In Hiatus

Dr Dork has unfortunately not been well, and after various scans and whatnot tomorrow is chuffing off to hospital for probably some weeks.

Dr Dork is not au fait with bluetooth and wireless laptops and PDAs, so won't be able to post until he eventually gets back to his crusty old PC.

Dr Dork sends his regards to his readers. All three of you.

Polypill versus Polymeal

A meta-analysis (basically a summary of all quality studies) was published in the British Medical Journal (BMJ) a couple of years back. It became known as the Polypill study.

In essence, it is a strategy to reduce the risk of cardiovascular disease, the biggest killer in Western society. Specifically, it aimed to reduce several risk factors clearly associated with cardiovascular disease, such as blood pressure, cholesterol, and clotting propensity. It provided some evidence that if everyone over 55 or with a history of cardiovascular disease starting popping this combination pill, the incidence of heart attacks and strokes would drop by 80-90%.

There has been considerable debate about this. Some question the methodology and statistical leaps of faith of the researchers. Some question cost effectiveness. A Dr Trewby, a Darlington physician, took the trouble to review the statistical claims in detail. He points out that, "if a typical 55 year old took the Polypill for the next 10 years the chance of benefit will be less than 1% per year and that of side effects 6% overall, some of which (such as aspirin related gastro-intestinal haemorrhage) may be life threating".

"There are three types of lies - lies, damn lies, and statistics." (Mark Twain)

A rather whimsical response to the Polypill proposition was published in the BMJ a year or so later: the Polymeal. By careful wording of statistical results adopting this particular dietary approach suggested a 76% reduction in cardiovascular events.


Ingredients of most benefit were red wine (1/2 a glass a day), fish four times per week, lots of fruit and vegetables, of course, almonds, garlic, and...100 grams per day of dark chocolate. The last one got a lot of lay press attention, that's for sure. Most didn't realise the whole exercise was a bit tongue in cheek, and the evidence tenuous.

Still...my dinner plans for tonight are garlic bread followed by a fish meal, accompanied by red wine, with a chocolate dessert.



Seriously.

RU 486, or against ?

Dr Dork has been wary of even approaching this topic.

Abortion.

This is an ethical minefield.

Dr Dork is not an obstetrician. He is also not a woman.

He is not an expert on exactly what point a termination remains permissible. He doesn't agree with this, though.

There is an interesting medicopolitical debate raging in Australia at present.

It is about RU486.

RU486, or Mifepristone, is principally an antiprogesterone. A type of hormone. It is fundamentally used as a medical, as opposed to surgical, method of inducing first trimester abortion, and also as an alternative to postcoital contraception.

Post-coital contraception, also known as "the morning after pill" (Postinor-2), can be purchased over the counter from pharmacists in Australia. Dr Dork thinks this is a problem. For one thing, those engaging in unsafe sexual behaviour are at risk of various STDs. Including HIV. This warrants professional counselling and education of the risks involved, so that people can make informed choices.

A chemist, on a shop floor, is neither qualified to do this, nor in a situation to do this with any modicum of privacy.

Abortion law is very complicated in Australia. It varies greatly from state to state. In some states, 1st trimester abortion is permissible only if there is endangerment of the physical or mental health of the prospective mother. In other states, it is permissible if there is "social or family risk", with the proviso that "counselling" of some form is given in regards to risks of abortion, and the risks of continuing pregnancy.

It is all very confusing. To cut through all the 'bull'...women in Australia have been able to obtain surgical abortions, if they so desire, quite easily, for decades. It is not for Dr Dork to pass judgement on this.

The issue of late has been regarding an alternative method for an already accepted procedure in Australian society. Some women, if they decide to abort a pregancy early, are at less risk of harm if they choose RU486 over surgical abortion.

There is little evidence which option is generally better, from recent reviews of the research evidence, here and here.

The issue has become more than a matter of science. Generally, matters in regards to approval of medications for use in Australia are decided by the Therapeutic Goods Administration, or TGA. The TGA serves as a risk management review authority of any medication or medical device. It is staffed by scientists, epidemiologists, and other experts in the relevant fields.

The problem with RU486 is that, in 1996, legislation was introduced by our current highly conservative government, still in power, enabling the health minister to veto the TGA on certain matters. Such as RU486. Our health minister,Tony Abbott, is a lawyer with a previous background in economics. He has no training or experience in any scientific discipline whatsoever, let alone health matters.

He is also a staunch Catholic.

A private Members bill to return the decision making process on medical abortion to the TGA is in the process of passing through the various stages of approval in the Australian parliament, and appears likely to succeed. It has become what we refer to as a conscience vote. Even from Mr Abbotts own party, the majority of female politicians have voted in favour of removing his veto.

Dr Dork doesn't like politicians deciding national matters on the basis of their religion. This is a very dangerous and slippery slope to tread.

Church and State should remain separate. Theocracy is a form of dictatorship.



Note: Dr Dork apologies to his NotifyList members...the service seems to be misbehaving.

Grand Rounds

Grand rounds are up at Intueri.

Maria, the author of intueri, is an American psychiatry resident who has blogged through much of her medical training.

Although young, she is thus one of the medical blogospheres more venerable figures.

Intueri mixes personal musings with compassionate and literary tales of psychiatry.

Heroism

It was March, 2005. A balmy Saturday evening in Koondoola, Western Australia.

Terry Vo was 10 years old.

Terry attempted a "slam dunk" on a backyard basketball ring.

It went horribly wrong.



The backboard, basketball ring, and wall, collapsed, landing on Terry. He had one foot severed midcalf, and both arms completely severed below the elbows.

Thanks to heroic efforts by the surgical team that night, all three limbs were reattached.



Eventually, the reattached foot did not take, and is now prosthetic. But Terry still has both arms, and is apparently progressing well in rehabilitation.

This is the real heroism. This courageous young mans positive outlook has never faltered. He has progressed beyond medical expectation.

He was back at school by September. He wants to be a doctor when he grows up.

He is now advocating child safety on behalf of the WA police service.

That is Dr Dorks kind of hero.

Passive Smoking

Dr Crippen of NHSBlogDoc posted earlier in the week on the topic of tobacco advertising that targets children in poisoning children again.

This led to a discussion on passive smoking, and Dr Dork has built upon the opinion he originally gave on NHSBlogDoc below.






Dr Dork doesn't like smoking, to be utterly frank. It is an addictive habit, and it kills many people. Dr Dork doesn't like things that kill people.

If one smokes in the privacy of ones own home, however detrimental to ones health it may be, this harm is limited to, well, oneself. When someone inflicts harm upon others as well, in Dr Dorks mind, it becomes a public health issue.

Passive smoking in confined spaces has been well estabilished to cause harm to innocent bystanders, and to employees working in those confined spaces. Some examples of research are provided Here and here and here and especially this below, which is the abstract from a 2001 meta-analysis (ie. statistical summation of all available evidence) from the Australian and New Zealand Journal of Public Health:

Aust N Z J Public Health. 2001 Jun;25(3):203-11.
Passive smoking and lung cancer: a cumulative meta-analysis.

Taylor R, Cumming R, Woodward A, Black M.

Department of Public Health and Community Medicine, Faculty of Medicine, The University of Sydney, New South Wales. richardt@health.usyd.edu.au

OBJECTIVE: To review the epidemiological evidence for the association between passive smoking and lung cancer. METHOD: Primary studies and meta-analyses examining the relationship between passive smoking and lung cancer were identified through a computerised literature search of Medline and Embase, secondary references, and experts in the field of passive smoking. Primary studies meeting the inclusion criteria were meta-analysed. RESULTS: From 1981 to the end of 1999 there have been 76 primary epidemiological studies of passive smoking and lung cancer, and 20 meta-analyses. There were 43 primary studies that met the inclusion criteria for this meta-analysis; more studies than previous assessments. The pooled relative risk (RR) for never-smoking women exposed to environmental tobacco smoke (ETS) from spouses, compared with unexposed never-smoking women was 1.29 (95% CI 1.17-1.43). Sequential cumulative meta-analysed results for each year from 1981 were calculated: since 1992 the RR has been greater than 1.25. For Western industrialised countries the RR for never-smoking women exposed to ETS compared with unexposed never-smoking women, was 1.21 (95% CI 1.10-1.33). Previously published international spousal meta-analyses have all produced statistically significant RRs greater than 1.17. CONCLUSIONS: The abundance of evidence in this paper, and the consistency of findings across domestic and workplace primary studies, dosimetric extrapolations and meta-analyses, clearly indicates that non-smokers exposed to ETS are at increased risk of lung cancer. IMPLICATIONS: The recommended public health policy is for a total ban on smoking in enclosed public places and work sites.

Note: The emphasis is Dr Dorks. "ETS"= environmental tobacco smoke

It is difficult to design a trial to accurately measure the degree of impact of passive smoking. This is due to logistical problems in measuring the extent of exposure, and also, given that evidence is already there that there is some level of harm, it is highly unethical to knowingly expose anyone to passive smoke.

The evidence is there, it is strong, you just need to know where to look. The evidence of harm is strongest in regards to harm to the health of children and pregnant women. Dr Dork also feels strongly that it is an occupational health issue - does ones "right to smoke" in a pub override the right of the hotel employees to not have their risk of lung cancer, asthma exacerbations, even heart disease be increased ?

Does ones civil liberties, which Dr Dork greatly values, entail the right to cause harm to others in the pursuit of ones personal pleasure ?

Dr Dork is interested in what his readers think. He provides some case scenarios for consideration :

1. A mother of a young child with severe asthma smokes in her car, and in her home. The child has frequent episodes of asthma requiring hospital admission, triggered by the mothers smoking. Is this a form of child abuse ?

2. A pub employee of many years develops lung cancer of a type clearly associated with smoking. She has worked in a crowded, smoky pub for 25 years, but has never smoked herself. Is her employer, the pub owner, liable for her illness for exposing her to passive smoking ?

3. There is evidence that secondhand smoke can trigger acute cardiovascular illness, such as heart attacks and strokes, in those at risk for other reasons. A smoker blows smoke in the face of an elderly gentleman after the gentleman requests he not smoke around him. The elderly gentleman immediately suffers a heart attack and dies. Is this manslaughter ?

This is a thorny issue. Dr Dork doesn't pretend to have all the answers.

If you are a smoker and are considering quitting, Dr Dork recommends you go here.

Absent poetry

Photo courtesy Jerome Leronte, Openphoto

Grand Rounds

Grand Rounds are up at the Science and Politics blog.

A suitably grand diversity of posting from throughout the medical blogosphere this week.

Stem Cell Research

Dr Dork has strong personal views, when it comes to stem cell research.

Unfortunately, this seems to boil down to an issue of theology, as much as neurology.

Dr Dork remembers studying obstetrics and embryology.

The issue a lot of people have, it seems, is...when does a morula, embryo, or foetus become a human being ?

That is a profound philosophical question, not just a scientific one.

The philosophy ? Dr Dork pleads ignorance.

Catholics claim consciousness occurs at the moment of conception. Dr Dork thinks this viewpoint is well summarised here

The science ?

There is no easy answer. Dr Dork recalls from his embryology training that the complexity at 8 weeks is barely that of a fish. Not a dolphin, mind you. A goldfish. Maybe a snapper.

But, Dr Dork recalls, a large proportion of pregnancies, 40% perhaps, spontaneously abort. A lot of these occur due to maternal use of alcohol, tobacco, even caffeine. If Dr Dork was Catholic, would this then be murder?

Dr Dork means no offence to the Catholic religion. His grandmother was a devout Roman Catholic. He wishes to engage in debate, and wishes to air his opinions. He apologises for any inherent offence.

This site gives a reasonable summary of details involved in stem cell research. To an extent, these can even be taken from peripheral blood samples (ie. typical blood samples) in adult donors. Dr Dork knows this from personal experience as well - he has donated his own peripheral blood stem cells for a bone marrow transplant patient with a haematological (blood based) cancer. One is injected with a type of hormone to stimulate more stem cells then these are drained just like a normal blood donati0n.

Dr Dork has much hope for the potential of this avenue of scientific exploration.

In particular, there is a just beginning trend, it seems, wherein stem cells are stored from the umbilical cords of newborn babies. And this is where the real potential lies.

These stem cells have the potential to be developed into any organ. A heart, a liver, a pancreas, a spinal cord.

Dr Dork hopes our children, or perhaps our childrens children, will be free of the spectre of organ failure.

Heart disease is the obvious fear, It is our biggest killer. Imagine growing a new heart, when ones own fails, from ones own blood sample, given at birth.

That is worth fighting for.



Dr Dork would like to thank dragonflylili of Flamingos Hideaway for
emailing Dr Dork in regards to this topic and inspiring this post.

Backdoor Big Pharma

Direct to consumer advertising of prescription drugs is banned in Australia.

"Current Affairs" television is a colloquialism for the evening tabloid news programs that reside between the "real" news and the gameshows.They are "journalism" of the lowest form.

Some recent examples from one called Today Tonight include:
Sex drive solution to be released and
Herbal therapy cures infertility

The last one is Dr Dorks favourite. It has a nice little retraction at the end where it acknowledges even the single case history, which they tout as evidence, is retracted due to obvious confounding bias.

These shows aren't all bad. But they are full of rubbish, fearmongering, false hope and shoddy journalism.

This article in the Australian Doctor magazine refers to a conviction recently against Roche. Roche had sent clearly positively biased material in relation to Xenical, a prescription weight loss drug, to these journalists, which they aired without any particular research or fact-checking. One suspects more was happening under the table. But this is speculation only.

Roche was fined $20,000. A small price to pay for such positively biased exposure. And free advertising.

UPDATE: Angry Doc has posted an eloquent discussion today exploring the relationship between doctors and the pharmaceutical industry. Worth a read.

UPDATE: This post originally vanished after posting. Thanks to AngryDoc who found a copy for him. Dr Dork suspects his computing inability is likely to blame. Apologies to readers.

There have also been some Blogger.com issues this week

All posts are now backed up more thoroughly.

Losing weight

Dr Dork is interested in weight loss. He is not a dietitian.

But many of his patients have obesity as a comorbidity of the conditions for which they see him. It often complicates treatment. It puts them at risk of diabetes, heart disease, certain cancers, among other things.

He often gives dietary and exercise advice to his patients. As should any doctor with a patient who has health problems due to their weight. This involves some finesse and delicacy, to say the least.

It is really up to the patient, of course. There is no miracle cure for this one.

Dr Dork knows it is hard work. He was once 30kg (66 lbs) overweight. He was working very long hours - that was his excuse.

At this time he changed career path, and decided to lose the pork. Despite still working 60-80 hr weeks, plus doing a specialist training program, plus doing postgraduate university study, he lost the weight in 5 months.

He changed his diet, and exercised for an hour 3 out of 4 days.

Dr Dork knows he is going on a bit...but this is a common problem.

Most studies show about 25% prevalence in the UK and Australia...and about 35% in the US.

Dr Dork has complicated views about dietary adjustments. He recommends monitoring calories as the primary intervention.

He believes in "outsmarting your body". Our brains live in the 21st century. But our physiognomy thinks we are still hunting mammoths.

If you eat lots of calories before you go to bed, your body will store them. It is thinking "I don't know when I'll next catch a mammoth". If you eat lots of calories at breakfast, you will generally use them to a greater extent. Your body is in active mode, not storage mode, during the day. Even if you sit behind a desk much of the day.

Dr Dork changed his main meal from evening to breakfast. It was hard for a few weeks. Then he got used to it.

When he has breakfast with his friends nowadays, they accuse him of "feasting".

But it worked.

It boils down to two things.

Eat less.

Exercise more.

Update: Dr Dork originally made the above comment in a discussion engendered by Dr Crippen at NHS Blog Doc in this erudite discourse on obesity management, and the dangerous allure of the chocolate digestive.

A tale of Aussie Guts

Australians are, like any nation, understandably proud of "their own".

Sometimes, creative interpretation of the truth occurs..
Blimey...I sound like an advertising executive.

Phar Lap was raised in New Zealand. As was Russell Crowe.
But we'll bend the rules for the national ego. They're Great Australians.

Sidenote: Dr Dork doesn't agree with beating up concierges. He did like A Beautiful Mind, though.

On the world stage, we are a small nation. Barely 20 million. About the size of Texas.

We take some pride in this. Per capita, we outperform the world at the summer olympics. Mind you, we suck at the Winter.

The story of Nobel Laureates Marshall and Warren is "Aussie" to the core.

They had a revolutionary idea.
It offended the establishment.
They fought. As unknown underdogs.

Barry Marshall ingested the bacteria in question. He gave himself an ulcer.
Risked his life, really.To prove his point.

Namely, that the Helicobacter Pylori bacteria caused most ulcers.

And could be cured.

Cervical cancer and Religion

Dr Dork is pleasantly surprised.

Professor Ian Frazer, an immunologist, (pictured right) has been named as Australian of the Year for his development of a vaccine against the Human Papilloma viruses (HPV).

HPV is the main cause of cervical cancer. This vaccine will ultimately prevent virtually all cervical cancer.

But Dr Dork is also angry.

There has, for some time, been a groundswell of argument from Christian religious fundamentalists against the use of this vaccine. Their argument ?

It will increase promiscuity. What bollocks. It will save hundreds of thousands of lives...as a conservative estimate.

This reminds Dr Dork of the resurgence of polio in Africa in recent years. This is due to the Islamic religious fundamentalist control of northern Nigeria, who harbour strange beliefs about vaccines. Polio was, prior to this, close to going the way of smallpox....complete eradication.

Dr Dork is glad of the separation of Church and State where he lives, and in most of the world. He respects people who have strong religious convictions as much as those who don't. But not when they proselytize. And certainly not when unecessary deaths result.