How the NHS failed me and mine.
What it did, to the most important person
in my life and how it could happen to you unless
we do something about it!

Thursday, 23 December 2010

And Now For Something Completely Different.

The Snow!

Yes it's all the fault of the Government. And the Railways and the Councils and the Airports! The Knobs we've now got in power (literally) should have seen this coming. We had a bad period in late winter of 2009, again in early winter, of the same year (at least where I am) and again early this year. Sufficient to provoke the then Government, to produce a report, about which stuff all was done. This lot are now having another one. We should have had more salt available, but we haven't, despite importing from as far away as, Peru? (You would think, that since we all stopped eating the damn stuff, we'd have a surplus).

According to many investigations, it would cost about £1.5 billion to have the country 'snow proofed', which is, well, not a lot. That would allow people who are vulnerable to at least get out of their house, such as the elderly or disabled without fearing for their lives. Yes it is that dangerous! People fall over in ice and snow and injure themselves. Those injuries can be life threatening, well there's a surprise! Perhaps that's why we have those big buildings, full of people in white coats, in most major towns and cities, d'oh!

Well maybe, if we spent the sort of money, we spend in one week in the NHS to prevent this annual toll of broken limbs, specially hips, in the elderly, and often less elderly, we might have more resources to expend on people who are genuinely ill, not simply the victim of short sighted Government and Local Authorities. Loss to the Exchequer, without computing in these costs, is alleged to be in the order of £1 billion a day! Surely the bunch of shiny faced twats in suits, in power currently, most of them millionaires, can see that! We don't need yet another report, from some 'tame' scientific adviser, who will no doubt tell the Cabinet exactly what they want to hear. We actually need someone to take action to curtail this misery by taking action!

Earlier this year, County Durham NHS, actually gave the Highway Authority a £1 million to carry out extra salting operations, in an attempt to diminish the toll of breakages they had to deal with. It was controversial, and prompted the resignation, of one of the Hospital Governors, but at least they were trying. We spend £2.5 billion to fix broken hips alone in the NHS each year. Surely any politician with even half a brain can work out that we could likely save a good proportion of that by judicious allocation of resources to prevent this or at least ameliorate it. That of course does not reflect the misery and death that ensues from broken limbs, often simply due to the trauma or the operation to fix the problem.

I personally, become extremely nervous, for my bone density challenged love, when snow hits the ground, because I know, one fall could be enough to end her days. And, those with prosthetic hips, break them more easily, because of the greater mass of the metal implants breaking out of bones, factor in the Diabetes and a potential exists for disaster. I therefore buy my own salt, and use it with profligacy, in my immediate vicinity. But, I can't precede each of her steps with a sprinkle of rock salt; clear a path with a snow shovel. I just have to live with the stress. I would like it to be diminished.

Friday, 10 December 2010

Profit in Healthcare- Coming Here Soon.

The ConDem's are forcing us toward a profit based model for Healthcare and Hospital Services, with their policy of 'any willing provider' as discussed in Pulse. Well actually, it did exist before under our old friend Andy Burnham, but he had a bit of change of heart, er, sorry, mind (he allegedly has a swinging brick where that organ should be). AWP is welcomed by some in Medicine although  I'm sure, not by my masked hero. Equally not by the journeyman doctor, whom I also admire greatly.

This is likely to be the result, in a country where Healthcare is always lauded as being better for having to be paid for. You may also find the export of another aspect of US health care, the 'pushing' of particular drugs by Doc's who are paid by Pharma. Great, really looking forward to it. Cheers Andrew, can't wait. You ******* ********!

Phew... that must be my shortest post, ever!

Wednesday, 8 December 2010

Aspirin and Cancer, Will it Help?

Much has been made of the recent meta-analysis of studies that were originally undertaken on the use of Aspirin for the prevention of heart disease. It has been hailed as a cheap and effective method of reducing all types of Cancer and in particular Colorectal Cancer.

So, what is Aspirin? Not a silly question because it has many uses, and is in fact the most prescribed (mainly self prescribed), medicine in the world.

It is an analgesic, so eliminates or reduces pain, usually mild pain. It is also classified as an NSAID, so it is a non-steroidal anti-inflammatory drug, because it's primary mechanism is to inhibit cyclo-oxygenase products in the body (inflammatory agents like prostaglandins). It also has antipyretic properties (reduces fever). In recent years it has been used at low doses as an anti-platelet agent (it 'thins' the blood) in the treatment and prevention of CHD and CVD. Pretty useful then it might seem, but it has been linked to gastro-intestinal and stomach bleeding and is contra indicated for hemorrhagic stroke, all due to this last mechanism.

Patented in 1897 by Bayer, as the synthetic form of the original white willow bark extract, it is acteylsalisylic acid (C9H804), it's patent has long expired but Aspirin as opposed to aspirin, is still a Bayer patent nonetheless. It has been an OTC (over the counter) medicine since 1915. The world uses about 35,000 tonnes of the stuff every year, so despite its low cost, it still turns a dollar for the generic pharmaceutical companies. It should not be given to children, because it can cause Reye's Syndrome which is potentially fatal and is only used for the treatment of Kawasaki Disease, which has nothing to do, with the penchant for riding motor cycles at an early age, but another problem altogether, or for certain types of post operative care, for which it is a useful product, to prevent DVT (deep vein thrombosis). Throughout its long life it has been over and under used, and recently used almost only for heart disease prevention. Many foolishly, I feel, self prescribe it for this purpose, to their cost, as long term use can cause ulcers. Before the widespread use of Acetaminophen (Paracetamol) and Ibuprofen, (when I was young), it was the only analgesic available over the counter. Except of course for Codiene, which was then widely available over the counter; now stopped of course due the possible addiction problems of opiates.

Cutting to the chase, what then is the 'break through' in its use that causes it to be hailed as a cheap and simple Cancer drug?

Well yesterday, the Lancet published details of a study (of studies), undertaken over some twenty years, of the use of aspirin as opposed to a placebo, originally for the prevention of heart disease. This meta-analysis highlights the preventative effect of aspirin for a number of Cancers, but the effect was not apparent for at least five years or even longer for colon, rectal or prostrate cancers. The effect seemed to be better the longer it was taken and the older you were. However, a number of quite large reductions in risk are quoted for this cohort (the one studied) of some 25,000 or so, for various cancers. I have reservations however, as the implied rather than actual, reductions are somewhat lower than described. Relative risk being used, rather than absolute. This paper provides a better explanation of the research involved. The abstract url I have given for the study is in fact pretty brief, and as usual, despite it's importance, one has to pay a fee, both to access all the data, and even more to publish it. Let not medicine, and science, miss an opportunity to make a few quid (bucks) extra, even when we have paid for the research, probably the Institution doing it, and the wages of those involved.

One thing stands out, and that is the length of time you need to take this drug before protection is afforded; between five and seven years. The reduction in 'absolute' risk is also quite minimal too; with a 2%  reduction in the twenty year risk for colorectal cancer, from 3.5% to 1.5%. Overall life time risk for this Cancer is in the order of 5%.

I personally view the enthusiasm with which this was greeted with some alarm. It is being sold as a 'get out of  jail free card' for humans, so they can go forward without changing their lifestyle. That's pretty much the same concept, as taking statin's if you're healthy. Lets medicate everyone, in the hope we'll catch all. Every time we've done this in the past things have gone badly wrong. You used to see bumper stickers in the US, that said " Kill em all and let God sort it out". Well it's the same mindset. Not one I aspire to.

The other problem, and this is true of all meta-analyses, is which of the many studies to include, to ensure there are no paradoxes or selection bias ( such as Simpson's Paradox ).They do have some strengths, but without more reference data to examine it is a little difficult to afford it the credibility of a long term, double blind placebo trial, which may have been too expensive or may have thrown up ethical problems. Also, the usual caveat has to apply; this study is observational and 'observation does not prove causation'. And finally, much has been made recently of 'what the placebo actually chosen is'. If, for instance one included as a placebo, in a trial of diabetic hypoglycemic agents, the obvious thing we believe placebo's to be; a 'sugar pill', we would for sure, get good results for the drug on trial. Although I'm certain that no Pharma company would stoop so low. Well reasonably certain; well maybe there's doubt. Thing is, we simply don't know.

There are plenty of other steps we can all take to limit our risks for Cancer, most of which relate to lifestyle and diet (see my many previous posts) and frankly, they are likely to lower risk, far more than the use of aspirin. But, if you have a family history of Cancer especially bowel cancer, then look at the risks. Maybe it would be worth it, for someone with a robust gastro-intestinal system and no history of problems, such as ulcers, IBS, gastritis etc.

Aspirin is a fairly simple chemical medicine, and I do applaud the use of simple solutions to complex health problems, because there are plenty out there. I have considerable doubt however, that this is one to adopt universally.  There are many more, even simpler that work. I will write about these soon.

Saturday, 4 December 2010

The Things They Do To Women. Part Two - Osteoporosis.

Is it 'disease mongering'. An unholy alliance between the WHO, 'Big Pharma', the FDA, and the Medical Machinery Cartels, or is it a genuine desire to better the lives of post menopausal women? Let's look at the evidence.

First of all, let's define what the problem is. If you or a loved one has had a DXA-scan any reading below -2.5 is seen as osteopenia not osteoporosis. You have the precursor to osteoporosis. Your bone mineral density is low but even if it's 2.5 (that's -2.5SD) you are not ill, you are just getting older (unless you have hyperparathyroidism that is). Most will be women and postmenopausal. Why? Well, the menopause alters the hormone level and that to some extent governs the levels of osteoclasts and osteoblasts. The former remove density and the latter build it, in a natural process that lasts most of our lives. As the repository of calcium, the bones will give it up, when the body needs it elsewhere, and reabsorb it when it does not. Largely the process is governed by the parathyroid, but also the levels of Vitamin D3 and intake of calcium from the gut have a part to play. As we get older, our ability to keep our bones strong naturally declines, so it happens to us all, with very few exceptions.

Men are somewhat less susceptible, as they do not suffer from the loss of hormones in the same way as women, but men do get it, but it is less severe or predominant than in women. So none are ill, just getting older. Why then is any importance attached to it?  Well, it can be crippling to a very small cohort, who have repeated fractures or their spine starts to crumble. These are rare, but becoming less so. But all of us lose some bone density, as part of the ageing process, it is inevitable. Calcium supplements are often prescribed, or they, were until a scare about these being contributory to MI (Heart Attack), in women went about, but on the whole western populations do not suffer from any scarcity of calcium, in the diet. We do suffer from a dearth of both Vitamin D3 and magnesium however, which can be contributory to bone density and is hypothesised by some to be part of the reason for density loss.

However, if we all lose some density as we age, do we need to diagnose it as an illness? We don't, unless our careers are determined by looks, do much to hide wrinkles, or hair loss or the myriad symptoms of ageing. What's so special about bone density? Well, it can make money, a lot of money. Both for the makers of dual Xray absorptiometry machines and 'Big Pharma', who produces various drugs which are alleged to halt it's progression or even increase density. Largely targeted at women (of course) these machines measure the absorption of radiation and via an algorithm and express this as a T-score. If you are thin or heavy the measurement can be 'skewed' as the algorithm is based on thickness of the bones and averaged out. So thicker/thinner than average can alter the true result.( If you do get a scan, then try to have any repeats done on the same machine, to ensure differences are measured against the original). But overall the scan itself, is not really dangerous as it uses very low levels of radiation.

"Bone mineral density testing is a poor predictor of future fractures, but an excellent predictor of the start of drug use."said Barbara Mintzes, in the BMJ, not so long ago. She was referring to the alliance between Merke and the makers of DXA scanners, formed at the outset of the Osteoporosis 'Industry' (1995). Their drug, Fosamax, was the first in the market. It suppresses the action of Osteoclasts and as a result, bones become harder, but, not necessarily stronger. Tensile strength tends to be lost and bones becomes harder but more liable to shatter. Like glass or an eggshell.

Biphosphenates have been linked to the very problem that they were designed (allegedly) to prevent. As well as thigh bone fracture they have also been linked to Necrosis of the jaw bone. Frankly they are also pretty awful to take as well, requiring that you do so on an empty stomach, with copious amounts of water, stand or sit upright for half an hour, all to prevent damage to the oesophagus, for which it is alleged they can cause cancer. What are they? Well, pretty much a type of washing soda; in other words a pretty caustic product and you drink this? Would any man do this? I think not. This information might help in any decision. but the overwhelming evidence is that Alendronic Acid (Fosamax etc)  will only decrease the risk by some 1%, at the expense of exposure to some quite horrific side effects, let alone the misery of taking the damn stuff. A simple but scientific explanation is detailed in the link that may help.

As may be realised, I am a little partisan about this problem and there is little science available in the form of any real studies. Most available, were undertaken way back in the 1990's, and by 'Big Pharma', who had much to gain from sales of a new product for a new 'illness'. The bone the drugs strengthen, is cortical bone (the outside layer). They do little or nothing to strengthen trabecular bone (the internal core). So an overall increase in density will show up on a DXA scan (although not a lot) but it will be predominantly cortical density, which will do little to nothing, to reduce your chance of fracture (absolute reduction of 0.5%). A warning, although a somewhat low level one has been issued from the FDA about the use of these drugs causing fractures. It seems to be related to the length of time of use, but my feeling that time should be never.

The intake of Cola drinks has been associated with bone density loss, so it's a good idea not to drink them. They're pretty toxic any way as I have related previously, so it's not a loss. Drinking milk, won't really help although many will tell you it will. But dietary calcium is abundant, the trick being to boost absorption, without any associated heart problems, so Vitamin D3 intake needs to be increased especially in winter when the sun is low and you're wearing lots of warm clothing. So supplementation is needed. At least 1000iu but maybe a lot more. So get a 25(OH)D3 test to ascertain levels. Take load bearing exercise and indeed, any exercise that helps to maintain suppleness (Pilate's?). Asian women suffer somewhat less than Western women, in general, which is attributed to their intake of fermented soy products. Soy is said to boost or even emulate Oestrogen, but I emphasise 'fermented' soy, not that Soy, the Food Cartels sell; that is not what the Japanese consume, so leave out the appalling soy milk. You need fat, to metabolise Vitamin D3, because it's fat soluble, so 'low fat' is not a good idea if you want to boost bone health. Oh, and fortified dairy products use inferior synthetic D2 not D3, which is poorly absorbed. Best use full fat 'real milk'. You know, the one with the cream on top, preferably Jersey, Guernsey of Buffalo.

 It should also be understood that a DXA scan result is a 'surrogate end point'; that is, a marker chosen by those, who wish to sell a drug, that alters that end point. It does not guarantee you will not get a fracture, or indeed reduce the risk by more than 1%. The 'clinical end point' would be an actual fracture. But intake of a toxic substance that largely does not do 'what it says on the tin', is merely to line the pockets of  'Big Pharma', to no useful purpose. It is likely, that if we screened every woman over 50, for bone density, the overwhelming majority would be found deficient. You see, the starting point, the zero on the T-score is a woman in good health at 30. So set the score impossibly high so most will fail to meet it and you have the largest cohort to treat, all of womankind.

Tuesday, 23 November 2010

The ConDems NHS (What Do We Make Of It So Far).

Well er... not a lot!

Six months down the line from the lack of any decisive victory over, well anyone, lets look at what has been achieved and what is planned.

GP Commissioning has been lauded, as the only way forward for the majority of Healthcare within the NHS. It is the Lansley answer, to all the previous 'top down', centralised decision process, that hallmarked the reign of NuLabour, but is largely the path that had already been ordained by Andy Burnham, before his demise as Health Secretary (and what a piss poor one he was). There is some 'spin' to this. GP's are the front line of all Medicine and Healthcare. The first point of contact (except for A&E), where the public becomes patient. Thus, it is posited that they should control the purse strings and commission any services, or treatments that, spring from that Primary Care role. In the process, we largely rid ourselves of the cumbersome and expensive, Primary Care Trusts (PCT). Except of course, that for all their faults the PCT's did most of the Admin, the Commissioning and Governance. And of course they provided the 'out of hours' cover the GP's wriggled out of for 6% of salary.

If then, the GP's are to cover all of this, they will have to undergo a step change in roles. One that they have little or no experience of, and, judging by the lack of enthusiasm displayed by many, one they have very little desire to fulfill. They will likely have to engage some of the Managers they have expressed considerable disdain for, or another organisation to undertake all the 'back office' work. Step forward the Private Sector, be it in the form of the 'Big Four' accountant/management bodies, or one of the many Private providers (Welcome to the Boots - Price,Waterhouse,Coopers, Healthcare Consortia, operated on behalf of NHS UK plc). I do not wish to be a merchant of neither doom nor gloom, but a void tends to be filled by the one who is quickest on their feet, and these people are pretty damn quick. When you ( a GP) are floundering in a mire of bureaucracy and red tape; have no real idea of the ramifications of what your new role needs, to give it credibility, with the National body that approves your Consortia; if someone offers you a 'model' that removes the doubt, many will grasp it.

Maybe some will gravitate toward the 'not for profit' social enterprise model, which could be a good thing, but the pitfalls and dangers, not the least of which is the very real possibility of 'inheriting' the debt and forward contracts of the existing PCT's, which Lansley has said he will not cancel or guarantee, may well put you off. Put you off, without the sort of financial 'clout' and dubious, but successful creative accounting capability of a well known Accounting LLP (remember the inspired auditing of the Banks that got us here in the first place).

And what about assuming the role of procurer of the drugs and supplies, now that NICE is to be emasculated? How do you evaluate the claims of 'Big Pharmas' products and devices, in a world of pitfalls and dubious trials, all proclaiming much, but generally delivering very little, except possible death in a bubble pack? How do you evaluate and procure an out of hours service for your patients? Do it yourself? There is a singular lack of enthusiasm to go back to that, I'm sure. Certainly from the sigh of relief that emanated from BMA Towers, when the Government gave it to the PCT's to provide, would lead one to that view. And, I'm pretty sure that giving GP's their 6% back will be met with howls of derision as an inappropriate value for such an onerous task.Will you spend your hard won budget at the local trust Hospital or contract with the ISTC or even BMI for routine operations?

I am not certain that such decisions should, or even could be made effectively by GP's. I am certain that many will not even want to. This is the largest change in Healthcare since the birth of the NHS. Whilst consultation is taking place, it is largely with those organisations, that most feel have failed to deliver a just and fair NHS that addresses inequalities; the GP bodies (see last post). I do have hope; not a lot, because I have little faith in any breed of Politician, especially those that are trying to make me happy, whilst removing hope of any prosperity in the next, how ever many years. I'm not at a time in my life, like many others, where there are years available to me, to observe these policies through to any conclusion.

I despair of the much that is happening. The complete madness of a 'responsibility deal' with the major fast food retailers (McDonald's, Pepsico etc) is akin to placing regulation of game keeping with the poachers. As is enjoining with the major food and drink suppliers, to promote 'health'. That any of these, will actively pursue a policy based upon any motive, other than self interest and profit, is somewhere between naivety and lunacy. They already produce products laced with the toxic, man made, chemicals that have likely caused much of the ailments that modern flesh is heir to. To devolve even more power of damage to these architects of high carbohydrate diets, infiltrated with High Fructose Corn Syrup, Soy fed meats, Hydrolysed Vegetable Protein and other injurious additives is madness of a scale only to be found in the USA. Do we wish to emulate a society where the food lobby guides Government Policy and the Drugs Industry then feeds off the damage? Because that is where we are going. If Lansley and Cameron have their way, that is where we will arrive.

PS This is one view. That from the Black Tower. If nothing else it is amusing.

Thursday, 18 November 2010

The Dept. of Health in the Dock (again).

The Editorial in the Lancet this week upbraids both Politicians and Doctors (mainly GP's) for failing to address Healthcare inequalities. It's is not very kind to Health Officials, and targets the Permanent Secretary particularly. In less than edifying language Margaret Hodge, was scathing about the failure to deliver the promise of NuLabour to remove these inequalities, despite the vast increase in the NHS budget and thirteen years of power.

The editorial was particularly strong in it's condemnation of the Profession and GP's in particular, for the vast rewards they have reaped, since 2005, when they took on the new contract. This saw income rise to an average of £105k, with some making £250k, by virtue of the bonuses paid for the achievement of goals within the Quality Outcomes Framework (QOF). These were mainly politically motivated objectives, that saw routine Healthcare reduced to a target culture, whereby GP's could derive payments for taking and recording things like blood pressure, or BMI, for certain patient cohorts. Worst of course, was the need to attain certain levels within QOF to reap a reward, which heralded the 'lipid' testing of perfectly healthy people, and the subsequent dosing of them with statins, or antihypertensives (whether they needed it or not).

Substantively, I agree with the sentiment of the Lancet article, although some of the detail is a bit 'overblown'. After all, some the GP's, who stand accused of indifference to their patients plight, may just have been exercising some scientific 'triage' of the goals set by various QOF's, and found them wanting of evidence of efficacy, and simply ignored them. Well more power to them, but why don't they stand up and be counted? As for Hodge, well she has an appalling record, in voting for all the Blair reforms in Healthcare, including the setting up of Foundation Trusts, yet she has obviously now 'seen the light' and wishes to align with the patient. The report is here.

When the 'blessed' Tony came to power in 1997, he was in a unique position. The majority of the country saw him as a reformer, with an evangelistic zeal, to drag Healthcare and Education into a new dawn, with reforms that were purported to be  based on scientific agenda, not the thinly disguised and hugely expensive, 'privatisation' of these core needs of the populace. Instead, he failed to carry through his promises but gave us the 'spin' of his continuation of the previous lot's desire to sell off the assets we all owned, for a handful of beads and a sack of corn.  Neo-Thatcherite to the core, he embraced private sector solutions to the urgency of improving Health (and Education) that were hugely expensive, and with it spawned legions of highly paid management cadres, who sucked up most of the money, building 'empires' to justify their ludicrous elevation within Healthcare.

He fostered many of the 'Quangos' that the ConDems are now pulling apart, on the premise that Governance was all about measuring process, at the expense of outcomes. The disenchanted Doctors, many of whom hated the rhetoric, failed to champion their patients and saw the chance to better their position by negotiating a new deal that placed them as financial equals to the Consultant cohort. Some at the time (2005) could not believe that they escaped from out of hours cover, for a paltry 6%. One of the senior negotiators for the BMA, even said he thought they were "having a a laugh". And, of course they were, all the way to the Bank! This single act alone hugely increased costs, but more; the outcome of QOF was to elevate costs even more, as the tests to prove it's effect spiralled.

So, money was spent that achieved little of any substance, other than the enrichment of most within the NHS, except the 'coal face' workers, who found themselves more and more, isolated from the patients they were there to serve. Management found ways to cut costs, that deprived patients of standards of care enshrined in that contract we all have with those we pay to help us when we need it. Emerging from this, large numbers of complaints began to arise, that then gave birth to a whole new Bureaucracy, given the task of 'managing' these. Not, I must add resolving them, because that does not seem to have been the objective. Obfuscation, delay, and even lies, were then employed, to prevent the delivery of truth, justice or candour. 

Well, that was then, and this is now. The Coalition has suggested, even promised to change, all that has gone before. But Neo-Thatcherism is not dead, and now lives on in all politicians, with little to separate any from all. Practice Based Commissioning was already being rolled out by Brown's lot, before he lost the election. Calling it GP Commissioning does not change it, although at least it was not wholesale, it was a slow 'rollout'. Wholesale change, may be a good thing, although trying to cut a ludicrous 20% in the process is both unrealistic and unattainable. It will be just the same as before; figures will be produced to prove it's happening, that some Select Committee in five or ten years time, will tell us were untrue. Some very good people will lose their jobs and evidence based Healthcare will continue as before, without any evidence to back it's ludicrous policies. We'll all get fatter, get Diabetes, Heart Disease and Cancer and interventions to allegedly reduce the incidence will fail, just as they have for the last thirty years. The good Doctors will retire early, the bad one's will become leading lights in GP commissioning. Everything will be different, but stay the same.

Oh, and patients; you thought you had been screwed already, now you're really going to be f****d.

Thursday, 11 November 2010

Is This How To Run A Railway?

No, this post is not about the appalling Railway system of the UK. It is an analogy for the NHS.

As the ConDems savour their power, with increasing confidence, imbued with the enthusiasm of born again Christians, maybe we should compare it to that which occurred, when the major transportation system of the UK was sold off to the highest bidders, ( the lowest, in truth)  for each region, or service. The end result of the Tory plan was a disjointed 'mish mash', of competing companies, supported by ever increasing volumes of Taxpayer Gold, that made millionaires of some, bankrupt  a few, and produced a worse service than we ever saw under the old British Rail. We also saw the rise and demise of Railtrack and its substitution with Network Rail, the governing body of the Industry and owner of the Infrastructure. It is a Company Limited by Guarantee and thus has no Shareholders. The DfT is a member, but does not own it. It pretty much does what it likes because Blair, who set it up, did not want the sort of Governance that had plagued him with other bodies. The result has been a huge increase in accidents, poor or even absent maintenance, overcharging, overcrowding, lack of any real democratic input or control.

So what has this to do with the NHS, one might ask. Well we are going down the same road. NICE is to lose its role of cost benefit analysis and negotiation with 'Big Pharma' the (piss poor) Care Quality Commission will be replaced by Monitor, because all Trusts will become Foundation Trusts. PCT's will become no more, being  replaced with GP Consortia in the role of the Commissioning bodies; poacher and gamekeeper under the same hat. ISTC's, the 'Big Four' accounting and management bodies (PwC, KPMG etc), will be handed roles on a plate, to organise or even provide services,despite their complicity in the debacle of Banking Audit, and the Private Healthcare companies, are 'to be encouraged' (bribed), to bid for contracts, to provide and commission services, for Healthcare. And the useless Complaints System will become a battleground of even more complexity and futility, being hamstrung by the lack of any Public Scrutiny brought about by the constitution of the changes.

Just as in the Railways, there will be a bewildering array of bodies, organisations, some spawned from 'Big Pharma' themselves, all trying to make a profit out of misery and accident. The rigid safety mechanisms overseen by the military precision of the engineers who ruled British Rail (nearly all ex REME engineers) was supplanted by companies who lost lives due to lack of safeguards and planned maintenance. The result has been escalating costs, obscene profits, lack of forward planning and danger to the passenger.

For passenger, substitute patient and you will see what I am getting at.

Thursday, 21 October 2010

The Things 'They' Do To Women.

As many who read this blog will know, I am a critic of the current and highly flawed practises perpetrated upon women by Medicine. It is my belief, that many interventions, alleged to be for their good, are in fact counterproductive, and include in these, breast cancer screening, with mammography and the use of HRT  (hormone replacement therapy). I'm also pretty convinced that most of the treatments persued in 'curing' cancer, especially breast (and prostrate cancer), are ineffectual to a large extent, but I'll save that last bit for another day.

Postmenopausal HRT, was hailed as a breakthrough in assisting women adapt to life after child bearing years were over, both in maintaining their femininity and easing, or eliminating the symptomatic 'hot flushes' (flashes for the yanks). This is obviously something many women prized as an outcome, because it seemed like an 'elixer for youth'. Well, it turned out to be something completely different, and for some it was a death sentence. In JAMA yesterday, the results of  an 11 year study of a very large cohort of women was published that concludes, that combined HRT increases breast cancer significantly; well, in the cohort study, it was nearly doubled. Worst still was the fact that the type of cancer was node-positive, not the 'benign' type that 'Big Pharma' had already acknowledged was more likely when on HRT. How any breast cancer can be viewed as such boggles my mind but hey-ho, drug companies often use such terms as their stock in trade. Highly regarded (by me anyway) Paul D. Maher also highlghts this study in his blog today, which may mean great minds think alike, (would that I was as credentialed or clever as he) but maybe not. 

Well, it was already known in 2002, that the Women's Health Initiative Trial (WHI) was halted due to evidence of harm, and that many advocates ('Big Pharma'), refuted this as being purely observational and as such inconclusive. Whilst I still hold to the view, that observation does not prove causation, at the same time, observed harm, is a serious problem.worthy of urgent and serious investigation. After all whilst the use of 'extract of pregnant horse piss' may have afforded women comfort in menopause, it was hardly something worthy of risking one's life to eliminate. Amongst the many charges leveled at HRT in both the 'combined' form and Oestrogen only types are;-
  • Heart Disease
  • Stroke
  • Lung Cancer
  • Blood Clots
Insulin Resistence is also attributed as being a highly possible side effect, which may throw some light on the high incidence of Type 2 Diabetes amongst post menopausal females. That's a hypothsesis only, but there does seem to be some anecdotal evidence for this. Once more the drugs industry stands charged with producing dangerous products that do much more harm than good. Well, no change there then!

Friday, 15 October 2010

Acedemic Arrogance in the Matter of CAM.

In the matter of Complimentary and Alternative Medicines (CAM), much has been said by both medical bloggers, Doctors and Clinicians. Such words as 'wibble', 'mumbo-jumbo' and other derogatories, have been usefully employed to deride CAM. And, sections of the protocols employed within CAM, have been highlighted to prove the point. Homeopathy and Acupuncture particularly, have been held up to the light of day, and pronounced as worthless, and without any scientific proof of efficacy. I heartily agree with this view, and would apply it to quite a few other aspects of CAM. But, I do think, that to classify everything outside of mainstream drug protocols and the medical 'mainstream' as useless, is nonsensical, counter productive and further, it is arrogant in the extreme.In many ways, it also flies in the face of a number of treatments already adopted by many Clinicians.

Physiotherapy has become an essential part of recovery protocols, or even primary interventions for many, both in Hospital and in the Community. Yet, it is, in strict terms 'complimentary', to Medicine and Surgery. So get your terms right Doc'. If the use of specific vitamin supplements by Medics is invoked, again you are venturing down this road again. Some will recommend or even prescribe fish oil concentrates, to certain patients (Amcor). This is of course despite the fact, that the NHS will be paying through the nose for an expensive version, of that which can be obtained, 'over the counter' from quality sources. But that's the problem we have with NICE; they often recommend (or don't) the use of particular products based upon flawed or skewed evidence, or simply price.

In the matter of evidence, a lot outside of the 'mainstream', is viewed as being without any evidence of efficacy or safety, when the truth is that there is wealth of well constructed trials, just as good, if not better than those conducted by, or paid for by 'Big Pharma'. It's just that Clinicians pronounce judgement without even bothering to look for them. It used to be a widely used protocol in coronary heart disease, to utilise magnesium both in IV form as well as orally. It is also viewed as a major deficiency, especially in the elderly, and with the concentration in the diet, of 'industrial foods', is also becoming a deficiency in the wider populace. Supplementation, is now the only way to ensure an adequate intake due to it's depletion in the soil and consequently the food grown, and animals who live on it. It is essential for human metabolism and a deficiency, is linked to many diseases as well as CHD. But prescribing it, and taking it is CAM. Yet it is embraced by many, both within and without Medicine. It is also the subject of much research as shown here and and here too.

Moving onto drugs; there are number currently in use that owe their existence to CAM, which of course embraces herbs, vitamins and supplements. Metformin, the drug almost of first use, for Diabetics, is the synthetic form of French Lilac. Statin's, for what use they are, are the result of a poison found in China called Red Yeast Rice, and of course many, if not most of the older drugs in use, especially analgesics, are all based on, or made from natural sources (Opiates). In fact in the early days of medicine there was nothing else, as anyone who has studied its history can attest. In many ways, some herbs can afford results to patients, that are better, or as good as drugs, and usually (but not always) with fewer or no side effects. The problem arises, that treatments, based on this type of medicine, yields little or no benefit to the Drugs Industry.' They' love to 'patent' everything, so as to make money; lots of money. It seems in fact that 'Big Pharma' and some Doctors view disease as an income stream, rather than something to cure, and patients as a means to a handsome livelihood.

Doctors also advocate diets. Diets are part of CAM. Most of that, which they tell the patient, is counterproductive, because they do not keep up to date with research, or slavishly follow the advice of vested interests of the Drugs Industry, which requires dietary input to legitimise its drug protocols. This often flies in the face of common sense (high carb diets for Diabetics) or legitimises heavily flawed, or unproven hypotheses such as 'fat causes heart disease' (see last post), but diets however, are part of CAM, so curb the hypocrisy, Doc' you recommend diet all the time! Just because it's the wrong one does not change this.

There is much within CAM that is wrong, so wrong it boggles the mind. It is full of 'snake oil salesmen', some legitimised (they think) by being actual Doctors, MD's that is, not simply graduates of some obscure institute on the 'net. Some will flog you a pendant, that will change your life, or a bracelet to cure your arthritis. Others will promise you explosive sex if you take their herbal concoction. But beneath it all are some good and honest practitioners, who utilise the best of both schools of thought and will resort to drugs when needed. One particular area dear to my heart, as a Diabetic carer, is the reckless use of antibiotics for Urinary Tract Infections.

A simple treatment with a sugar derivative, called D-Mannose, cures the bulk of UTI's that stem from E-Coli, but by a different mechanism. It simply attaches to the bacteria preventing it adhering to the bladder wall and is flushed out. It cures about 80% of common UTI's

Closed minds. Hubris. They all contribute to the arrogance displayed by many in Medicine. The dismissing of everything outwith drug protocols peddled by 'Big Pharma', or the politicised advocacy of useless or even harmful diets, displays the lack of any real pragmatism in Healthcare. There is some light; some are now looking to supplements such as Vitamin D3 and CoQ10 as a means of supporting patients immune systems. Some will even advocate lifestyle changes as a means of curing rather than simply treating symptoms with spurious drugs that prove to be more dangerous to the patient than the ailment with which they present. More power to them.

There is a place in Medicine for all that is science based, but sometimes a gamble has to made. You can't do a double blind placebo trial in humans for UTI's with D-Mannose. It would be unethical. But I can attest to it working. And I became very seriously ill with it, and had three courses of antibiotics and was diagnosed with possible cancer. It wasn't I'm pleased to say, but I and many others (not all) could be spared that and the NHS much cost if this simple protocol was invoked. There are many others; most inherently benign. Is it not time at least to try a middle road?

Tuesday, 5 October 2010

Andrew Lansley, Evidence Based Nutrition and the NHS.

Chis Kresser aka the healthy sceptic highlights the fact, that the new 'Dietry Guidelines for Americans' is not an evidence based document in any way. Considering it is the first complete update since 1977, with the intervening years being significant, in that despite the uptake of low fat, high carbohydrate diet, both CVD, CHD and Diabetes have increased dramatically. The Committee, seems to have conveniently ignored this fact in its deliberations and closed it's mind to any view, outwith conventional one's peddled by the moron's that govern Healthcare in the US and of course, in the UK as well. Because it is certain, that these guidelines will form the basis for those recommended for UK citizens be they Diabetic, Obese or suffering from heart disease

 Some scientists, so affronted by the lack of science displayed by the report and its lack of evidence in its conclusions, have seen fit to write a critique. You can read this here.  It is important to do so, to realise the depth of stupidity that is often displayed in advice handed down to the populace by this or indeed almost any Government.

In the UK, we will soon see, the closure of the Food Standards Agency (hurray) with the role being assumed by the Dept. of Health (boo). And we are told by the Secretary of Health, one Mr Lansley that;  “I am committed to improving the public’s health by providing evidence-based advice to support people in making healthier choices. The transfer of nutrition policy in England to the Department of Health means we can give the general public more consistent information". 

I do not know, whether to be pleased to hear this or not. It depends greatly, which evidence he will base this policy upon, and whether there is any real desire by the current coalition, to make a sea change in policy that will effect real improvements in Health, for the populace and at the same time save money, because there is little doubt in my mind that basing criteria for nutrition upon  real evidence based guidelines, will indeed achieve significant cost savings and real improvements in health.

If we are to view some policy decisions already made, such as the 'scrapping' of the piss poor Private Finance Initiative for Schools, which would have seen huge, but 'off balance sheet' costs being borne by council tax payers to fund schools, planned by  'NuLabour', then there is hope. So far this model, for Hospital building has created worse constructs, than would otherwise have been the case, together with huge costs to the Taxpayer. For instance, the new Birmingham 'super' Hospital, as reported in Private Eye, will cost some £2.6bn over 35 years for a build cost of £627m. However in that same journal we learn that despite the criticism leveled at 'NuLabour' for their "flawed PFI model"  by a Mr. Osborne, that there are now "no plans to review the use of the private finance initiative, as a procurement vehicle in the National Health Service".

The future looks even bleaker for justice and candour too. With the emphasis on GP commissioning and Foundation Trusts as the future of Healthcare, we will no longer have any sort of public scrutiny of , well just about everything. Public access, to what will be Private Consortia, in the case of GP's and closed meetings, as is the case with Foundation Trusts, will make the public even less informed than now. Which is little hard to contemplate. As 'social enterprises' they will also be immune to Freedom of Information requests. If the LibCons, really want enjoin with people in discussing our futures, this decidedly seems the wrong way to go about it. Nothing new there then!

Wednesday, 29 September 2010

More Drugs for Diabete's - Back to the Future?

Way back in the mists of time, chemists discovered a glycoside compound from the bark of apple trees that had a profound effect on glucose disposal in Diabetics. This extract, called Phlorizin, brought about glucosuria, which is the excretion of glucose in the urine. It also to some extent also caused polyuria (excessive urination). As these are often symptoms of  Diabetes itself, and as it was only 1835, it took a while for it to be viewed as anything that could be useful. As time went by experiments were undertaken to find a use but it was not until the 1970's that the mechanism of the compound was discovered and named. Sodium-Glucose Co Transporter-2  inhibitor (SGLT2)  is what it became and is the current theme of most research, for yet another drug for Diabetes.

I say yet another, because rather than using the original compound, which was in fact poorly absorbed in the gastro-intestinal tract, 'Big Pharma' needed to come up with a better 'mousetrap' in the form of a synthetic compound that could be patented, so that money could be made. Frankly, I find it a little alarming as the way it works is to inhibit the capability of the kidneys to 'save' glucose from being excreted in the urine. This a process discovered, that the kidneys perform, to conserve vital energy in the body and functions at a certain level. In Diabetics with high circulating glucose in the blood, the kidneys filter out the excess and do not conserve it all, as with normal humans, hence both glucosuria and polyuria are symptomatic in the Diabetic with low level control of hyperglycemia. What these new experimental drugs aim to achieve, is to enhance this phenomena, outwith the normal kidney function, so that the process 'kicks in' at lower levels of concentration. It does this by inhibiting SGLT2 in the kidneys.

 Astra-Zenica are conducting trials of their contribution to this wonderful idea at present; it is called  Dapaglifozin and is being developed in conjunction with Bristol-Myers Squib.What is important is the unintended consequences that may ensue from this, and the effect it may have on kidney function in the longer term. These may be obvious to many Diabetics with a grasp of their problems and the primary one is the enhancement of urinary glucose. All Diabetics are prone to urinary tract infections and genital fungal infections. This is largely because of the high glucose content of their urine, as bacteria and fungi feed on this. Low levels of glucose and acid urine inhibit this but Diabetics struggle to maintain this and, as a consequence get this type of infection and use antibiotics regularly as a result. This of course adds to the problems most already have and exposes them to long term or repeated incidents of UTI's for which ever more drugs are prescribed adding to the polypharma to which they are all subjected. To expose them to even more risk in this area seems somewhat counter productive.

In addition these drugs thus far have not displayed a great deal of success and are viewed very much as an 'add-on' protocol, for use with other hypoglycemic agents, such as metformin. They do enhance the performance of of these agents and lower HbA1c a little, but nothing startling. They also do enhance weight loss to a small extent, which is usually a good thing for a Diabetic, but, is it not about time, that science stopped its constant search, for a fix for something that is easy to stop. Reduce the glucose level at source, by stopping eating carbohydrates to any extent and Diabetics ease the burden on their already overburdened pancreas, and both the need or at least the volume of drugs needed is reduced or even eliminated.Of course that presents a problem for healthcare and especially 'Big Pharma'. So much money is at stake, both for them and for the NHS, which spends in excess of 10% of it's entire budget on Diabetics. The gravy train would halt and quite a few employees would no longer be needed. Turkeys voting for Christmas, I think not!

It also goes to show the panic in the Industry at the moment to come up with new ideas for drugs because patents are fast expiring and little is in the pipeline. There has been nothing of any significance, discovered  in Medicine in nearly twenty years, except more 'me too' drugs or new strains of the old one's. So they are turning once again to the old favourites such as cancer or diabetes. They've peddled useless or near useless and dangerous drugs to these cohorts for years, without any glimmer of a cure and it's costing them billions in compensation for some, such as Avandia, the cost of which has virtually wiped out GlaxoSmithKlines profits for the whole of the last year. Makes your heart bleed does it not?

It would be nice for a change to see research being directed at a cure, for some of these ailments or at least some acknowledgement that lifestyle changes can be just as effective as taking a store cupboard full of dangerous and often self-defeating drugs. Perhaps that is asking for the impossible.

Tuesday, 28 September 2010

At Last, Some Real Evidence of Efficacy of Omega 3's

This study , at last gives credence to the view that Omega 3 oil, in the right quantity and mix, alleviates some of the worst elements of depressive illness. (Sorry about the quality, but the cached version is free).

There have been a number of previous studies that were inconclusive from a scientific standpoint, but such interventions were viewed as relatively benign, except where high levels were consumed, when gastro-intestinal problems ensued.. The difference here is that the effect was dose related, with a high EPA to DHA level. And in a relatively low dose. It was also a high quality study conducted as a double blinded placebo trial. This is the 'gold standard' we all seek to give proof to a hypothesis. In addition, the cohort was suffering from major depression, not the "I'm feeling a bit low", type, but full blown serious depression, that can challenge life itself. Patients with co morbid anxiety symptoms were not shown to improve, however, so this group derived little benefit from the trial.

It ticks every box of study protocols, It was long term, of a size to be significant, but most of all the scientists involved went to great lengths to ensure even the placebo tasted the same as the genuine oil capsule. Sure, it was supported by the makers, in that they supplied product, but there is no patent on fish oils, so no real axe for them to grind, other than the satisfaction of proving a hypothesis, long held anecdotaly, but always never quite proven categorically. It is also significant that the cohort using other antidepressant drugs in addition to Omega 3's also derived little benefit.

Omega 3's have long been associated with a number of health benefits, quite numerous in fact. They are viewed as an anti-coagulant, an anti-hypertensive and have been associated with pain relief in arthritis. A number of studies for all uses have been undertaken, but most owe their origin to the study of nutrition in the Inuit of Greenland in the 1970's, when it was found that the Eskimo (Inuit) consumed large quantities of polyunsaturated fatty acids from their diet of fish. They also consumed even larger quantities of saturated fats as well, but that's another story. This diet even if confounded slightly by this, did seem to confer a protection from heart disease, stroke and hypertension. Consequently these long chain fatty acids became a 'must' for health.There are a few downsides, perhaps with consuming very large quantities, in that those prone to bleeding, say into the brain (hemorrhagic stroke), or with Type 2 Diabetes could worsen their symptoms by consumption, but on the whole it is relatively benign and is attributed with health improvements.

It is important that the EPA (eicosapentaenoic acid) content is somewhat higher than is found in most proprietary capsules with a ratio of 1050mg/d EPA to 150mg/d of DHA (docosahexaenoic acid) so some addition of EPA to a standard capsule regimen may be needed. But pure EPA capsules to enable this are now widely available. I also, personally feel, that 8 weeks is quite a short time for full benefit to be derived, as I found, certainly with my arthritis that real relief was not felt for almost three months. but that is my anecdotal experience. It seems, again anecdotaly, that the lessening of depressive episodes that I had been having, was more a side effect of taking Omega 3 for arthritic pain. The underlying problem of osteoarthritis, of joint deterioration, is of course not improved by this regimen, it is merely a means of pain control without the use of NSAID's.

Any one wishing to follow this protocol should engage with a medical practitioner, if at all possible, prior to commencement, and ensure that it does not, reduce or enhance the effect, of any medication already in use. This is especially important for people on Warfarin or Heparin protocols as the anticoagulant properties of Omega 3's can be pronounced in this cohort.

Friday, 17 September 2010

Evidence (or lack of it ) Driving Healthcare Objectives.

Healthcare has always been a Political subject. Back to the founding of the NHS, when Doctors railed against the deprivation of their 'Demi-God' status, by a State funded machine, to the Quality Outcome Frameworks of today, the Government, of the day,  has tried to manipulate the public, and to some extent Doctors too, to achieve 'goals' that they feel are cost effective or laudable. Some were self evidently beneficial, such as the, largely, but not entirely, elimination of killer diseases such as polio. But as time has elapsed and various Governments have come and gone, the systems that guide and govern the protocols for health, have been corrupted by the concept, that Medicine has the answer to all of mankind's ills; that a 'pill' can always be devised that will fix virtually any and every problem that humanity faces.

Science itself, has been corrupted in many ways. Studies are now undertaken almost exclusively by makers of drugs, prosthetics and diagnostic machinery. Very little 'peer review' of the outcomes or dangers is undertaken, except by those same makers. The manufacturers are now corporate entities that span the globe and have sales in excess of small (and not so small) countries. Their influence in our everyday lives has become both persuasive and pervasive and sadly, Medicine and Healthcare slavishly follows the hypotheses propounded by various segments of the Public Health Community, the Regulatory Bodies, the (so called) Charities, all, who stand to gain, from the perpetuation of a disease, condition or ailment, because elimination would hail their demise.

Each feeds on the other, perpetuating the appearance of scientific unanimity, about a health benefit for which there was probability, which becomes a certainty. Drugs only prescribed for seriously ill cohorts, then become beneficial for the 'worried well'. Protocols are invented to guide what we eat, drink, spend our leisure time embracing, all guided by dubious healthcare benefits, for which there is weak evidence of any good or useful outcome.  Powerful tools and organisations promote goals for which there is no real opposition, because it is not brooked, even in the face of incontrovertible proof that it is of no benefit, or worse, that it does harm. Possibility, becomes probability, and then certainty. Everything is presented as such; rational discussion is absent. Advice becomes diktat and all dissent is marginalised.

National policy currently advises us all that;-

Fat makes you fat and causes heart disease - not proven.
Cholesterol gives you heart disease - not proven, in fact proven to be false.
Statin's lower the risk of heart disease, in everyone - proven to be false.
Statin's lower heart attack risk in men with heart disease - now viewed as unlikely.
Hypertension (high blood pressure) is caused by salt - contradictory evidence therefore not proven.
Regular Mammograms save lives - in fact they do more harm than good.
Cancer rates are falling - not true, we are just better at extending the lives of those with it.
Heart disease rates are falling - as above.
Five-a-day lowers heart disease risk - in fact no benefit accrues.
Five-a-day lowers cancer risk - in fact there is little to no benefit except a small one for the vegetables only.
Green leafy vegetables lower diabetes risk - very little benefit.

The list is becoming too long, so I will stop now to save boredom setting in, but I can prove everyone of these tenets of healthcare to be either wrong or of so little benefit as to be virtually worthless. So how come the public doesn't know this and the bodies for whom we look to guide our health continue to peddle this worthless drivel? Well it's complicated. 'Big Pharma' and the food and drink industry have permeated all the agencies of the state and Politicians are so busy perpetuating power that they are indifferent to reason or dissent. Conclusions about healthcare are presented to the public with such forceful conviction that no balance now exists with the strength of the evidence that guides them or any that opposes it. There is a view that only the Politicians and the professionals that guide them, can weigh the evidence and they often view these protocols as inherently benign. So no harm then? Well er .. yes, but let not the truth guide you, if you are a Politician or 'Big Pharma' or the Food Standards Agency etc.etc.

Friday, 10 September 2010

Continuity of Care in the NHS (Joined up Medicine).

This tenet of Health care has long been regarded as the ideal, by most if not all Practitioners. It is the best way of safeguarding the patient from errors and mismanagement, be it in Hospital or the Primary Care Unit, such as the GP's practice. Most Trust's trumpet it as the pathway they all adhere to, but the reality is far from the rhetoric.The Kings Fund views it as being essential to the patient experience, whatever that is, and is researching and asking for input to achieving this goal. So what is it that is going wrong that prejudices patient safety and causes the almighty 'cock ups' that occur with alarming frequency in some of our alleged 'best' (sic) hospitals?

Well we do not have enough good Doctors or probably not enough Doctors at all. That is Doctors, who are either prepared to follow a patient through treatment to discharge, or ensure an adequate handover to another at the end of shift. And by good I mean adequately trained and motivated, not some 'wet behind the ears' youngster, virtually straight from medical school, tasked with the job, of taking care of numbers of wards, and patients on the night shift, with only a 'phone number to obtain Consultant backup. And of course with the knowledge, that it would take a major disaster to drag him/her off the Golf Course or away from the dinner guests.

Not 'joining the dots' seems to be the biggest problem. Looking at symptoms in isolation without looking at the history, making judgements about treatment, without reviewing the notes and tests, that some lab technician has worked through the night, to deliver in time for the operation to be scheduled, or not? Not bothering to see the patient prior to treatment, and failing to provide sufficient information for patients to provide informed consent, due to the unbridled hubris that many display in their protocols and procedures. It is this lack of a continuous care pathway that leads to the sort of disaster that has befallen heart patients at the Nottingham University Hospitals NHS Trust, who failed their patients due to lack of diligence, in ensuring that information about serial episodes of endocarditus was not passed on to others, which in turn allowed lives to be lost without need.

It is far from the first time that this Trust, which is a major Teaching Hospital with intake of 500 F1's per year, has made the headlines. It is in fact rarely out of them, as my friends at National Death Service will attest. This is just in one week! Joining it all together, so that bewildered patients actually get to see a Doctor more than once, during their Hospital stay would be a first step. Actually reading test reports prior to giving dangerous general anaesthetics to people without first knowing, if that act alone might kill them might be the next. Acting on the results of tests, with knowledge of the patient history, is the foundation of treatment. It is not something you should leave to some half baked F2, at midnight on a Friday, whom you have conversed with on your mobile, and directed them to list a trauma patient,  for operation, without seeing them, reading the notes, reviewing the tests and discussing informed consent. Yet it happened. And lives were irretrievably changed, and one almost lost.

Was there any contrition, any meaningful attempt at redress or even candour. Was there even any honesty in providing a prognosis for the future or information of any improvement intervention. Was there b******s. The attitude seems to be, that one should be grateful for having one's life threatened, when you entered their halls, without a life threatening injury; be grateful for surviving. Such compassion. Such empathy!

And there was Peter Homa, standing in front of his Gulag, apologising profusely for the death of the innocents who consigned themselves, to his and others care at his Trent Heart Unit. Only he doesn't care and he never will. Otherwise he would resign, and let someone else take the helm of this graveyard of unnecessary deaths.

So far as the NHS is concerned, it is getting worse as the statistics for Complaints attest. And the bulk of most harms are down to errors. And errors occur most of all when the simple stuff goes wrong. Not the heroic interventions, the open heart surgery, because it was not that, that killed the patients. It was a simple bacteria, that could have been guarded against by protocol. But only if the information had been pieced together. The evidence chain is important, but it is not being given the emphasis needed in today's NHS. Everyone is so busy filling in the screen, the report, the check sheet, that they then fail to read, or take action about. The Doctors can all howl as much as they like, but they are too callow and spineless to do anything about it. They are usually too busy working out the superannuation, and the date of their retirement.

Monday, 6 September 2010

Panorama Highlights Drug Danger to Diabetics

The controversy over Avandia continues to rumble on, and the BBC have at last picked up, that it can cause heart failure in patients, despite the fact that it's makers continue to defend its use. John Briffa, as you see, has warned about this before. But as usual, the machinery of control in the UK, the Medicines and Healthcare Regulatory Agency is once more on a 'go slow' as regards it's withdrawal. Meanwhile more Diabetics may die or be harmed by it's use and Diabetes UK sits on it's hands (Some surprise).

The sad story of Avandia started in 1999 and it was approved for EC use in 2000. It belongs to a group of drugs in the usual 'me too' ranges marketed by 'Big Pharma', called rosiglitazones. They are thiazolidinediones or TZD's (a lot quicker to say, so let's do that). TZD's are PPAR-gamma angonists, which simply put, increase  fat cell generation, as means of increasing glucose disposal. Pause a moment there, because are we not always told, that glucose, is not responsible for fat, but that fat is? So the excess of glucose, probably borne of the excess carbohydrates, you are told to consume as a Diabetic, is being metabolised, more rapidly by gist of this medication, and the mechanism it uses to achieve this is to make you fat! And this is to lower the risks associated with being Diabetic?

At this point I and my few readers may wish to lie down in a darkened room and ponder the logic of such a protocol. So I did and I still cannot see the sense in such a stupid idea, but 'Big Pharma' seems incapable of  going beyond treating symptoms, with measures that bring about others, usually to the detriment of the poor souls who consume the drug. Well, as far back as 2004 there have been rumblings about the drug, with calls for the US FDA to ban it, and 'black label' warnings have been applied to the packaging, warning of the possibility of fluid retention (oedema) which in turn can cause heart problems, but an outright ban has not been invoked
The NEJM of June 14th 2007 (New England Journal of Medicine) highlighted the fact that Avandia was associated with a high risk of MI, which was some time ago but as usual little to nothing was done and millions of prescriptions continue to be filled, both in the US and Europe including the UK. The ACCORD Trial was halted due to safety concerns over this, and similar drugs and a number of clinicians are at last raising serious doubts about the validity of all drugs trials, due to the incestuous nature of the (often) authors links with the drugs industry, the grants paid, structure of trials and the withholding of essential data to enable proper independent peer reviews. Well, no shit Sherlock! An increase of 43% of heart attacks, in people that took Avandia for 24 weeks seems pretty conclusive to me!

I also find it unprincipled and alarming, that in most trials, the only way that the full data can be accessed is by paying for for it! The BMJ has a lot to answer for in this by having a pay wall between it and most data other than the (often) 'piss poor' abstract. This is often manipulated to give a 'slant', that is not borne out by the data in the full document. Most if not all trials are in fact paid for directly or indirectly by the drug companies who have vested interests in specific outcomes, and adverse results are often 'buried'. Some principled Doctors and Scientists have condemned this. Perhaps tonight's Panorama programme will delve more deeply into this aspect of 'Big Pharma's' persona. I'm not holding my breath however.

Thursday, 2 September 2010

Freedom (well of a sort) Maybe

She cupped her hands, lifted them high, and said "it's time to fly free!". I told her she was a sarcastic bitch, but I knew from the smile, she was just joking. And so we parted. It was the end of an era; an episode in my life that had been perhaps the hardest I had to endure. But she had helped me come to terms with a life less ordinary, that has taxed my identity, my very being at times.

She came to be, that very significant 'other' in my life, someone I became dependent on to help me find a path through the swamp of misery and self loathing I waded through. Someone who became my emotional crutch, my guide, mentor, teacher and so much more. She was all that I did not believe therapy was all about. I have always been a sceptic, a doubter, but this woman treated me with respect, with kindness and did not hector, condescend or in any way act like that I had assumed a therapist would.

She gave me permission at first, to be this incoherent wreck who almost lost the last thing left in his life, and then went about destroying himself in blind rage at the iniquity of it all, and in sorrow for all my failings, as a father, husband, son, and much more. No one had ever done that before, especially for me. I was the serpent, the destroyer of lives. I was not worthy, so I set about proving just how pointless, it all had been, and in the process, nearly lost, that which I had sacrificed much of my wealth, my status, my self worth, for.

Over quite a long time, she set about restoring my soul. That essence of life within us all, that lets us get through each day. With kindness and humility, she teased out, all the horrors, in the Stygian corners that harboured my bleak outlook, were laid bare. I came to depend on those hours; one a week. Sometimes with tears, often with black humour, and eventually, some laughter. She fortified my well being sufficient to face each day. I relapsed many times, but as time went by she tasked me with visits to my worst fears, the place, the time, the events that had shaped my life, and had brought me to her in terror and misery.

I think I owe her my life, and yes, it did get that bad. I had experienced much stress in life, and trauma, as have we all. But I had no idea of what Post Traumatic Stress was about, except that battle scarred soldiers sometimes suffered from it. I really had no idea that I could get it. But I did. It's a dark and terrible place to be. Those who visit it's halls are always left with scars, often worse one's than those that brought them down in the first place. She taught me to honour the experience, that it was not a weakness, merely a symptom of strength that had been stretched beyond it's limits.

Then, she said one day, not too long ago, that we had to part; my time was over. It was her job to impose her own redundancy upon our relationship. I viewed this with some trepidation; fear even. It seemed again that she had trumped the stereotypical view I had held, that this does not happen, that therapy goes on for years. Keeping the fees coming, the subject held to dependence, always seeking new areas of one's psyche to explore, was my cynical take. Well, I had been wrong, and now it was a bit scary to be alone again, responsible for negotiating my own way across the swamp, without a guide!

I kept putting it off, saying I was not ready, that I still had issues we needed to address, but she pressed me, hard. Implying if I did not do it, she would have to. All of course, in the nicest possible way. I have a backstop, an escape route, if all goes wrong. I can ring her for help, talk again in a few months time. In some ways our relationship had changed, with me preempting some of her strategies, even teaching her a few things about my knowledge of the side effects of drugs. I even think she humoured me sometimes to cajole me into taking the reins, not being lead.

It has been a journey. Some of it even a saga related. But. it's over, at least for now and she has my gratitude, my thanks, for leading me into a slightly less dark tomorrow. I hope to be able to walk again without that crutch. I wish I could tell her name, but that would betray all the tenets she lives by. But thank you, you know who you are, and hopefully now, I know who I am too..

Tuesday, 31 August 2010

Big Mac, Cheese, Fries and HMG-CoA Reductase Inhibitor?

Do you want statin's with that sir? Yes it really did happen. I thought it to be one of those urban myths; a play on words of some journalist. But no, Darrel. P. Francis of the British Heart Foundation did actually do a study, with others, that suggested we take a pill with our Big Mac and fries. I kid you not!

Now Darrel seems quite a prestigious guy. He's an FRCP (Fellow of the Royal College of Physicians) and reader in Cardiology at the National Heart and Lung Institute and, he has a list of published works as long as, well, several arms. He has travelled the world lecturing and studying, it would seem, and undertakes work for the British Heart Foundation. You can, if you are really bored, read the 6 page pdf of his report here. I wouldn't if I had something else better to do, like watching some paint dry, but I would not want to be accused of not representing his view in full. But what a load of b******s. Is this really serious research? More importantly is this what our hard earned taxes and charitable donations are for?

The details of this study contradict the many recently undertaken (and many from the past) that indicate that intake of statin's do not confer any protection to low risk or indeed high risk cohorts of those likely to fall prey to CHD/CVD (see posts passim). This study confirms, that even persons admitted with heart attacks, did not have high levels of LDL, which is the reason why statin's are generally prescribed in the first place. Makes one wonder why anyone would want to take them then! Especially with the ketchup for the fries!

And what's the fat got to do with it? It's the bun (high carb plus it's wheat), the fries (high carb plus trans fat used for frying), the burger (well some saturates but more, it's cheap, lot fed beef with high polyunsaturate content from soy meal). Oh let's not forget the shake. That will be sweetened with high fructose corn syrup, bulked with protein powder and is as far away from real milk as it's possible to be! So, all in all, it's something I would not recommend eating to almost anyone. Well, perhaps a few, at the Food Standards Agency, or Diabetes UK, for instance because it fulfills their stupid criteria of 66% carbohydrates, and might rid us of a number of those who have advocated diets that cause positive harm and increase obesity.

All in all, I do concur with Darrel, that it's not a meal to be eating at any time, but to advocate it to be taken with a statin. Well that's a step too far. It plays to the gallery of stupidity embodied in healthcare at present that advocates intake of harmful substances, like carbohydrates in abundance, and to then take a drug to ameliorate the effect of such intake. Such as hypoglycemic agents for Diabetics. I suggest that Darel et al take their study and stuff it where the sun doesn't shine, along with the statin's they advocate!

People like this, do not gift the population, with the brains they are born with. They feel the need to inject fear into the populace, as a means of manipulation of diet, that flies in the face of common sense, that since low fat has been the mantra of healthcare for the past thirty years, all they have achieved is more sick, fat people, not less.

Thursday, 26 August 2010

Still No Integrity ?

Doctors have difficulty with reporting colleagues for incompetence or impairment as shown by a recent study in JAMA (Journal of the American Medical Association). In fact 31% of Doctors surveyed would not report a colleague. Yeah, OK, so 67% said they would but it's often quite easy to say when it's purely an academic situation. When polled most of the population always say they would do the the 'decent' thing in most situations about integrity, but to be a 'whistleblower' takes a lot of b***s. A lot of the time it is so much easier to cross on the other side, turn a blind eye and other such idioms because all too often the outcome is to 'shoot the messenger'.

Doctors (along with policeman), even when brought to ordure, have a knack of escaping the justice they deserve, but that is often a result of the naive belief in civilised society that the Law has anything to do with Justice, which it patently does not. We only have to refer to the bolam test to see that 'joe public' has the weight of the establishment pitched against them, if he or she questions the integrity of Medicinae Doctor. I think probably, since Hippocrates demise, doctors have contrived to cover their a**e in the event of an error of judgment or treatment and their colleagues have generally tended to back them up with an implacable wall of rhetoric, obfuscation and on occasion lies. The Management of Health care, primarily the NHS in the UK, has grasped this mettle also and we now have non-medics colluding with medics because they could also stand accused with their (often hated) colleagues.

There are allegedly, bodies to safeguard the public against the dangers of medicines excesses but it seems they have consummately and consistently failed to achieve any measure of success in this if one examines the results. Over some years, the number of bodies tasked with invigilating over Doctors, indeed all aspects Health care have burgeoned, some would say out of all proportion to need. Most have heard of the GMC, NMC who directly license Practitioners ( Doctors and Nurses that is). But we also have the National Patients Safety Agency, Medicines and Healthcare Regulatory Agency etc, etc. In fact there are a legion of bodies all monitoring this or that, some I'm sure quite uncertain of what they are for at all, and of course many monitoring overlapping areas. They burn money (some of it mine) and produce reports in their area, of alleged expertise, with tedious content couched in the language of the bureaucrat spattered with that hated word 'facilitate'.

It is not surprising then that Doctors grow weary of the 'target culture', the spreadsheet and the top down diktats of apparatchiks that often rule their lives, if they are not Consultants that is, who pretty much do what they like most of the time. A few of them even become Management, but generally, The Management are hated by Doctors, especially the good and caring one's because they get in the way of them and their patient cohort. However, that does not excuse the Profession from a lack of integrity or individuals from spineless indifference to patient care. It does not excuse the GMC and NMC from failing in it's duty to discipline adequately it's licence holders and instead to vent it's spleen on those that care enough to stand up and be counted. Or indeed to conduct it's show trials of those who have seriously betrayed the tenets of care and then let them off with minor punishments or codicils for future conduct that are meaningless in the face of the enormity of their sin's.

The future, under the last Government was invested in the possibility of a change, and I say that not without some trepidation. Because most change in the NHS has been for the worst, with funds being squandered on pointless and tedious bureaucratic interventions and organisations that have contributed little (nothing?) to the need for justice and candour in the event of medical errors and incompetence. But, looking at it's remit and the structure of the Office of the Health Professions Adjudicator  it did seem that we might be getting somewhere. Well, now it seems that this infant body, is probably going to die at birth and then be incinerated on the conflagration of the Quangos that the LibCon's are lighting up with glee. I am not convinced. For the paltry sums involved it is worth at least a try at changing the landscape of justice for the legions of the dead and injured, sacrificed on the alter of the hubris of Doctors.

A consultation is taking place at the moment. It is important that the voice of the people is heard above the clamour of the Profession and bean counters. The NHS Justice Group has some words about this from the inimitable George Kuchanny. Have your say!

Saturday, 21 August 2010

The Study

 Much publicity today from scientists at the University of Leicester who have undertaken a prospective cohort study and found that Green leafy vegetables reduce Diabetes risk.

Well would that it was true. If it was certain I would for sure be dancing a jig (not a pretty site). But hold the front page, because I'm pretty sure that this observational study, sadly does not really prove any causation. There was much hype on the Today programme (a much admired breakfast radio programme), which pretty much allowed 'Arnold spokesperson' for said University to say what they liked, in support of this study. Including of course the inevitable conclusions that eating 'five-a-day' was good for us and should be part of a 'proven' lifestyle agenda. If one actually reads the study, or rather the extract, because you can only read the full study by buying it, the only reference to fruit and vegetable consumption was to say that NO significant benefit accrued.

This study I use as an example of the virtually worthless research that is being undertaken with my money to prove something that some pompous Medic thinks might be true, but can't really prove even when they have done the study. It is an established fact that the brassica family are a useful source of vitamins and minerals and even anti-oxidants. How much protection these can impart is still somewhat in conjecture, although it is some. What is proven, even by this study is that fruit and vegetables generally or even in isolation do not impart any protection against Diabetes. Earlier studies have proven that fruit and vegetable consumption imparts little, to no protection, from cancer and heart disease (see posts passim). The protection that is claimed in this study was of a 14% reduction in the risk of becoming diabetic; not a huge amount one might say but nonetheless worthwhile. And, whilst I am convinced that leafy greens are good for you, I do not feel that this rather poor study does anything  to advance the cause of that particular food group because it has been linked to an opinion about fruit and vegetables that is not evidence based.

I quote from the study,"The summary estimates showed no significant benefits of increasing the consumption of vegetables, fruit, or fruit and vegetables combined". So why then did Prof. Davies state in her interview that eating 'five a day' was intrinsic to good health and implying, as a consequence that it was proven by this study, by association? Her own data actually states the contrary. She is then advocating once more, the unproven, even dangerous ( for diabetics and the obese) advice that we should eat fruit and vegetables in abundance. Root vegetables, most fruits and potatoes in particular contain an abundance of carbohydrates and fructose. Sucrose (table sugar) is made from  root vegetables. Fruits are made into 'smoothies', those appalling thick concoctions of fruits that allow all '5 a day' to be condensed into a small bottle. So that busy people can get their 'health fix' in one shot. This is madness! Feeding this, as medically sanctioned nutrition, for diabetics is madness. Telling fat people to do this is likely to make them fatter and could push them into NIDDM. This is from a Professor of Diabetes Medicine! (Whatever that means).

This is I feel indicative of the way that so much scientific endeavor is now going. Producing endless meta analyses (studies of studies), vast databases of observational material that is nothing more than correlation. Remember 'correlation (and observation) does not prove causation. It can provide one with the hypothesis upon which to conduct a proper trial. But it proves little else other than association. One astounding element is that at no point was the Professor was questioned by the journalist about this statement. Do journalists no longer do any research about the subject of their interview?  Or they all part of a conspiracy to subvert the truth? Well probably not. Just p**s poor at the job. Come back Paxman wherever you are!

Thursday, 19 August 2010

August is a Dangerous Month.

Hot on the heels of the need to reduce costs in NHS Hospitals, which will reduce the numbers of Locum Doctors and Agency nurses, used to prop up the systems inability to provide adequate patient care, come the new intake of trainee doctors. These young men and women will now begin the 'on the job' training essential for their careers. But, with less mentors to assist in this endeavour, they will increasingly be thrust into the front line and will assume roles they are ill equipped to perform. August is the first month of their many rotations in all the aspects of Medicine and will likely, in these initial months expose those they treat to more dangers than perhaps would otherwise be the case.

Particularly, at the moment, some Trusts have openly admitted they are unable, or unwilling to pay out the vast sums they have, any longer, on temporary staff to cover both holidays and the chronic absenteeism prevalent in the NHS. In fact one Midland teaching hospital with a new intake of F1's of 500, has clearly stated that the deployment of these, to all corners of the Hospital will ease their current staff shortage. So looking forward to emptying a few bedpans then, Doc or perhaps running the mop over the floor?

The current Government of the LibCons is looking for savings everywhere, irrespective it seems, of any endeavour to ensure it does not damage safety or regulation. I will be the first to applaud the demise the f**k wits at the Food Standards Agency, but that does not mean that I wish to see the end of regulation. Trusts have taken on board the softening of 'target culture' with a vengeance; getting an appointment now seems to have been stretched to an horizon of a seascape. The realisation that the PFI has cost so much is now dawning, and some will have to utilise vast proportions of their curtailed budgets simply to meet the extraordinary costs of maintaining these Hospitals and Health Centres for the next thirty years, from dwindling resources. So the youthful (mainly) intake, will be used more and more, at the front line of health care. Attached to this will be the consummate risks to the patient, whose care will be in the hands of doctors 'in training'.

Worse, their mentoring by more senior staff, already at a low, will be further eroded, perhaps to breaking point. Mistakes in Health care are in my view at an all time high. And whilst the NHS can and does excel in the area of Trauma and Emergency care most of the time, it is complete crap at aftercare, health advice and routine medicine. CHD and CVD mortality has been falling for years, but incidence continues to rise. Whilst breast cancer  mortality is falling, we still have one of the worst rates in Europe. For a country that spends over £100billion on the NHS we are achieving extremely poor results for that vast sum.

I would strongly advise all who are planning to be sick and in need of a Hospital to postpone until at least December, to give these would be Doctors time to get a bit more experience, before you venture through their doors! And to those who are venturing down the road of becoming a healer, I entreat you to heed the words of Hippocrates, " I will use treatments for the benefit of the ill, in accordance with my ability and judgement, but from what is to their harm and injustice I will keep them".