socio-economic status is an obvious important confounder. The work itself may be more stressful, at the same time as their being fewer other staff members in support 'out of hours'. Shift workers may also take more caffeine to try to stay alert during often long shifts.

Nonetheless there are several key messages reinforced by this report.

Shift-workers are more likely to have an excess of a wide range of cardiovascular risk factors. They  should therefore be encouraged to seek regular medical advice and their employers to raise awareness of these health risks and to support their staff in seeking regular medical advice. Shift-workers should also be supported in ensuring a healthy lifestyle despite the constraints on exercise and diet of unsocial hours of work.

Clinical pharmacologists and other health professionals should make sure to take a good occupational health history, including identifying whether a patient does shift work. They should make sure particular  care is taken to identify and reduce severity of cardiovascular risk factors in shift workers, supported by effective regular advice on healthy lifestyle. And where drug treament is indicated, prescribing treatment targets should be adjusted to take account of the increased cardiovascular risk to be prevented.

Employers should also make sure that patterns of shift work follow international guidance regarding avoiding abrupt shift changes, maximum shift duration and ensuring sufficient staff are working 'out of hours' to ensure that work is done both safely for employers' outcomes as well as their workers' health.

Tuberculosis, Bel Ami and the Belle Epoque

Guy de Maupassant

@HealthMed Maupassant's 1885 book Bel Ami concerns the rise to wealth and influence of ex-soldier Georges Duroy, son of a poor rural family. Themes which still have a topical international resonance include the power of the press, foreign wars, corruption in business and government, and stock market insider trading. The anti-hero's success is largely due to the power of the wives of the rich, through their husbands, or direct involvement in political intrigue. A major subplot in Bel Ami is the impact of tuberculosis - estimated to cause the death of between 1 in 4, and 1 in 7 of the population in the mid 19th Century. In Bel Ami, Forestier, a wealthy publisher, develops rapid serious lung involvement, coughing blood, becoming breathless, and fevered. His early death provides a key opportunity for Duroy to enter formally into society.

Belle Epoque France was the outcome of cultural and economic flourishing during the latter part of 19th Century. An obvious question is what people at that time thought about tuberculosis. They knew that is was a serious and often deadly disease: Forestier's rapid death is anticipated as a matter of fact by Clothilde, a faithful companion of Duroy. An important academic view was that the 'soil'' - individual susceptibility - played a major role in the likelihood of developing consumption. There are several apparent similarities between those perceptions and public reaction to the epidemic of HIV-AIDS which emerged in the early 1980s. Tuberculosis was known as consumption because of its wasting effect. The term in translation dates back at least to Hippocrates in 460BCE: the Ancient Greeks used the term phthisis (wasting away) to describe the commonest disease of their time.  This was echoed by the description 'slim disease' for a wasting disorder which emerged in rural Uganda in the early 1980s, strongly associated with infection with the HTLV-III, and thus recognized to be a feature of HIV-AIDS. A major cause of weight loss in HIV-AIDS is associated opportunistic infections such as tuberculosis - a clear illustration of the importance of the impact of impaired host defence on development of a disease.

 

At the time of publishing Bel Ami, Maupassant was ill with syphilis. Not a socially acceptable disease to reflect in a literary work - although ample opportunity for this to be acquired by Maupassant's  anti-hero Duroy and passed on to his high society conquests. The concept of the risk of progressing from a 'night with Venus to a lifetime with Mercury' emerged shortly after the 1494 siege of Naples. In an epic poem of 1530, the Veronese doctor poet Girolamo Fracastoro refers to use of mercury as a possible cure for the disease. And its late effects were well known to Shakespeare, with examples in his play 'Timon of Athens'. One of Fracastoro's many contributions to science and medicine was the idea that certain diseases are spread by particles. In the 1600s, early inventors of microscopy went on to confirm the existence of minute particles. Antoni van Leewenhoek was the first to report single-cell micro-organisms, in 1676 correspondence to the Royal Society, which, after initial scepticism, then confirming his findings, made him a member in 1680. 

A dramatic change in medical thinking and knowledge about tuberculosis occurred in the early 1880s. In 1881, French doctor Louis Landouzy gave a series of influentual lectures on causes of consumption, including speculation that routes of transmission could included infected dust, milk and meat. And in 1882, the Prussian pathologist Robert Koch was the first to describe the causative tubercle bacillus, supported by his formulation in 1884 with Friedrich Loeffler of 4 postulates about the evidence needed to confirm disease causation by microbes. This direct work on the germ theory of disease had been anticipated 350 years before by Frascatoro. Koch's investigations and discoveries in relation to tuberculosis lead to his receipt of the 1905 Nobel Prize in Physiology and Medicine.

The timing of publication in 1885 of Maupassant's novel Bel Ami is therefore of special interest, following 3 years after Koch's discovery. There is no explicit recognition in Bel Ami of the resulting logic for isolating patients with what later became called 'open' tuberculosis - when the TB germs are free to travel from the lungs through the air to nearby contacts. However the move of Forestier to a remote house may have served both to give him a quiet place to convalesce or die, and tacitly to isolate him from at risk friends.

Modern parallels to the public response to tuberculosis in the Belle Epoque range from reactions such as fear, concern and denial for mystery illnesses with no cause known (e.g. pre-HIV 'slim disease'), the response of the public to those affected by HIV-AIDS, before the emergence of effective treatment; and responses to the many types of cancer without known cause, and other  reasons for premature illness and mortality, for example - sudden cardiac death syndromes in young athletes and older adults, despite many advances in diagnosis and treatment.