Leprosy, from old Spittals to modern times

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

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

RC St Clemens, ex Benedictine Cloisters, Bad Iburg

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

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

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

Red staining of organism that causes leprosy

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

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

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

Sharpening memory and cocoa - how interested should you be?

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

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

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

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

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

Distinguished barrister Robert Francis QC joins 2014 Hippocrates Prize Judges

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

Photo of Philip Gross by Stephen Morris

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

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

Young pharmacologists from 5 continents at EACPT Clinical Pharmacology Summer School

Over 120 young and senior pharmacologists from 5 continents attended the EACPT Summer School in Edinburgh 4-6 July: half the young clinicians and researchers from the UK and half from around the world: continental Europe, from Estonia and Lithuania to Denmark and Spain, 16 from China, others from Australia and elsewhere. 

Hear the podcast from delegates at the EACPT Summer School from 6 European countries talking about why they came and how useful they found the EACPT Summer School in Edinburgh: Eglė Svitojūtė, Lithuania; Morten Rix Hansen, Odense, Denmark; Aurelija Noreikaite, Lithuania; Gareth Barnes, London, UK; Alexandra Androu, Romania; Madli Pintson, Tartu, Estonia; Julia Daragrjati, Padua, Italy.

Blogs from delegates from 8 countries

EACPT Summer Schools consist of keynote presentations and workshops on all aspects of clinical pharmacology by invited expert speakers, poster presentations, and social events. There is a strong interactive element and ample opportunity for delegates to network with speakers. 

See also information on the 11th EACPT Congress in Geneva: 28th - 31st August, 20

Entries open for the 2014 Hippocrates Prize for poetry and medicine

Entries are open for the 2014 Hippocrates Prize Open, NHS and Young Poets categories - deadline 12MN GMT 31st January, 2014.

Submit entries online

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 4 years, the Hippocrates Prize has attracted over 5000 entries from 55 countries, from the Americas to Fiji and Finland to Australasia. 

Awards for the 2014 Prize will be announced by the judges in May, 2014 at the Wellcome Collection in London at the end of the 5th International Symposium on Poetry and Medicine. 

Rules for the Hippocrates Prize
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. 

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The judging panel for the 2014 Hippocrates Prize includes poet Philip Gross, a winner of
the TS Eliot Prize.

Co-organizers are medical professor Donald Singer and poet and translator Michael Hulse.  

The Hippocrates poetry and medicine initiative received the Award for Excellence and Innovation in the Arts in 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, the National Association of Writers in Education, and the University Warwick's Institute of Advanced Study

Launch of Pocket Prescriber 2013

The 6th edition of the Pocket Prescriber I co-edit with psychiatrist Tim Nicholson has just been launched.

Our aim is to provide core information to junior doctors, nurse and pharmacist prescribers and medical students and other health professional students interested in drugs and prescribing.
As in previous editions, there is a listing of ~500 of the most commonly used medicines, informed by advice from  experts in the wide range of therapeutic disciplines reflecting current medical practice in assessing and treating common medical problems from infection to hypertension and alleviating pain.

We also include national guidelines aimed at improving safety and effectiveness in prescribing, and advice on management of medical emergencies, supported by guidelines from national and international professional societies, NICE guidelines and Formulary updates.

Over 110,000 copies of the Pocket Prescriber have entered national and international circulation since the first edition was published in 2004.

Since 2010, the Pocket Prescriber has been an annually updated source of prescribing advice.

The Pocket Prescriber is published as a convenient sized small book. The new 2013 edition will shortly also be published as an app for smartphones, laptops and desktop computers.

Suggestions for additional content are very welcome.

Hippocrates Society for Poetry and Medicine launched

The Hippocrates Society forPoetry and Medicine provides an international forum for people from anywhere in the world interested in the interface between poetry and medicine. To find out more about the Hippocrates Society, email the organizers.

Activities

Activities of interest to members include an annual international symposium on poetry and medicine, workshops, readings, and reduced cost of publications by the Hippocrates Press. Members also have discounted registration for the awards for the annual Hippocrates Prize which has 3 categories: an international Open category, an international Young Poets award, and a UK NHS category.

Membership

The annual membership subscription of the Hippocrates Society for Poetry and Medicine includes

- one free copy of the current year's Hippocrates Prize Anthology

- 20% discount on Hippocrates Press publications

- 20% discount on registration for Hippocrates initiative events, including the annual International Symposium on Poetry and Medicine, Hippocrates Prize awards, workshops, readings and other events.

Pending events eligible for 20% discount on registration include 

- Hippocrates in Venice workshop 21st - 22nd September 2013

- 5th International Symposium on Poetry and Medicine: May 2014

- 2014 Hippocrates Prize awards: May 2014

Subscription: 1st July 2013 - 30th June 2014

Standard membership - £40

Student - undergraduate or PhD - £30

Retired - £30

Hippocrates in Venice: workshop on poetry and medicine

Hippocrates in Venice

Weekend of Saturday 21^st – Sunday 22^nd September

Venue: 15^th Century Palazzo Ca' Pesaro Papafava
For more information: email the organizers.

15^th Century Palazzo Ca' Pesaro Papafava

Aims of the workshop

This workshop is designed as a scoping and networking event to take forward the work of the Hippocrates Initiative for Poetry and Medicine.

The four annual International Symposia on Poetry and Medicine held since 2010 by the Hippocrates Initiative have shown that there is a substantial wish for an international umbrella association that would serve as a switchboard for the gathering, coordination and dissemination of information in the field, and to institute activities that further an understanding of relations between poetry and medicine.

The Venice workshop will principally be a two-day exchange of views aimed at establishing the priorities an umbrella association ought to have, identifying focal interests for potential research groups and working parties, and identifying interests for exploration in subsequent workshops.

There will be a small number of talks but the emphasis will be on discussion and consultation. Themes to be considered by speakers and during break-out sessions and round table discussions will include historical perspectives, epidemics of infection from the plague of Athens to syphilis, tuberculosis and HIV-AIDS, and modern non-infectious epidemics, from obesity to heart disease, psychiatric disorders and cancer.

Other themes may be added arising from suggestions from workshops participants.

The Venice workshop offers a key opportunity to be part of the planning process and to help shape a significant new aid to workers and researchers in a growing field.

Palazzo Pesaro Papafava is a few minute’s walk from the Rialto Bridge and Ca’ d’Oro.

It is located on the Canale della Misericordia, opposite the Scuola Grande della Misericordia, with views towards the Grand Canal and the Lagoon.

Methylphenidate (Ritalin) – does use by ‘healthy’ students matter?

In their report in the Telegraph, @Josiensor and Rosa Silverman discuss implications of a survey from Cambridge which notes that so-called 'smart' drugs continue to be used by students to try to improve their academic performance, with methylphenidate (Ritalin) a common choice.

Why should this be of public interest?

Methylphenidate has been in use since 1960 for treating ADHD, with effects mainly considered to be improvement in attention and concentration. It is used to treat a number of rare syndromes involving abnormalities in chemical transmission in the brain. The drug is also reported to be in widespread use by students in the UK, the US and elsewhere in the hope that it will improve studying, learning and exam performance.
 

1.    Does it work? Studies of possible effects on studying and learning are typically short-term and usually based on artificial tests – ie not usually test possible benefits of the drug what students may be trying to learn, or effects on the types of exams students may be sitting. Evidence compared to placebo of benefits or risks appears limited to studies lasting 4 weeks or less.

The evidence of benefits from methylphenidate in apparently healthy students is disappointing. For example, in a study in health young volunteers there was a reported benefit from the 1^st dose for a spatial (3D) task and for planning, but not for attention or fluency. However even these effects were not sustained: with a second dose, spatial task performance was less good; ie there was little evidence of sustained benefit on repeat use of the drug and possible evidence that performance might be worse. And one of the side effects is insomnia – fatigue could also therefore be an indirect reason why performance might be impaired by the drug. There are also reports by users that with the drug, too much focus on details may make it difficult both to complete an assessment and to consider a broad enough range of issues to give a complete answer.

2.    Is use of methylphenidate any different from using caffeine? Because of the lack of convincing evidence of benefit from methylphenidate and concerns about serious risks, methylphenidate is not approved for use in the absence of specified medical conditions – e.g. ADHD. As for other drugs, the balance between risk and benefit must be considered by prescriber and user. In the event of any benefit for studying from the drug, others not using it are put at a disadvantage. In contrast caffeine is widely available for those who chose to use it. Too much caffeine, or sensitivity to caffeine can cause troublesome symptoms, including anxiety, tremor, sleep disturbance and palpitations. 

3.    Risks of methylphenidate Potential risks may be serious and include serious cardiac and psychiatric disorders. This has lead to important restrictions by regulatory authorities such as the FDA on use of the drug, even when the drug is medically indicated. 

Withdrawal symptoms of methylphenidate can include psychosis, depression and irritability.

Risks of the drug may be greater if there are medical problems, in particular if the user has a medical history of cardiovascular or psychiatric problems. Use without clinical advice may mean that important underlying conditions are not identified, for example high blood pressure, disorders of heart rhythm, and psychiatric risk; and potential important interactions with other drugs (including other stimulants) may not be considered. For example: 

-      alcohol can delay clearance of the drug from the body, increasing risk of adverse effects; 

-      concurrent use of stimulants such as caffeine would be expected to increase risk from methylphenidate of serious disorders of heart rhythm.

4.    What about access to the drug from internet pharmacies? For the above reasons, licensed pharmacies would not supply methylphenidate in the absence of specified medical conditions. Unlicensed internet pharmacies should be avoided. The quality of medicines is not reliable, with serious risk of being supplied poorly active or counterfeit or contaminated medicines. And medical contra-indications need to be identified and discussed to minimize the risk of preventable serious adverse effects.

5.    Fairness and coercion There are also a number of ethical concerns including:

a)    the need to protect students and others from using so-called ‘smart drugs’ in response to pressure to compete, both in exams and in professional life; 

b)    being fair to other students who do not have access to the drug, or do not wish to use what may be a medically harmful pharmacological aid to improving performance in examinations or to meeting challenges at work.

See also
June 2009: Opposing opinions in the British Medical Journal from John Harris and Anjan Chatterjee

September 2011: Methylphenidate and delayed puberty
July 2012: Methylphenidate for Parkinson's disease
November 2012: Commentary in the Guardian by William Leith: Ritalin before an exam fails the test of common sense 
June 2013: Cautionary report in from Canada on methylphenidate use and learning in  ADHD

Poet and doctor Dannie Abse awarded Honorary Fellowship by Fellowship of Postgraduate Medicine

Dannie Abse has been made an Honorary Fellow by the Fellowship of Postgraduate Medicine, announced at the FPM's 3rd Annual Summer Event on 24th June, 2013.

FPM President Donald Singer with new Hon. FPM Fellow Dannie Abse

His book of poetry, Running Late received the Roland Mathais Prize in 2007. The Presence was the winner of the prestigious Wales Book of the Year award for 2008. In 2009 Abse brought out a volume of collected poetry. In the same year, he received the Wilfred Owen Poetry Award. Abse was a judge for the inaugural 2010 Hippocrates Prize for Poetry and Medicine.

He was awarded a CBE in the 2012 New Year Honours for services to poetry and literature. 
See more 

Dannie Abse at the FPM for the 2010 Hippocrates Prize judging