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.