Monthly Archives: December 2008

Sorry to have been away from the blog for so long recently. Holiday diversions: If you are struggling to entertain children in the long, long, Christmas holidays, I recommend the Naked Scientists Kitchen Experiments . I met one such Naked Scientist (fully clothed) at an event at National Pathology Week earlier in the year. Also, on Radio 4, 8pm, Jan 1st is a programme ‘Virgin Births’ written by Aarathi Prasad. I know Aarathi through the work she has done via the charity Sense about Science. The programme is about the science of real virgin births – from komodo dragon eggs that don’t need sperm to reproduce, to parthenote embryos and Catholicism. Promises to be very interesting.

Further diversion: my favourite science joke of 2008 (courtesy of my eldest son)

One atom says to the other atom: I think I’ve lost an electron.

Other atom: Are you sure?

First atom: I’m positive.

Happy 2009.

When I suggested, a while back, that walking was fabulous for health, I thought I was giving readers of this column sound advice.

All the evidence suggests that it’s good for mental, physical and environmental health, as well as being something many people find pleasurable. Who, I thought, could object?

Well, the man who wrote to tell me that he had tripped over his walking stick and fractured his ankle certainly did. (Sorry about that.) As did the lady who became so enthused by the prospect of reaping all those benefits I had mentioned that she decided to walk everywhere, only to have her bunion become infected – requiring antibiotics and surgical drainage. (I do apologise.) So too, the distinguished editor who, I understand, is still requiring treatment for foot pain. (Again, mea culpa.)

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Sometimes, it is easy to recognise a good idea. Oral rehydration solution, a simple sugar and salt formula, costs about 10 cents per packet. Since its development in the 1970s, it has saved millions of people, mainly in the developing world, from dying of diarrhoea. It could well have saved those in Zimbabwe who, in the past few weeks, are reported to have died from dehydration following cholera.

Western healthcare, meanwhile, is expensive, and our contribution to humanitarian aid remains inadequate. When we fret about whether a test for genetic biomarkers will help us to avoid assault by nefarious disease, we seem to be missing the point. We could be concentrating our efforts on saving other people’s lives with simple remedies instead of worrying about how complicated tests could buy us a few more years.

Indeed, the more advanced the medicine, the more equivocal the benefits. A thought provoking piece in the British Medical Journal last year questioned whether the rise in statin prescriptions for elderly people might decrease the number of sudden deaths due to heart disease, only to increase the incidence of cancer.

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Every year, as the Christmas festive season gets going, my heart starts to sink. Flyers for parties offering “10 free drinks per person!” are plastered all over the gym. Pubs roar with drunken office lunches. Getting sloshed seems to be normal, if not mandatory.

Excess, of course, can be lots of fun. I have six different types of gin in my house, and am not exactly unknown at the local bottle bank. The problem is that when it comes to alcohol, one can happily surpass excess without noticing anything particularly wrong, until it all goes very wrong indeed. A famous gastroenterologist used to do a “vomit audit” once a year in Aberdeen by counting vile pavement reminders of the night before on a pre-prescribed route. This gave a ready snapshot of gastric side effects. But this is not the biggest problem with alcoholic excess.

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Yep. In this week’s BMJ, is an advert for a ‘vacancy for a member’ for the Herbal Medicines Advisory Committee , which advises the Medicines and Healthcare Regulatory Agency on the ‘safety, quality and efficacy of herbal medicinal products for human use.’ Of further concern to me is that they wish their newly appointed member to have recent experience in paediatrics.

Herbal medicines are, if they work, nothing special – St John’s Wort, aspirin (willow extract), vincristine, a chemotherapy drug, which is derived from plants….they all have side effects and interactions with other drugs. In fact, one could say that herbal medicines which work are in fact just medicines, to be used with the same provisos as any other medicines.

These leaves the ‘other’ herbal medicines as the ones which don’t work. And which, by definition, we should be ensuring either aren’t used, or are properly researched so that we know whether they should be or not.

What is gained by having a Herbal Medicines Advisory Committee? Obfuscation, and the danger of having a different set of standards for one set of chemicals compared to another, I suggest.

As an unschooled observer of the money markets, I have been struggling in recent months to understand what anything is actually worth. In healthcare, there is a similar problem, though it makes for rather less exciting headlines. All NHS procedures have to be costed to the last penny, and reported on in “completed care episodes”. But just like financiers, healthcare professionals can’t put an exact price on everything.

Blood, for example, is a commodity given free of charge by people willing to sacrifice time and comfort in order to make a significant difference to someone else. Bone marrow is another “gift”, donated by those who know they will not be repaid financially for being inconvenienced. And then there are the gifts given in the aftermath of death: corneas, kidneys, livers, skin, hearts… all capable of transforming a stranger’s life.

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The British Association of Plastic Reconstructive and Aesthetic Surgeons have issued the results of a questionnaire asking surgeons if they have had to give emergency treatment to people who have had cosmetic surgery abroad. Unsurprisingly, the answer was yes. This is only the tip of an iceberg – there have been reports of patients returning after “transplant tourism” abroad, where people have paid for kidney transplant operations. What are doctors to do when patients present needing drugs to prevent rejection of the organ, or if a cosmetic surgery wound is badly infected?

BAPRAS says that there is a need for clear guidance as to what doctors should do. Should patients in this situation be made to pay private fees for medical intervention – after all, these are not things that the NHS has instigated, and normally, the team responsible for follow up care are those who did the procedure in the first place. It hardly seems fair that the NHS should be made responsible instead – costing time and money that should have been available to NHS patients. The uncomfortable bit is that doctors should be treating on the basis of need, and by the time there is a complication of surgery abroad, there is usually a need for urgent care. Where is the solution? Can doctors ethically ignore patients with such complications? Or should they simply be billed for their cost to the NHS?

A very interesting paper just published in the Archives of Internal Medicine. The study followed women before and after the introduction of a breast screening programme in Norway. They were compared to a control group of women who did not take part in the screening programme, but who would have been, had the programme been started in their area. This control group were invited for a one-off screening at the end of the observation time in order to work out how many had invasive breast cancers.

When the two groups were compared, the amount of invasive breast cancers was found to be significantly higher in the group of women who had regular screening. On first glance, this may appear to be a good thing – it seems that screening picked up more invasive breast cancers. But is it? The problem is that the natural history of these “invasive breast cancers” may not be as predictable as we would like to think, in that not all may cause a life-threatening situation. The authors concluded that “it appears that some breast cancers detected by repeated mammographic screening would not persist to be detectable by a single mammogram at the end of 6 years. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress”.

This is but one paper in a complex field, and I wouldn’t suggest that this research alone should make women decide what to do when the invitation to breast screening comes in. However, there are already uncertanties about how beneficial breast screening is. I think this paper does emphasise that there are still a lot of unknowns when it comes to breast cancer screening. The NHS Behind the Headlines service provides a useful analysis of the news coverage of this story but concludes that “women should continue to attend screening programmes”. I think this is a bit unfair; surely the best position is to invite women to weigh up the pros and cons for themselves, as they become known. But maybe this is also unfair; most people probably don’t have the time to devote to investigating this sort of thing and they should be able to expect disinterested, fair advice from their health professionals. 

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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