Monday 29 December 2014

Bootin' Gluten!

               I haven't read  the latest dietary fad book yet, Dr. David Perlmutter's 'Grain Brain', but I have read a couple of reviews of it by informed reviewers.   Of interest to me is the  fact that in fifty-five years of  medical practice I may have seen a dozen or so cases of coeliac disease and a few possible gluten sensitivities but the astronomical numbers claimed today are absurd.  It never ceases to amaze me that in this and other fad books, an article of faith  seems to be that if only we could get back to our 'natural' hunter - gatherer diet we would prevent a litany of degenerative diseases.  These 'experts' seem quite able to ignore that life expectancy on the regimens that they are recommending was thirty to forty years and that not many lived beyond fifty.   Diseases and malnutrition were rife and most people didn't live long enough to get the degenerative diseases that they claim the diets protect against including Alzheimer's Disease and other neurological , psychological and physical diseases.  Dr. Perlmutter's suggestion that a diet consisting of 75% fats is healthy  and that carbohydrates are poison is closer to nonsense that commonsense.  What amazes me is how many people have bought and taken for gospel this book, recommended by Dr. Oz.  That alone should make  people wary.  In most instances the research is tenuous. It is ironic that the other great dietary boon to humanity quinoa, of the amaranth family appears to be one of the offending grains!
In fact, gluten intolerance may not even exist outside of  coeliac disease.  In 2011, Peter Gibson, a professor of gastroenterology at Monash University and director of the GI Unit at The Alfred Hospital in Melbourne, Australia, published a study that found gluten, a protein found in grains like wheat, rye, and barley, to cause gastrointestinal distress in patients without celiac disease, an autoimmune disorder unequivocally triggered by gluten. Double-blinded, randomized, and placebo-controlled, the experiment was one of the strongest pieces of evidence to date that non-celiac gluten sensitivity (NCGS), more commonly known as gluten intolerance, is a genuine condition.  When Gibson repeated his study under much more rigorous conditions he found that there was no relationship between gluten and the patients symptoms.
     ( Sales of gluten-free products are estimated to hit $15 billion by 2016 — that’s a 50% jump over 2013′s number.)
         Another problem with Perlmutters recommendations is the potential to do harm.  There is a vast amount of evidence to support the  general concepts of the heart healthy diet, not least of which  is the decrease of cardiovascular mortality and morbidity.   

Source: Biesiekierski JR, Peters SL, Newnham ED, Rosella O, Muir JG, Gibson PR. “No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates.” Gastroenterology. 2013 Aug;145(2):320-8.e1-3. doi: 10.1053/j.gastro.2013.04.051. Epub 2013 May 4.

Thursday 25 December 2014

The Rotunda Hospital, Dublin.

               The Rotunda Hospital, where I learned where babies came from and how difficult it could be sometimes to get them out, originally known as "The Dublin Lying-In Hospital", was founded in 1745 by a surgeon and man-midwife who was appalled at the conditions that pregnant mothers had to endure at the time. It was the hospital where my wife was born. It was originally a charitable institution so the hospital had several public function rooms in which fundraising activities were held. One of these areas was a large rotunda, after which the hospital is now named. The Rotunda (round room)is now the home of the famous Gate Theatre. The Rotunda Hospital is the oldest extant maternity hospital in the world. It was the training centre for Obstetrics and Gynecology for Trinity College Dublin and is where I got my midwifery and gynecology training.
                 Many of the deliveries took place, not in the hospital, but on the "district", that is, in the homes of the pregnant women. Some of these homes were slums in which no one should have had to live, let alone have babies. Although it may sound hazardous, there was an effective back-up team. When a woman was having a home delivery  (by far the most inexpensive way to be delivered), a family member, often one of the many other children in the family would run up to the hospital and announce "Me Mammy's having the baby.  Come quickly!"   Often it was baby eight, nine or ten, so labour could be pretty short.  The core delivery team was the mid-wife and two medical students and upon receiving the call, the mid-wife would mount her bicycle and head for the home to assess the situation. If the patient was indeed in labour, she would send a message back to the hospital to dispatch the students on call to the home. We joined the midwife and she, clearly in command, instructed us and supervised us in examining and assessing the patient. Thus we received all our early practical experience under the tutelage of the midwife. Of course, we had received all the theoretical instruction at lectures and clinics and watched the specialists work their miracles, but the 'hands - on' experience went to their interns and residents and not to us lowly medical students. Lest you fear for the poor patients, there was an efficient 'flying squad' operating from the hospital that could have a highly efficient team out at the house, usually within minutes, at the call of the mid-wife or the students. This included an obstetrician and an anesthetist and we could do things in the home that would not be done outside an hospital today. Despite the fact that many of these slum homes were far from clean, our infection rate was extremely low because patients had resistance to their own germs. Often the dwellings were one room and we had to rig up a screen so that the woman could have some privacy from the other five children and her husband. That's just the beginning of Rotunda Days and you  will be hearing more about them in the weeks to come!
               Let me know if you'd like to hear more!

Monday 22 December 2014

3 years to become a Physician - gimme a break!!

Why are we shortening Medical degrees?/            
              When I started to study medicine it was a five year course, now it's a four year course.  Looks like even that may be changing!  When I started studying Medicine in the fifties in  the British isles, it was a five year program and we wondered when it would be extended to a six year program.  It seemed there was so much to learn and the rate of expansion of medical knowledge seemed to be growing so rapidly  that it would be impossible to master the required knowledge in  the time available.  
              Many years later when I became a faculty member at the University of Saskatchewan College of Medicine, I was quite sure that we had a program that was exceptional because of its five year duration.  I was disappointed when that fifth year was eliminated to fall into line with the rest of North America and thought it a retrogressive step.   That fifth year, known as the Junior Undergraduate Rotating Student Internship (the students known as JURSIs) was in my opinion a remarkable year that allowed students to reflect on what they wanted to do  for the rest of their lives.  Somewhere between students and interns, it allowed them to take responsibility in a graduated manner and it also allowed for adequate elective time for the students to gain exposure to the specialty that they might consider entering, when most students were making that decision based on  what they imagined it would be like.  They were encouraged to do the electives of their choice globally, provided that the sites met with certain basic requirements.  Thus these young men and women were able to observe a very broad range of both medical practice and of life styles.  Some gained amazing experience and insight of medicine and life outside of their home environment and some just had fun.  In either case it was an enriching experience and contributed towards their maturity  and understanding.     Notwithstanding my own biases as a residency training director, I was convinced that the fifth year contributed to both the medical and life skills of our graduates when compared with the four year graduates of other schools including ones with international reputations.  That extra year was evident in their skills on the wards as well as their general confidence and comfort  in dealing with both patients and colleagues.
           As an increasing number of schools contemplate reducing the curriculum to three years, I fear for the future of my profession.  No doubt they will turn out competent enough technicians, the administridiots will see to that but I doubt that they will turn out dedicated graduates comparable to the committed physicians of the past, who had more  to contribute to the healing arts than technical skills.
                                   Ars longa, vita brevis.   Hippocrates

If you have any opinions on  this, please share them.

Friday 19 December 2014

The Medical Dog and Pony Show!.

       I just happened to walk by my  television  set and see a section of one of those sensational and often misinforming medical shows.  So I stopped for a moment to listen and watch the ex fashion model and now expert on all things medical, perform.  I caught the end of a section on sunblockers which was essentially the same old boring stuff dressed up a little in scientific terminology and was just about to walk on and go about my business when Act II started.   This was a thirty-ish woman who told the interviewer that she had recently been misdiagnosed with multiple sclerosis by a physician and mentioned he had done an MRI, as close to a definitive test for MS as there is.  The lady decided she was not going to take any treatment as she didn't think that she had MS.
     "So did you get a second opinion?" asked  Carol. "Everyone should do  that if  they have any doubts."
     "I did," said Pt.
     "And how  did that work out?"
     "I didn't agree with that doctor, either!"
      "So did you get another opinion?"
      "Yes," said the pt." I got several more, and it wasn't until the TWELFTH that I found a doctor who knew what she was doing!"
      "Oh, tell me about that."
       "Well, she got me to keep a food  diary for a week and then after she  studied it she was able to tell  me what was wrong!"
        " And?"
         "It was gluten allergy and I stopped  eating gluten and now I'm better!"
          Gluten is responsible for everything these days, everybody has it.   Strange.   In fifty-four years of medical practice I might have seen a dozen or so cases.  It's certainly the flavour of the  week these days.
           Multiple sclerosis exacerbates and remits and its course can be extremely variable.  Nowadays  there is effective treatment to prevent exacerbation and at least delay  the progression of the disease.  This woman  may indeed have had a total remission but I very much doubt that it has anything to do with her  gluten free diet.  I  hope she is not missing a treatment opportunity.     Maybe she needs one more consultation!

Monday 15 December 2014

Back to Sex! ( or Sex to Back! )

         Reading the science and technology section  in a several weeks old copy of  'The Economist' lately, I came across an interesting  study completed at the University of Waterloo,  just down  the  road from me.  Waterloo University has been researching positions for sexual intercourse that work best for different kinds of back pain.  They are offering doctors hard evidence (sic) to base their recommendations to patients upon.  The research documents the way the spine moves during sex and postulates that certain positions are better than others.  They tracked how ten couples' spines moved in five different sex positions.  They created a set of guidelines based on which movements cause pain.  There appears to be two components of the study, one studying males and the other studying female positional distress.   Younger folk are usually bothered most by flexion movements, while older people tend to be more stressed by extension.  They used infra-red motion cameras to track the movements for twenty seconds of sex in each position.  They describe the positions studied.  Subsequently., the full range of their back movements were calculated to establish their maximum range of movement.
        The research, published in 'Spine' will be developed into a fuller guide to sexual positions. The team plans to study other positions.
         What a shame that in my years in Academe if I had made a proposal like this it would have been greeted by hoots of laughter.  Either that or I would have been fired  - though that may have been impossible, since I was tenured!!
          Let me know if you want to hear more about how this develops.

Wednesday 10 December 2014

The Family Doctor and the neighbourhood Pharmacy.

               The Health Care system costs us a package.  It shows every sign of becoming more expensive with developing technology, increasing longevity with more and more resources being allocated to those in the  last years of life and more heroic procedures being developed at an impressive rate.  Where are all the resources going to come from?  What is going to be rationed and how is it going to be done?
                 Recently  we have seen the 'Choose Wisely' program initiated as an attempt to rationalize tests and various investigations to avoid harm and waste and that is admirable.  However, let there be no doubt that this will have many other consequences as it is manipulated by health care administrators and their political masters.   Expect to see further initiatives in  the  future and while every effort has to be made to conserve our resources, a healthy wariness as to where these changes may lead is warranted.
                 A recent supplement with my newspaper last week was entitled "Healthcare closer to  home" and labelled 'An  independent supplement by MediaPlanet'.      The supplement deals with evolving your local pharmacy into a sort of  mini health care centre for dealing with minor ailments, and expanding the role that pharmacists play in patient care.  The supplement has several articles on the manner in which this can  be effected.  Some of the suggestions are already in  effect, such as flu vaccination, medication education including instruction regarding diabetes management and diet.  These roles are effective and probably financially sound.   Other expansions, sometimes possibly of questionable safety, have already been enabled, and vary from  province to  province.  These include changing drug dosage/formulation, making therapeutic substitution, initiating prescription drug therapy, prescribing for minor ailments and conditions, ordering and interpreting lab tests.   There is no doubt more changes are coming. 
                    One article in the MediaPlanet supplement reads as follows:  " If you or a family member are suffering from  a bad head cold, a sore throat, a rash, an ear infection or other minor but troubling ailment, the benefits of quick and convenient access to  professional health care are simple and convenient."
                    The problem is that most of the  above can be the prodrome  of a more serious illness.
                                       Follow this space for more on this.  Feel free to comment.                

Sunday 7 December 2014

Graves - a hyperthyroid antic!

               Dr Graves of international fame as the discoverer of thyrotoxicosis, also known as Grave's Disease was a great hero to all of the students, faculty and staff of the Mead Hospital, Dublin.  (Estab 1753) where I was a student.   A bust of the Great Man decorated the main atrium of the Hospital where he had trained, atop a broad flight of concrete steps.  
              Dean Eleftry, was an older medical student from Vancouver, BC, who had come to Dublin to study medicine.  He was a nice guy, who everyone liked to poke a little fun at, because he was considerably older than the rest of students and also because he spent a lot of time polishing his little old Ford convertible.

             That night, a motley crew of students were heading back to the hospital after a good night at the local pub.  All three sheets to the wind, the older ones handling their booze a little better than the younger.

            "Let's do something with old Eleftry's car," Tom Snowdon said, in a loud self-assured English accent. (he was actually South African!)  "I'm so fed up watching him polishing and nursing it, I think it's time we taught him a lesson."

            "Yes, lets let the air out of his tires," Pete Sangster responded.

            "For God's sake, Sangster, can't you think of anything more original than that," Snowdon responded scornfully."

            The rest of the noisy group suddenly quietened down, wondering where this was going next.

            "Why don't we carry his stupid little car up the steps and deposit it in the main lobby of the hospital.  That would certainly create a little pandemonium in the morning." Snowdon said.

            Hoots of drunken approval emanated from the group.

            "We'll get into terrible trouble if we're caught,"I said.

            "Don’t be such a funk," Sangster said contemptuously.

            The herd mentality was kindled and there was no stopping now.                                          
            " Do You think we can lift it?" Sangster asked.

            "Let's give it a try," an anonymous voice suggested.

            Many pairs of hands squeezed around the little car tried to get a good grip on some lifting point and heaved.

            "It's as light as a feather," another responded.

            Twenty or so, able -bodied students lifted the car and slowly carried it up the twenty - eight concrete steps that opened onto the main lobby of the hospital.   Others held the hospital's large twin doors open, while the car was quietly placed in the centre of the lobby.

            "It looks wonderful there, but it would look much better if we put that bust of Robert Graves behind the steering wheel," drawled Tom Snowdon, pointing to a bust of the greatly revered physician.

            "Christ,"said I, "all hell will break loose."

            A contemptuous glance from Snowdon, while  a couple of his followers struggled to get the bust propped up in the front seat behind the steering wheel.

            "Let's put a scarf around his neck and a cap on his head, just to complete the picture," Snowdon added.

            One of the more fashionable members of the group volunteered his scarf and rather racy cap which he carefully arranged to give the long deceased Graves a decidedly sporty appearance.   Even I had to admit that the effect was dramatic.  We stealthily withdrew to the students residence before releasing whoops of apprehensive delight at the daring act.

           I awoke in the morning slightly hung-over and reflected on the previous night's action.  I got up as quickly as I could, anxious to see the damage.  I walked out into the courtyard.  About twenty maintenance workers were laying wooden planks in parallel tracks down the concrete steps.  The car, with Dean Eleftry sitting behind the wheel was purring gently, having just been driven through the twin doors and was now being secured by ropes attached to the axle so that it could be lowered slowly down the parallel planks to street level.  A large crowd stood in small groups at various vantage points around the courtyard.  Some laughing, some talking in hushed tones.  Dean was now anxiously supervising the manoeuvrings to make sure his beloved car wasn't damaged.

            The next morning  there was a line-up that the students and interns were ordered to attend, and the perpetrators were exhorted to turn themselves in so that the entire class wouldn't suffer the consequences for the desecration of the venerable and internationally respected [except by us!] Robert Graves.  Of course knowing that there's safety in numbers, no-one claimed responsibility and no-one remembered there being any consequences.

Tuesday 2 December 2014

The Wind - more dangerous than you think?

         Those of us who are scientists with open minds have grown tired of listening to the LWL crying that the science of climate change/global warming is established beyond doubt, that the issue is closed.  They thereby demolish any claim they may have had to understand the fundamental foundation block of science, that a theory  is only a theory until  it is proven.  I believe that the science is far from  proven and that we must continue our investigation without hysteria.  We also have to be vigilant of ill-effects from alternate power sources.
         There are concerns from many living in the vicinity of wind turbines, that they pose a risk to their heath.  There are reports of adverse health effects from around the world.  Wind turbines produce a noise that can lead to the 'wind turbine syndrome'.  A Statistics Canada survey revealed a number of self -reported effects including tinnitus, migraines, dizziness, blood pressure, stress and sleep disturbances.  There are also sound waves below the audible level (20Hz) known as infrasound that we know little about.  For the human ear to perceive infrasound  the sound pressure must be sufficiently high. 
         There is considerable debate over whether the symptoms described in the wind turbine syndrome represents an actual disease or a hypochondriacal state.  
          In an experiment performed in the UK in 2003, an experimental music concert entitled Infrasonic,  contained musical pieces  laced with 17 Hz undertones, were played for a blinded audience.  The participants were not informed of the pieces which contained the inaudible tones.  The presence of the tones resulted in 22% of respondents reporting anxiety, uneasiness, extreme sorrow, nervous feelings of revulsion or fear, chills down the spine and feelings of pressure in the chest.  Prof. Richard Wiseman said, "These results suggest that low frequency sound can cause people to have unusual experiences even though they cannot consciously detect infrasound."
           What do you think ?   Real health risk or hypochondriasis?   What should we be doing  about this now?