Saturday 26 August 2017

Three shoulders and a back.

Case 1.

   She swam back and forth like a shark cutting through the water. Every time I went to the pool she was there and really meant business. She would do two or three lengths in the time it took me to do one. She did the crawl like Johnny Weismuller (Olympic star and then the best Tarzan that ever there was - check Turner Classic Movies, if you don't believe me.). We knew each other well enough to say 'good morning' and that was it. Then , one morning, the pool was so busy we had to share a swimming lane.  
   "I'll take the left side of the lane and you take the right so we won't run into each other," I said. She smiled and nodded in agreement.
    At the completion of three lengths for her and one for me, we both docked at the end of the pool at the same time.
    "How many lengths do you do every morning?" I asked her.
    "Eighty" she said. That was pretty impressive to someone who could barely do half of that amount, but I figured she was in her fifties and I'm eighty!
   "Are you training for something? Are you a competitive swimmer?" I asked.
    "No, I used to do a bit years ago, but I developed some shoulder problems that took me some while to get over."
(Everyone at the pool knows I'm a retired doc, even folks I don't know from Adam, much as I have tried to keep it secret! So I asked the obligatory question.)
    "Oh, what was wrong with your shoulder?"
    "About twenty-five years ago," said she, "I developed a really painful shoulder, so painful, I could hardly swim, so I went to see my doctor. He sent me for physio and put me on some pills , but that didn't do much for me, so he sent me to an orthopedic surgeon. The orthopedic man told me to stop swimming for six months and then to come back to see him. When I did, my shoulder wasn't any better and I felt a whole lot worse. He did a few further investigations and then told me I would need surgery or I would never be able to swim properly again."
    "So what did you do?' I asked.
    "There was no way I was going to have surgery and I told him that. So he told me that there was nothing he could do for me. The following morning I started back at the pool and it was pretty painful. I went every day and it was hell for quite a while but gradually it started to feel better. That was twenty five years ago and now I do eighty lengths at least three times a week, sometimes four or five times."

   " And  does it bother you much?"
   " No," she said, "an occasional twinge," that's all.

Case 2.
    He was in his seventies, with a history of shoulder pain.  He went through an early period similar to the above, but after a trial of the conservative therapy when the orthopedic consultant recommended surgery, he proceed with it.  The end result may have been as good as case one, but certainly no better.  Fortunately, other health risk factors that could have been serious complications did not complicate the case.

Case 3.
    A younger man, with neck and shoulder symptoms and pathology decided to avoid the surgical option and follow conservative treatment.  Improvement has been slow but definite, but it is easy to imagine that an aggressive surgeon could have and would have operated on this patient.  The long term results are not yet known.

The Back.
    A number of years ago, a patient of mine with a long history of worsening low back pain but no progressing neurological systems was seen by a very competent orthopedic surgeon who concluded that she required disc surgery to relieve her pain and prevent further damage.   The patient was admitted to the hospital and booked for surgery the next day.  Following admission to the hospital the patient stated her pain  had abated and on the  morning that she was scheduled for surgery she decided that she did not need it and signed herself out of hospital.  She remained my patient for a considerable time after this event and despite occasional mild low back-pain never required anything more than non narcotic medication.

If you know any stories like this, send them to me.

Saturday 19 August 2017

Gene editing and Crispr- cas9.

  Crispr-cas9 is an enzyme that acts like a pair of scissors and cuts strands of DNA.  It was isolated from bacteria and other single celled microorganisms, to deal with attacks by viruses and other micro organisms.   The bacteria protect themselves by cutting up and destroying the DNA of foreign invaders.   This allows scientists to snip a piece of DNA and replace it with a different piece.  This type of targeting is in its infancy but the technique is there and will become more precise very quickly. CRISPR stands for "clustered, regularly interspaced short palindromic repeats."  It is the quality of some bacterial DNA that enables them to create RNA, a single strand version of DNA, that seeks out DNA that matches its series of bases   The bacteria then sends a protein called 'Cas9' to attack the marked DNA.  The Cas9 can also be used to destroy and replace the targeted DNA with something better.
   The science is pretty difficult for folks without a science background and for some, like myself, who do.  A nice youtube diagrammatic explanation is worth looking at.    'CRISPR/Cas9 -how it works.' 
   At my stage in the game, my interest is more philosophical than scientific.  I have no doubt that the science will be mastered, that's only a matter of time.  The potential for good is as limitless as the potential for disaster.  Genetic diseases that were and are untreatable will be amenable as we become more skilful at tracking down the offending genes that nature has dealt to some and cutting them out or replacing them.   Gene editing is just beginning and very dangerous. The very nature of the human race may be radically altered.  Genetic interference may have outcomes that we cannot as yet imagine.   There will be major ethical issues to deal with in the use of these techniques to breed super and beautiful humans with perceived advantageous traits.  Mother nature will no longer direct human evolution.  Humans will do that.  Both physical and mental advantages may be for sale in the future.  In any event and for many reasons, we all need to  be informed about what is going on in the area of genetics.   A new semi-human species may be just around the corner.  
   Good luck!  We're going to need it.

Saturday 12 August 2017

"Don't complete your course of antibiotics!" (BMJ)

    That is the advice of an article recently published in the prestigious British Medical Journal.  In an article entitled "The antibiotic course has had its day." by Dr. Martin LLewelyn et al. it is suggested that continuing the course of antibiotics for the recommended time is not only unnecessary but is actually harmful, in that it promotes the emergence of resistant strains and also that it is more likely to cause side-effects.  Funny, because the rationale used to be if you DIDN'T finish your course of antibiotics that you promoted resistance by allowing resistant mutations to supervene.    Both the CDC and Public Health England in their public health information recommend taking the medicine "exactly as prescribed", whereas previously they had recommended "completing the course".  So they are both sitting on the fence. The article even goes so far as to recommend that the patient be advised to stop the antibiotic when they feel better - a dangerous recommendation, especially if they are not under close medical supervision.
   Fifty five years in the trenches as a general practitioner have convinced me that it is essential to prescribe a course of antibiotic treatment that is clearly defined, based on the best current knowledge and on the experience of the practitioner.  Notwithstanding the fact that experience is much derogated in this age when everyone wants to feel their opinion is equal, it has no substitute.  Years of study, observation and practice in the field does confer on the practitioner a level of expertise that is not generally shared by the public or even by many medical specialists.  I suspect that the sort of specialist practice that Dr. Llewellyn follows does not include seeing large numbers of patients of all ages, body types, gender and ethnicities and their response to antibiotic treatment.  I suspect that he has no experience of the recurrences of symptoms and repeat visits generated by early discontinuation of treatment and I suspect that most of his data has been dragged out of computer databases or dusty charts.  His conclusions are based on dataism and statistics, mine are based on patient observation.  I think there is at least as much objective evidence to support the importance of completing the course even if one totally disregards actual experience in the field.
Please comment if you have any views on this.

Saturday 5 August 2017

Put the clown in the pot.

   Since the clown has already put the Pot in himself, I think it is time for Canada to put the clown in the pot.  The clown to whom I am referring is, of course, the PM.  He knows, that the best chance of re-election is to keep his supporters as 'happy' as possible and he knows that with a good suck of pot, his followers will be almost as happy as he is.  Most of them won't follow the damage he is doing as long as he keeps entertaining them with with his circus and feeding them marijuana. The Romans called it
'Panem et circenses', which literally translates to 'Bread and circuses', the implication being that if you feed them and entertain them, the masses don't care about much else.  We're different only in that we want more, instead of bread and circuses, we want pot and circuses.  In that way we can delude ourselves into believing that not only do we deserve all we can get, but that we are 'noble' in our objective of supporting everyone to be just as stoned as we are.  Put in charge an elite with a 'name', who inherited his mother's good looks, but unfortunately not his father's brain and you will understand why Canada is on the decline, not a gentle gradual decline, but a disastrous precipitous decline that pains me just to think about.  Like the Spitfires in 'Dunkirk', the Canada we knew and the one I emigrated to will be no more.  Tarek Fatah, explained all this to the Canadian Senate recently and responded to the unmitigated gall and naive effrontery of Senator Grant Mitchell, whose comments made it is difficult to understand how an egotistical ignoramus of this caliber qualifies for my tax dollars.  
  Drug addiction in Canada continues to be a huge and growing problem.  Despite this, Tricky Trudeau still intends to legalize pot.  Premier Brian Pallister of Manitoba said the following, " It's time to take a deep breath and put pot on the back burner for an extra year."  He is trying to persuade the provincial premiers at their annual conference to ask Trudeau to delay the legalization.   He raised question about traffic safety, physical and mental health impacts and concerns re detection levels in stoned drivers.   Most of the Premiers seem to be in agreement.   Although it makes sense, is it likely to happen.  I think not, because the PM and his minions will see it as costing them votes and revenue, the two things they are really committed to.

In a report on persistent pot use, by several American universities, a University of California (Davis) news release showed that Cannabis was not safe for long term users. The study leader stated the following: " Our study showed that regular cannabis users experienced downward social mobility and more financial problems than those who did not puff persistently.   Regular long-term users," she continued,  "also had more anti-social behaviours at work, such as stealing money or lying to get a job and experienced more relationship difficulties such as intimate partner violence and controlling abuse."  
   Difficult to support legalizing such a drug for recreational use, but the Man-child PM likes his pot!