lsjm 15 june 2009 volume 01
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UNHEALTHY BEHAVIOUR
The nation’s health compass awaits resetting by a) Those in charge b) Healthcare professionals or c) Healthcare students doi:10.4201.lsjm/ed.001
Far in the past lies the times when our governors and health advisors encouraged harmful health attitudes. Their unhealthy nature was then yet to be realised. In 2007, smoking - as an unhealthy and antisocial habit - was finally kicked out of the nation’s public places. This year sees the government and health watchdogs turn to the nations use or rather abuse of alcohol. The change in legislature currently used to discourage unhealthy behaviours was not always the preferred employment of the law where abusive substances are concerned. In 1563, Queen Elizabeth I ordered all land owners with 60 acres or more to grow cannabis or face a £5 fine. Sir John Russell Reynolds, personal physician to Queen Victoria, wrote an article in the first edition of The Lancet about the benefits of cannabis.1 Queen Victoria was at the time rumoured to have managed her menstrual pains with the drug. In the early years of the United States one could be jailed for not growing hemp during times of shortage in Virginia between 1763 and 1767. Now in 2009, the recent reclassification of Cannabis to a class B drug- without accordant sanctions – demonstrates a new commitment by government to the physical and mental health of current and future generations. The image of a physician was used in the 50s by tobacco executives to reassure the consumer that their respective brands were safe. The somewhat prevalent use by healthcare students and professionals might send a similar message to the general public today. To echo the words of Rene Descartes “To know what people really think, pay regard to what they do, rather than what they say”. It is time that our attitudes as current and prospective healthcare professionals be aligned with the stated intention of healthcare. The definition of unhealthy behaviours remains complex and therefore difficult to categorise. In this foundational issue of the London Student Journal of Medicine, student articles have come together to shed light on different aspects of such behaviours, with alcohol abuse, obesity and the attitudes of future healthcare professionals in prime focus. Along with an increase in the regulation of such behaviour by law, now transferring to medical students by the GMC, we ask - Are such behaviours that bad? If so, why have they been tolerated for so long? The implications could be far reaching: future applicants to medical schools and other healthcare institutions may have to consider not only their desire to “save lives” but also the lifestyle changes required to reflect healthy behaviour. Lawyers, with the responsibility of upholding the nation’s legislature, will be disbarred for criminal acts. Should we follow in the same vein? Alcohol, cigarettes and fatty foods are now so deeply intertwined with acceptable social interaction and UK culture that this could mean an infringement on individuality and human rights. Healthcare professionals now face a battle with their inner demons – for themselves and the sake of patients.
Nana Seiwaa Opare & Kevin Owusu-Agyemang Editors-in-Chief 1. Reynolds JR. Therapeutic uses and toxic effects of Cannabis indica. The Lancet 1890;1:639.
Kevin Owusu-Agyemang Co-Editor-in-Chief 2
Nana Seiwaa Opare Co-Editor-in-Chief
Jonathan Hyer Creative Director lsjm 15 june 2009 volume 01
15 June 2009 Vol 01
Contents Page:
Sections of the LSJM Medicine pg.8 Editors - Maham Khan and Laura Vincent Submit to: medicine@thelsjm.co.uk Psychiatry pg.26 Editors- Samuel Ponnuthrai and Alexander Ross Submit to: Psychiatry@thelsjm.co.uk Surgery pg.42 Editors- Jonathan Cheah and Milan Makwana Submit to: Surgery@thelsjm.co.uk Global and Community Health pg.56 Editors- Vishal Nivani and Harpreet Sood Submit to: gch@thelsjm.co.uk Health Law and Ethics pg.72 Editors- Tiffany Munroe-Gray and Rani Subassandaran Submit to: hle@thelsjm.co.uk Careers pg.88 Editors- Sonia Damle and Rob McGuire Submit to: careers@thelsjm.co.uk
The London Student Journal of Medicine (LSJM) is published by the LSJM Publishing Group, an independent non-profit organisation. The LSJM Ltd grants editorial freedom to the editors of the LSJM. Whilst the authors and editors have taken all reasonable measures to ensure the accuracy of the articles published and images used, they do not warrant that the information is complete, correct and or accurate. All articles published in this journal, are views of the authors and do not reflect that of the editors, organisation or institutions to which they are affiliated to or the LSJM unless otherwise specified by Law. Acceptance of advertising does not imply endorsement. LSJM Ltd shall not be liable for the any loss, injury or damage caused by your reliance on any article published. For further terms of use, see www.thelsjm.co.uk. © the London Student Journal of Medicine 2009.
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Editorials The written word Why quality should matter to you Unhealthy and unlawful face of medical technology: a story of india
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Reflection Influenza a (H1N1): echoes of spanish flu?
16 18 22 38 62 68 75
Reviews Mitochondria more than meets the eye The successes and failures of leptin in the fight against obesity Rheumatoid arthritis and the anti-tnf revolution Amphetamines Poultry vs poverty Is it time to put the lights out on sleeping sicknesss Allocating organs: two bodies, one heart
13 28 30 32 34 46 48 66 70 81 86 95 96
Articles Alcoholic peripheral neuropathy in a 24 year old Online roleplaying games addiction Narcissistic personality disorder: the case of jack sparrow Time to take seasonal affective disorder seriously Ethnicity & depression in london medical students? The IHI open school: primum non nocere ‘Two-week rule’ in the diagnosis of colorectal cancer Chikugunya A short introduction to the human papilloma virus The dangers of multiple pregnancies: the octuplets’ story No consent, no defence Graduate entry medicine European working time directive
10 12 24 25 60 78 84 90 98 100
Perspectives Risky business Another pint? Go on, it’s not going to affect anyone.... Rheumatoid arthritis – a medical student’s perspective Will homo sapiens continue to evolve? If so, how? From equasy to obesity Promoting IVF: the (un)hidden effects of playing god Baby shambles? Fitness to practise The blame game UK foundation programme
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Also in this issue Profiles Comments Mystery object competition 3
Advice. Support. Defence. Throughout your career. Discounts on medical text books Educational support through the MDU website 24-hour advisory helpline for medico-legal and ethical issues Support planning your elective with The Electives Network website Free discretionary indemnity for your elective The MDU Revision Courses Sponsorship of student events For more details on how we can support you visit our website or contact your MDU student support coordinator. Lozanne Stephenson 07989 609418 stephensonl@the-mdu.com
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ORACLE Developing appropriate methodology for the study of surgical techniques J R Soc Med 2009: 102: 51-55 Peter McCulloch, a surgeon based at the University of Oxford, UK describes the problems with evaluating surgical techniques using the methodology currently in practice for the evaluation of new drugs. He suggests that in future, evaluation should recognise these difficulties and proposes a methodology from the first description of a new technique through to long-term monitoring that may begin to address these problems. Immobilisation leads to faster recovery of function after ankle sprain Lancet. 2009 Feb 14;373(9663):575-81 The National Co-ordinating Centre for Health Technology Assessment funded Collaborative Ankle Support Trial Group aimed to compare the efficacy of different methods of ankle support on recovery following ankle sprains. In the UK-based study, 584 patients over the age of 16 were randomised to either double-layer tubular compression bandage or an immobile support (Aircast brace, Bledsoe boot, or a 10-day below-knee cast) and followed up at 1, 3 and 9 months. At the primary outcome measure, which comprised of blinded-assessment of ankle function at 3 months using the Foot and Ankle Score, both the Aircast brace and belowknee cast showed improved function compared to compression bandaging, whereas the Bledsoe boot did not. However, by 9 months, there were no differences in ankle function between compression bandaging and any of the immobile supports. Adverse events were rare but included venous thromboembolism and were not significantly higher in any one group. The authors conclude a short period of immobilisation is beneficial in promoting rapid recovery from ankle sprains. Laryngeal transplantation? http://www.rcseng.ac.uk A taskforce has been convened by the Royal College of Surgeons of England to consider the complex clinical and ethical issues surrounding the transplantation of the trachea and larynx. Combining, Ear, Nose and Throat surgeons, transplant surgeons and medical ethicists, the taskforce met for the first time in March and considered issues such as patient selection and suitability, how to appropriately gain consent and the relative benefits and harms. Using financial incentives to achieve healthy behaviour: BMJ 2009; 338:b1415 http://www.bmj.com/cgi/content/extract/338/apr09_2/b1415 How effective are financial incentives in trying to get a patient to change their behaviour and their health outcome? Are these incentives ethically and morally plausible? The article describes the effectiveness of certain financial incentive programmes relating to various programmes such as weight loss and smoking cessation. Some of the outcomes show that the bigger the financial incentive, the more effective the change of behaviour and health outcome. We all have dilemmas regarding our health behaviour in which what we want to do and what we do can be very different. Maybe through these incentives we can align the two so that they are more alike in outcome. Therefore maybe with a little bit of incentive we
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would do what we want to do with regards to our health behaviour. However, we must be cautious as financial incentives can impede on the intrinsic motivation that an individual has to change health behaviour, it can also take away the autonomy of a patient by undermining informed choices and it can also encourage the doctor-patient relationship to become more like a business transaction. Should we pay people money to live a healthy lifestyle? Or should health be valued as more than just a financial gain? Medical journals and ethics: Pity the messenger The Economist print edition Mar 26th 2009 | NEW YORK http://www.economist.com/science/displaystory.cfm?story_ id=13361480 Every day millions of scientists and academics across the globe dedicate their time to furthering our progress in the ever dynamic field of medicine. Their work is usually funded by big organisations that are able to invest a significant proportion of their money to research and development. Research depends on some kind of financial assistance and big pharmaceutical companies depend on good research to maintain a cutting edge reputation. Most publications tend to express acknowledgement towards the institutions that have given a monetary contribution thus allowing the research to proceed. However, although this may seem to be a symbiotic relationship, sometimes the balance is tipped such that research papers disguise the actual findings, and masquerade their results in a way that appeases the institution that has funded the work. The true extent of these cases is unknown but their very occurrence reflects the competitive nature of the profession. Fabricating results or number crunching to reflect desired correlations is unacceptable in medicine not least because evidence based medicine is our rationale for treating the many millions of people we do. Next time we read a paper it is important to take account of who has funded the research and then proceed to critically appraise it. Obesity and virtue. Is staying lean a matter of ethics? MJA 1999; 171: 609-610 Self-control of one’s own weight might be described as a form of bioethics http://www.mja.com.au/public/issues/171_11_061299/burry/ burry.html Why staying lean is not a matter of ethics MJA 1999; 171: 611-613 http://www.mja.com.au/public/issues/171_11_061299/proietto/ proietto.html Is it unethical to be fat? With obesity putting increasing pressure on health services, these articles discuss the potential bioethics of being obese. Ben Collard, Oracle Editor
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PATRON’S EDITORIAL
The Written Word Joe Collier
Emeritus Professor of Medicines Policy, St. George’s University of London Professor Collier is former Editor of Drug and Therapeutics Bulletin. He writes for BMJ Blogs.
A universal feature of living things is their capacity and determination to communicate. In plants and animals, cells or groups of cells ‘tell’ other cells what to do (at its simplest the message is ‘divide’ or ‘not divide’). Through colours, shapes and ‘smells’, it is common for plants and animals to give out ‘messages’ that serve to attract or repel other life forms. Through relatively crude devices, such as touching, pointing, grimacing, beckoning, humans exchange quite sophisticated messages about what we want, how we feel, what we advise. On another plane from these very immediate messages, we have a capacity to convey powerful emotions and sentiments using pictures and music (the tears shed by seeing Picasso’s Guernica, and the chest pain on hearing Wagner’s Ring are renowned). But for me the pinnacle of communication must be the word. It encapsulates and even determines concepts. Moreover, when used in language, they empower us to transmit the most complicated of facts and ideas in the most precise of ways from one person to another and even across generations. Such a capacity for communication occurs whether language is presented in the spoken form emanating directly from the mouth or through some recording, or is embodied in a unique arrangements of characters/letters written down on paper or screen. Given that words are such extraordinary devices they deserve to be treasured and revered. Indeed, those of us who are wordsmiths (and this necessarily includes the authors and editors involved in the production of the London Student Journal of Medicine) owe words particular respect. To this end, here are some pointers for journal authors and editors as they go about their business.
completeness also applies to the text generally, at least for articles presenting original findings. Remember that enough data should be given such that the selfsame experiment could be repeated by a reader. Remember that sometimes clarity can be enhanced through the careful use of grammar and punctuation. Check that the article as a whole has consistency both within itself and within its context. Remember that the whole text is given hollowness and its integrity undermined if the message in an ‘abstract’ strays from the data; if the ‘conclusion’ is at odds with the results; if the ‘introduction’ fails to take into account the published literature; if a reference has no relevance to the text. Finally, it is important that the wordings used in the text are those of the author and not of someone else. In writing, plagiarism or false authorship are heinous sins and cannot be tolerated. So much for words and language. Of course it is their use that will shape how the article is understood. They will not, however, ultimately determine whether or not the article is published. Here the issues are much broader and include, for example the article’s originality, topicality, timeliness or relevance, and for these judgements, the editors are not wordsmiths but policy makers. Needless to say, whether wordsmith or policy maker I wish all involved in the London Student Journal of Medicine the best of luck.
In every article ensure that the words used accurately express the message(s) the authors wish to convey. Avoid wording that could lead to misinterpretation, and with this in mind avoid words that have ambiguous meanings, are open to misinterpretation or that rely on the reader’s valued judgements ( ‘improvement’, ‘good’ results, etc). Beware of wording that is emotive, or that introduces ideas through insinuation, innuendo or association. Be very careful to avoid wording that might be personally hurtful or offensive. When choosing sentences remember that the message must reflect our shared reality – there is no place for exaggeration, distortion, fabrication, and obviously deceit (hopefully editors will sort these out!). When developing an argument remember that the order in which points are put can be critical. Ensure that the argument is complete with no steps assumed and none omitted. The notion of
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lsjm 15 june 2009 volume 01
LETTER TO THE EDITORS
Patients Do Not Understand Doctors Lebur Rohman St. George’s University of London leburrohman@doctors.org.uk Dear Editor, Doctors and students are all too aware of the impact of bad communication and how good communication may provide better patient care and thus constitute good medical practice. In particular, with many patients on geriatric wards being in a state of confusion, it seems pertinent to ascertain whether they understand what is being communicated to them, if one is to follow the General Medical Council (GMC) principle of encouraging patient participation in the management of their condition. Well-known barriers to communication include, social status, race, age, gender, fear, embarrassment and medical jargon. A small pilot questionnaire survey was conducted whilst on a Geriatric placement, examining the level of understanding of medical jargon amongst the Geriatric population, with particular emphasis on ambiguous words. Furthermore an additional aim of the study was to assess whether any miscommunication is attributable to age. There is no validated questionnaire for this study. Therefore, the author constructed the majority of questions and some were adapted from a previous study on terms used in cancer consultations to the focus of this study1. The questions were revised for content by a consultant Geriatrician. 50 patients were interviewed (25 over 65-years, 25 under 65-years), all with an AMTS of 8 or more. Data from the questionnaires were entered and analyzed using SPSS v12.0.
The results demonstrate that a significant proportion of patients, regardless of age are misunderstanding common words used by clinicians. Furthermore, the data does not support any difference in comprehension of words amongst the two age groups. The limitations of this study include: small sample size, possible selection bias and interviewer bias (not all interviewers read the statements word for word from the questionnaire). Nevertheless the results obtained are profound and of importance to all healthcare professionals. In particular, medical students are being molded into jargon-speaking doctors, such data should warn all students of the importance of good communication skills In conclusion, healthcare professionals should not assume what patients will and will not understand, and instead follow the recommendations of Chapman et al.1 that comprehension should be ‘Verified by asking them what they have understood, rather
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than if they understand’. Finally, this study highlights that simple/ ambiguous words, a particular type of jargon is an additional barrier to effective communication. References: 1. Chapman K, Abraham C, Jenkins V, Fallowfield L. Lay Understanding of Terms Used in Cancer Consultations. Psychooncology 2003; 12 (6): 557-566
Table 1. Responses for each question in the questionnaire QUESTION
<65 years old (%)
>65 years old (%)
χ2 test overall
χ2 test between age-groups
p<0.001
non-significant
p<0.01
non-significant
p<0.001
non-significant
p<0.01
non-significant
p<0.001
non-significant
p<0.01
non-significant
1)"Your blood test has come back POSITIVE. Do you think this means:" Good news
71.4
68
Bad news
21.4
4
7.1
28
Don’t know
2)"Your blood test has come back NEGATIVE. Do you think this means:" Good news 35.7 20 Bad news 57.1 56 Don’t know 7.1 24 3)"If you were told that your condition is PROGRESSING, is this:" Good news 38.8 Bad news 61.5 Don’t know 0
60 36 4
4)"If your condition is in REMISSION, what do you understand by that:" Getting better 14.3 48 Getting worse 7.1 16 Don’t know 14.3 8 Other 64.3 28 5)”If you were told your condition has RELAPSED. What does this mean?" Getting better 0 Getting worse 28.6 Come back 64.3 Don’t know 7.1
4 36 52 8
6)"If you were told your condition was BENIGN, what does this mean?" serious 35.7 20 not serious 50 48 don’t know 14.3 24 other 0 8
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lsjm 15 june 2009 volume 01
EDITORIAL
A very warm welcome to the Medicine section in this landmark edition of the London Student Journal of Medicine. The Medicine section aims to challenge the limits of current understanding, and refine clinical practice across the allied health professions. A wide and diverse section, we select articles conveying an insightful, novel approach reflecting pertinent issues in healthcare today. In the light of the revised GMC and Medical Schools Council guidelines released earlier this year1, defining professional values and fitness to practise have become hot topics of discussion. Jaimie Henry explores how our actions now impact upon our practice as healthcare professionals tomorrow. Also under the microscope are our attitudes towards our own health, we take a look at one upshot of binge drinking in a case report on alcohol induced peripheral neuropathy. The latest WHO estimates suggest , 1.6 billion adults are overweight worldwide with another 400 million clinically obese2; society’s expanding waistline is getting harder to tuck away. The war on BMI reached new heights as popular obesity treatment ‘Orlistat’ (brand name ‘Alli’) became available over the counter for the first time in the UK. In this issue we look at origins of obesity therapy, as Daniel Hammersley reopens the story of Leptin. This review highlights ongoing research dedicated to further unlocking Leptin’s potential; showing far from being a footnote relegated to the past, Leptin may still aid our fight against a fat future. A fundamental aim of the medicine section is to inform without regurgitating information easily available in a textbook. With this in mind we kick off our ongoing series into chronic conditions with an educational and engaging review of anti-TNF therapy. To complement this review is a piece from the patients view as a student shares their experience with RA treatment. Visit our section online to read these articles. With the promise of potential new treatments, mitochondrial medicine is an area rapidly gaining in recognition as top clinicians and experts worldwide compile a letter to President Barack Obama urging him to include the field amongst his top research priorities3. As we investigate current doors being opened by mitochondrial medicine, Professors Vamsi Mootha and Richard Haas, signatories of the letter and leading experts in the field, provide us with their thoughts on the incredible potential mitochondrial medicine offers and where it may take us in the future. With a bright future in view we take a fascinating look into the past in a topical tour of humankind’s evolution; in a whirlwind journey combining genetics, language and culture, Kartik Logishetty looks at the direction our species is taking, asking how will we continue to evolve? This is your journal, dedicated to help you in developing your ideas for publication. Whether you have an article for submission, an idea or simply want to write, get in touch by emailing medicine@thelsjm.co.uk. We welcome your input and also encourage you to help us improve by writing in with any comments, feedback and suggestions. Finally, an enormous thank you to all involved in putting this issue together. From the talented authors, peer and expert reviewers to Laura Vincent co-editor and the superb medicine panel, for their commitment, consistent hard work and continuous support. I hope you enjoy reading this issue, as much as we have enjoyed putting it together.
Maham Khan Section Editor of Medicine References 1. Illustration: Robert de Niet
2. 3.
Medical Students: Fitness to practise and behaviour guidelines document. General Medical Council [online]http:// www.medschools.ac.uk/documents/FitnesstopractiseguidanceSep2007.pdf (last accessed 21st April 2009) The WHO media centre, 2006. Fact sheet no 311. http://www.who.int/mediacentre/factsheets/fs311/en/index.html (last accessed 21st April 2009) Letter to President Obama, downloaded from United Mitochondrial Disease Foundation [online].http://www. umdf.org/atf/cf/%7B28038C4C-02EE-4AD0-9DB5-D23E9D9F4D45%7D/Mitochondrial%20Research%20 Letter%20to%20the%20President-Elect%20-%20rev04%200122.pdf (Last accessed April 21st 2009)
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PERSPECTIVE
Risky business: are fast-living healthcare students endangering the lives of their future patients? Jaimie Henry Year 2 Medicine, Imperial College jaimie.henry07@imperial.ac.uk It is something many healthcare students will have heard countless times just as they are about to tuck into their family sized bucket of deep fried chicken: “You’re going to be a doctor/nurse and you’re eating that rubbish!” That scenario is usually taken in a light hearted manner and such a rebuke is normally shrugged off and ignored. However, it does raise a very important question: how does this type of potentially damaging health behaviour impact upon the public’s perception of healthcare students and the profession in general? For a long time it has been a cliché of medical education and indeed the profession in general that doctors, and in particular student doctors, have the inalienable right to abuse their health, often in a way that far exceeds the misdemeanours of their patients. Studies have shown that medical students not only drink more than their counterparts in the arts, but suffer more adverse effects, including liver cirrhosis and alcohol-related vehicular deaths or violence1. This not only presents the obvious issues of poor performance at work and the direct endangerment of patients as a result of acting under the influence, but also presents indirect consequences: those students who are excessive drinkers omit to routinely counsel patients with excessive alcohol intake2. In itself, this could mean failing to advise a patient about a potentially fatal yet manageable condition.
Such behaviour has been shown to put at risk the inherent trust which forms the basis of the doctor patient relationship. With the move away from paternalism, patients no longer accept medical advice without remark but frequently question both the advice and the doctor. It is not surprising that evidence indicate that patients put poor confidence in any health advice given to them by an obese doctor.5 The overriding responsibility placed upon all healthcare professionals is to “make the care of the patient your first concern.” Perhaps now the GMC should consider whether it is not simply the conduct or health of student doctors that calls into question their fitness to practise, but whether it is also these risky health behaviours. Whilst there is currently little in the way of explicit or acute embarrassment of the profession as a result of binge drinking or smoking more insidious embarrassment is becoming plain to see and could even go so far as to jeopardise the long-term care of patients. On the whole, the behaviour of healthcare students is substantially underappreciated especially when one considers the effect such behaviour has on a future health professional’s ability to effectively treat or counsel their patients. Whilst patients would generally avoid consultation with an incompetent doctor/nurse or one with a criminal record, the overall outcome is equally ineffective if they disregard the advice given by a competent physician because of their apparent medical hypocrisy. References:
This is a problem that continues all the way through to qualified doctors and other healthcare professionals, where as few as 13% of all healthcare staff in one hospital (including respiratory registrars) believed all cigarettes were harmful3. It would appear that the only way to effectively deal with such a gaping lack of knowledge is at a grass roots level. Unfortunately, surveys have consistently found that teaching on smoking has not been sufficient enough to inform students themselves about the risks; they are then unable to effectively counsel patients in smoking cessation4.
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1.
2.
3. 4. 5.
McCarron P, Okasha M, McEwan J, Davey Smith G. Association between course of study at university and causespecific mortality. J R Soc Med 2003;96: pp. 384-388 Frank E, Elon L, Naimi T, Brewer R. Alcohol Consumption and alcohol counselling behaviour among US medical students: Cohort Study. BMJ 2008;337: a2155 Bowen EF, Rayner CFJ. Medical students’ knowledge of smoking Thorax 1999;54: p.655 Richmond R. Teaching Medical Students about Tobacco Thorax 1999;54: pp. 70-78 Hash RB, Munna RK, Vogel RL, Bason J. Does Physician weight affect perception of health advice? Preventative Medicine 2003;36(1): pp. 41-44
lsjm 15 june 2009 volume 01
NEWS Image: Change4Life
Obesity: The Next Generation Laura Vincent Change4Life is a government survey which was launched in January to tackle increasing rates of obesity by promoting healthy eating and exercise. Based on 260,000 responders in England it showed that 72% of children do not participate in the recommended hour of daily activity outside school and therefore do not do enough physical activity to keep them healthy and prevent obesity. The survey reported that 45% of children either watched TV or played videogames before school, and only 22% did physical activity after their evening meal. The current exercise recommendations for children and young people state that they should achieve at least one hour of moderate intensity physical exercise every day. Also at least twice a week they should include additional activities which should improve strength, flexibility and bone health. The survey highlights the huge challenge that the government and the department of health face in the on-going battle with the nation’s obesity crisis. Marni Craze from World Cancer Research Fund said “The survey is a concern because it is important children get into the habit of being regularly physically active as early as possible. This is because habit formed as children often last into adulthood and there is convincing evidence that being physically active reduces risk of cancer and other chronic diseases.” Change4Life has launched a new marketing campaign which aims to motivate families to work together to improve their lifestyles. This highlights the consequences of inactivity, including cancer, heart disease and type-II diabetes. www.nhs.uk/Change4Life
The LSJM is a partner of the Change4Life initiative
Problems with the internet Laura Vincent
Laura Vincent is the associate editor of LSJM Medicine
A recent survey conducted by GP magazine has found that at least a quarter of doctors have treated adverse reactions caused by medicines brought on the internet. Along with treating adverse reactions, 85% of responders felt that online pharmacies need tighter regulations. Dr Sarah Jarvis from the Royal College of General Practitioners told GP “Surveys looking at many online medications suggest that the proportion of counterfeits is enormously high and the many of them contain very worrying ingredients”. The Royal Pharmaceutical Society of Great Britain (RPSGB) have recently issued a warning relating to the dangers of internet pharmacies. They are concerned that the general public are not fully aware of the risks of purchasing medicines online, as they may not be suitable for the patient and could lead to serious health risks. Although controls are in place, counterfeit drugs are still available in large volumes. To try and combat this problem the RPSGB have launched an Internet Pharmacy Logo, which identifies legitimate pharmacy websites where patients can be sure they are buying safe products. The Medicine and Healthcare products Regulatory Agency (MHRA) is working with the RPSGB to highlight the dangers of counterfeit drugs and help patients become more aware of the problems. This includes information leaflets which will be handed out with the dispensed products from all pharmacies which will provide advice on how to purchase medicines safely.
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PERSPECTIVE
Another pint? Go on, it’s not going to affect anyone ... Mitul Palan Year 3 Medicine, Imperial College Mitul.palan06@imperial.ac.uk A healthy lifestyle - something we emphasise to patients seen on wards or in clinics. I say this whilst wolfing down my scrumptious Indian takeaway. Have we as medical students forgotten to practise what we preach? The first topic to surface in this discussion is undoubtedly alcohol. A strong drinking ethic is prevalent in many medical schools, both in the USA and UK; gallons of alcohol are shovelled down first-year throats in the first few weeks. Is this the right mindset to impose on budding physicians? Recent studies in the USA 1 and in European 2 medical student populations have highlighted this binge-drinking culture, marking men as more likely to partake in such conduct than women. Binge drinkers also seemed to see more positives from drinking than others – does this suggest that our viewpoint on alcohol intake is completely wrong? Although compared to the overall population medical students drink less on average,1 we are the role-models of the future, and we should set an example. Illustration: Elaine Parker
Smoking does not seem to be as prominent in medical student population as excessive alcohol intake, but poor nutrition is very apparent. 3, 4 Current studies show students to have a very high saturated fat intake, and to be deficient in vegetables, fruit, dietary fibre and vitamins.4 Our grasp of the UK and US obesity problem has been found to be fairly poor. Studies suggest that the hectic schedules we are subjected to, along with the increased stress over years may be to blame for our poor nutritional intake.5 Once again, it is a lifestyle we must endeavour to change, both for our sakes and that of our patients. After all, is it ethical for a clinically obese physician to advise an obese patient on their diet? Perhaps we are unaware of what constitutes healthy behaviour, or perhaps we choose to ignore it: the latter seems more plausible. However, as a country with a rapidly increasing obese population, renowned for a smoking and drinking culture, the future of the nation’s health falls to us – and before changing their health behaviour, we have to first change ours.
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References 1.
2.
3.
4.
5.
Frank E, Elon L, Naimi T, Brewer R. Alcohol consumption and alcohol counselling behaviour among US medical students: cohort study. BMJ (Clinical research ed.) 2008 Nov 7;337: pp. a2155. Keller S, Maddock JE, Laforge RG, Velicer WF, Basler HD. Binge drinking and health behaviour in medical students. Addictive Behaviors 2007 Mar;32(3): pp. 505-515. Frank E, Carrera JS, Elon L, Hertzberg VS. Basic demographics, health practices, and health status of U.S. medical students. American Journal of Preventive Medicine 2006 Dec;31(6): pp. 499-505. Skemiene L, Ustinaviciene R, Piesine L, Radisauskas R. Peculiarities of medical students’ nutrition. Medicina (Kaunas, Lithuania) 2007;43(2): pp. 145-152. Swift JA, Sheard C, Rutherford M. Trainee health care professionals’ knowledge of the health risks associated with obesity. Journal of human nutrition and dietetics : the official journal of the British Dietetic Association 2007 Dec;20(6): pp. 599-604.
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SHORT CASE
Alcoholic Peripheral Neuropathy in a 24 Year Old Ronit Das Year 3 Medicine, Kings College London ronit.das@kcl.ac.uk doi:10.4201.lsjm/med.002 The extended abuse of alcohol leads to a myriad of health issues, and in up to 50% of cases results in a peripheral neuropathy.1 The corrosive effect of ethanol produces a primary axonal degeneration that characteristically takes several years to develop and manifest as symptoms. Sensory features often dominate the typical neuropathy, with minor motor compromise. It is therefore unusual to see an alcoholic neuropathy, with major motor and sensory features, manifest in a young abuser.
cally light touch, was diminished distally in the hands The lower limbs were the most obviously compromised. The patellar and ankle were absent with equivocal plantar reflexes. Power was preserved at the hip though diminished at each level distally, such that the power of the extensor hallucis longis was rated at MRC 1 bilaterally. The sense of light touch, vibration and pain were absent along with proprioception, below the level of the patella. The distal weakening of the upper limb and the stocking distribution of lower motor neuron signs in the lower limb clearly indicated a peripheral neuropathy. The patient’s report of “burning” and “tingling” pains in the absence of pain perception was also typical of peripheral neuropathies. Figure 1: Findings on examination
The patient, JD, was a 24-year-old female who chronically abused alcohol in the four years up to admission. She presented to A&E unable to walk, complaining of a burning pain over her shins and feet. Initial clinical suspicion was that a primary pathology was being compounded by alcohol abuse. This diagnostically challenging case provided an atypical perspective into alcoholic neuropathy. Miss JD presented to emergency services with numbness, pain and weakness in the hands and legs. The symptoms arose progressively over several weeks, prior to attendance at A&E. Tingling in the feet and fingertips was the initial sensation the patient became aware of. Within two weeks the “slightly odd” discomfort was replaced by intense burning pain over the feet and shins, and was accompanied by an inability to walk normally. On the day of admission the patient awoke “in agony”, unable to mobilize or stand. Prior to this event, JD had been treated for depression, opiate dependence and had a single hospital stay for a delivery at age twenty. Heroin use was initiated at age 17, and non-intravenous abuse continued for 3 years. JD was managed on methadone for the duration of her pregnancy, leading to sustained heroin-abstinence. At JD’s request methadone treatment was stopped after18 months of addiction management. Opiate withdrawal was not well tolerated and alcohol use escalated to alleviate symptoms. The patient reported drinking 4-5 bottles of wine per day, supplemented with other beverages – daily consuming approximately 60-85 units of alcohol. This 4-year period of binge drinking was associated with a nutritionally limited diet. Clinical Evaluation On admission JD was not distressed, though in severe pain. Immediate observations of blood pressure and temperature were normal. General inspection revealed no loss of muscle bulk or obvious lesions. A neurological examination found no tremors or involuntary movements in upper or lower limbs. Tone was also normal throughout. Testing did not reveal signs of an upper motor neuron lesion. Reflexes in the upper limb were normal. Power was bilaterally maintained at a MRC 5 rating except at the interossei, at which it was weakened to MRC 3 bilaterally. Similarly sensation, specifi-
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Differentials & Investigations The initial pre-investigative thinking was that JD’s neuropathy was aggravated by excessive alcohol consumption, though not produced by it. A primary aetiology was sought. Vasculitis was suspected following a DVT two hours into admission. A blood test revealed normal inflammatory markers and a sedimentation rate within range. Most small or medium artery inflammation syndromes, capable of producing neuropathic change, would distinctively affect such indicators. Paraneoplastic syndromes could cause autonomic and peripheral disturbances, but are rarely confined to motor and sensory deficits in pattern distributions. Though no primary lesion suggestive of neoplasm was found, paraneoplastic antibodies could present anomalously and had to be excluded. The paraneoplastic antineuronal antibodies “Hu” and “Yo” were absent on CSF sampling. Multiple myeloma, which is associated with anti-neuronal immune activation, was also excluded with a negative urine screen for Bence-Jones proteins. JD’s HIV status was questioned. The virus could appear as a neural lesion reflecting a CD4 drop or opportunistic invasion. The patient’s HIV status was negative.
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SHORT CASE References The symmetrical distribution of neurological deficits and symptoms meanwhile strongly suggested Guillain Barre. Protein concentration in CSF samples though did not meet the diagnostic criteria of greater than 10g/L.
1.
This meticulous process of exclusion left only alcohol-abuse as the potential cause. A sural nerve biopsy was conducted, and the subsequent nerve conduction study showed patterns consistent with axonal damage– characteristic of alcohol related neuropathy. A head CT also revealed significant brain volume loss, a feature of long-term alcohol abuse. Additionally, late into investigation, it came to light that JD’s father had abused alcohol and suffered a peripheral neuropathy. The positive family history along with the nerve study results strongly suggested alcoholic neuropathy.
3.
The principal treatment was alcohol cessation and dietary vitamin supplementation. Neuropathic pain was managed on Amitryptilline, Gabapentin, Paracetamol and Ibuprofen. Muscular pain was managed on Tramadol. Physiotherapy to rehabilitate lower limb functionality remains on going. Discussion This syndrome most commonly presents after years of alcohol abuse. How is it possible that a young person, with a relatively short period of abuse, presented with such fulminant signs? It is difficult to establish a reason for early onset, as the exact cause of alcohol related neuropathy is disputed. The syndrome is clinically distinct from the thiamine deficiency etiology of Wernicke’s encephalopathy and Korsakoff’s syndrome; though low vitamin B levels certainly are a factor.1 Animal models indicate that ethanol distorts cytoskeletal elements and neuronal organelles.2 Acetaldehyde, a metabolite of ethanol, is also directly neurodegenerative. A study by Monforte et al suggested that the severity of polyneuropathy is primarily dose dependent, implicating excessive alcohol use.3 What is clear is that female alcohol abusers suffer higher rates of peripheral neuropathy with a high incidence often seen amongst women with affected family members.4 A growing body of evidence suggests that alcoholic peripheral neuropathy is related to genetic susceptibility to ethanol toxicity and damage. Results from a Japanese study showed a correlation between an alcohol dehydrogenase gene mutation which results in decreased ethanol metabolism to diminished peripheral nerve conduction.5
2.
4.
5.
Koike H, Iijima M, et al. Alcoholic neuropathy is clinicopathologically distinct from thiamine-deficiency neuropathy. Annals of Neurology. July 2003 – Vol 54: p. 19-29. Corsetti G, Rezzani R, et al. Ultrastructural study of the alterations in spinal ganglion cells of rats chronically fed on ethanol. Ustructural Pathology. August 1998 – Vol. 22: p.309-19. Monforte R, Estruch R, et al. Autonomic and peripheral neuropathies in patients with chronic alcoholism. A dose-related toxic effect of alcohol. Archives of Neurology. January 1995 – Vol. 52: p. 45-51. Pessione F, Gerchstein JL, et al. Parental history of alcoholism: a risk factor for alcohol-related peripheral neuropathies. Alcohol. November 1995 – Vol. 30: p. 749-54. Masaki T, Mochizuki H, et al. Association of aldehyde dehydrogenase-2 polymorphism with alcoholic polyneuropathy in humans. Neuroscience Letters. June 2004 – Vol. 363: p. 288-90.
How much is too much? The most recent Government recommendations are up to 2-3 units per day for women and up to 3-4 units for men. 1 unit is equivalent to 8g of alcohol, which is approximately half a pint of 4% beer or a 25ml measure of spirits (40%). Statistics show over 40% of men and 33% of women drink more than this, with over half drinking double their recommended intake at least one day in the last week. Young people were found to be more likely to exceed daily guidelines and were also more likely to drink heavily, with 19% of 16-24 year old men drinking more than 8 units on a particular day and 8% of 16-24 year old women drinking more than 6 units. While the proportion of young women (age 16-24) drinking heavily was increasing rapidly reaching 28% in 2002, this figure has been falling in recent years and went down to 22% in 2005. Between 2006-2007 there were nearly 60,000 NHS admissions where the main diagnosis was related to alcohol, which is an increase of 50% over the last decade. Sources: NHS Information Centre, Statistics on Alcohol: England 2008, The General Household Survey 2005 and the National Statistics Omnibus Survey 2006.
JD, fell into a surprising number of these risk categories, implying a greater susceptibility. A cumulative effect of familial vulnerability, poor diet, and considerable alcoholic insult lead to her presentation. Whether a genetic mutation or trait was present is speculative although highly intriguing when considered as the root abnormality. Such cases are unique, though no longer rare due to soaring rates of youth alcohol misuse. Should this trend continue similar presentations could become familiar.
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EXPERT COMMENTS Source: Wellcome Images
Mitochondrial medicine: What the experts say This is a field of growing importance as the role of mitochondria in common diseases such as diabetes, heart disease and the neurodegenerative disorders is becoming better understood. There is currently a NIH funded trial of Coenzyme Q10 in Parkinson disease underway in the US and Canada recruiting 600 patients at over 50 centres – a therapeutic opportunity which stems from the recognition of the mitochondrial role in Parkinson’s disease. An estimated 1% of young diabetics have a mitochondrial DNA cause and worldwide research on the mitochondrial role in Type 2 diabetes is underway. There is good evidence that the study of primary (genetic) mitochondrial diseases and their treatment provides valuable insights into mitochondrial function with important implications for more common diseases – this is the focus of mitochondrial medicine.’ Richard Haas, MD Professor of Neurosciences and Paediatrics Director UCSD Mitochondrial Disease Laboratory
Mitochondrial medicine is an exciting new field that focuses on human disorders that stem from inherited or acquired defects in mitochondria. There are a large number of inborn errors that are due to mutations in the mitochondrial genome or mtDNA - these are often termed the primary mitochondrial disorders, and we know with certainty that mitochondrial dysfunction causes the disease. What’s important to remember is that for the majority of the more common disorders [such as diabetes and obesity], it is unclear at present whether the mitochondrial dysfunction is a cause or consequence of the disease. Human genetics studies of common disease will help answer this question. Regardless, the important lessons we are learning from the primary mitochondrial disorders will impact our approach to even the common disorders. The mitochondrion is a remarkable organelle, and scientists from a variety of disciplines are helping to understand how it functions as an integrated system. I think the mitochondrion will prove to be a valuable model for systems biology - and that the lessons we learn from mitochondrial medicine can be extended to virtually all other human diseases.’ Vamsi Mootha, MD Associate Professor, Department of Systems Biology Harvard Medical School
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Mitochondria … more than meets the eye Stuart Potter
Year 1 Medicine, St. George’s University of London m0701759@sgul.ac.uk doi:10.4201.lsjm/med.005
For the full article and references see thelsjm.co.uk
Introduction Mitochondria play a significant role in one of the most important processes in the human body: aerobic (or cellular) respiration. Mitochondria are double-membrane organelles that primarily provide energy for the cell. Utilizing the products of glycolysis in a series of reactions called the citric acid cycle, mitochondria generate Adenosine Tri-Phosphate (ATP), the hydrolysis of which releases a substantial amount of energy. This is a very efficient process, where as many as 36-38 molecules of ATP can be converted from a single glucose molecule1. It is in this capacity as an energy supplier that mitochondria are often referred to as the ‘powerhouse’ of a cell, however this is not the only function they provide. Mitochondria also have the ability to synthesise hormones, such as oestrogen and testosterone2, store calcium, and are associated in the processes of cell signalling3. Another function that if not correctly regulated could have devastating effects on the body, is in apoptosis. Apoptosis Apoptosis is the controlled and regulated series of events which results in cell death. These events can be initiated by an immune response to stop an infection spreading or induced through extracellular (extrinsic) signals such as hormones and developmentalmediated signals. Apoptosis can also be induced when intrinsic (intracellular) signals are produced as a result of cellular stress; injury, oxidative stress caused by free radicals and exposure to radiation, chemicals or a viral infection. This programmed cell death (PCD) or ‘cell suicide’ is favourable to the other form of cell death, necrosis, which is uncontrolled and can result in potentially serious health problems. Cell death plays a vital role in many mechanisms and is important in the normal development of any multi-cellular organism. During development PCD causes superfluous tissue to disappear, effectively sculpting the developing tissue4. An example of this is the induction of apoptosis in inter-digital tissue, which prevents human hands being web-like. Apoptosis can also be induced to defend an organism against unwanted or potentially dangerous cells, such as tumour cells5 or cells infected by viruses6. This mechanism is drastic, but also the most effective at halting viral proliferation. PCD also serves to regulate the number of cells in an organism, keeping the number relatively constant to maintain homeostasis7. This is essential for the normal function of an organism, as without
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Figure 1: Diagram showing the role of mitochondria in apoptosis (Reproductive and Cardiovascular Research Group)
proper regulation the consequences can prove fatal. Mitochondria contain many pro-apoptotic proteins and therefore have a very important role in the regulation of intrinsic PCD. The role of mitochondria in apoptosis Apoptotic signals such as cellular damage or stress trigger apoptosis by activating the bcl-2 family of proteins found in the cytoplasm. Pro-apoptotic proteins, in this family such as Bax and Bid, relocate to the surface membrane of mitochondria where they disrupt the functioning of apoptosis inhibitors. The anti-apoptotic protein Bcl-2, works to maintain the membrane potential of the mitochondrion8 ; disruption of this function leads to the formation of permeability transition (PT) pores 9which release pro-apoptotic molecules, including cytochrome C. The release of cytochrome C initiates a caspase (Cysteine Aspartate Specific ProteASE) cascade, which is one of the main executors PCD. Upon release, cytochrome C binds to Apaf-1 (apoptosis proteaseactivating factor 1), a cytosolic protein that normally exists as an inactive monomer, this institutes a conformational change that allows it to bind with ATP 10forming apoptosome. Apoptosome then recruits multiple pro-caspase 9 molecules, facilitating their activation to caspase 9, which in turn activate caspase 3 (the executioner caspase) and the induction of apoptosis (Fig. 1)
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REVIEW Consequences of Unregulated Apoptosis Unregulated apoptosis, where more cells are induced to die than can be replaced by mitosis, can exacerbate or even cause diseases. These include neurodegenerative diseases like Alzheimer’s and ischemic strokes (a result of restricted blood supply to the brain) 11,12 as well as immunodeficiency disease such as AIDS.13 Dysfunctional or damaged mitochondria can affect the balance between cell death and cell division (mitosis), the effect being unregulated mitosis. Without the balance provided by apoptosis, the cell effectively becomes ‘immortal’ with its unrestrained mitosis resulting in the development of a tumour. Recent research into the role of mitochondria in the propagation of tumours has lead to some promising developments in combating cancer.
Conclusion With many important functions vital for normal cell processes, mitochondria are an essential component of a cell. The current research into the application of mitochondrial-stimulated apoptosis in combating cancer is particularly promising. This development, when considered in conjunction with other mitochondria-associated functions, demonstrates that mitochondria are more than just the cells’ powerhouse. References 1.
2. 3.
Medical Application of Apoptosis Researchers in Edmonton, Canada believe they have found a cheap, effective and relatively safe treatment for many forms of cancer. Dr. Evangelos Michelakis, a professor of the Department of Medicine at the University of Alberta, has shown that the drug dichloroacetate (DCA) attacks cancer cells while leaving surrounding healthy tissue intact. The drug has been used for years to treat metabolic conditions due to mitochondrial disease, but when introduced to cultures of lung, breast and brain tumours, the drug caused regression of the cancer cells.
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Researchers originally thought that cancer resulted in the irreparable damage of mitochondria; however Dr Michelakis and his colleagues found that DCA revived cancer-affected mitochondria, showing that the cancer only suppressed their function. Dr Michelakis believed that DCA could be selective for cancer cells whilst leaving normal cells as “it attacks a fundamental process in cancer development that is unique to cancer cells”14
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It was believed that cancer cells use glycolysis because their mitochondria were damaged, but Dr Michelakis’ study suggests that these cells ‘switch off’ their mitochondria as a survival mechanism. When the cells don’t receive enough oxygen for their mitochondria to function properly they ‘switch off’ the mitochondria so they can produce energy through glycolysis. Incidentally, a product of glycolysis is pyruvate, which in anaerobic conditions generates lactic acid. It is thought that lactic acid can work to propagate the spread of cancerous cells, spreading tumours throughout the body.15 As the normal function of mitochondria is the apoptosis of abnormal cells, switching it off confers immortality on the cell. DCA reactivates mitochondria, shifting metabolism from glycolysis to glucose oxidation16. This reduces lactic acid production and restores the normal function of the organelle. With normal function restored, the mitochondria initiate PCD in the abnormal cancer cells; leaving non-cancer cells unaffected. Side effects Results for clinical trials using DCA to treat cancer in humans are unavailable presently; the drug has been used to treat other conditions with some of its side-effects known. These include pain, fatigue, gastrointestinal distress, numbness and gait disturbance.17, 18 Dichloroacetate can also cause toxic neuropathy in certain individuals.19 Such problems would be considered minor if clinical trials substantiate its effectiveness as an anti-cancer treatment.
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Cooper, G. M. Metabolic energy. [Internet]. The Cell: A Molecular Approach 2000. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?indexed =google&rid=cooper.section.294 [Accessed October 25th 2007] Widmaier, Eric P., Raff, Hershel and Strang, Kevin T. Vander’s Human Physiology.10th edition 2006 New York: McGraw-Hill Smaili, S. S. Mitochondria in Ca2+ signaling and apoptosis. 2000 Caspases.org. <http://www.caspases.org/showinfo. php?pmid=11768760>[Accessed October 15th 2007] Clarke, P. G. & Clarke, S. Nineteenth century research on naturally occuring cell death and related phenomena. 1996 Anat. Embryol. [Internet]. (193). 81-99. In:Mignotte, B. V. (1998). Mitochondria and Apoptosis. Eur. J. Biochem. 252. 1-15. <http:// www.blackwell-synergy.com/> [Accessed 25th October 2007] Williams, G. T. Programmed cell Death: apoptosis and oncogenesis. 1991 Cell [Internet]. (65). In: Mignotte, B. V. (1998). Mitochondria and Apoptosis. Eur. J. Biochem. 252. 1-15. <http://www.blackwell-synergy.com/> Vaux, D. L.. An evolutionary perspective on apoptosis 1994 Cell [Internet]. (76). In: Mignotte, B. V. (1998). Mitochondria and Apoptosis. Eur. J. Biochem. 252. 1-15. <http://www.blackwell-synergy.com/> Raff, M. Social control on cell survival and cell death 1996 Nature [Internet]. (356). In: Mignotte, B. V. (1998). Mitochondria and Apoptosis. Eur. J. Biochem. 252. 1-15. <http://www.blackwell-synergy.com/> Zamzami, N. S.-M. Mitochondrial control of nuclear apoptosis. 1996J. Exp. Med. [Internet]. (183). In: Mignotte, B. V. (1998). Mitochondria and Apoptosis. Eur. J. Biochem. 252. 1-15. <http://www.blackwell-synergy.com/> Antonsson, B. C.. Inhibition of Bax channel-forming activity by Bcl-2. Science 1997 [Internet]. (277), 370-372. In: Mignotte, B. V. (1998). Mitochondria and Apoptosis. Eur. J. Biochem. 252. 1-15. <http://www.blackwell-synergy.com/> Wang, X. The expanding role of mitochondria in apoptosis. Genes and Development 2001 [Internet]. 15 (22), 2922-2933. <http://www. genesdev.org/cgi/reprint/15/22/2922.pdf> [Accessed October 2007]
Mitochondrial Medicine Research in the UK has demonstrated that mitochondrial diseases are not rare. A study carried out at Newcastle University shows that 1 in every 200 people have a DNA mutation that could potentially cause a mitochondrial disease.1 Symptoms of Mitochondrial Disease Mitochondrial diseases are extremely complex. The affected individual may present with the following symptoms: • Seizures • Muscle weakness • Severe vomiting and diarrhoea/constipation • Feeding problems • Poor immune system • Failure to thrive • Delayed achievement of key milestones • Heat/cold intolerance • Diabetes and lactic acidosis A “red flag” would be where a patient has more than three systems affected, or when a disease exhibits atypical signs and symptoms. Further Reading http://www.ncl.ac.uk/biomedicine/research/groups/mitochondrial.htm References 1. Turnbull, D and Chinnery, P. How Common are Mitochondrial Disorders? s.l. : United Mitochondrial Disease Foundation, 2001.
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The successes and failures of Leptin in the fight against obesity Daniel Hammersley BA Hons(Oxon) Year 4 Medicine, Imperial College djhammersley@googlemail.com doi:10.4201.lsjm/med.001
For the full article and references see thelsjm.co.uk
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The world obesity problem is now reaching pandemic proportions. Using criteria drawn up by the World Health Organisation (WHO) defining ‘overweight’ as a Body Mass Index (BMI) of over 25 and ‘obese’ as a BMI of over 30, worldwide estimates in 2005 were of the order of 1.6 billion overweight and 400 million obese. The WHO predicts that by 2015, an estimated 2.3 billion will be overweight and more than 700 million obese.1 The considerable morbidity and mortality associated with obesity mean that the condition now presents one of the leading world health burdens. Despite the overwhelming proportions of the obesity problem, obesity is a poorly understood condition for which therapeutic intervention and clinical management strategies are clearly inadequate. In 1994, the discovery of the hormone Leptin3 was heralded as a major breakthrough in the field of appetite control and obesity. Initial hopes that the hormone would yield a ‘magic bullet’ treatment for obesity were met with disappointment; however the implications of the discovery of Leptin reach far beyond these initial hopes. The discovery of Leptin has opened up a whole new area of biology relating to appetite and energy homeostasis and provided a scientific framework for approaching obesity and developing novel therapeutic approaches.
Leptin and its role in energy homeostasis Leptin is a single-chain protein hormone with a molecular mass of 16kDa .4 Leptin is the cleaved transcript of the ob gene, produced predominantly by adipocytes in white adipose tissue.5 It functions as an afferent signalling molecule responsible for feeding back the body’s energy status from peripheral adipose tissue to the hypothalamus. Leptin signalling results in the modulation of feeding and energy expenditure, and thus is involved in energy homeostasis and weight maintenance. Circulating basal Leptin levels reflect the total fat stored in adipose tissue. Fluctuations from this level occur during times of energy imbalance, especially during times of energy deficiency, when circulating Leptin levels are rapidly reduced.6
Historical background Understanding the physiological control of appetite and energy homeostasis has long been an elusive goal for scientists. Fundamental to the understanding of energy homeostasis was an initial appreciation that humans obey the first law of thermodynamics; meaning that in order to maintain body weight, energy input must balance energy expenditure. 6 Such is the stability of body weight that it was assumed that this balance was maintained by extensive regulatory mechanisms; the identification of which remained unknown to scientists for many years. 6 Hypothalamic lesion studies indicated that the hypothalamus plays a key role in
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REVIEW the regulation of energy balance and body weight. 7 The concept of a peripheral factor responsible for relaying energy status to the hypothalamus was later introduced. 8 It was suggested that this factor was responsible for matching changes in body energy status with compensatory changes in food intake and energy expenditure, so as to maintain energy stores. Evidence for this being a bloodborne factor came from Hervey’s parabiosis experiments. 9 Hervey showed that parabiosis between a rat that was obese due to a lesion of the ventromedial hypothalamus (VMH) and wild-type rat, caused profound weight loss in the latter; this was assumed to be a result of an unidentified circulating factor produced in the lesioned rat acting on the wild-type rat. It was not until 1994 that Friedman’s group identified the ob gene by positional cloning, identifying also its gene product Leptin.3 This discovery was soon followed by the identification of the Leptin receptor.10 Such high hopes were held for Leptin, that the commercial rights to the hormone were bought by Amgen for US$20 million in 1995. 11
Knowledge acquired from the discovery of Leptin The discovery of Leptin has opened up an entirely novel area of research which has given energy homeostasis a biological context, whilst offering a new perspective from which to consider obesity.21 Human understanding of the biology of energy homeostasis has increased exponentially since its discovery, and this knowledge is crucial in understanding how this system may malfunction in obesity. It is through understanding the pathophysiology of obesity that effective novel therapies will be developed. The discovery of Leptin has facilitated the precise unravelling of many molecular pathways and the hypothalamic neurocircuitry involved in energy homeostasis, and in particular in appetite control. Crucial to this, is the ability of Leptin to manipulate anorexigenic (inhibiting appetite) and orexigenic (stimulating appetite) neuropeptides in the hypothalamus. This is illustrated in Figure 1.
Hy pothalam us
Early work following the discovery of Leptin If we consider the early experiments published following the discovery of Leptin, one can begin to understand the scale of the initial ‘scientific hype’ that surrounded its discovery. Early experiments involved the morbidly obese ob/ob mouse, which is homozygous for mutation of the ob gene. Following administration of recombinant Leptin, the ob/ob mouse showed marked weight loss characterized by a reduction in the percentage body fat. 12 This finding lead to hopes that the pathophysiology of common human obesity related to low levels of Leptin, and therefore that recombinant Leptin therapy could act as a novel and revolutionary treatment. However, only in a very small number of cases has recombinant Leptin therapy proved effective; 13 this is limited to individuals with absolute congenital Leptin deficiency caused by homozygous mutation of the human ob gene. 14 Congenital Leptin deficiency is exceedingly rare, and in the years following the discovery of Leptin, evidence accumulated to suggest that the direct use of recombinant Leptin alone was of little therapeutic value to the vast majority of obese patients. The initial evidence for this came from the observation that subjects suffering from common obesity had raised plasma Leptin concentrations.15 This inferred that in common obesity there is a state of ‘Leptin resistance’. Subsequent evidence from a number of clinical trials showed that subcutaneous recombinant Leptin administration did not induce a significant reduction in body weight in obese patients.16, 17 These findings accompanied a shift in opinion concerning the major physiological role of Leptin from a prevailing view that it acted as an anti-obesity hormone to a belief that Leptin was in fact more important as an anti-starvation hormone, and that in low concentrations, Leptin signalling initiates some of the adaptive physiological responses to starvation.18 Why was the discovery of Leptin a major scientific breakthrough? The failure of Leptin to provide a therapy for obesity coupled with its suggested primary role in signalling during starvation, initially lead some to question whether Leptin has lived up to its early promise as a major breakthrough in the field of obesity and appetite control. However, the significance of its discovery is justified by first considering the scientific knowledge that has been acquired as a result, and second by considering the future implications of its discovery.
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ARC W hit e A di pose T issue
L epti n
-
NPY A gR P
+
PO M C CA R T
L HA F ood int ak e
En er gy expendi t ure
PVN
BBB
Figure 1: Simplified schematic diagram illustrating the major effects of Leptin on hypothalamic neurocircuitry. Leptin is transported across the bloodbrain barrier (BBB). Leptin binding in the hypothalamic arcuate nucleus (ARC) results in the inhibition of orexigenic neuropeptide Y (NPY) and agouti-related protein (AgRP) neurons and the stimulation of anorexigenic pro-opiomelanocortin (POMC) and cocaine- and amphetamine- related transcript (CART) neurons. AgRP is an endogenous antagonist of receptors downstream of the POMC neurons (melanocortin – 3 and – 4 receptors [MC-3R, MC-4R]). First-order neurons project primarily to the lateral hypothalamus (LHA) and the paraventricular nucleus (PVN). The action of Leptin on the hypothalamic neurocircuitry results in reduced food intake and increased energy expenditure. Conversely, low levels of Leptin, as occurs during starvation, stimulates NYP and AgRP and inhibits POMC and CART.
Leptin signalling undoubtedly affects a number of other neuropeptides such as corticotrophin-releasing hormone (CRH), orexin, galanin and neurotensin, also involved in energy homeostasis signalling.23 Leptin is therefore important in integrating the many different hypothalamic neuropeptides involved in energy homeostasis.
A further integrative role for Leptin As well as integrating hypothalamic neuropeptides, Leptin signalling is known to mediate some of its effects on energy balance via the regulation of other parallel systems involved with communicating peripheral energy status to the CNS. Leptin is known to regulate the responsiveness of the Nucleus of the Solitary Tract (NTS) to short-acting gut-derived satiety signals such as cholecystokinin.24 Leptin has also been found to directly modulate reward pathways associated with feeding. 25 Beyond the homeostatic control imposed by the hypothalamus, feeding is known to also be influenced by the reward value and pleasure associated with particular food,
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REVIEW mediated via the mesolimbic pathway.26 Leptin receptors are expressed on dopaminergic neurons in the ventral tegmental area and Leptin binding has an inhibitory effect on this circuit, reducing the reward value of food.27 Conversely, decreased Leptin signalling increases the reward value of food, accounting for the increased palatability of food during starvation.25 Therefore, there is increasing evidence for Leptin being a ‘kingpin’ hormone with a number of integrative roles linking different systems that influence food intake and energy balance. The future implications of the discovery of Leptin Much research is ongoing in the field of Leptin resistance. Leptin is undoubtedly an effective signalling molecule in low concentrations; however what remains to be seen is whether overcoming Leptin resistance will result in Leptin acting at higher concentrations to reduce body weight. It is likely that Leptin resistance is a remnant from our evolutionary past which once conferred a selective advantage.18 This probably evolved in response to ‘feast-famine’ feeding habits, when the Leptin resistance allowed the development of ‘latent obesity’ during times of plenty, and that this storage of excess fat was advantageous during subsequent times of food scarcity. 6 Thus Leptin resistance may have been a component of the so-called ‘thrifty genotype’. However, in modern society where food is generally unlimited and a sedentary lifestyle the norm, the existence of such ‘thrifty genes’ is associated with the widespread development of obesity. If Leptin resistance is indeed involved in the pathophysiology of obesity then understanding and overcoming this resistance could provide the key to novel therapies. Two main hypotheses have been put forward to explain Leptin resistance; the first relates to a failure in the BBB Leptin transport system and the second to impairment of Leptin signal transduction pathways. Considering the former, rodent studies revealed that the transport system responsible for transporting Leptin across the BBB is saturable28 and that diet-induced obesity is associated with a reduction in the ability to transport Leptin across the BBB,29 this proposed mechanism is termed ‘peripheral resistance’. The second hypothesis, relates to the finding that Leptin signal transduction is inhibited by regulatory molecules such as suppressor of cytokine signalling 3 (SOCS3). The activity of such molecules has been shown to be increased in obese rats compared with wild-type,30 termed ‘central resistance’. Although presently the manipulation of downstream Leptin pathways has not yielded novel therapies for obesity, it is hoped that given the current level of research this approach will soon result in a breakthrough. That said, critics question the existence of Leptin resistance, believing that the hormone only functions at low concentrations and that high Leptin levels in obesity are purely a consequence of the increased adipocyte fat mass, rather than a cause of the condition.35 Further research will reveal whether this theory holds true.
life-style alterations. Consistent with this hypothesis, it was found that weight loss caused by Sibutramine (a centrally-acting appetite suppressant that can be prescribed to promote weight loss in obese patients) was enhanced by the serendipitous administrations of low doses of Leptin in rats.2 Summary The discovery of Leptin has greatly expanded human understanding of appetite control and energy homeostasis and it is for this reason that this discovery has been a scientific advance of major significance. Leptin itself has not provided an instantaneous cure for obesity, but its discovery has unveiled a whole new area of biology which has opened up a ‘Pandora’s box’ of possible therapeutic targets for the future. One cannot expect to find an effective treatment for obesity without first having a sound understanding of the physiology of energy homeostasis and the pathogenesis of obesity. The discovery of Leptin has resulted in major advances human understanding of both these areas. An understanding of Leptin biology is likely to underpin future developments in appetite control and obesity. References 1.
2.
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4.
5. 6. 7. 8. 9. 10.
WHO media centre. WHO Fact Sheet No. 311. 2006. Available from http://www.who.int/mediacentre/ factsheets/fs311/en/, accessed on 05/03/09. Boozer CN, Leibel RL, Love RJ, Cha MC, Aronne LJ. Synergy of sibutramine and low-dose Leptin in treatment of dietinduced obesity in rats. Metabolism. 2001; 50:889-93. Zhang Y, Proenca R, Maffei M, Barone M, Leopold L, Friedman JM. Positional cloning of the mouse obese gene and its human homologue. Nature. 1994; 372:425-32. Meier U & Gressner AM. Endocrine regulation of energy metabolism: review of pathobiochemical and clinical chemical aspects of Leptin, ghrelin, adiponectin, and resistin. Clin Chem. 2004; 50:1511-25. Trayhurn P & Bing C. Appetite and energy balance signals from adipocytes. Philos Trans R Soc Lond B Biol Sci. 2006; 361:1237-49. Friedman JM. Modern science versus the stigma of obesity. Nat Med. 2004; 10:563-9. Anand BK & Brobeck JR. Hypothalamic control of food intake in rats and cats. Yale J Biol Med. 1951; 24:123-40. Kennedy GC. The role of depot fat in the hypothalamic control of food intake in the rat. Proc R Soc Lond B Biol Sci. 1953; 140:578-96. Hervey GR. The effects of lesions in the hypothalamus in parabiotic rats. J Physiol. 1959; 145:336-52. Tartaglia LA, Dembski M, Weng X, Deng N, Culpepper J, Devos R, Richards GJ, Campfield LA, Clark FT, Deeds J, Muir C, Sanker S, Moriarty A, Moore KJ, Smutko JS, Mays GG, Wool EA, Monroe CA, Tepper RI. Identification and expression cloning of a Leptin receptor, OB-R. Cell. 1995; 83:1263-71.
Another potential future role for Leptin is to prevent the re-gaining of weight following weight loss. The reduction in Leptin levels following weight loss and the physiological response to this is thought to be a major contributing factor to the subsequent re-gain of weight. Therefore it has been hypothesized that exogenous Leptin therapy, in order to maintain high Leptin levels, may help to maintain weight loss. Leptin therapy could be used in this way in combination with other anti-obesity therapies or simply with
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lsjm 15 june 2009 volume 01
REVIEW
Rheumatoid arthritis and the anti-TNF revolution Bernard Freudenthal BA (Hons)
Year 5 Medicine, University College London bfreud@gmail.com For the full article and references see thelsjm.co.uk
Introduction Advances in biotechnology have given rise to ‘biotherapeutics’ synthetic proteins that mimic antibodies or large-molecule inhibitors to directly modulate specific disease pathways. The development of anti-TNF cytokine inhibition in rheumatoid arthritis (RA) is a great success story of recent medical science. Background RA is a systemic inflammatory disease marked by a symmetrical peripheral polyarthritis 1. It affects approximately 1% of people worldwide, with a highly variable clinical course. Features include joint swelling, pain, stiffness, fatigue and fever. RA can be highly debilitating with significant morbidity, loss of productivity and shortened life expectancy. Articular involvement is characterised by erythema, effusion and synovitis that can lead to progressive joint destruction and deformity especially of the proximal interphalangeal, metacarpaland metatarsal-phalangeal joints, and of the wrist and ankle. Common extra-articular manifestations include subcutaneous ‘rheumatoid’ nodules, anaemia, pulmonary fibrosis, and Sjögren’s syndrome .2 Before recombinant biotherapeutics, treatment was restricted to non-steroidal anti-inflammatory drugs (NSAIDs), smallmolecule disease-modifying anti-rheumatic drugs (DMARDs), and corticosteroids. Though DMARDs such as methotrexate can allow sparing of corticosteroids, they often have toxicity and limited efficacy .3 Cytokines in RA RA is commonly regarded as an autoimmune disease with 80% of patients having serum rheumatoid factor (RF) (anti-IgG autoantibodies). Deranged antigen presentation or T-cell recognition have also been implicated, given RA’s correlation with HLA-DR4/DR1 alleles (MHC class II) and since T-cells are found in the synovial infiltrate.1 With increasing knowledge of the role of cytokines in inflammation, RA disease mechanisms are better understood, though what triggers its onset remains unclear. Cytokines are extracellular short-range paracrine or autocrine signalling proteins that regulate inflammation, tissue repair, immunity, and cell division . 4 There are over 100 known cytokines,
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which function via complex network-like interactions. Though they must also drive pathogenic inflammatory processes, it is difficult to demonstrate an aetiological role for specific cytokines in a given disease .5 For a given cytokine to become a potential therapeutic target, it must be shown to have a key rate-controlling function. Qualified deductions can be made from animal models by cytokine over expression or total abrogation in transgenic mice, or by infusion of neutralising antibodies5. Alternatively, human in vitro models using cultures or explants can be used. However, transient and variable cytokine expression, and synergy and antagonism between cytokines and physiological inhibitors, can frequently cause negative results .6 To discover which of the many cytokines identified are upstream and rate-limiting, anti-TNF antibodies were added to rheumatoid synovial cell cultures, which caused a decrease in IL-1 production.11 Furthermore, TNF induced the synthesis of IL-1 in endothelial cell cultures12, while an IL-1 receptor antagonist did not reduce TNF expression in rheumatoid synovial cell cultures.13 IL-1 was already known to be a crucial stimulator of fibroblast proliferation and prostaglandin synthesis in cell cultures, bone resorption and proteolysis in tissue explants, and release of systemic acute phase proteins.10,14 TNF - the key RA cytokine? Tumour necrosis factor (TNF) was first identified in 1975 as a serum extract from mice inoculated with bacterial endotoxin, which induced haemorrhagic necrosis of tumours .15 By 1985, the molecular identity of human TNF was characterised and cDNA clones were synthesised .16 A structurally homologous cytotoxic factor was named TNFβ to differentiate from the original ‘TNFα’.17 TNFβ was subsequently renamed ‘lymphotoxin’ and is mainly produced by stimulated T-cells. TNF is synonymous with TNFα, and is produced in disease by macrophages. Physiological functions of TNF include protection against bacterial infection, and also modulation of cell growth, viral replication, tumour genesis and immune regulation.17
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PERSPECTIVE Animal models further demonstrated TNF’s role in RA. Collageninduced arthritis (CIA) arises in genetically susceptible mice injected with collagen type-II and an adjuvant, and has many similarities with RA. Administration of anti-TNF antibodies in CIA mice reduced both active inflammation and joint damage.18 In addition, over expression of TNF in transgenic mice caused an erosive polyarthritis, which anti-TNF antibodies could prevent.19 Therapeutic anti-TNF Sufficient evidence had been accumulated to move onto clinical trial of TNF blockade in RA. Fortuitously, anti-TNF antibodies and TNF-receptor (TNFR)-IgG-Fc fusion proteins were already in development as experimental treatment of TNF-mediated sepsis.18 The first anti-TNF agent tested was a chimeric antibody, later named ‘infliximab’, with a mouse variable region grafted to a human constant region. In 1992, an open trial was performed at Charing Cross Hospital, London. Infliximab infusion was given to twenty longstanding RA patients who were unresponsive to DMARDs.20 All the patients responded, many with dramatic symptomatic improvement, and at 6 weeks there was a 70% reduction of swollen joints. By 26 weeks, all the patients had relapsed, showing that TNF blockade only brings temporary relief, but the therapy appeared efficacious and safe, warranting further trials. A phase-2 double-blind randomised placebo-controlled trial was performed in 1993 with two doses to demonstrate dose response, with 79% response to the high dose.18 Many questions remained concerning the feasibility of long-term TNF blockade. Might the infused antibodies, even if completely humanised, still prove to be immunogenic on the long-term and so elicit a neutralising host antibody response? Even if TNF could be successively inhibited, might another cytokine replace TNF’s function, given the dynamic cross-communication of cytokine pathways? An additional concern was that permanent disruption of TNF’s physiological functions might increase susceptibility to infection and malignancy.18
including ankylosing spondylitis, psoriasis and Crohn’s disease.17 However, results have been more mixed in other diseases such as systemic lupus erythematosus and multiple sclerosis, and anti-TNF proved to be ineffective in treating septic shock, for which it was first developed.25 Even in RA, anti-TNF treatment is not without its problems, with concerns that anti-TNF could cause infection and malignancy. UK National Institute for Clinical Excellence (NICE) guidelines require all patients to be enrolled in the Biologics Registry of the British Society of Rheumatology to monitor the long-term safety of anti-TNF. Rates of serious infection are so far unchanged, though there is an increase in skin and soft tissue infections, in particular with intracellular pathogens such as salmonella, listeria and legionella, and as of March 2005, there were 11 cases of tuberculosis.26 A recent meta-analysis of adverse effects in antiTNF trials (excluding soluble TNFR) showed a dose-dependent increase in malignancies and serious infections, suggesting that a minimum required dose should be used, and that patients should be screened for subclinical malignancies before initiating anti-TNF therapy.27 Conclusion Anti-TNF is a remarkable clinical success and continues to be the predominant biological therapy for RA over a decade after being licensed. It has transformed the lives of many thousands of sufferers of a severely debilitating progressive illness. However, the use of biotherapeutics will always be affected by their prohibitive expense – a year’s treatment of infliximab costs nearly £10,000. Treatment by cytokine inhibition requires that continuous blockade will always be required, and the requirement for parenteral administration is an important practical consideration. With advancing understanding of disease mechanisms, future goals for biological treatment of RA should be to induce long-term remission by targeting the underlying pathogenic causes. References
A subsequent study with five doses over three months showed that immunogenicity could be managed either by using larger doses or by co-administering methotrexate, which is known to deplete T-cells.18 This suggests a synergistic effect similar to the successful co-administration of anti-CD4 (a T-cell marker) and anti-TNF antibodies in the CIA model.21 A two-year phase-3 study with six months’ treatment showed that cartilage and bone damage was arrested, with sustained benefit in over half the patients.22 In some patients there was even evidence of repair to damaged joints. Trials of a TNFR fusion protein, etanercept, followed soon after, and both drugs were subsequently licensed for use in RA. Current UK guidelines advocate their use in patients who have failed to respond to at least two DMARDs including methotrexate.23 With response rates of 60-80% in trial subjects who were resistant to all other treatments, anti-TNF was a huge success.18 Nonresponders might have raised a neutralising human anti-chimeric antibody (HACA) response, they might have TNF or other cytokine polymorphisms, or they could require higher dosing. Synovial biopsy has shown that patients with low TNF in their synovial fluid are less likely to respond,24 suggesting heterogeneous pathogenic mechanisms.
1. 2. 3. 4.
5. 6. 7.
8.
9.
10.
Lee DM, Weinblatt ME. Rheumatoid arthritis. Lancet. 2001; 358(9285):903-11. Young A, Koduri G. Extra-articular manifestations and complications of rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2007; 21(5):907 Smolen JS, Steiner G. Therapeutic strategies for rheumatoid arthritis. Nat Rev Drug Discov. 2003; 2(6):473-88. Oppenheim JJ, Feldman M. Introduction to the Role of Cytokines in Innate Host Defense and Adaptive Immunity, In: Cytokine Reference, Vol 1: Ligands. London: Academic Press, 2001. Feldmann M, Brennan FM. Cytokines and Disease, In: Cytokine Reference, Vol 1: Ligands. London: Academic Press, 2001. Feldmann M, Saklatvala J. Proinflammatory cytokines, In: Cytokine Reference, Vol 1: Ligands. London: Academic Press, 2001. Brennan FM, Chantry D, Jackson A, et al. Inhibitory effect of TNF alpha antibodies on synovial cell interleukin-1 production in rheumatoid arthritis. Lancet. 1989; 2(8657):244-7. Nawroth PP, Bank I, Handley D, et al. Tumor necrosis factor/ cachectin interacts with endothelial cell receptors to induce release of interleukin 1. J Exp Med. 1986; 163(6):1363-75. Butler DM, Maini RN, Feldmann M, et al. Modulation of proinflammatory cytokine release in rheumatoid synovial membrane cell cultures. Comparison of monoclonal anti TNF-alpha antibody with the interleukin-1 receptor antagonist. Eur Cytokine Netw. 1995; 6(4):225-30. Saklatvala J, Sarsfield SJ, Townsend Y. Pig interleukin 1. Purification of two immunologically different leukocyte proteins that cause cartilage resorption, lymphocyte activation, and fever. J Exp Med. 1985; 162(4):1208-22.
Anti-TNF treatment has since been successfully tested and licensed for use in other autoimmune inflammatory diseases
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PERSPECTIVE
Rheumatoid Arthritis – A Medical Student’s Perspective Sarah Hewett Year 3 Medicine, Imperial College Sarah.hewett06@imperial.ac.uk Ironically, I was sitting in a rheumatology lecture when I first realised that I had arthritis. I had had a few random joint pains for a month or so, but assumed I’d just bumped my hand, or twisted my ankle. I was probably in denial for a while - four or five years previously, I got a virus, which lead to arthritis, and I did not want to admit that it was back. Eventually though, the arthritis was interfering with daily activities like walking and writing, so I knew I had to get some help. At the beginning of the summer 2008, I went to see the GP. Unfortunately, he could see no signs of active inflammation and so, despite the pain I was in, he was unable to give me a referral. Shortly afterwards, I had the first of many flare ups. My left hip was excruciatingly painful on any movement and to the touch. I went to my local A&E, and was given co-codamol, which helped hugely, and a referral to an excellent rheumatologist in London. My rheumatologist has been wonderful. He suspected rheumatoid arthritis from the start, and ordered bloods (including rheumatoid factor and anti-CCP antibody, both of which were positive). He also gave me an IM injection of depo-medrone, a corticosteroid, which calmed the arthritis for about a month, and allowed me to enjoy the rest of the summer. I was formally diagnosed at the next appointment in September 2008. I do not have the typical symmetrical rheumatoid arthritis. Different joints are involved at different times. My shoulders, elbows, wrists, hands, hips, knees, ankles and feet have all been affected. The arthritis jumps at random between the joints, affecting varying numbers of joints at any one time. I was started on a low dose of methotrexate (7.5mg once weekly). Methotrexate is a disease modifying anti-rheumatic drug (DMARD). The dose was slowly increased as I didn’t seem to have any benefit from the methotrexate, up to the maximum dose for rheumatoid arthritis (20 mg once weekly). Luckily, I didn’t have any side effects either! However, the methotrexate didn’t seem to do the trick so, a few months later, hydroxychloroquine (another DMARD) was added, along with a regular NSAID (diclofenac). The next step in the treatment of rheumatoid arthritis is anti-TNF. Anti-TNF is currently the best treatment for rheumatoid arthritis, but patients have to jump through many hoops to get it. Current NICE guidelines state that a patient has to have tried at least two DMARDs for six months each, partly because anti-TNF is a very expensive medication. Of course, this means up to twelve months of failed therapy before getting the medication which works, which can cause unnecessary suffering and irreversible joint damage. The addition of hydroxychloroquine was done with future anti-TNF treatment in mind, so that I would meet these criteria as soon as possible. I was hugely lucky, because my rheumatologist and the rheumatology specialist nurse did so much to help me. One month ago, I started taking Etanercept 50mg once weekly.
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The first hurdle there was learning how to inject myself. The first time was terrifying, and it took about ten minutes before I worked up the courage to do it! But after that, it became much easier. The benefit of being on the anti-TNF quickly became apparent, so that gave me some incentive. Of course, anti-TNF disrupts the immune system, making me more prone to infections. I developed a chest infection a couple of weeks ago, so had to miss my dose of anti-TNF to give myself a chance to recover, and wound up having two flare ups in as many weeks. Back on the anti-TNF now, I’m feeling a hundred times better again. The flare ups, when I have them, are really tough. The pain is often excruciating, and can be in just a few joints or all over. Pain killers don’t do much for the pain on the first day of the flare up, but do help after that. Flare ups usually last for a few days. Since being on the anti-TNF, I have found that the flare ups I have don’t seem to last as long as they did before I started treatment, which is a definite bonus. One of the hardest things to cope with has been the tiredness. The arthritis means that everything is a huge effort, so I’m always exhausted by the end of the day, and I usually don’t sleep very well because of discomfort. But, by going to bed very early, and giving up my extra-curricular activities, I have been able to continue with my studies. Something else that has been quite difficult is the fact that physically I look quite well. This means that the people around me, who do not know about my condition don’t understand why, for example, it takes me a few moments to get off the bus, or longer to walk up the stairs. I often get unpleasant looks from people who simply don’t realise what is wrong with me. I have been extremely lucky with the support that I have been given. My rheumatologist and the rheumatology specialist nurse are always happy to talk to me, and I am extremely grateful for this, as there have been times when I have needed advice quickly on how to manage pain during flare ups, or information about my medication. My mum lives fairly close to me, and has always been there to drop everything and take me home whenever I need her. She has made it possible for me to continue studying medicine and I owe her so much. My wonderful boyfriend puts up with my whinging, and is always there for me when I need him. My friends have all stuck by me, giving me both moral support and helping me to complete tasks that I physically can’t do, like changing my sheets, or brushing my hair. All of these people have made this so much easier for me, and I am eternally grateful to them all. I am now in the middle of a ten week clinical attachment, and, despite everything, really enjoying it. My team are really understanding of my condition, and do everything they can to help me. Medicine is what I’ve always wanted to do, and, although I do have times when I feel down, usually I can look to the future, when the arthritis should be under much better control, with great enthusiasm.
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PERSPECTIVE
Will Homo sapiens Continue to Evolve? If so, how? Kartik Logishetty BSc (Hons) Year 4 Medicine, Kings College London karlog43@googlemail.com In the shadow of the 200th anniversary of the birth of Charles Darwin, biologists continue to furiously debate the continuation or, indeed, the end of human evolution. The increased average life-span of the homo sapien means that a greater proportion of the population reach reproductive potential than ever before, leading to decreased deletions of unique genes.1 Simultaneously, the inter-breeding of ever more distant and distinct populations has produced a colourful blending of genes. In the ‘Western’ world, the unchallenging availability of food, provision of healthcare and dominance of hygiene, has dampened the environmental conditions that Darwin, Mendel, Huxley and their contemporaries deemed necessarily for evolution through natural selection. Most humans, especially the male of the species whose reproductive potential is not limited by child-bearing mechanics or timing, are able to propagate their genotype to the next offspring, irrespective of the extent of their adaptability to the prevailing environment. More so, with fewer older fathers there are fewer spermline mutations potentially passed on, and therefore decreased individual variation. This homogeneity suggests that evolution has ground to a standstill, and that without a sensational change in climate or an epidemic proliferation of cloning and gene therapy, the future is as we see it today. Inversely, a large body of scientists argue that evolution is as unstoppable as it is unpredictable, particularly in the developing world. The slow phenotypic changes, produced by today’s larger gene pools, serve to mask the unremitting dialogue between the species and environment. The capricious advent of new diseases will force natural selection of Homo sapiens – for example, incidence of haemoglobin ‘C’, which confers a resistance to malaria without anaemia, is increasing exponentially in West African populations. Some even predict the emergence of an AIDS-resistant population in areas currently epidemically ravaged by HIV. The clash of these two opposing perspectives could in fact exist concurrently. It may well be that evolution has stopped in certain populations, and is continuing in others. However, a new conflict arises when one attempts to define evolution, and whether in a more fluid sense, it continues as strongly and ubiquitously as ever. Evolution, in its most literal sense, means change over time – changing species, changing populations, or changing characteristics. Evolution is not only a genetic mechanism, and perhaps natural selection and culture are the motors of change.2 The continuing development of the human race, spurred by technology, creativity, and money, itself engenders competition – the foundation of natural selection.
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Homo sapiens are considered uniquely capable of representational communication. Language is one of our greatest commodities and has developed in tandem with another almost exclusively human trait: culture. Language allows for ‘productivity’ i.e. the capacity to say things that have never been said or heard before, yet still be understood, and ‘cultural transmission’ i.e. our genes have a strong capacity to acquire language, which can be transmitted extragenetically by learning and teaching. Darwin claimed that the human brain is selected for sociability, which would explain the origin and strength of culture, as well as its variability.3 As argued by Pinker, 1990, human language is the product of Darwinian natural selection, arising from the reproductive advantages that linguistic compositionality affords. Furthermore, cultural transmission (e.g. seen in the recent proliferation of the ‘SMS’ language) combined with biological transmission, influence the evolution of language, and indirectly, the evolution of homo sapiens.4 As well as the transmission of language, culture has spawned materialism. The evolution of human behaviour is seen in three dynamic processes termed ‘first nature’ (matter originating from the Big Bang), ‘second nature’ (the evolution of life forms, from bacteria), and ‘third nature’ (the dawn of ideology, symbolic thought, and agrarianism). ‘Third nature’ has infused the human mind with the idea of progress, which has itself fueled the evolution of complex institutional order and technology, and their unfortunate symbiosis with war and environmental degradation.5 A concerted effort by neuroscientists and archeologists has demonstrated that the rapid encephalization seen in early homo sapiens was intimately related to social relationships, later extended by an increasing engagement with material culture. The ability today to manipulate social networks using a variety of material resources continues to reflect the evolution of culture.6 The craft with which homo sapiens can now apply material devices is under the constant scrutiny of morals and ethics. The recent manifestation of international and local standards of ethical ‘acceptability’ has demonstrated a new form of evolution in culture.7 The argument on the prevalence of evolution can therefore only be settled based on the fluidity of its definition. Using the broader brush, it is clear that our species is still evolving on a genetic, linguistic, and cultural plane, albeit in more subtle ways. The future will almost inevitably be one of a uniform brown skin phenotype, but where our verbal, social, and moral compasses direct us is altogether unknown. References 1. 2. 3. 4. 5. 6. 7.
Hockett, C. F. (1960). “The origin of speech.” Sci Am 203: 89-96. Aoki, K. (2001). “Theoretical and empirical aspects of geneculture coevolution.” Theor Popul Biol 59(4): 253-61. Hayflick, L. (2000). “The future of ageing.” Nature 408(6809): 267-9. Johnston, W. A. (2005). “Third nature: the co-evolution of human behavior, culture, and technology.” Nonlinear Dynamics Psychol Life Sci 9(3): 235-80. Kirby, S., M. Dowman, et al. (2007). “Innateness and culture in the evolution of language.” Proc Natl Acad Sci U S A 104(12): 5241-5. Phillips, C. S. (2001). “Culture, social minds, and governance in evolution.” Politics Life Sci 20(2): 189-202. Mesoudi, A. and P. Danielson (2008). “Ethics, evolution and culture.” Theory Biosci 127(3): 229-40.
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lsjm 15 june 2009 volume 01
EDITORIAL
Recreational drugs are a significant starting point in psychiatric research. Firstly they are interesting in that they might contribute to the aetiology of some mental illnesses (the ongoing debate of cannabis and schizophrenia for example)1. Secondly, in understanding them as part of the pathology of a mental illness, we indirectly learn more about what might be going on in the brains and hence the minds of patients. Even if there is no immediate application of knowing the neurochemical changes that occur in an illness, appreciating these as well as the social and psychological factors contribute to the psychiatrist’s understanding of how to treat a patient. The explanation of a drug as a cause or treatment of a mental illness cannot alone answer the question of why someone has a particular mental illness. As the mind emerges not only from its physical and chemical make-up but also from the experiences that have moulded it, so does mental illness. Physiological but also psycho-social factors must all contribute to an illness, as exemplified by Schilderman’s review of amphetamine abuse and self harm. Despite this, there is much hope in recent literature that neuropsychiatry will bring psychiatry forward as a discipline. It will hopefully provide us with new ways of approaching treatment for mental illness as Craddock et al2, and more recently Bullmore et al3 have argued in The British Journal of Psychiatry. For example, it has been suggested that depressive illness in adolescents may alone be a cause of substance use in adolescents. However it has been shown recently that by testing for stress (measuring cortisol levels) it now seems possible that we were missing stress as a key link. However, the greatest hope from this perspective is that it will provide better targeted treatments. For example, last month Ross and Margolis argued that the basis of the major psychiatric illnesses – schizophrenia, bipolar disorder and depression - may all stem from alterations in the cell signalling systems of neurons altered during neuronal development.5 Targeting these pathways with more effective treatments and fewer side effects may therefore become possible. It is important to remember however, that not only are such innovations a long way off but also research into them should not come at the expense of research into the other contributing factors of mental illness – the sociological and psychological elements. In fact, where possible, neuropsychiatric research should try to integrate the existing aetiological models that are based on these factors.4 It is in this context that our section hopes to publish new student writing in psychiatry. It is the fact that psychiatry meets at the crossroads of all of these disciplines that makes it so interesting. We want to publish work that focuses on sociological factors - like Baigel et al’s paper on the impact of ethnicity upon the reporting of depression in London medical students - as well as papers on psychological and even neuropsychiatric factors. This includes work in the form of research but also as literature reviews, news articles and case studies from students of any of the health sciences. Samuel Ponnathurai Section Editor Psychiatry References
Illustration: Robert Hare
1. 2. 3. 4. 5.
Arsenault, L. et al The British Journal. of Psychiatry, Vol 184, (2004), 110-117 Craddock N, Antebi D, Attenburrow M-J, Bailey A, Carson A, Cowen P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6 –9 Ed Bullmore and Peter Jones. Why psychiatry can’t afford to be neurophobic. The British Journal of Psychiatry (2009) 194: 293-295. Rao et al . Mechanisms underlying the comorbidity between depressive and addictive disorders in adolescents: interactions between stress and HPA activity. Am J Psychiatry. 2009 Mar;166(3):361-9. Epub 2009 Feb 17. Christopher A. Ross1 & Russell L. Margolis. Schizophrenia: A point of disruption. Nature 458, 976-977 (23 April 2009)
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RESEARCH REPORT
Massively Multiplayer Online Roleplaying Games (MMORPGs) addiction Amin Golmohamad BSc(Hons) Year 4 Medicine, St. George’s University of London m0400037@sgul.ac.uk doi:10.4201.lsjm/psy.002 Screenshot from the online game EVE
For the full article and references see thelsjm.co.uk. Conflicts of interest: Amin is a panellist for LSJM Psychiatry.
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In the electronic age, computers and the internet continue to be further integrated into day-to-day activities. Facilities such as email, social networking sites and online games are ubiquitous and a norm. The available literature on the subject of computer-related disorders has grown exponentially over the last decade, resulting in coined terms such as ‘internet addiction’, ‘problematic internet use’ and ‘pathological internet use’. 4, 5, 6 However it is not the internet itself that is addictive, rather that it is the interactive applications that seem to play the prime role in the development of problematic use.7 One such interactive application of particularly addictive potential currently in ascendance is the genre of online game, the ‘Massively Multiplayer Online Roleplaying Game’.
These computer games, also referred under the acronym ‘MMORPG’, represent a new paradigm in computer gaming that now immerses tens of millions of players worldwide. A typical MMORPG consists of a complex, persistent virtual environment that facilitates real-time interaction between large numbers of players in geographically different locations. They are a relatively new phenomenon, having only been in existence in their current form for just over a decade. Examples of such games include titles such as ‘World of Warcraft’, ‘Eve Online’, ‘Guild Wars’ and ‘Everquest’. Their unique formula combines the allure of traditional stand-alone video games with that of the social networking capacity afforded by ever more accessible high speed internet connectivity. Their appeal is reflected in the near exponential rise in subscription numbers, with the growth rate reported to be
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RESEARCH REPORT several-fold faster when compared to that of ‘traditional’ electronic game genres such as arcade, PC and console video games. 8,9 A ‘strong multi-faceted appeal’ How can their appeal be explained? The extensive work of Yee10 concluded, “MMORPGs have a strong multi-faceted appeal to a diverse demographic, motivating individual users in very different ways”. While some traditional stereotypes may associate affiliation with ‘computer games’ with people of teenage years, Yee also demonstrated in a study of 30,000 MMORPG users that the age ranged from 11 to 68 years, with the average lying between 25-27 years, underscoring their broad appeal and weakening the cogency of such views. Upon exploratory factor analysis, Yee identified a five factor model of user motivations: achievement, relationship, immersion, escapism and manipulation - motivations that typically carried different import to players of a different demographic. According to this model, the motivating factors external to the game define the degree to which inherent ‘attractive factors’ offered by a MMORPG act as an ‘outlet’. MMORPG users can immerse themselves into worlds that are rich, varied and detailed; detail that can provide fulfilling game-play experiences varied playstyle preferences; that may vary from casual socialising to combat, strategy, commerce and fantasy role-play. The goals are only limited by player ambition, with instant and measurable rewards available at progressively lengthening cycles. The perceived ability to supersede limitations present in the real world by using the adapted identity in the virtual world can be appealing where life cannot offer these options. Social activity derived from an MMORPG is another dominant motivating factor. Characterised by anonymity, users can avoid real world prejudices of colour, gender, age and physical attractiveness. These prejudices are partially replaced by an order of meritocracy based on gaming aptitude and behaviour. This can be an added attraction for people who face difficulty in the real world on account of these factors. Furthermore, a player can discard their identity and assume a new one by creating another avatar, should their relationships or online ‘reputation’ not be to their liking. Social interactions can be controlled, taking place in structures similar to chat rooms, online forums and 3rd party voice communication. As the relationships accrue over time, increasing obligations to them emerge. Social contact has also been postulated to be used as ‘self-medication’ to compensate for the lack of family or social support in a player’s real life11. Negative sequelae and comorbidities To play MMORPGs requires lots of time investment; they are not games that one can play for a short period of time.12 In-game advancement encourages increased use, which can be excessive.13 Chronic MMORPG addiction can lead to self-maintaining factors.12 For instance, where playing an MMORPG is used to escape a difficult situation in the real world, it acts only as a temporary nepenthe. When the player logs out of the game, problems may have been further compounded due to resultant neglect. Chronic usage can also lead to isolation, loss of friends and contacts. Mental and physical health co-morbidities have been postulated.5
Can it qualify as an addiction? While research into the concept of MMORPG ‘addiction’ continues to proliferate, there remain no agreed diagnostic criteria or treatments, with recognition of the disorder pending. In July 2007 the American Psychiatric Association released a statement stipulating that they did not recognise any type of ‘video game addiction’ as a mental disorder.14 The DSM IV criteria for addiction require three or more of the following: • • • • •
Tolerance Withdrawal Large amounts over a long period Unsuccessful efforts to cut down Time spent in obtaining the substance replaces social, occupational or recreational activities • Continued use despite adverse consequences The term ‘addiction’ does not require a substance of abuse, it can include non-physical, behavioural addictions. Examples include pathological gambling, eating disorders and sex addiction.15, 16, 17 Studies have identified self-reported usage despite adverse consequences, withdrawal, tolerance and that it is difficult to quit playing even with intent to do so. The frequency of these findings was found to be proportional to the number of hours spent playing per week. It would be a misconception to consider these games as a niche, for they represent a rapidly growing problem. It could be labelled as a ‘silent’ addiction, only presenting in extremis. An ideal addiction in a time of a poor economic climate in that it is rewarding, constantly available, legal and requires relatively low investment. As successful treatment is predicated upon the medical professional being aware of the nature of this 21st century problem, it is important that research into this area continues to help provide answers for the lack of widely agreed methods for screening, diagnostic criteria or treatment approaches. References 1.
2.
3.
4. 5.
6.
7. 8.
9. 10.
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BBC news article (2005), S Korean dies after games session, Retrieved from http://news.bbc.co.uk/1/ hi/technology/4137782.stm, on 28/4/2009 Gamespot.com article, Couple’s online gaming causes infant’s death, Retrieved from http://uk.gamespot.com/ news/2005/06/20/news_6127866.html, on 28/4/2009 BBC news article, (2005), ‘Game theft’ led to fatal attack, Retrieved from http://news.bbc.co.uk/1/ low/technology/4397159.stm, on 28/4/2009 Freeman C.B., (2008), Internet Gaming Addiction, The Journal for Nurse Practitioners, vol.4, no.1, pp42-47 Yen J.Y., Ko C.H., Yen C.F., Wu H.Y., Yang M.J., (2007), The Cormorbid Psychiatric Symptoms of Internet Addiction: Attention Deficit and Hyperactivity Disorder (ADHD), Depression, Social Phobia and Hostility, Journal of Adolescent Health, Vol.41, no.1, pp93-98 Shapira N.A., Lessig M.C., Goldsmith T.D., Szabo S.T., Lazoritz M., Gold M.S. Stein D.J., (2003), Problematic Internet use: proposed classification and diagnostic criteria, Depression and Anxiety, vol.17, pp207-216 Young K.S., (1998), Internet addiction: The emergence of a new clinical disorder, CyberPsychology & Behavior, vol.3, pp237-244 Woodcock, B.S. (2008), An Analysis of MMOG Subscription Growth, MMOGCHART.COM 22.0, retrieved from http://www.mmogchart.com on 27/4/2009 Harding-Rolls P., (2007), Western World MMOG Market: 2006 Review and Forecasts to 2011, Screen Digest Yee, N., (2006), The Demographics, Motivations and Derived Experiences of Users of MassivelyMultiuser Online Graphical Environments, PRESENCE: Teleoperators and Virtual Environments, 15, 309-329.
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SHORT CASE
Narcissistic Personality Disorder
Jeremy Hoffman BSc (Hons)*, Adiele Hughes BSc (Hons), Andrew Allard BA (Cantab), Sarah Greenough BSc (Hons) Image: Actor Johnny Depp as Captain Jack Sparrow in Pirates of the Caribbean
All Year 4 Medicine, University College London j.hoffman@ucl.ac.uk doi:10.4201.lsjm/psy.004 Introduction Captain Jack Sparrow displays numerous attributes of Narcissistic Personality Disorder (NPD), which affects approximately 1% of the population. Captain Jack Sparrow is a 33-year-old male pirate with no previous contact with psychiatric services. He presented with a multitude of symptoms including visual and auditory hallucinations, alcohol intoxication and grandiose delusions. He was found by colleagues wandering alone on an island responding to visual and auditory autoscopic hallucinations (see Table 1), talking to several versions of himself. Little is known about the events leading up to this episode however, it is thought from collateral history that this is not the first hallucinatory episode and his colleagues regularly hear him talking, apparently, to himself. There is no significant psychiatric family history, however he has never been close to his father who is also a pirate in his mid-sixties and carries around the shrunken head of his deceased mother. JS is not currently taking any medication. His alcohol use is bordering on dependence with stereotyped drinking of only rum. He is known to drink when in stressful situations such as when under attack, shows binge drinking behaviour and drinks first thing in the morning. He also craves alcohol and shows agitation when rum is not available. He is a non-smoker and denies other recreational drug use.
Autoscopic hallucinations
These are a blend of visual and proprioceptive hallucinations. In these cases, the vision is of one’s double, like in a mirror, sometimes repeating one’s gestures, and on occasions busy with other activities.
Ego-syntonic
A term referring to behaviours, values, feelings, which are in harmony with or acceptable to the needs and goals of the ego, or consistent with one’s ideal self-image.
Lilliputian hallucinations
Hallucinations in which the patients see imaginary people of a small size.
Pressured speech
The patient keeps talking, with no interruption between thoughts or sentences. The speech may be loud and rapid, with creative, amusing, or trivial and irrelevant content.
Circumstantiality
In conversation, the use of excessive and irrelevant detail in describing simple events, the speaker eventually reaches his goal only after many digressions.
Table 1: Definitions of psychiatric terms referred to in text
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He has been a pirate all his working life, however, little is known about his birth, childhood and education history. A significant life-event occurred 10 years ago in which the crew of his ship mutinied and left him on an island. At this point he showed low risk suicidal ideation as he was left a gun with just one bullet, which he considered using but was protected by a revenge motive. Following this event he became very fixated on revenge and there is concern over risk of harm to others, however he does not appear to deliberately self harm or have any current suicidal ideation. One previous long-term relationship is confirmed, although he is known to have had many other sexual partners, most of which ended ‘badly’. His forensic history is extensive and includes mugging, wilful crimes against the crown, impersonating a cleric of the Church of England and a member of the Royal Navy, arson, kidnapping, pilfering, depravity and before absconding, he was sentenced to be hung by the neck until dead. On presentation he appeared to be a scruffy Caucasian pirate in his mid-30s with ‘questionable personal hygiene’. He was unshaven, with dread-locked hair and clearly had not changed his clothes for many days. He was dressed in grand 18th century pirate attire, congruent to that expected. Although appropriate his attire was eccentric, slightly outside boundaries of normality with added femininity including make-up, beads in his hair and many rings on his fingers. His behaviour was markedly socially and sexually disinhibited with invasion of personal space and inappropriate and lewd comments such as “You need to get a girlfriend” and “Are you a eunuch?” He made good, often intense eye contact. He also had an ataxic gait, explainable by alcohol consumption but no psychomotor abnormalities His speech was pressured, suggested by quotes such as “Me? I’m dishonest. And a dishonest man you can always trust to be dishonest. Honestly, it’s the honest ones you want to watch out for, because you can never predict when they’re going to do something incredibly... stupid”. It was also at times over-inclusive with circumstantiality, for example “No! If we don’t have the key, we can’t open whatever it is we don’t have that it unlocks. So what purpose would be served in finding whatever need be unlocked, which we don’t have, without first having found the key what unlocks it?” It was of normal volume and tone. His mood was, objectively, persistently elevated with situational incongruence, for example inappropriate laughter when his life was
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SHORT CASE in serious danger. He was reactive to his surroundings. He clearly had a grandiose sense of self-importance, believing himself to be special as the greatest of all pirates and requiring excessive admiration, insisting on being called ‘captain’ although he did not technically have his own ship. He is selfish and lacks empathy towards others, always thinking about saving himself with no consideration for others, using friends for his own gain for example holding them at gunpoint. He is also constantly preoccupied with ideas of questionable success and power regarding treasure and The Black Pearl ship. He embellished stories about himself, making himself sound grander or more daring than in reality. His perceptions were disordered as he described many episodes of ego-syntonic hallucinations. One described involved a Lilliputian hallucination of small versions of himself and another episode of multiple autoscopic hallucinations. These could potentially be related to alcohol withdrawal. Collateral history suggests many other episodes of him having conversations with ‘himself’. He was orientated in time, place and person, however had limited insight into his hallucinations, unsure as to what was real and what a hallucination was. Our impression is that JS is suffering from NPD, possibly with hypomania and/or alcohol withdrawal. Discussion Captain Jack Sparrow is arrogant to the extreme of grandiosity – he believes he is far more superior than he actually is. He makes constant reference to being called “Captain” Jack Sparrow and does not let people forget that he can out-think others: “Today will be the day that you will always remember that you almost caught Captain Jack Sparrow”. He sees himself as special or unique, and constantly requires admiration from others around him. He exploits others to his own personal benefit and is constantly preoccupied on his quest for success. These personality traits interfere with Jack’s life and constantly lead him astray, developing a significant forensic history in the process; he only just managed to escape the hangman’s noose. As a result of this, we believe it is possible to diagnose him with NPD. The term “narcissism” comes from the Ancient Greek mythological story of Narcissus.1 Narcissus, a Greek hero from Thespiae, was famous for his beauty. After rebuking the nymph Echo who tried to embrace him, he fell in love with his own reflection in a pool and killed himself when he realised that he could not act upon his love. Freud, who often used mythology to aid his theories of psychopathology, formally introduced the term “narcissism” into the psychiatric literature in his 1914 paper On Narcissism.2 Since then, NPD has become a formal psychiatric diagnosis as defined by the American Psychiatric Association in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, which outlines the diagnostic criteria.3 To receive the diagnosis of a NPD, a person must meet these diagnostic criteria (Table 2). It is evident that Jack meets at least five and arguably all nine of these criteria. It should be noted that that the ICD-10 does not specifically code for NPD, but instead categorises it in “Other specific personality disorders”.4 Other authors suggest various “dominant features” of NPD.5 These include “Pathology of the self; pathology of the relationship
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with others; pathology of the superego; and a chronic sense of emptiness and boredom, resulting in stimulus hunger and a wish for artificial stimulation of affective response by means of drugs or alcohol that predisposes to substance abuse and dependency.” Patients typically present with the complications of their disorder as opposed to their primary symptoms. This includes drug dependence and alcoholism, sexual promiscuity or disinhibition, suicidal ideation, and when under extreme stress, brief psychotic symptoms.
Image: Caravaggio’s Narcissus
The prevalence of NPD is approximately 1%, rising to between 2 and 16% in clinical situations, with up to 75% of those diagnosed being male. The aetiology of the disorder is largely unknown but various risk factors have been identified. These are mainly childhood parenting and developmental factors such as parental overindulgence or overvaluation, excessive admiration, learned manipulative behaviour and early severe emotional abuse. 6 Medication and hospitalisation are indicated in NPD only for co-morbid conditions such as anxiety or affective disorders. The management therefore largely involves a multi-disciplinary approach with psychosocial interventions such as supportive psychotherapy, cognitive behavioural therapy and social skills training.7 A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1
Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
2
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3
Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
4
Requires excessive admiration
5
Has a sense of entitlement, i.e., unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations
6
Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
7
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
8
Is often envious of others or believes that others are envious of him or her
9
Shows arrogant, haughty behaviours or attitudes
Table 2: DSM-IV criteria for Narcissistic Personality Disorder
References 1. 2. 3.
4.
5.
6.
7.
Ovid, AD 8, Metamorphoses III. 340 - 350, 415 – 510. Freud S. On narcissism: An introduction. SE, 14: 67-102. 1914 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th Edition, revised. American Psychiatric Association, Washington, 2000. World Health Organisation. ICD-10 : The ICD-10 Classification of Mental and Behavioural Disorders : Clinical Descriptions and Diagnostic Guidelines. World Health Organisation, Geneva. 2007 Kernberg O, Pathological narcissism and narcisstic personality disorders; Theoretical background and diagnostic classification in Disorders of Narcissism; Diagnostic, Clinical, and Empirical implications, ed. E. F. Ronningstam. Washington, DC: American Psychiatric Press, pp. 29-51. 1997 Groopman L and Cooper A. “Narcissistic Personality Disorder”. Personality Disorders - Narcissistic Personality Disorder. Armenian Medical Network. 2006. http://www.health.am/psy/ narcissistic-personality-disorder/. Retrieved on 8/03/2009. Davison S E. Principles of managing patients with personality disorders. Advances in psychiatric treatment 2002 8:1-9
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ARTICLE
Time to take Seasonal Affective Disorder seriously Neil Graham1, Prof Anne Farmer2 Medical Student, University College London 2 Institute of Psychiatry, King’s College London
1
Conflicts of interest: None declared.
When we labour through the short days and long nights of the British winter, the perennial column-filler, Seasonal Affective Disorder (‘SAD’ - which lends itself to puns like few other illnesses), is never far from headline-hungry newspaper pages. Skepticism is a key facet of modern, evidenced-based practice, but is the prolific cynicism about SAD (‘the winter blues’, or ‘seasonal depression’) justified? And is there any mileage in the debate over whether this is a true ‘illness’? What is seasonal affective disorder? The American Psychiatric Association’s Diagnostic and Statitistical Manual of Mental Disorders (DSM-IV) characterises SAD as a ‘specifier’: a cohort of features which can occur within major depressive or bipolar disorders, emphasising seasonality and prominence over non-seasonal depressive episodes, for at least two years. Symptoms occur in autumn and winter, accompanied by full remission, mania or hypomanias in summer. Depressed mood, diminished interest, psychomotor agitation, loss of energy, feelings of worthlessness, guilt, and thoughts of death may be experienced in addition to what appear to be SAD specific features – increased appetite with associated weight gain, tiredness and over-sleeping.1 Critics who argue that aspects of SAD are likely to be experienced by most people at this time, and disagree with the concept in the most general terms, fail to appreciate a key feature of this, and many other psychiatric ailments: for diagnosis and treatment to be indicated, symptoms must be of a given severity, quantity, duration and pattern. One could read entire books about the ‘medicalisation’ of benign phenomena, and there is a place for this debate. In respect of seasonal depression, however, it seems that many have been too quick to apply labels – obviously not everyone who is miserable in winter has an illness, and nobody is claiming that they do. Epidemiology and the nature of the disorder The population prevalence of the disorder is highly variable and has been shown to increase with latitude. Landmark research by Rosen
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et al. in the USA found incidence of 1.4% in Florida increasing to 9.7% in New Hampshire.2 This may be compared with estimates at non-seasonal mood disorder prevalence of between 8% and 20%.3 Genetic factors are implicated in the aetiology of winter depression, and concordance studies found correlations in dizygotic twins to be fewer than half those observed in monozygotic twins.4 Identification of specific mutations associated with the disease has generally been unfruitful – though an association has been established with serotonin transporter polymorphisms.5 Management While evidence fails to support light therapy for unipolar depression, other than as an adjunct to classical therapies,6 over seventy therapeutic trials, and two meta-analyses have found light therapy to be effective in the treatment of seasonal depression, with a dose-response relationship observed in the control of some symptoms.7,8 Best outcomes are achieved with light of sufficient brightness (10,000 lux) and duration (15-90 min per day), which is timed appropriately: morning exposure is usually most effective.9 Treatment may produce a range of transient side effects (headache, eye strain) but appears to be safe in patients without ocular abnormalities.10 Evidence to support the use of traditional antidepressants is weak, though the selective serotonin reuptake inhibitor drugs appear to help in established episodes. Recently, the FDA licensed bupropion hydrochloride (a noradrenaline-dopamine reuptake inhibitor), specifically for prevention of winter depression, after convincing results in three placebo controlled trials.11 Pathophysiology Finding an inactive placebo treatment in trials of phototherapy has contributed to the uncertainty about winter depression, and the
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ARTICLE Source: Wellcome Images
mechanism of action of many therapies is not entirely clear. Diverse pathophysiological explanations exist, but irrespective of their ingenuity and logical appeal, little evidence exists to conclusively support any one over another. Rosenthal et al originally proposed the ‘melatonin hypothesis’, which argues that an abnormal secretion or sensitivity underlies the phenomenon. Winter depression has often been portrayed as a disorder of delayed circadian rhythms; and more recently, as a product of dopaminergic system dysfunction.12 That a clear mechanism of action is yet to be elucidated ought not to empower doubters to ignore this phenomenon. Indeed, squabbling over whether seasonal depression merits the label ‘illness’ is quite unnecessary. Life after semantics The facts are that this experience affects the quality of life of a significant number of individuals, in a stereotyped, recurrent manner. Safe, low cost, effective treatments exist which can ameliorate these symptoms. Withholding these for the sake of word-play is hardly the enlightenment thinking that detractors imagine it represents. The time has come for us to update their practice to keep pace with the research in this field.
3.
4.
5.
6.
7.
8.
9.
10.
11.
References 1.
2.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:317-91. Rosen LN, Targum SD, Terman M, Bryant MJ, Hoffman H, Kasper SF,
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12.
Hamovit JR, Docherty JP, Welch B, Rosenthal NE. Prevalence of seasonal affective disorder at four latitudes. Psychiatry Res. 1990 Feb;31(2):131–144. Blazer D. Mood disorders: epidemiology. In: Kaplan, H.I., Sadock, B.J. (Eds.), Comprehensive Textbook of Psychiatry, 6th ed. 1995. Vol. 1, pp. 1079–1089. Madden PAF,Heath AC, Rosenthal NE,Martin NG. Seasonal changes in mood and behavior. The role of genetic factors. Arch. Gen. Psychiatry. 1996. 53, pp. 47–55 Rosenthal, N.E., Mazzanti, C.M., Barnett, R.L., Hardin, T.A., Turner, E.H., Lam, G.K., Ozaki, N. and Goldman, D. Role of serotonin transporter promoter repeat length polymorphism (5-HTTLPR) in seasonality and seasonal affective disorder. Mol. Psychiatry 3, pp. 175–177 Even C, Schröder CM, Friedman S, Rouillon F. Efficacy of light therapy in nonseasonal depression: a systematic review.. J Affect Disord. 2008 May;108(1-2):11-23. Epub 2007 Oct 22. Terman, J.S. Terman, F.M. Quitkin, P.J. McGrath, J.W. Stewart and B. Rafferty, Light therapy for seasonal affective disorder. A review of efficacy, Neuropsychopharmacology 2 (1989), pp. 1–22. Lee and Chan, 1999 T.M. Lee and C.C. Chan, Dose–response relationship of phototherapy for seasonal affective disorder: a meta-analysis, Acta Psychiatr. Scand. 99 (1999), pp. 315–323. Thompson et al 1999 C. Thompson, I. Rodin and J. Birtwhistle, Light therapy for seasonal and non-seasonal affective disorder: A Cochrane meta-analysis, Society for Light Treatment and Biological Rhythms Abstracts (1999), p. 11. Gallin et al., 1995 P.F. Gallin, M. Terman, C.E. Reme, B. Rafferty, J.S. Terman and R.M. Burde, Ophthalmologic examination of patients with seasonal affective disorder, before and after bright light therapy, Am. J. Ophthalmol. 119 (1995), pp. 202–210. Modell JG, Rosenthal NE, Harriett AE, Krishen A, Asgharian A, Foster VJ, Metz A, Rockett CB, Wightman DS (2005). “Seasonal affective disorder and its prevention by anticipatory treatment with bupropion XL”. Biol Psychiatry 58 (8): 658–67 Lee TM, Blashko CA, Janzen HL, Paterson JG, Chan CC. Pathophysiological mechanism of seasonal affective disorder. J Affect Disord. 1997 Oct;46(1):25-38.
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RESEARCH
Does ethnicity impact upon reporting of depression in London medical students?
Rachel Baigel*, Robert Freudenthal, Deborah Ragol Levy, Daniel McNaughton, Sara Taha All Year 4 Medicine, University College London rachel.burns@ucl.ac.uk doi:10.4201.lsjm/psy.003 For the full article and references see thelsjm.co.uk. Conflicts of interest: Rachel is a panellist for LSJM Psychiatry.
Abstract An online questionnaire was distributed to preclinical medical students in UCL, Kings college London and Barts and the London Medical School and students were asked to respond to four case vignettes. These were constructed based on the ICD-10 criteria for mild, moderate and severe depression and one vignette that acted as a control group presenting with subclinical symptoms of depression. Students were asked how likely they were to seek help from several different services and the reasons that would prevent them from going to these services. Statistical analysis was performed using chi squared tests. With regard to ethnicity, we found that African students were less likely to seek help from friends for either subclinical (p=0.032) or mild depression (p=0.043) and less likely to seek help from relatives in subclinical depression (p=0.047) that other ethnicities. South East Asians were more likely to seek help from a counsellor in mild depression (p=0.025) and from a university tutor in subclinical depression (p=0.04) than students of other ethnicities. When students were asked about the factors deterring them from seeking help for depression 31% said they definitely would not seek help because they believed their grades would suffer as a result, 35% said the same because they would not want the label of depression, and 33% said the same because they believe that seeking help for depression could affect their medical career. We believe that these are significant and that greater effort should be made elucidate at the start of medical school. Introduction Mental illness, particularly depression, is responsible for a significant proportion of the worldâ&#x20AC;&#x2122;s health burden. The World Development Report 1993 states that depression ranks fifth amongst women and seventh amongst men as a cause of morbidity, whilst the World Health Organization has predicted that by 2020 depression will be the most common cause for disability worldwide, second only to ischaemic heart disease.1 Depression is massively under-diagnosed with an estimated 56% of people worldwide exhibiting clear-cut features of clinical depression but receiving no treatment and an estimated 74% of Europeans are affected by mental illness but remain untreated.2
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Prevalence of depression varies across different socio-economic and occupational groups. There is evidence that young people have the highest population prevalence rates for mental health problems and substance abuse, however, their use of primary care and specialist services tends to be low when compared to other population age groups.3 This remains true amongst university students, where the high prevalence of anxiety and depression is thought to be related to social and academic factors â&#x20AC;&#x201C; indeed, one study of Oxford University students reported higher rates of suicide than in the general population. Half of these students had clinical depressio students, particularly in London, are a heterogeneous group with a large proportion from ethnic minority backgrounds. It has been shown that presentations of depression are culturally dependent with somatic complaints dominating over psychological symptoms amongst non-Western cultures.5 Within the UK it is unclear if the prevalence of Depression is higher amongst ethnic minorities, with one study showing that whilst London Punjabi populations have a lower rate of diagnosis, they do experience more depressive thoughts than their white counterparts.6 The interaction between ethnicity, culture, clinical depression and its symptomatology amongst London students is complex however this study aims to ascertain how this interaction impacts on the likelihood of self-presentation to healthcare services when experiencing features of clinical depression. As discussed above, previous studies have shown that Depression is prevalent in both student groups and ethnic groups in the UK. In this study London medical students will be used as subjects, as this group is a culturally diverse high risk group. Methods To study the impact of ethnicity upon an individualâ&#x20AC;&#x2122;s likelihood in seeking help for symptoms of depression, four vignettes were prepared (Appendix 1). One vignette describes a person with no symptoms of depression with another three representing scenarios of mild, moderate and severe degrees of depression according to the ICD-10 classification of depression. In relation to each vignette presented, participants were asked to rate how likely they were to use any one of a range of services and were asked to score them regarding the likelihood of their using each service for that vignette (box 1). Participants were asked about different factors affecting
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RESEARCH their decision to attend these services and asked to score these factors (box 2). This questionnaire was distributed to preclinical medical students at University College London Medical School, King’s College Medical School and Bart’s and The London School of Medicine. The questionnaire was hosted online at http://www.surveymonkey. com and a link to the questionnaire was provided in an e-mail to students. The survey was left open to access for a period of three weeks. An incentive of £20 was made available to encourage responses. On entering the online domain, participants were presented with contact details of the counselling services of the respective institutions and were given the chance to opt out of the study at any point. Ethical approval, data protection and research governance for this study was granted by University College London. Ethnicities were grouped together under 6 categories and chi squared tests were performed to analyse if there was significant differences between the attitudes of people of different ethnicities to seeking help for sub-clinical, mild, moderate and severe depression from internet/books, friends, relatives, their GP, university counsellor, other counsellor or university tutor. Chi squared tests were also used to identify statistical differences between ethnicities regarding factors that would affect them seeking help for depression. Results • This questionnaire was sent to 1760 students. 311 (18% of the study population) completed it. • Approximately 56% were second year students and 44% first year students. 10% of the students had suffered from clinical depression beforehand. • Of the students who had suffered depression: 31% mild, 25% moderate 9% severe (75% White, 9% Chinese, 6% African, 6% Asian, 3% South East Asian). See figure 1 for more demographics. • Of the students who completed the questionnaire: 58% female, 41% male and all were aged 18-30 with 64% aged 19-20. • The representation of ethnicities in the study was: White 62% Asian 16% Chinese 8% Mixed Race 5% South East Asian 5% African 3% • Statistical significance of the results was calculated at the 5% significance level.
and the ICD-10 criteria (either unaffected by clinical depression or mild, moderate or severe Depression) and whose help would be sought. Four bars are displayed for each ethnic group representing the percentage of that group who selected each response (seek key). The degree of significance is indicated in the title of each graph. Reasons for students experiencing symptoms of depression for presenting to welfare or healthcare services are complex. This study attempted to ascertain what factors lead to some students presenting earlier than others, and to identify any correlations between the ethnicity of the students and their presentation. The results for the students responding to the vignettes representing moderate and severe Depression did not show significant differences between the ethnic groups in their likelihood of presenting to different welfare or healthcare services with symptoms of depression. However there were some significant differences between the attitudes of different ethnic groups in the mild depression group and the control group. When asked about seeking help from friends, people of African origin were far less likely to seek help than people of other ethnicities in both of the above groups (control p=0.032, mild Depression p=0.047). In mild depression, Asian, South East Asian and Chinese participants were significantly more likely to seek help from friends. When unaffected by clinical depression, it seems that students would consider turning to their relatives for help, but the African students were significantly resistant to this avenue p=0.047. Consulting University tutors and counsellors was universally an unpopular service to access for depression. However, students of White, South East Asian and Asian origin were more inclined to consult a university tutor for subclinical symptoms of depression. A similar pattern was seen for consulting a counsellor in mild depression. In this study, the African students seemed more reluctant to seek help from any cause. However, our study population of African students was small and therefore may not be representative of the African population as a whole. If it were to be confirmed that Africans were less likely to seek help for depression, then steps should be taken to increase African awareness of services at university of a confidential nature in order to increase help seeking in this ethnic group.
The graphs 1-5 illustrate the statistically results that were significant at the 5% significance level. There were 5 instances where there were significant differences between ethnic populations concerning the degree of depression as established by the vignette
The study found that despite the diversity of the respondents to the questionnaire there were some unifying factors across all groups that prevented presentation of the depressive symptoms. Seeking help from friends and family was always more popular than seeking help from tutors or counselors:63% of respondents had concerns
Type of depression within each ethnic group (%) Ethnicity
Percentage of each ethnicity who had been depressed
Unknown
Mild
Moderate
Severe
African
25
50
50
0
0
Chinese
12
33
67
0
0
Indoasian
4
50
50
0
0
South East Asian
6
0
0
100
0
White
11
29
29
29
13
Mixed
0
50
50
0
0
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Figure 1: This tabulates the demographics of our findings. Overall, the South East Asian population suffered the highest morbidity with all of the subjects who partook claiming to have experienced moderate depression. The only cases of severe depression were found in the White population. In the African, Chinese, IndoAsian and Mixed populations, all participants classified their depression as either mild or unknown.
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RESEARCH Graph 1: Unaffected - seeking help from a friend p = 0.032
that seeking help for depressive symptoms would affect their medical career whilst 69% of students were concerned that seeking help would result in an unwanted label of ‘depression’.
Keys for graphs 1-5:
Graph 1 & 2: these graphs show that the majority of students of african origin would not seek help from a friend if they experience symptoms of sub-clinical depression or mild depression. In contrast, chinese, south east asian and mixed race students are more likely to seek help from a friend in the case of sub-clinical depression, but this likelihood is slightly reduced amongst white students. Graph 2 shows that all students, with the exception of africans, are inclined to seek help from a friend if they experience mild depression
Graph 2: Mild depression - seeking help from a friend p = 0.043
Graph 3: Unaffected - seeking help from a relative p = 0.047
Graph 3: This bar chart shows that the majority of students would consider hep from a relative if they experience sub-clinical depression. This affirmation is higher among Chinese and Asians. Africans were particularly unlikely to seek help from relatives when experiencing sub-clinical effects of depression.
Graph 4: Unaffected - seeking help from a university tutor p = 0.04
Graph 4: Help seeking for subclinical depression from a university tutor appears universally unpopular. However students of White, Chinese, Asianand South east Asian origin were more likely to present than those of African or mixed race.
Graph 5: Mild depression - seeking help from a counselor p = 0.025
Graph 5: Seeking help from a conselor in this instance seems to be universally unpopular. However, students of Chinese, White, South East Asian and Asian origin were morel ikely to present than those of mixed or of African origin.
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Previous research into students’ attitudes to Depression showed a lack of knowledge about the illness and the implications that a diagnosis and its subsequent treatment may (or may not) have.7 These statistics are concerning as they highlight the stigma that exists within the medical world and implications for the presentation of depression in students. This carries a significant risk of under-diagnosing the condition in this group and subsequent poor management. There are some confounding factors that mean that these results cannot be extrapolated to the remainder of the London student population. In using medical students as a study population, we surveyed a highly educated, medically interested subsection of society, who have all been trained in the importance of confidentiality in a professional setting. We would expect that this group would have greater immunity to society’s stigmatisation of depression than other social groups. Therefore, our results showing such a high tendency to question seeking help due to stigmatisation of depression on the grounds that it could affect their careers are worrying. We would suggest that action should be taken in medical schools to promote a better understanding of the issues on confidentiality. This would impact both on the care of future patients and the unwillingness of medical students to seek help in the knowledge that their disclosure would remain completely confidential. Further research needs to be done as to why these attitudes persist amongst the London medical student population. Improvements/Further Work Study Design: 1. 18% of the students who received our e-mail completed the questionnaire. Whilst this response was good, it could have been improved by going into lecture theatres and asking all present to fill out a handwritten form. 2. Feedback from students made us aware that students responded to the cases set out in the vignette in different ways. Students did not always base their answers on the symptoms of depression laid out in the vignette, but responded on the significance of the ‘trigger’ eg. Grandparent dying versus breaking up with a boyfriend. For this reason it would be particularly important to analyse the data with respect to history and family history of depression. Statistical analysis: 1. 34 chi squared tests is a large number of tests to run and it is possible that running this number of statistical tests, will by chance, procure some statistically valid results. Therefore better planning should have taken place in order to minimise the number of tests performed and the amount of data collected. 3. For some of the chi squared tests, the expected values were under 5. This has been said to reduce the validity of this statistical method and in future we would either try and increase the number of respondents to the questionnaire or group several ethnicities together to achieve higher expected values. 9 Ideal Study Design Our study asked theoretical questions about the likelihood of
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RESEARCH students seeking help for depression. The majority of the students we assessed claimed to have had no history of depression and therefore the study largely surveyed the attitudes of healthy students as to whom they would go to for help. To accurately address the question of how likely students are to present for help with depression, it would be important to interview and identify students who were depressed, classify their depression according to ICD-10 criteria and then ask them how likely they would be to present to each service. These results would be far more accurate than the results obtained in our study, but would require a larger study population and large amounts of time as each student would need to be interviewed to assess their mental state. Conclusion Having achieved these results, we feel that it is important to address the negative attitudes of medical students to seeking help for depression, We propose a further study where information is provided to students about confidentiality in the services available to help people suffering from depression and to assess if this information could improve the attitudes of students to seeking help.
of weeks running up to your first big set of exams. You wake earlier in the morning in order to make it to lectures, but oversleep a couple of days a week. Your eating habits have changed – you haven’t had much time to cook for yourself and find yourself skipping breakfast due to the morning rush and consequently eat more during the day. Sometimes, especially towards the end of the day, you find it hard to concentrate in lectures. One evening in the last week you felt a bit down, and so you decided to go to the cinema and watch an upbeat film. Vignette 4 – Moderate depression Since your boyfriend/girlfriend broke up with you over a month ago, you’ve started to notice some changes. Your appetite has gone and you notice that your clothes are starting to look increasingly baggy. You feel tired a lot of the time, but still wake most mornings at about 5am. Things take you a lot longer than they used to, so often you just stay in your room. You begin to feel guilty about this and think that you don’t deserve anything better anyway. Your friends have been out partying and normally you would have loved to join them, but just don’t seem to enjoy the things you used to anymore.
If you believe your experiences can help others in a similar situation please write to the editor with a short 350 word response.
References 1.
Box 1: For each vignette students were presented with the following statement:
2.
If you were experiencing these problems how likely would you be to see help from: please fill in 1-4 where 1 = wouldn’t go, 2 = might go, 3 = would probably go, 4 = would definitely go)
3.
a) Internet/books b) A friend c) A relative d) GP e) University counsellor f) Other counsellor g) University tutor h) Someone else not on this list, please specify ________
4.
Appendix 1 – Case Vignettes Vignette 1 – Severe depression Since your grandma passed away three months ago, you have noticed some changes in your daily routine. You wake at 5am despite feeling tired all the time. You have little energy and rarely cook for yourself. You are feeling down and have little interest in your university course. You remember an incident from the beginning of the summer when you left a shop with an apple and forgot to pay for it. You feel very guilty about this and feel that you have brought shame on your family. Sometimes you hear voices talking about you and to you saying that you are worthless and you should turn yourself in to the police for stealing the apple. Vignette 2 – Mild depression Since starting university over three weeks ago you have been feeling quite low. You are struggling to make it in for your 9am lecture, despite getting a reasonable night of sleep and you find that you are eating less and rarely make your own food. You find that you are going out a bit less in the evenings, but are finding it harder than usual to concentrate in lectures, and you no longer enjoy some of the things that you used to. Vignette 3 – Unaffected by clinical Depression You have noticed that a few things have changed in the last couple
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5. 6.
7.
8.
9.
Bhugra et al. Globalisation and mental disorders. Overview with relation to depression. The British journal of psychiatry : the journal of mental science (2004) vol. 184 pp. 10-20 Thornicroft. Most people with mental illness are not treated. Lancet (2007) vol. 370 (9590) pp. 807-8 National Mental Health Report 1996, Fourth Annual Report. Changes in Australia’s Mental Health Services Under the National Health Strategy 1995–96. 1998 Canberra : Dept. of Health and Family Services, 1998. Hawton et al. Suicide in Oxford University students, 1976-1990. The British journal of psychiatry : the journal of mental science (1995) vol. 166 (1) pp. 44-50 Minhas FA, Nizami AT. Somatoform disorders: Perspectives from Pakistan. Feb 2006; International Review of Psychiatry. 18(1) (55-60) Bhugra D, Mastrogianni A. Globalisation and mental disorders. Overview with relation to depression. 2004 Jan, British Journal of Psychiatry. 184:10-20 Merritt RK; Price JR; Mollison, J, et al. A cluster randomized controlled trial to assess the effectiveness of an intervention to educate students about depression. Psychological medicine (2007) vol. 37 (3) pp. 363-72 Roness A, Mykletun A, Dahl AA. Help-seeking behaviour in patients with anxiety disorder and depression. Acta Psychiatr Scand. 2005 Jan;111(1):51-8. Armitage P, Berry G and Matthews JNS. Statistical Methods in Medical Research, Wiley-Blackwell 2001
Box 2: at the end of the questionnaire the participants were asked: How likely would it be that the following factors prevented you from seeking help from the list above? 1-3 where: 1 = wouldn’t prevent me at all, 2 = might prevent me 3 = would definitely prevent me a) They would think less of me. b) I wouldn’t want other people interfering with my business. c) Wouldn’t want to waste their time. d) This could affect my career as a doctor. e) This could affect my grades or go on my university record. f) Wouldn’t want to have a label of “depression”. g) The opening hours wouldn’t suit me/I wouldn’t have time. h) The service is too far away. i) Another reason ___________
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REVIEW
Amphetamines Marcela Schilderman BSc (Hons)
Year 4 Medicine, St. Georgeâ&#x20AC;&#x2122;s University of London m0401306@sgul.ac.uk doi:10.4201.lsjm/psy.001
For the full article and references see thelsjm.co.uk.
Abstract A relationship between amphetamine misuse and deliberate self-harm has been cited1, yet few epidemiological or research studies have been carried out to verify or nullify this link. The author explores the relationship between these behaviours through examination of the neurobiological, sociological and psychological similarities in their effects and occurrence, with a view to suggesting why the two might co-exist in the same patient and the implications of this relationship. Introduction The term amphetamine misuse is used here to refer to any nonprescribed (and therefore illicit) amphetamine administration from single use to complete dependence; whilst self-harm and self-injury are used interchangeably to denote deliberate infliction of injury (most commonly poisoning or skin laceration)2, to an individualâ&#x20AC;&#x2122;s own body in the absence of the intention to die from the damage caused. Epidemiology Amphetamine misuse and self-harm are significant problems in their own rights. 16% of the 4713 11-35 year olds interviewed in the 1996 UK National Drugs Campaign Survey had used amphetamines.11 Amphetamines are the second most popular illicit substance after cannabis in the UK and Australia, and fourth most popular.3,11 Self-harm is estimated at between 400 and 1400 per 100,000 population per year. 4 In conjunction, drug misusers have a greater incidence of suicide and self-harm than the rest of the population.5 But amphetamines have especially been related to severe self-harm such as self enucleation and removal of the hands,6 with three documented cases of repetitive genital self-injury.7 The Department of Psychiatry belonging to the University of California reports encountering serious self-harm with amphetamine induced psychosis, and recommends screening for amphetamine use in cases of unusual or serious self-harm.6
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Demographic factors Gender Self-harm is an estimated four times more frequently reported in females than males, though self-poisoning (and therefore the use of drugs to procure injury) is greater in women.8 Contrarily, surveys place amphetamine use as 1.25 to 2 times greater in males than in females, both in the preceding year to the surveys and over the participantâ&#x20AC;&#x2122;s lifetime. 9,44 The latter could be explained by the recent discovery that men release more dopamine in the ventral striatum (including the reward-associated NAcc [nucleus accumbens]) and report a significantly more positive experience on amphetamine administration than females. 10 Age The greatest percentage of amphetamine misusers are aged 16 to 24 based on their amphetamine consumption in the preceding month (4% of a total 4647 respondents of a general drug survey), three months (7%), year (13-14%) and entire lifetime (22-26%).11 Similarly, self-harm is more frequently reported in the younger population, those aged 12 to 30, with figures as large as 61% ascribed to adolescents.12,13 Ethnicity Surveys in the USA have shown the prevalence of self-harm, stimulants, and particularly methamphetamine use to be amongst the greatest in Hispanic and white groups, and the lowest in the black subpopulation. 14,15,44 Biological Factors: Biochemistry and Neurophysiology Higher doses of amphetamines elicit stereotypical self-mutilatory behaviour in rats (such as biting and gnawing)16 dogs 17 and horses.18 This would suggest a biochemical theory of causation. Dopamine Differences in transmission of dopamine are thought to underlie variance in the Behavioural Approach System (BAS) within the population. BAS is stimulated in positive or negative appetitive reinforcement, and those with high BAS are thus considered more likely to enter into, and respond positively to, reward- related
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REVIEW behaviour including substance abuse.19 Experiential avoidance such as self-harm is a form of negative reinforcement via distancing the self from unpleasant emotional responses to stimuli; and may therefore also be associated with greater degrees of BAS; with the impulsivity and novelty-seeking aspects of a BAS trait personality likewise linked to such avoidance.20,21 Amphetamines are sympathomimetic. 22 They function as indirect agonists by acting on intracellular vesicles, instigating the reversal of catecholamine transporters at the vesicle and the release of noradrenaline and dopamine.23,24,25 Amphetamines also inhibit the re-uptake of dopamine released in the Nucleus Accumbens (NAcc.). Both of these mechanisms thus lead to a rise in the amount of this neurotransmitter acting on its postsynaptic receptors in the NAcc, an occurrence deemed essential to the reward sensation in the ‘dopamine reward hypothesis’ of drug addiction.26 An ‘addiction’ to self-harm hypothesis, has been put forward suggesting that the release of endogenous opiates onto μ receptors (β endorphin in particular) in response to pain, results in pleasure.27 Opioids active at the μ receptors block the action of GABA interneurones on neurones of the Ventral Tegmental Area (VTA). The disinhibition of VTA neurones causes them to increase their firing rate, and thus increase dopamine function in the NAcc upon which they synapse.28,30 Furthermore, a defective dopamine mechanism has been recorded in half of self-harming patients with Tourettes’ syndrome.22,29
with OFC lesions.40 This is likewise true for patients with borderline personality disorder patients and history of violent behaviour inclusive of self-injury. 48 Further research is required to determine whether or not amphetamine induced 5-HT depletion, particularly in the orbitofrontal region, leading to the typical decision-making abnormalities (a tendency to make delayed, ineffective choices) of an OFC lesion, may result in self-harming behaviour, or at the least aggression and a propensity towards it. Caudate As well as the NAcc; self-harm and amphetamine use may share the caudate in their instigation. Lesion of the caudate using 6-hydroxydopamine terminated the stereotypical amphetamineinduced gnawing and biting in rats.26 Whilst Yaryura J.A. et al proposed a possible neuronal circuit responsible for self-harming behaviour wherein the caudate and other basal ganglia, in addition to the thalamus, are involved with mediations between rageregulation of the amygdala, fear and appetite regulation of the hypothalamus, and the activity of the frontal lobe. 22,39 Sleep deprivation Sleep-related problems were reported in 93.4% of methamphetamine users in one survey.40 A quantity of research exists to suggest that self harm in amphetamine abusers may be a result of the lack of REM sleep obtained by some misusers of the drug.1
Serotonin Serotonin may also be a mediator. Several reports associate p-chloro-N-methylamphetamine abuse with a significant depletion in serotonin levels. 20,31,32 Conditioned preference for amphetamine-associated places by rats was inhibited with the administration of the 5-HT transmission amplifier zimelidine, but increased with the administration of the serotonin antagonist ritanserin.33 Sekine et al. found density of 5-hydroxytryptamine (5-HT) transporters decreased inversely with length of methamphetamine abuse in universal areas of the brain; and that their density in the anterior cingulate, orbitofrontal, and temporal regions was highly connected with the raised levels of aggression they documented in methamphetamine abusers. 34
Genetics Incidence of substance misuse was shown to be greater in monozygotic than dizygotic twins, indicating a genetic component.41 Whilst the A779 allele for tryptophan hydroxylase was more frequently encountered in deliberate self-harmers than controls in one survey, which supports a serotonin hypothesis for the disorder, as well as suggesting a genetic basis for it.42 It may therefore be that some amphetamine users who self-harm have a genetic predisposition towards it.
Aggression has been listed as one causative factor in self-harm; and self-injury may frequently be the major presenting symptom of an aggressive disorder. Studies in humans and animals have shown a link between self-harm and problems in 5-HT regulation. 22,35 The efficacy of selective-serotonin reuptake inhibitors in the treatment of self-harming and aggressive behaviour supports 5HT’s role in their genesis.22
Borderline Personality Disorder The DSM-IV requires a minimum of five out of the nine criteria listed for a diagnosis of Borderline Personality Disorder (BPD). Criterion 5 refers to recurring self-harm or threats of it, (occurs in an estimated 48-79% of sufferers 43,44,45) and criterion 4 refers to two or more other impulsive and possibly self-injuring acts such as substance misuse (57.4% of BPD patients also have a substance use disorder).46,47 Thus amphetamine misuse and self-harm can easily co-exist in a BPD individual, since they are common to, and relate to, fundamental aspects of the psychiatric disorder.48
Serotonin and Decision Making Serotonin appears to have a role in decision-making ability. Experimentally reduced serotonin function resulted in slow, maladaptive deliberation in subjects akin to that displayed in patients with orbitofrontal cortical (OFC) lesions. 36 Evidence has indicated that abnormal decision making is central to substance abuse. 37 Recent research shows that the problems in decision-making exhibited in chronic amphetamine abusers are also very similar to the decision-making problems seen in individuals
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Psychiatric factors There is an increased prevalence of both self-harm and substance abuse in certain psychiatric disorders.
Conduct Disorder Those with conduct disorder are at increased risk of self-harm (12.6% prevalence)49 and substance misuse.50 A study of delinquent adolescent boys concluded that they all achieved modified criteria for conduct disorder, and found a significant association between the number of conduct disorder symptoms and self-harming history. 51
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REVIEW Children suffering from conduct disorder have a greater probability of discord with their contemporaries,52 of association with delinquent and rejection by non-delinquent contemporaries. It could be that the psychological impact of rejection and conflict, and deviant peer influence guide a person with conduct disorder towards self-harm and amphetamine use. Post Traumatic Stress Disorder (PTSD) PTSD has been linked to an increased probability of both substance abuse and self-harm.1, 10 Jacobson et al comment on the large amount of data supporting a pattern where substance misuse occurs secondary to PTSD as a means of altering the symptoms of PTSD (the self-medication hypothesis); they propose that the high level of comorbidity in this area is indicative of a functional similarity between the two disorders.53 Prospective and analytical studies by Chilcoat H.D. and Breslau N. are in favour of this hypothesis over the two alternatives: namely, that substance abuse occurs prior to PTSD and is causative of it, either through placing the individual at increased risk of exposure to traumatic events, or through increasing their susceptibility to PTSD on exposure to trauma .54 In terms of more general stress, chronic stress caused development of sensitisation to the stimulatory behavioural effects of amphetamines in mice of particular strains (DBA/2 but not C57BL/6) , 55 thus suggesting a plausible hypothesis that individuals of some genotypes are susceptible to amphetamine sensitisation on prolonged or repeated exposure to stressors Self harm as a means of feeling some sensation to overcome numbness (automatic positive reinforcement), was found to be associated with PTSD.89 Study findings have shown that serotonin (SERT) gene knockout mice have greater vulnerability to predator stress,56 and that persons with low-functioning forms of this gene are more susceptible to depression and anxiety (and thus, symptoms of PTSD) following traumatic incidents.57,58,59 Inactivation of the serotonin SERT gene, although leading to increased 5HT2A receptor binding density in the amygdala,60 leads to a decrease in 5HT1A receptor binding density in numerous areas of the brain as well as the amygdala.61 Decreased binding density might suggest decreased response to serotonin. In light of the aforementioned associations between self-harm, amphetamine use and 5HT, it could be postulated that an underlying SERT gene malfunction affecting 5HT receptors, exacerbated by the effects of amphetamine use, may make some individuals vulnerable to anxiety and depression in response to stressful life events, and therefore PTSD and/or self-harm. Eating Disorders Amphetamines, being appetite suppressants, are open to common abuse amongst individuals with bulimia nervosa.62 The level of severity that those with an eating disorder limit their calorie intake has been shown to correlate with their likelihood of amphetamine use. 63 An association between self-harm and eating disorders has likewise been noted, with epidemiological research placing self-injury at a 25% for inpatient and outpatient bulimics, and 23% for outpatient anorexics.64,65
40
It may be that the lack of esteem in the self, particularly the body, which can direct an individual towards taking amphetamines in the propagation of an eating disorder, may also direct them towards self-harm (see later, under self-esteem.) Depression Depression has been associated with amphetamine misuse and very much so with self-harm .66,67 Major depressive disorder was diagnosed in 67% of self-poisoners in a study by Kerfoot et al.68 The vast majority of deliberate self-harmers in another survey achieved scores on the Beck Depression Inventory indicating moderate to severe depression. 73 There was a significant decrease in the 5HT binding capacity in the individuals of one study who had self-harmed, which would suggest a reduced response to 5HT in these patients. 69 Evidence, including lower concentrations of serotonin metabolites in the cerebrospinal fluid and serotonin in post-mortem brain tissue, reduced numbers if serotonin transporters in such tissue and the efficacy of selective serotonin reuptake inhibitors in depressed individuals all suggest that depression is likewise affiliated with impaired 5HT function. 70 Self-medication with amphetamines in order to combat depression occurs commonly; typically one user in a qualitative study recounted being â&#x20AC;&#x153;so low in moraleâ&#x20AC;? that she was drawn into the habit to resolve this. 71,72 In another such survey, those respondents who were also administering the drug for this purpose did report the desired elevation of affect on initial use; however, over 66% of the overall 450 questioned described depression as a serious result of chronic use. 73 It is not clear where precisely causality might lie. Whilst it appears pre-addiction depression might instigate either behaviour, and thus possibly both in the same individual, either simultaneously, or sequentially; it is also plausible that dysphoria produced by amphetamine withdrawal 50 or the effect on neurotransmitters of its chronic use, or the impact of sociological factors (such as unemployment) resulting from its misuse, may produce a depression that leads to self-harming behaviour. Sociological Factors There are several cofactors in substance misuse and self-harm in young people, including those following. Peer Influence Peer pressure is viewed as a possible reason for commencement of self-injury, and the negative influence of self-harming individuals among peer groups has been noted.74,75 Amphetamine use by peers significantly raised the likelihood of amphetamine use reported in a large sample of adolescents in America.76 Childhood Abuse Review of both retrospective and prospective research suggests most of the research indicates that childhood physical and sexual abuse is a risk factor for substance abuse, often through generation of depression and anxiety which put the victim at greater risk of such behaviour. 77 In one survey of self-harmers, 25% reported childhood physical abuse, and 49% childhood sexual abuse, as factors in the distress that caused them to self-harm. 78
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REVIEW Family problems Single parent status and one third of divorces have been linked to substance abuse , whilst over 50% of those self-harming under the age of 16 have divorced or separated parents.79,80,81 American research has categorised victims of emotional abuse as being at risk of substance use;82 and emotional abuse was cited in 43% respondents in one survey as a factor for their self-harm.109 Lack of warmth has been associated with both self-harm and advancement from experimental to more frequent substance use.83,84 Connections have been made between family disruption and dissension, and both self injury and substance misuse.85,110,114 The object relations theory hypothesises that people, objects and fantasies in the environment of a child will form the basis from which the child acquires their sense of self. In cases of childhood abuse and family turmoil and lack of warmth, the childâ&#x20AC;&#x2122;s environment is unstable, love is conditional, and trust may be abused.86 Van der Kolk proposes that this may cause the child to envision themselves as lacking in trustworthiness and unable to be loved unconditionally leading to self-injury as a form of punishment or a need to re-enact the trauma.87,88 The childâ&#x20AC;&#x2122;s emotional system may also be sensitised to future traumas by these earlier experiences, making them more difficult to withstand, and perhaps therefore necessitating self-injury and amphetamine use as coping strategies for the emotions (experiential avoidance). Conclusion Both self-harm and amphetamine misuse are significant medical issues in their own rights in terms of their high popularity and negative effect on multiple aspects of quality of life. It is clear that there is a paucity of research into the exact relationship between amphetamine misuse and self-harm in humans. Currently, only animal studies have provided firm evidence of a link between amphetamines and self-mutilatory behaviour though many possible explanations for a human association are plausible. There is a need for further research in this area to establish causality, which will be beneficial in establishing the extent of comorbidity or sequential morbidity with these disorders, and vital in planning the treatment approach; for example, an underlying neurobiological problem would favour pharmacological treatment, a psychiatric problem might favour a problem-solving emendation approach. Unified nomenclature would help make research studies comparable with each other.
It is likely that not just biological but also psychosocial factors mediate. From the factors involved in relation to self-harm and amphetamine misuse, it is clear that there is scope for further research studies into combined treatment involving 1. Raising of self-esteem. 2. Family therapy to resolve conflict and care issues. 3. Amendment of poor problem-solving abilities 4. Amendment of poor decision-making capabilities 5. Alternative medicine The high physical, psychological, financial and social health costs of amphetamine use and self-harm, and its popularity in an age group of individuals expected to be at the peak of their health, and at critical junctures of their educational or working lives, make research into the incidence and co treatment of it prudent. Routine screening for amphetamine use in self-harmers and vice versa may also be worthwhile given the apparent relationship between them. Where there is a diagnosable underlying medical condition, such as PTSD, then recommendation is made to treat the cause. Cotreatment of amphetamine use is considered advisable, to ensure amphetamines do not mask an underlying psychiatric condition, and so that physical harm is limited. References 1.
2. 3.
4. 5.
6.
7. 8. 9.
10.
Much of the research into amphetamine and self-harm focuses on the adolescent to 30 year old age group since this is the one with the highest prevalence of both disorders. This is inadequate for a full understanding of the populations with these disorders and ought to be addressed in future studies, particularly as possible contributing psychosocial factors such as life events and education status tend to show variance with age.
Lara-Lemus A., Perez de la Mora M., et al.,(1997) Effects of REM sleep deprivation on the d-amphetamine induced self-mutilating behaviour, Brain Research, 770;60-4 Patton G.C., Harris R., et al.,(1997) Adolescent suicidal behaviours: a population-based study of risk, Psychol. Medicine, 27(3);715-24 Yoshida T., Use and misuse of amphetamines: An international overview. In: Klee H, ed. Amphetamine Misuse, International Perspective on Current Trends, The Netherlands: Harwood Academic Publishers, 1997;43-59 Favazza A.R., Rosenthal R.J., (1993) Diagnostic issues in selfmutilation, Hospital and Community Psychiatry, 44(2);134-40 Hasin D., Grant B., Endicott J.,(1988) Treated and untreated suicide attempts in substance abuse patients, Journal of Nervous and Mental Disease, 176;289-94 Kratofil P.H., Baberg H.T., Dimsdale J.E. (1996) Self-mutilation and severe self-injurious behaviour associated with amphetamine psychosis, General Hospital Psychiatry, 18;117-20 Israel J.A., Lee K.,(2002) Case Report: Amphetamine usage and self-mutilation, Addiction, 97(9);1215-18 McAllister M.,(2003) Multiple meanings of self harm: a critical review, International Journal of Mental Health Nursing, 12;177 Grahame-Smith D., Barlow J., et al., Drug Misuse and the Environment, A Report by the Advisory Council on the Misuse of Drugs, Norwich: Her Majestyâ&#x20AC;&#x2122;s Stationery Office, 1998;15-6 Munro C.A., McCaul M.E., et al.(2006) Sex differences in striatal dopamine release in healthy adults, Biological Psychiatry, Article in press, corrected proof accessed via www.sciencedirect.com at 23:14 hrs on 21/04/06
Evidence is strongest for a neurobiochemical link between behaviours, specifically serotonin depletition and dopamine mediated reward. It could be that in the future, there may be the opportunity of development of one pharmaceutical therapy to treat both conditions.
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lsjm 15 june 2009 volume 01
EDITORIAL
Welcome to the Surgery Section of the London Student Journal of Medicine. We aim to inform all healthcare disciplines through historical pieces, reviews of fundamental topics and cutting edge research. By understanding the basis of past and current surgical science, current practice can be challenged and future practices shaped. The Surgery Section encompasses all surgical specialties, Obstetrics and Gynaecology, Anaesthetics as well as aspects of Clinical Oncology and Clinical Radiology. This first issue of the journal concerns itself with the topic of ‘unhealthy behaviours’. The Surgery Section includes a discussion around the area of patient safety and the consequences of errors in healthcare. The impact of events that have an adverse effect on patients while under the care of healthcare professionals is substantial and has been known for a very long time. The UK’s Department of Health, in 2000, released the report An Organisation with a Memory which revealed that adverse events affected 10% of hospital inpatients, translating to approximately 850,000 individuals.1 Furthermore, the report highlighted the fact that many of these adverse events were happening time and time again as lessons were not being learned. In 2004, the UK’s Chief Medical Officer spoke at the launch of the World Alliance for Patient Safety and said, ‘To err is human, to cover up is unforgivable, and to fail to learn is inexcusable’.2 This is an ‘unhealthy behaviour’ within healthcare that we must eradicate to ensure that we are not adding to the burden of illness. So how can we as healthcare professionals improve upon our ‘unhealthy behaviours’? Sebastian Yuen in his Expert Comment covers a range of strategies. What is needed first and foremost is an awareness of these issues. Speaking from our perspectives as medical students, we admit to having little exposure to patient safety, and perhaps this needs to be the first issue to be addressed. We would like to know of your experiences of patient safety as a student in a healthcare discipline around the world as well as your suggestions on how to improve patient safety. The use of the World Health Organisation Surgical Safety Checklist (see our Ask the Expert feature) is a strategy being implemented in the area of surgery to address this issue. This issue also features a review of Primary Care referral guidelines for patients with suspected colorectal cancer. Over the coming months the surgery section hopes to share with you the opinions of experts currently shaping the landscape of surgical practice. Alongside original contributions, the section includes articles of general interest and hopes to impact on student life with our perspective pieces. Making the most of a surgical placement, profiles of eminent individuals and a Mystery Object competition are a few such articles which we hope will do just this. We are always on the lookout for potential ideas and articles that can be turned into published pieces in the LSJM. To discuss an idea or submit a manuscript to the Surgery section, please e-mail us at surgery@thelsjm.co.uk. If you have an individual in mind to profile, please contact us first as there are certain questions we want all our profiles to include to create a quick and interesting comparison between them. Looking forward to subsequent issues, we hope to build an issue specifically around peri-operative care and would welcome any submissions in this area from students of all healthcare disciplines. As with any publication, feedback is essential both for reflection and improvement. We welcome your views and suggestions that our readers may have and encourage you to write to us with ‘Letter to the Editors’ as the subject line of your email. Our thanks go to everybody who has contributed to this issue including the authors, peer and expert-reviewers. They have provided insightful and pertinent comments, which have thus improved the quality of submissions. However, most thanks must go to our group of panellists for all their hard work, dedication and support. We sincerely hope you enjoy this inaugural issue of the journal, consider it as a place to publish your work and begin to make it part of your regular reading. Jonathan Cheah & Milan Makwana Section Editors of Surgery References Illustration: Robert Hare
1. 2.
Department of Health. An organisation with a memory: Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. Crownright. Department of Health. HMSO. 2000. WHO World Alliance for Patient Safety. World Health Organisation [online]. 2009. http:// www.who.int/patientsafety/en/ [Last Accessed 11 April 2009]
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EXPERT COMMENT
Why Quality Should Matter To You Sebastian Yuen MBBS DCH MRCPCH FHEA
Consultant Paediatrician, Royal Free Hospital, London Fellow, NHS Institute for Innovation and Improvement sebastian.yuen@institute.nhs.uk
Sebastian Yuen is leader of the Royal Free Hospital IHI Open School Chapter
“
In 2004 in the UK, 2180 patients died as a result of mistakes; this is not acceptable. Medicine is changing rapidly. Once, it was enough to acquire knowledge, clinical skills and expertise in a specialty. Now, however, there is increasing recognition that high quality healthcare also depends on creating reliable and effective systems and processes. Lord Darzi’s High Quality Care for All defines quality care as being safe, effective and patient-centred.1 Many patients are actually harmed by the care they receive, resulting in injury and even death. In 2004/5, 2180 deaths occurred in the UK due to error.2 Of the 16 million admissions to hospital each year in the UK, one million experience harm and half of this is preventable. The US Institute for Healthcare Improvement (IHI) is working towards a vision they call the “No Needless List”: No needless death, no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one left out. Healthcare students have a key role to play in making this vision a reality. The following discussion will signpost a number of organisations and resources that will help you learn to see things differently.
will beings always carry risks; human beings are fallible. Healthcare will always carry “Healthcare risks; human are fallible. However, harm to patients should not be viewed as an acceptable However, harm to patients should not be viewed as an acceptable part of modern healthcare.” Liam Donaldson, UK Chief Medical part of modern healthcare.
”
Officer Liam Donaldson, UK Chief Medical Officer
Patient safety curricula have been developed by the World Health Organisation and Medical Royal Colleges Adverse events occur, not because people intentionally hurt patients, but because of the complexity of the system of medical practice. Other high risk industries, such as aviation, have embraced the science of safety and transformed the way they operate. The Academy of Medical Royal Colleges has developed the Medical Leadership Competency Framework.3 This describes the competencies that all doctors need to know about planning and delivering services. The five domains are: personal qualities, working with others, managing others, improving services and setting direction. The competencies are outlined for students, trainees and consultants. The WHO is currently piloting its Patient Safety Curriculum Guide for Medical Schools.4 The future of healthcare will depend on a workforce that is skilled in methods of quality improvement and which can work collaboratively with
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other professions. But who is teaching this? The challenge faced by most medical schools is of squeezing ever more into a crowded curriculum. The NHS Institute pre-registration training: Improvement for better, safer health and social care The NHS Institute for Innovation and Improvement aims to transform healthcare by rapidly developing and spreading new ways of working, new technology and world-class leadership. In 2006 it worked with three universities to incorporate improvement methodology training into their pre-registration programmes for healthcare professionals.5 There are currently 32 universities involved. Core principles of the training include an introduction to systems-thinking, understanding the patient’s perspective and sustainable ways to improve the service. In addition to the theory, students are encouraged to work as inter-professional teams and practise using one of the improvement tools. The programme enables them to understand that quality improvement is an everyday task, not one carried out on us by managers. 88% of participating students felt that service improvement was important or very important to their professional development. 85% agreed that knowledge of service improvement would enhance their job prospects. The NHS Institute continues to promote this training and aims for it to become compulsory in all universities. “We all have two jobs, one is to do the job we’re trained to do; We have two one is to doimprove the job we’re trained do; the second the all second one jobs, is to constantly the job we’retodoing.” one is to constantly improve the job we’re doing.” Healthcare student Healthcare student
The NPSA has created Safe Foundations, a training package for junior doctors The NHS National Patient Safety Agency (NPSA) has also produced a programme for teaching junior doctors.6 Entitled Safe Foundations and available free online, it consists of four workshops with UK examples of patient stories and videos. The first focuses on human error, which it describes as inevitable. It emphasises that you are most likely to make errors when you start as a junior doctor. The series continues by contrasting the individual’s actions with the impact of the system. Whilst error will never be eradicated, harm to patients is not inevitable and can be avoided. To achieve this, clinicians and institutions must learn from past errors and learn how to prevent future errors. Root cause analysis of critical
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EXPERT COMMENT incidents is normal in other complex industries such as aviation. Systematic investigation of adverse incidents exposes system failures that often can then be minimised or eliminated.
approximately one hour each to complete. Students are able to explore the extensive IHI literature that experts and professionals around the world read and refer to.
Doctors and other frontline staff are harm absorbers, the last line of defence in the healthcare system. Through a better understanding of human factors and systems, you will be able to recognise when things are going wrong. As an emerging clinical leader, you will be able to prevent that situation from spiralling into a patient safety incident.
Open School Chapters in the UK allow face-to-face discussion and learning The web-based resources are complimented by “chapters” where students from a variety of professions meet face-to-face. There is one chapter in London, based in the Royal Free Hospital. There are seven others in England, six in Wales and three in Scotland. Worldwide, the total has reached 122 chapters in 12 countries. Each has a chapter leader, usually a student, and a faculty advisor who will have experience of leading quality improvement. The membership and frequency of meetings will vary, but their purpose is to engage, enthuse, challenge and stimulate learning and action. The leaders have monthly calls with IHI to share experiences and ideas for activities. There are regional clusters which develop their own support networks. The UK hosted its first UK Chapter Congress in Stirling, Scotland, on 28th April 2009. As members of Open School, students are invited to attend the inspirational IHI national forum (6-9.12.2009, Florida) and International Forum (20-23.04.2010, Nice, France) with free registration.
“Great doctors are not the ones that never make errors. Rather, they are the people who expect errors to happen and who have strategies in place to cope with them, before these adverse events could cause harm to a patient.” Professor James Reason BAMMbino is developing resources for students to complement the BAMM Fit To Lead programme for consultants. BAMMbino is the junior doctor division of the British Association of Medical Managers (BAMM).7 They are supported by the senior leadership of the NHS and are currently developing resources for medical students and trainees. These will complement the BAMM Fit To Lead programme for consultants. Learn To Lead will involve two years of active participation for doctors and lead to a certificate in medical management. It will follow the Medical Leadership Competency Framework and combine courses, project work and coaching. The student development programme will target medical students in their clinical years. The format will include facilitated small group teaching, a management project and individual mentoring. “The doctor’s frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism.” Professor John Tooke
A final thought Improving quality (safety, effectiveness and patient experience) is now the number one priority in the NHS. In a recession, with the NHS budget contracting after 2011, improving the quality and safety of systems will be essential. Those with experience of effectively implementing innovations and processes (however small) will be very attractive to employers. Take advantage of the above opportunities now, learn to see differently and help provide the best care for your patients.
“
Wekind can’t problems by using the same kind of “We can’t solve problems by using the same of solve thinking we thinking we used when we created them. used when we created them.” Albert Einstein Albert Einstein References
The IHI Open School is a free international interactive resource for healthcare students The IHI is an independent not-for-profit organisation helping to lead the improvement of healthcare throughout the world. During an 18 month period in 2004-6, they organised the ambitious 100,000 Lives Campaign.8 They enrolled 3,000 hospitals and introduced six interventions including rapid response teams, better medication management, and care bundles for acute myocardial infarction, ventilator-associated pneumonia and central line infections. The impact was dramatic and saved an estimated 123,000 lives. Similar techniques have spread to many countries across the world. In the UK, the IHI worked with The Health Foundation and 24 hospitals on the Safer Patient Initiative (20048). This has evolved into the Patient Safety First Campaign covering England9 and equivalent programmes in Ireland, Scotland & Wales.
1.
IHI launched the Open School for Health Professions in 2008 to transform thinking about how healthcare should be delivered10. It is free and makes full use of Web 2.0 applications to engage its worldwide audience as fully as possible. Examples of 21st Century media used include Google Groups, WebEx, Facebook, Blogger, Twitter, Podcasts and YouTube. The curriculum covers core fields such as the science of patient safety, systems thinking, quality improvement, teamwork and communication. This is contained within six online courses, each comprising four lessons which take
7.
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2.
3.
4.
5.
6.
8.
9. 10.
1. Darzi A. High Quality Care for All: NHS next stage review final report. Crownright. Department of Health. HMSO. 2008. 2. Department of Health. Safety first: a report for patients, clinicians and healthcare managers. Crownright. Department of Health. HMSO. 2006. 3. Medical Leadership Competency Framework. NHS Institute for Innovation and Improvement [online]. 2009. http://www. institute.nhs.uk/mlcf [Last Accessed 27 April 2009]. 4. WHO Patient Safety Curriculum Guide for Medical Schools. World Health Organisation [online]. 2009. http://www.who. int/patientsafety/activities/technical/medical_curriculum/ en/index.html [Last Accessed 27 April 2009]. 5. Building improvement capability into pre-registration training. NHS Institute for Innovation and Improvement [online]. 2009. http://www.institute.nhs.uk/building_capability/building_ improvement_capability/building_improvement_capability_into_ pre-registration_training.html [Last Accessed 27 April 2009]. 6. Safe foundations. National Patient Safety Agency [online]. 2008. http://www.npsa.nhs.uk/nrls/improvingpatientsafety/learningmaterials/safe-foundations/ [Last Accessed 27 April 2009]. 7. BAMMbino. The British Association of Medical Managers [online]. 2009. www.bamm.co.uk/Services/Support_&_Development/ BAMMbino_2007072440 [Last Accessed 27 April 2009]. 8. The First Campaign Initiative. Institute for Healthcare Improvement [online]. 2009. http://www.ihi.org/IHI/ Programs/Campaign/Campaign.htm?TabId=6#TheFirst CampaignInitiative [Last Accessed 27 April 2007]. 9. Home. Patient Safety First Campaign [online]. 2009. http:// www.patientsafetyfirst.nhs.uk/ [Last Accessed 27 April 2009]. 10. IHI Open School. Institute for Healthcare Improvement [online]. 2009. http://www.ihi.org/OpenSchool [Last Accessed 27 April 2009].
”
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ARTICLE
The IHI Open School: Primum non nocere Andrew Carson-Stevens BSc (Hons)
Intercalated MPhil Medical Student, Cardiff University carson-stevens@doctors.net.uk doi:10.4201.lsjm/surg.002
Andrew Carson is the leader for the Wales Chapter for Healthcare Improvement
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Simple interventions can save lives Lives are being saved everyday in the National Health Service (NHS) but thousands more preventable deaths and incidents of harm could be avoided. Lasting cultural change within the NHS is required to ensure this. Healthcare students, as the workforce of the future, are vital to this process.
Students, with eyes fresh to the healthcare system, are uniquely positioned to spot opportunities for improvement. Think about it. From your experience of the system - as a healthcare student on a clinical placement, as a patient, as a relative of a loved one - how often have you thought ‘this could be done so much better’?
The Wales Chapter for Healthcare Improvement1 is part of a global movement, initiated by the Institute of Healthcare Improvement’s (IHI) Open School,2 to advance healthcare quality improvement and patient safety competencies in the next generation of health professionals worldwide. The Wales Chapter was launched on April 24th 2009 on the 1st Anniversary of the Wales 1000 Lives Campaign.
A new generation of healthcare professional The IHI Open School’s free and certified courses aim to provide students with the opportunities to learn how to improve the healthcare systems in which they will work as professionals. Course content raises awareness of healthcare quality and patient safety issues, and also equips learners with the skill base to implement change which can lead to improvement.
The 1000 Lives Campaign recognises the tireless efforts of frontline NHS professionals and aims to save an additional 1000 patient lives and prevent up to 50,000 episodes of harm over two years.3 Early figures indicate that in the first six months, 410 patient lives have been saved.4 The combined and unceasing efforts of frontline NHS healthcare professionals to deliver simple, evidence-based checks and changes in practice, have contributed to this success. The Wales Chapter believes that students can assist identify areas for improvement and save even more lives.
The Open School encourage the set up of a ‘chapter’, which is the UK equivalent of ‘society’, and the courses serve as a sound starting point for generating initial buy-in from colleagues. However, once students are signed up to the chapter, what next? The Open School has generated and collected a plethora of learning resources that promote the sharing of experiences and understanding of roles between the healthcare professions. Such activities go a long way towards encouraging a student-led interprofessional learning environment.
Every system is perfectly designed to achieve exactly the results it gets The IHI is working to change the way in which medical error is understood and managed. IHI advocate that when a medical error occurs, it is important to acknowledge that the system within which it happened was perfectly designed for that error to occur.5 The same could be said for medical education. In fact, it is possible that as young professionals entering the workplace, we could actually do more harm than good, despite the very best of our intentions.
A few examples of Chapter activities: video case studies of patient experiences or interviews with experts in patient safety prompt discussion and reflection from practice; journal articles can initiate debate about current and future implications for practice; monthly audio calls given by world renowned experts in improvement can help keep momentum, generate new ideas for testing improvement locally and maintain enthusiasm amongst the group. Setting global challenges Monthly Chapter Leader calls provide direction through sharing and discussing successes and challenges. The IHI Open School has
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COMPETITION created a network of global partnership and friendship between groups of enthusiastic and dedicated students that share similar values, visions and goals, successes and challenges, across the globe. Chapter members are encouraged to use their newly identified skills in practice by getting involved in projects through established safety campaigns, or even initiating their own improvement projects to test their individual ideas for change.
A sobering thought ... By being part of an IHI Open School Chapter and completing the online courses, students can make a big difference to patient care. Changes made to create an improvement are very often the simplest ideas, and IHI Vice-President Joe McCannon reminds us, “If we can improve care for one patient, then we can do it for ten. If we can do it for ten, then we can do it for 100. And if we can do it for 100, we can do it for 1,000.”
If so, the Surgery Section has a signed copy of The Knife Man: Blood, Body-Snatching and the Birth of Modern Surgery, a biography of John Hunter, eighteenth-century surgeon by Wendy Moore, to give away. The prize has been kindly supplied by the Hunterian Museum. To enter, e-mail your answer to surgery@thelsjm.co.uk with ‘Mystery Object Competition’ as the subject line along with your name, course and year/place of study by 30 July. The winner will be the first randomly selected from all the correct entries.
© The Royal College of Surgeons of England
We want the Surgical Safety Checklist to be used in every hospital, for every surgical procedure, by every surgical team, in Wales by 2010. Students observe procedures in operating theatres on a daily basis. We have asked our medical students to record a series of observations (e.g. Yes/No) against five key processes that are already considered standard procedure (e.g. correct site marked prior to surgery and antibiotics given within the correct time interval). In collaboration with the 1000 Lives Campaign Surgical Complications team, this baseline data will be used to encourage uptake and implementation of the Surgical Checklist in Wales. The Wales Chapter is working with colleagues at Harvard University, to establish a global drive to engage students in encouraging the spread and implementation of the WHO Surgical Checklist, through the international network of over 100 IHI Open School Chapters.
Can you identify this object from the Hunterian Museum, based at the Royal College of Surgeons of England?
© The Royal College of Surgeons of England
A student-led improvement project conducted by the Wales Chapter involves collecting data to encourage the implementation of the WHO Surgical Checklist.6 Analogous with pre-flight checks carried out by an aeroplane pilot prior to take off, the surgical checklist involves a series of checks prior to, just before and following surgery. The checklist was implemented at eight sites across the world, in developed and developing countries, and resulted in a rate of major complication decrease by one-third and a 40% reduction in patient death.7
Mystery Object Competition
References: 1. 2. 3. 4.
5.
6. 7.
The Wales Chapter for Healthcare Improvement [online]. 2009. http:// www.waleschapter.wales.nhs.uk [Last Accessed April 29th 2009]. IHI Open School. Institute for Healthcare Improvement [online]. 2009. http://www.ihi.org/OpenSchool [Last Accessed April 29th 2009]. 1000 Lives Campaign [online]. 2009 http://www.1000LivesCampaign. wales.nhs.uk [Last Accessed April 29th 2009]. Over 400 lives saved in first six months of Campaign. 1000 Lives Campaign [online]. 2009. http://www.wales.nhs.uk/sites3/news. cfm?orgid=781&contentid=11897 [Last Accessed April 29th 2009]. Improvement Tip: Want a New Level of Performance? Get a New System. Institute for Healthcare Improvement [online]. 2009. http://www.ihi.org/ IHI/Topics/Improvement/ImprovementMethods/ImprovementStories/ rovementTipWantaNewLevelofPerformanceGetaNewSystem. htm [Last Accessed April 29th 2009] Safe Surgery Saves Lives. World Health Organization [online]. 2009. http:// www.who.int/patientsafety/safesurgery/en/ [Last Accessed April 29th 2009] Haynes, A.B., Weiser, T.G., et al. 2009. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. 2009 Jan 29;360(5):491-9. Epub 2009 Jan 14.
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ARTICLE
A Retrospective Analysis of the ‘Two-Week Rule’ in the Diagnosis of Colorectal Cancer Mostafa Albayati
mostafa.albayati@kcl.ac.uk Intercalating BSc Medical Student, King’s College London doi:10.4201.lsjm/surg.003
Image Courtesy of Cancer Research UK & Bobby Moore Fund
The views expressed are not necessarily those of cancer research. For the full article and references see thelsjm.co.uk. For further reading please see NICE guidelines on CRC/ TWR.
Michael Carrick Pass the message on
David James Saving lives
Rio Ferdinand Defend your body
Micah Richards Defend your body
Shaun Wright-Phillips Pass the message on
Registered Charity No. 1089464
Theo Walcott Attack the disease
Results A total of 75 referrals were made to the fast-track clinic during the study period. 68 of these were made via the TWR, of which 3 (4.4%) were diagnosed with CRC. 7 patients with CRC presented to the colorectal unit in the same study period through other means. 38 (56%) referrals complied with the DoH guidelines for appropriate TWR referral and 66 (97%) complied with the 14 working days target.
44 people die from bowel cancer every day in the UK
There is Moore to know Visit www.bobbymoorefund.org www.teamenglandfootballerscharity.com Photography by John Davis @ Soho Management; anatomical layers generated by www.TheVisualMD.com and scans by Philips Medical Ref ED078B.April2009
Abstract Objective: Colorectal cancer (CRC) is the third most common cancer in the UK. CRC patients in the UK are known to have poorer survival rates compared to other European countries, with a three-year survival rate of approximately 44%. In 2000, the Department of Health (DoH) introduced the Two-Week Rule (TWR) for fast tracking all urgent cancer referrals, with the aim of identifying 90% of bowel cancer cases. We aimed to assess the efficacy of the TWR for suspected CRC in a large university teaching hospital. Methods A retrospective study of all patients referred to the colorectal unit during a six-month period was conducted, documenting various outcomes. Parameters in the study included source of referral, CRC diagnosis and GP compliance with referral guidelines.
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Conclusion The detection rate for TWR-referred CRC was low and accounts for only approximately a third of all CRC cases diagnosed during this study period. This low yield suggests that the referral guidelines are not as effective as the DoH target. Reasons for this may include poor compliance with the guidelines by GPs and poor specificity of the guidelines. Introduction Colorectal cancer (CRC) is the third most common cancer in the United Kingdom, with 32,300 new cases diagnosed and 14,000 deaths annually in England and Wales alone. In addition, patients presenting with CRC in the UK have been shown to have poorer survival rates compared to other European countries, with a three-year survival rate of approximately 44% compared to 67% in Italy.1,2 The reasons for this are unclear. CRC implies major health costs to the National Health Service (NHS) (annual expenditure of more than £300 million) and is important to overall public health strategy because it is common and frequently fatal. In order to improve cancer survival rates, the UK’s Department of Health (DoH) issued the ‘NHS Cancer Plan’ in 2000, with the introduction of the Two-Week Rule (TWR) for fast tracking all urgent cancer referrals from primary to secondary care.3 The DoH also published guidelines for General Practitioners defining those patients with high risk symptoms that required specialist assessment within the two week time frame (Table 1), with the aim to “identify up to 90 per cent of patients with bowel cancer”.4 Previous studies have commented on the impact of the TWR on the detection rate of CRC. Chohan et al. revealed that, while the TWR was successful in speeding up patients’ access to clinic, only 27% of referrals had a confirmed diagnosis of CRC.5 Similarly, a systematic literature review by Thorne et al. in 2006 indicated that only 10.3% of patients referred by the TWR were eventually diagnosed with CRC.6 Several other studies have cited pitfalls and have suggested that the poor yields may be due to the guidelines’ poor sensitivity and specificity.7
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ARTICLE Table 1: Department of Health high risk criteria for suspected colorectal cancer.
However, it has also been suggested that these findings reflect the inappropriate use of the guidelines by GPs. It has been suggested that the high numbers of nonconforming referrals made are as a result of some GPs using the TWR referral system as a quick disposal route for all patients presenting with rectal bleeding.8 Some authors have shown that approximately 60% of all CRCs identified when analysed retrospectively appeared to fit the guidelines, therefore suggesting that the guidelines, if accurately implemented, might prove useful.9
All ages • • • • •
Over 60 years • •
The principal objective of this study was to assess the CRC detection rate to determine whether the TWR is effective in identifying suspected CRC patients, and whether findings from our unit agree with those from other studies published.
Rectal bleeding with a change in bowel habit to looser stools Increased frequency of defecation persistent for 6 weeks A definite palpable right-sided abdominal mass A definitive palpable rectal mass (not pelvis) Unexplained iron deficiency anaemia (Hb < 11 g/dl in men or < 10 g/dl in postmenopausal women) Change in bowel habit as above without rectal bleeding and persistent for 6 weeks Rectal bleeding persistently without anal symptoms
Table 2: Number of colorectal cancers diagnosed Number of patients N° TWR referrals received
Methods All TWR referrals to the colorectal unit at Bassetlaw Hospital, Nottinghamshire were audited over a six month period between April 2006 and September 2006. Referrals were identified from both faxed TWR proformas and standard GP referral letters. Data collected from the referral letters included age, sex, and symptoms for referral. In addition, other outcomes were noted, including GP compliance with the TWR guidelines (patients fulfilling one or more of the six high-risk criteria), other routes of referral, investigations undertaken, the number of cancers diagnosed, timescale from referral to investigation, and the waiting time from referral to diagnosis. Diagnosis of all malignancies was confirmed histologically and graded using Dukes’ classification. Results In total, there were 75 referrals made to the colorectal unit during the six month study period, all of which were new referrals. Seven referrals were from outside of the TWR referral system and were subsequently not included in the main study. The ratio of male:female patients was 28:40 (41%:59%). Of the 68 patients seen in the fast-track clinic, only three (4.4%) were subsequently diagnosed with CRC (Table 2). A further seven patients with CRC presented to the department in the same time period via other routes; three were internal consultant referrals from other departments, two were GP urgent referrals, and two were GP routine referrals. The final diagnosis of CRC was greater from referrals outside of the TWR referral system (70% (7/10) versus 30% (3/10), respectively). Furthermore, of the three malignancies diagnosed through the TWR referral system, one was Dukes’ stage B and the remaining two were Dukes’ stage D. Compliance with the published guidelines for appropriate TWR referral by GPs was generally poor, with only 38 (56%) of the 68 referrals complying with the guidelines. The remaining 44% of patients referred did not fulfil at least one of the six referral criteria (Table 1). Table 3 documents the symptoms for referral to the fasttrack colorectal clinic. The majority of patients presented with a change in bowel habit, which was documented 47 times, followed by rectal bleeding (documented ten times). Rectal bleeding with a change in bowel habit was noted six times. Unexplained iron deficiency anaemia was noted five times, and a palpable right sided abdominal mass was noted once. Abdominal pain and weight loss were also documented as presenting symptoms (ten and four times, respectively).
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N° CRC cases identified from TWR referrals (%) Total number of CRC cases diagnosed
68 3 (4.4%) 10
Table 3: Symptoms for referral to fast-track colorectal clinic. Symptoms
Incidence in patients
Rectal bleeding in patients >55 years
10
Change in bowel habit: looser/increased frequency
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Rectal bleeding and change in bowel habit
6
Unexplained iron deficiency anaemia
5
Right-sided abdominal mass
1
Abdominal pain
10
Weight loss
4
The proposed Government target of 14 working days from referral to outpatient appointment was met in 66/68 (97%) of the TWR referrals. Figure 1 shows that the majority of patients underwent colonoscopy during the course of their investigation, followed by barium enema. Other investigations included abdominal ultrasonography, flexible sigmoidoscopy and abdominal CT. The overall median time from referral to investigation was 3 weeks (range 1-6 weeks) and the overall median time from referral to diagnosis was 9 weeks (range 2-12 weeks). The most common final outcome of the fast-track patients was diverticular disease (24/68). Discussion The current DoH guidelines for suspected CRC were put in place to be used by GPs in primary care as a guideline to prioritise referral.7 Despite original targets, more than two thirds of the CRC patients in this audit were referred via routes other than the TWR referral system. The low number of CRC patients identified following a TWR referral in this study, suggests that the guidelines are not as effective in identifying CRC patients at first presentation to their GP as was hoped. Poor compliance with the guidelines has been documented at many centres as one of the major reasons for this poor CRC detection rate. The results from our study demonstrated that only 56% of referrals complied with the guidelines, reflecting many previous audits. Rai et al., in a recent review of all audits on the TWR
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ARTICLE referral system published in mainstream peer-reviewed journals, found that compliance with the published guidelines by GPs at primary care level is poor in the majority of centres.10 Possible reasons for this poor compliance may be due to a lack of time in the general practice consultation, poor experience with taking colorectal histories, or exaggeration of the symptoms by the patient or GP in order to speed up their hospital appointment. The Advisory Group formulating the guidelines for the TWR referral system did, however, emphasise the importance of close adherence and implementation at the time of the guidelines’ publication.11 Ideas on improving compliance in the future include a personalised feedback system from the hospital clinician to the GP which may help to emphasise the importance of not referring patients with transient symptoms or symptoms over 18 months duration to the fast-track clinic.11,12 However, increased compliance with the TWR referral guidelines reported in some centres has not necessarily improved the diagnostic yield of CRC in the fast-tracked population. For instance, Barwick et al. reported only a 10% yield in CRC despite a 96% compliance rate with the TWR referral.13 This suggests a problem with the specificity of the guidelines. Furthermore, CRC is notoriously difficult to diagnose due to its very non-specific symptoms, dependent on the anatomical location of tumours. Patients with proximal cancers are more likely to present with anaemia and therefore be referred to medical outpatients, whereas those with more distal tumours, producing rectal bleeding, will be referred to surgical outpatients.14 This suggests that it may not just be poor GP compliance or poor guidelines that makes the detection rate using the TWR system hit-and-miss but rather due to the nature of the disease itself. More worryingly, the sharp increase in the total number of TWR referrals in England (60% increase from 13,410 referrals in 20012002 to 21,234 referrals in 2004),15 is overwhelming the system and a significant number of patients referred routinely are now being disadvantaged by longer clinic waits and delays in diagnosis, suggesting that a change is urgently needed.
provides an opportunity to identify precursors to invasive disease and polyps.19 However, recent results from the NHS Bowel Cancer Screening Pilot demonstrate that, despite the feasibility of population-based FOBt screening, this method of screening has a sensitivity of 57.7% and a positive predictive value of 5.3% for CRC. This low positive predictive value means that it has the potential to produce many false-positive results, and therefore the associated cost, risk and anxiety of colonoscopy.20 There is a need to improve the screening tool in order to produce an effective, safe, and relatively inexpensive screening method with a high positive predictive value that will function as a good addition to the TWR referral system. Conclusion Ultimately, the objective of any fast-track referral system is to diagnose and treat suspected cancer at an earlier stage in order to improve survival. The evidence presented in this paper indicates that the detection rate for TWR referred CRC was low and accounts for only approximately a third of all CRC cases diagnosed. This may be reflected by the fact that many patients referred to the fast-track clinic did not comply with the guidelines. Although the TWR remains a valuable service to GPs and their patients and that its low CRC yield may be partly due to the nonspecific nature of the disease, the results from this study and many similar audits suggest that the system is in need of independent evaluation and improvement. The effectiveness and efficiency of any future system in detecting CRC will depend on the sensitivity and specificity of the referral criteria, the ease with which GPs could identify the criteria, and the extent to which they choose to use the new service. This will require well funded programmes with increased support and feedback to GPs to encourage the appropriate use of guidelines in the decision to seek referral. Acknowledgement Advice regarding the submission was sought from Mr. Kamal Nagpal, Upper GI Research Fellow, St Mary’s Hospital, London References: 1.
Interestingly, similar outcomes in the cancer detection rate using the TWR referral system have been reported for other cancers. There has been a decline in the breast cancer detection rate since the introduction of the TWR, despite an increase in the number of fast-track referrals.16 Our study has shown that CRC is most often detected using the TWR system in patients presenting with later stage (Dukes’ stage C and D) disease. Similarly, Debnath et al. reported an early cancer detection rate of only 4.6%.17 These findings suggest that the referral system is ineffective in identifying early stage CRC and raises a question of whether it translates into any apparent future survival benefit. Earlier presentation of CRC is very non-specific, and if the TWR system is to detect these earlier malignancies, its criteria would need to be even more non-specific than it currently is. A solution to this problem would be to introduce a national screening programme for CRC. Faecal occult blood testing (FOBt) has been suggested as a possible screening tool and can detect CRC at an early and more treatable stage. It also
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3. 4. 5.
6.
7.
8.
9.
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Gatta G, Capocaccia R, Sant M et al. Understanding variations in survival for colorectal cancer in Europe: a EUROCARE high resolution study. Gut 2000;47:533-8. Ciccolallo L, Capocaccia R, Coleman MP et al. Survival differences between European and US patients with colorectal cancer: role of stage at diagnosis and surgery. Gut 2005;54(2):268-73. Department of Health: NHS Cancer Plan. London; 2000. Department of Health: Referral Guidelines for Bowel Cancer. London; 2000. Chohan DPK, Goodwin K, Wilkinson S, Miller R, Hall NR. How has the “two-week wait” rule affected the presentation of colorectal cancer? Colorectal Dis 2005;7(5):480-5. Thorne K, Hutchings H, Elwyn G. The effects of the TwoWeek Rule on NHS colorectal cancer diagnostic services: A systematic literature review. BMC Health Serv Res 2006;6:43. John SKP, Jones OM, Horseman N et al. Inter general practice variability in use of referral guidelines for colorectal cancer. Colorectal Dis 2006;9(8):731-5. Smith RA, Oshin O, McCallum J et al. Outcomes in 2748 patients referred to a colorectal two-week rule clinic. Colorectal Dis 2006;9:340-3. Eccersley JA, Wilson EM, Makris A, Novell JR. Referral guidelines for colorectal cancer – do they work? Ann R Coll Surg Engl 2003;85:107-10. Rai S, Kelly MJ. Prioritization of colorectal referrals: a review of the 2-week wait referral system. Colorectal Dis 2006;9:195-202.
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ASK THE EXPERT
What is the WHO Surgical Safety Checklist? Sebastian Yuen MBBS DCH MRCPCH FHEA
sebastian.yuen@institute.nhs.uk Consultant Paediatrician, Royal Free Hospital, London Fellow, NHS Institute for Innovation and Improvement
In 2000, in Llanelli, South Wales, two experienced surgeons removed the wrong kidney, leaving the patient in complete renal failure. A medical student had realised the error prior to surgery and alerted the surgeons.1 She was unable to persuade them to stop and the patient died five weeks later. The root cause was the clerking, which identified the wrong side for surgery and led to the operating list being booked incorrectly. In theatre the scans were displayed back to front. Catastrophic events are seldom the result of a single error, but more commonly result from the accumulation of multiple minor errors. The World Health Organization (WHO) created the Surgical Safety Checklist as part of the Safe Surgery Saves Lives programme.2 A world-wide study with nearly 8000 consecutive patients compared complication and mortality rates before and after the introduction of the checklist.3 The results demonstrated a reduction in mortality from 1.5% to 0.8% (P = 0.003) and complications from 11.0% to 7.0% (P<0.001) when the checklist was used. The impact was greater in developing countries than high-income centres, but there were improvements in all eight sites. In January 2009, the United Kingdom’s National Patient Safety Agency released an alert requiring all hospitals to implement the checklist for every patient having surgery.4 25 items are divided into three sections, each to be read out loud. “Sign In” occurs pre-anaesthesia and confirms the patient’s identity, allergies, procedure, site (including mark) and consent. Other important checks include anticipated airway problems and risk of significant bleeding. “Time Out” occurs prior to skin incision. All team
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members introduce themselves by name and role. During the surgical pause, the surgeon and anaesthetist verbally repeat the patient, site, procedure and predictable complications. The “Sign Out” requires a written plan of management, instrument count and ensures specimens are labelled correctly. The aim is to ensure that key safety checks are made reliably for every patient, instead of relying on memory. It is important to remember that the checklist is simply a tool. Its effectiveness will depend on how it is implemented and the value placed on safety within the culture of the department. As students observing procedures in theatre, you have a duty to speak up if you have any concerns. As a result of the introduction of the checklist, the team should now respect and listen to you. The WHO website has videos of Atul Gawande using the WHO checklist.2 References 1.
2. 3.
4.
Dyer O. Surgeon is struck off for failing to mention disciplinary action. BMJ 2005;330:274 (5 February) doi:10.1136/bmj.330.7486.274-a WHO Safe Surgery Saves Lives. World Health Organisation [online]. 2009. www.who.int/safesurgery [Last Accessed 11 April 2009] Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9 doi:10.1056/NEJMsa0810119 WHO Surgical Safety Checklist. National Patient Safety Agency [online]. 26 January 2009. http://www.npsa.nhs.uk/nrls/alerts-anddirectives/alerts/safer-surgery-alert [Last Accessed 11 April 2009]
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STUDENT COMMENTS
Maximising your Surgical Placement Anish Amlani BSc (Hons), Amin Elmubarak BSc (Hons)
Year 5 Medicine, Imperial College London anish.amlani@imperial.ac.uk, amin.elmubarak@imperial.ac.uk
Medical students can often take some time to find their feet when AA and AE are joint co-authors on surgical placements. Upon reflection, the early weeks are Competing Interests: None often unproductive and disorganised, until familiarity, etiquette Declared and routine are eventually established. This article aims to provide anecdotal advice from two medical students who have been through this cycle too many times, and have learnt from their mistakes. Surgical placements are NOT just for ‘future surgeons’ – there’s a lot to be learnt by every medical student. The surgical rotation is often as equally revered as it is anticipated. But with the right preparation and attitude, you can not only sail through your surgical exam but also get an accurate taste of a life in surgery. Hopefully, this guide will help you get the most experience out of your placement. Keenness is the KEY There is a lot to be gained from a surgery firm, whether you want to become a surgeon or not. Surgical firms allow you to get into theatre and see anatomy first hand. You will get a chance to see all those signs and symptoms that you can recite but have yet to see. This will aid you in retaining and understanding knowledge better than any textbook can. As you will also get to see and possibly (if you play your cards right, see later) feel real abnormalities. Following a case from admission to discharge can be extremely interesting and in some cases fascinating.
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Surgical firms provide an invaluable opportunity to gain proficiency in basic examination Practising examinations with other students is great, especially for exams earlier on in medical school, but at the end of the day we are in medical school to become doctors (something often lost sight of). You will be a much more confident and better prepared Foundation Year 1 (FY1) doctor if you have examined real patients throughout your medical school training and found abnormal signs yourself. Also, more importantly how can you identify organomegaly if you have never felt it? The early bird Get there as early as possible – if handover starts at 7:30, make sure you’re there 10 minutes before. At the very least it will give you a chance to skim through the handover sheet and read up on any of the conditions that the patients have. Be part of your team Talk to your team, from House Officer to Registrar and try to gauge how things are done in the firm; every firm differs from hospital to hospital, speciality to speciality and Consultant to Consultant. Do not forget that an integral part of the team are the nurses and ward clerks – ensure that you introduce yourself to them from the start – as they are on the wards for a lot longer than anyone else and are an invaluable resource for doctors and medical students alike. They are great for teaching you those basic clinical skills that are
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STUDENT COMMENTS important both for exams and your first few years as a junior doctor. Also, if you are looking for interesting or co-operative patients to examine or clerk, the nurses will always be able to point you in the right direction. Try to clerk, and if possible examine all the patients that are in the care of your firm and present to any member of the team that has time for you. Read up on as many patients’ conditions as possible including: signs, symptoms, management (surgical and medical) and prognosis. You will definitely be quizzed when presenting your history. Be useful House Officers are very busy and Surgical House Officers are very, very busy. So if you want teaching offer to do their bloods or take the histories of patients that they need to see. If the House Officers finish early with your help, they may be free to give you some teaching. Clinics Though it may sound boring in your first few visits, you will quickly learn that with the advancements in both surgical and non-surgical management, a vast majority of the modern surgeon’s time is spent in the clinic. Remember the old motto: proper preparation prevents poor performance. If you know what the clinic is about then make use of your journey by reading up on the subject and never be afraid to ask questions if things are unclear. Beyond that, the same principles apply: push yourself forward. Before you know it, the staff nurse will be giving you your own room, you will be clerking patients and coming up with your own differential diagnoses and treatment plans. Don’t be afraid of making mistakes as long as you learn from them.
Assisting Surgery like all aspects of medicine is about teamwork and a surgeon cannot perform an operation by himself or herself. Even if you are just holding a retractor, as an assistant you are performing an essential role. Is it worth it? Definitely – whilst assisting, you will be able to observe the operation from the best seat in the house. Finally Never be afraid to ask to be excused if you are feeling faint. It would be a lot worse to faint mid-surgery and land face first in an open surgical field (it has happened). Surgical firms offer incredible and rapid learning opportunities for medical students. However, they are often not exploited for the wealth of experiences available. So turn up early, make yourself a regular and get stuck in.
Box 1 : Top 10 tips for theatre 1. 2. 3.
4. 5.
From practising how to ask sensitive questions, to taking histories and practising those all-important examinations, clinics are a great time to learn. If you know what your weaknesses are you may be able to get some guidance in real relevant clinical situations and you may also be lucky enough to receive one-on-one tuition from the Registrar or Consultant – depending on how busy the clinic is. The fun bit – Theatre! Whether you are going into theatre to hone your anatomy, see some abnormalities or because you know that surgery is for you, it’s important to know what to expect and to observe the etiquette of theatre to maximise your experience. Theatres can be surprisingly small and medical students are not usually in there to contribute anything, so if you get in the way it will not go down well. So follow our ten handy hints (see Box 1): Scrubbing up This is an essential skill in theatre and one that is easily learnt. If you do not demonstrate the competence to scrub in proficiently and quickly, surgeons are never going to let you near an open surgery. Queen’s University Belfast provide easy to follow instructions (see Further Reading) – read this before your first day in theatre and never be afraid to arrange time with a scrub nurse to teach you if you are still not sure.
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6. 7. 8. 9. 10.
Try to eat and have something to drink prior to going into theatre, fainting isn’t fun and can be pretty embarrassing. Find the changing rooms. It is easy to get lost. Find some clogs that fit well because you could be standing for a while. N.B. Wearing your Consultant’s/Registrar’s clogs will NOT go down well. It is not normally worth buying your own clogs as an undergraduate but for those of you who do not want the hassle of continuously looking for clogs, go to http://www.crocs.eu/. Turn your mobile phone OFF, no one likes the medical student who leaves it on silent and then everyone hears the vibrating or worse still, tries to stop it ringing whilst scrubbed up. Prior to entering the scrub room or theatre, ensure you are wearing a scrub cap to cover your hair. (Girls tie your hair up and then put on the cap. For students that wear religious headscarves of turbans, the larger theatre caps will normally go over these. Always ask your specific consultant for advice, however, if you are unsure as to what to do.) Introduce yourself to the scrub nurse. (Re) Introduce yourself to the patient prior to them being anaesthetised. If you have not managed to clerk and examine the patients on the list, at least ask the scrub nurse or your FY1 which procedures are being performed that day. When instruments and the patient are being wheeled in, do not stand in front of anything, especially doorways – you will only be in the way. Always ask to scrub in and do not be afraid to assist.
Further Reading http://www.qub.ac.uk/cm/sur/teaching/year3/introductorycourse.pdf – Queen’s University Belfast Guide to Scrubbing The authors of this published article do not claim to be experts. If you would like to act on any advice provided, you are strongly advised to seek expert opinion in the field. Any mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the authors, editors or the London Student Journal of Medicine.
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BOOK REVIEW Principles of Surgery Principles of Surgery: Everything you need to know but were frightened to ask! Sam Andrews and Luke Cascarini Publisher: TFM Publishing Ltd ISBN: 1903378575 United Kingdom Recommended Retail Price: £25 Imagine the morning ward round on your first surgical attachment. The registrar has just asked you a seemingly simple question, “Why was this patient shivering when she woke up after her operation?” You find yourself searching for a coherent answer, fully aware that the longer you keep the registrar waiting, the better the answer he expects. “They might have been cold?” you reply sheepishly, hoping they ignore your patent answer – but they push on, “and…?” demanding you to delve deeper into this conundrum. Principles of Surgery intends to sum up ‘everything you need to know but were frightened to ask’ about the field of surgery. This is a tall order for such a short text but as you read, you will quickly realise that the authors, Messrs. Andrews and Cascarini, fully appreciate the classical medical student dilemma of trying to work out what we need to know whilst still trying to learn for the career ahead. The authors - a Consultant General and Vascular surgeon and a Specialist Registrar in Maxillofacial surgery respectively - have a combined experience of fifteen years of being a student. Through an effective question and answer format, they cover the key issues that any health professional should know about peri-operative medicine. For each question posed, there is a comprehensive answer, explaining the reasons for routine tests and pertinent ‘Red-Flag’ signs and symptoms, for example: ‘what factors predispose to wound dehiscence?’ and ‘how do you recognise and treat postoperative pneumothorax?’ The book is targeted at students of any healthcare profession that have contact with surgical patients. Principles of Surgery is more than a surgical dictionary but a well-structured discussion of the medical care of a surgical patient. In this way, it can be compared to popular surgical texts such as Surgical Talk. However, this book does not describe favourite OSCE examinations: It instead fills in the gaps in a student’s knowledge that these other texts fail to cover. Written in an informal yet didactic style, the book is easily digested and allows for quick referencing with a comprehensive index and division into three sections focusing on pre-operative care, operating theatre environment and post-operative care and complications. It is all too easy on a surgical ward round to miss the opportunity to ask about a patient’s individual management. For example, students have to try and collate information from many sources to deduce why some patients are sent to ITU and others can be treated as day cases. The answers are clearly described in this book. Principles of Surgery has an excellent chapter discussing concomitant conditions and the resulting differences in the management of the elderly, emergency patients and those with co-morbidities. The authors also explain the basic principles of anaesthesia and describe the functions of basic operating equipment. It even lists commonly used drugs with the trade names printed alongside to give students a fighting chance on a lightning-fast ward round.
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The pre-operative section of Principles of Surgery focuses on the clerking jobs carried out by house officers and in this respect is not directly relevant to medical students but does explain the reasoning for pre-operative haematology and biochemistry. The section about the operating theatre environment does state the obvious in places and you could be forgiven for thinking that it is written for students and junior doctors that never bothered to scrub in when at medical school. All of the information offered is extremely useful when on the wards, in theatre and when presented with a surgical patient with multiple pathologies, but will this help you in exams? The book gives students a framework on which to hang information gleaned from bedside teaching and other sources. I personally found the post-operative sections the most useful and elements of this included potentially examinable material especially for critical care OSCE stations. In conclusion, Principles of Surgery would be an excellent candidate for a companion read to other surgical, pathology and clinical examination textbooks and would certainly be of benefit whilst on the wards or just to read up before presenting a surgical case. It is surprising how much useful information is contained within this book and perhaps a more appropriate subtitle should be, ‘everything you hope you never get asked in surgery (but really should know!)’ Conrad von Stempel Year 1 Clinical Medicine, UCL Medical School vonstempel@gmail.com
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LSJM PROFILE
Mr Niall Kirkpatrick Current post Consultant Craniofacial Plastic Surgeon Lead clinician for the Craniofacial Unit, Chelsea & Westminster Hospital, London Member of the Head & Neck Unit, Charing Cross Hospital, London Medical School/Undergraduate Studies BDS Guy’s Hospital Dental School, London 1984 MBBS Guy’s Hospital Medical School, London 1990 Postgraduate MD University of London 1996 FRCS (Eng) 1996, FRCS (Plast) 2001 What do you do? Reconstruction of congenital paediatric & adult craniofacial deformities. Acute facial trauma and reconstruction following Head and Neck cancer ablative surgery. I work within a large multidisciplinary team consisting of a number of head/neck surgical specialists including ENT, Neurosurgeons, Oculoplastic and Maxillofacial Surgeons. I also participate in joint clinics with Dermatologists in the treatment of complex facial skin malignancies. Why did you get involved in surgery? My interest in surgery stems from my time as a final year dental student. During a Maxillofacial surgery elective attachment at St Richard’s Hospital, Chichester there was a large road traffic accident. I worked throughout the night with the surgical team in the reconstruction of those involved in the accident. This is where my early interest in surgery began. After completing my medical studies at Guy’s Hospital I went on to do a number of surgical jobs in A&E, Anatomy Demonstration, General Surgery, ENT and Plastic Surgery. I then went on to complete a Specialist Registrar rotation in Plastic Surgery on the Pan-Thames scheme and eventually subspecialised in Craniofacial surgery in light of the training I had completed previously, with specialist Fellowships in the Craniofacial units at the Chelsea and Westminster Hospital and Great Ormond Street Hospital as well as a Head and Neck Fellowship at the Royal Marsden Hospital. Why plastic surgery? I have always been interested in art and especially enjoyed pottery whilst at school. Plastics is a specialty where there is a meld of science, surgery and artistry. It requires the surgeon to be manually dextrous, with good visuo-spatial ability as well as the ability to plan ahead. Describe a typical day. I get up at around 6.15am. I am usually in the hospital by 7am to sort out my administrative duties. The pre-operative ward rounds start around 8am. I spend most days operating. It is not unusual for operations to last 6-8 hours with several consultants operating simultaneously. 8 hours feels like a few minutes because one becomes so engrossed in the surgery. I finish the day with a post-operative ward round at about 6.30pm and am usually back at home at 8.30pm.
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What is the most important thing you learnt as a student? To adopt a holistic approach to surgical care. The surgery itself only forms a small part of the care of a patient and one must understand their psychological and social backgrounds. Surgery as a specialty is a predominately postgraduate apprenticeship. It is important to develop your communication skills and to develop other parts of patient care whilst at medical school. I understand that you are involved with the charity ‘Facing the World’. How did you become involved and what are the charities main aims? I have been involved in the charity since its inception whilst working as the Craniofacial Fellow at Chelsea and Westminster Hospital with my colleagues Mr Norman Waterhouse and the late Mr Martin Kelly. My brother is a charity lawyer and helped found it. We, along with a number of other volunteer surgeons, offer complex facial reconstructive surgery that usually requires postoperative intensive care facilities not locally available to children across the world. These children otherwise have no chance of finding the surgery to overcome their disfigurement. We also support research and have PhD opportunities in partnership with Imperial College London. We are also in the process of collaborating with centres in Vietnam and Ghana. An exchange programme has been organised where senior surgeons from Vietnam come to train in the UK for a period of 6 months and then take back their knowledge and disseminate it within their own departments. What advice do you have for those wishing to pursue Plastic or Craniofacial surgery as a career? Firstly, be honest with yourself about whether you have good manual dexterity. It also helps if you have an artistic bent. Learn more about the profession and understand that Plastic surgery is much more than just Aesthetic/Cosmetic surgery. The main thing when choosing a career is to “follow your heart”, and if you really want to pursue something then “go all out for it”. Plastic surgery is an immensely wide ranging, and rewarding profession. Kalpesh Vaghela Year 5 Medicine, Imperial College London and LSJM Panellist vaghela04@imperial.ac.uk
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EDITORIAL
Dear Reader, Welcome to the Global and Community Health section of the inaugural edition of the LSJM. My panel and I hope, in this section, to inform, educate and stimulate debate on a wide range of healthcare issues, both at home and abroad. We recognise the short and precious nature of your free time and with this in mind have selected articles that appeal due to their originality, importance and clarity. Exposés on resurgent tropical illnesses and calls for worldwide vaccination programmes sit with a unique piece examining the effect of “bird flu” on smallholder poultry farming, in what I hope you will find to be an interesting and entertaining section. Two of the articles illustrate neglected diseases, namely sleeping sickness and chikungunya, which “Big Pharma” and governments have ignored, and that are now increasing in virulence. I believe though, that slowly but surely, change is afoot in global health. As you will read in our news area, Glaxo-Smith-Kline’s pledge to simultaneously discount the price of medicines to developing countries and to create a drug patent pool is an encouraging sign. This, together with the advent of philanthrocapitalism, the application of techniques borrowed from successful businesses to create more efficient and transparent charities (as seen in the Bill and Melinda Gates Foundation) will, I hope, be a transforming force in the future. This edition of the journal is themed “unhealthy behaviours.” We link to this theme with a fascinating article comparing food addiction to drug addiction. Obesity has reached epidemic proportions worldwide and is now a major contributor to the global burden of disease. Time is rapidly running out for governments to act, before we are faced with a crippling healthcare crisis and this socially acceptable “unhealthy behaviour” merits more serious engagement throughout society. Community health has undergone a not-so- quiet revolution in the past few years, with a greater emphasis being placed on preventative medicine. The tragic death of Jade Goody has done much to highlight the importance of cervical cancer screening, and our section boasts a topical article dealing with possible screening initiatives for cervical cancer in the developing world, together with the potential ramifications of nation-wide vaccination projects in these countries. We live in a world where every year 1.4 million children under 5 die of diseases that could have been prevented by routine vaccination.1 Such figures are beyond the pale and as future medical professionals we would do well to remember the words of the Global Health Council, “When it comes to global health there is no them, only us.” I hope that the LSJM in the future will do much to illustrate the dire need for doctors and medical aid in the developing world and that this will encourage some of you to lend your extraordinary talents to those in need away from these shores. I would like to end by thanking my co-ordinator Katherine Sharrocks, my panel, peer and expert reviewers and of course the exceptional authors whose work I have had the privilege of reading. Editing this section broadened my horizons greatly and I hope that engaging with these articles does the same for you. This journal can only improve with the participation of medical and allied health students. With this in mind, if you have any comments, criticisms or suggestions then please write to gchm@thelsjm.co.uk, with “Letters to the Editor” in the subject line. Also, if you are interested in writing for the publication then do submit your work by email. I look forward to hearing from you. Best wishes Vishal Navani Section Editor of Global and Community Health References: Illustration: Robert Hare
1.
http://www.who.int/immunization_monitoring/diseases/en/
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NEWS “Big Pharma” GSK in price slash and patent pool pledge Sandra Sadoo Year 4 Medicine, Imperial College Drug giant Glaxo-Smith-Kline (GSK) will offer medicines at a 25% reduction to 50 developing countries, affirmed CEO Andrew Witty at Harvard Medical School. This groundbreaking move by the company involves the sharing of 800 of its patents to third parties researching neglected diseases such as tuberculosis. It has been pledged that 20% of profits made from these selected countries will be invested back into the development of infrastructure such as health clinics. Middle-income countries such as Brazil and India will also be proposed a cost cut. Drug treatments for malaria, hepatitis B and asthma are amongst those included in the scheme. These proposals came 12 days after GSK showed itself to be another victim of the economic downturn by axing 6,000 jobs worldwide. It is hoped that the world’s second largest pharmaceutical company has raised the bar and will challenge other pharmaceuticals to question their practices. In Witty’s words, “Society expects us to do more in addressing these issues. To be frank, I agree. We have the capacity to do more and we can do more.” Witty acknowledged that the investment costs to Glaxo are likely only to extract up to £2m of the £30m that Glaxo make annually from its sales to the lowest-income countries. The minister for international development, Ivan Lewis said to the Guardian, “We’re all concerned about the economic circumstances we’re living in and the danger that that will push an increasing number of people into poverty”. Lewis believes that “Challenging pharma to do their bit ... is entirely legitimate.”
Naltrexone is a drug which blocks receptors in the brain responsible for the ‘highs’ drinking can produce. It has been available in daily tablet form for some time, but in 2006 the United States Food and Drug Administration approved a long-lasting formulation, which can be injected into muscle once a month. A small study has been undertaken in Cambridge, Massachusetts, which shows the injections decrease the frequency and severity of drinking sessions. Heavy drinking represents an enormous public health burden across the globe. David Rosenbloom, a specialist in substance abuse from Boston University, says these injections may have a “huge” significance for public health, and he envisages them being offered to repeat drink-drive offenders. At a time when the public health implications of binge drinking are constantly in the news, Naltrexone injections may yet prove a real ‘shot in the arm’ in the fight against alcoholism. Published previously in ‘Perspectives’ (UCL MEDSIN). Taken with permission from magazine and author
A new weapon in the arsenal against cervical cancer The fight against cervical cancer has been augmented with a series of defining blows; safe and effective vaccines have been developed against oncogenic Human papilloma viruses (HPV), national vaccination programmes have been rolled out in several countries and public awareness about the condition has increased. These events should fuel a reduction in the rates cervical cancer and its associated mortality. However, these changes have benefited a few lucky countries. In many low resource countries, where the prevalence of HPV and cervical cancer are higher, a solution still needs to be found. Results from a cluster-randomised controlled trial in rural India may provide an answer.
It is clear that the sense of social responsibility of pharmaceutical firms is increasing. The anticipations are that knowledge-sharing and more affordable drugs for impoverished countries will accelerate the development of new drugs and broaden the access of the world’s poor to essential medicines.
Sankaranarayanan et al showed a significant reduction in advanced cervical cancer incidence and mortality using a single round of HPV screening compared to cytology and visual inspection of the cervix with acetic acid (VIA).1 HPV screening was found to be more objective, reproducible and easier with regards to training. However, it was more expensive than other screening programmes.1 Cytology or VIA can then be used in HPV-positive patients to assess the risk or presence of cervical cancer respectively.2 Those without cervical cancer can then receive cryotherapy reducing the risk of progression to malignancy. The authors suggest that HPV screening should not be used in women under the age of 30 because of the tendency of these lesions to regress thus discarding the need for treatment.1 This study provides an encouraging option for resourcelimited countries to curb the incidence of cervical cancer and its associated socio-economic implications.
A Shot for Alcoholics?
Reference
Michael Malley Year 4 Medicine, University College London m.malley@ucl.ac.uk
2.
Glaxo nonetheless have been criticised in their decision to withhold their HIV patent rights, due to a conviction that “other efforts are addressing the need for anti-virals”. Lewis hopes that in a meeting with executives of rival drug firms, he will be able to increase the participation of companies in such a patent pool.
1.
Sankaranarayanan R, Nene B, Shastri S et al. HPV Screening for Cervical Cancer in Rural India. N Engl J Med 2009;360:1385-94. Schiffman M and Wacholder S. From India to the World - A Better Way to Prevent Cervical Cancer. N Engl J Med 360;14
You would not think it would be a problem giving shots to alcoholics. However, a different type of ‘shot’ may well help recovering alcoholics – a monthly injection to prevent craving for alcohol.
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REFLECTIVE PIECE
Influenza A(H1N1): Echoes of the Spanish Flu? Mukhtar Bizrah BSc (Hons) Year 4 Medicine, St. George’s University of London m.bizrah@gmail.com For many, the Flu may be an inconvenient state of health one has to put up with once or twice a year. For wary historians, however, the emergence of a pandemic Influenza A(H1N1) flu outbreak may mean the beginning of a humanitarian crisis. The last global outbreak was that of the Hong Kong flu in 1968, killing 3 million people. The true global implications of a flu pandemic, however, may be more accurately reflected by the Spanish flu in 1918. Killing 50 million people around the globe, it is one of the deadliest known events in human history.
Conflict of interests: Mukhtar is an executive member of the LSJM.
To date (5 June 2009), the World Health Organisation (WHO) has confirmed 19273 cases of swine flu in 48 countries. Of the 117 resultant human deaths, 97 have occurred in Mexico and 17 in the United States (US). Yet the true number of those infected is estimated to be much higher. Although 10053 cases have been reported in the US to date, the director of the National Center for Immunization and Respiratory Diseases, Dr Anne Schuchat, stated that “this is the tip of the iceberg -- We estimate more than 100000 cases.” This may not come as a surprise seeing that most people with flu symptoms do not see their family physician. Of those that do, a considerable number do not have swabs taken for laboratory analysis. Is an H1N1 pandemic inevitable then? As the WHO gets closer to raising the pandemic alert level from phase 5 to 6, it has laid great emphasis on the fact that this is simply a reflection of demographical spread, rather than severity of illness. Europen Union (EU) Health Commissioner Androulla Vassiliou comments: “It is very likely that we will reach a pandemic, but this does not mean that it will be deadly.” More questions are consequently being posed regarding the true virulence of the virus and impact of an H1N1 pandemic. Wendy Barclay, chair of Influenza Virology at Imperial College in London, analysed influenza A(H1N1) genes to find that H1N1 has “no genetic features of a highly pathogenic virus at all.” She told The Lancet Infectious Diseases that rather “it looks as though this virus should target the upper respiratory tract and not the lung”.1 Nancy Cox, the chief of the Center for Disease Control (CDC) influenza division has also stated that the swine flu is not as ‘virulent’ as the Spanish flu causing the 1914 outbreak, and this over the past few weeks has become more apparent. As a matter of fact, it may be much less deadly than the ordinary flu, which is estimated to kill around 36000 people in the US every year.2 Yet there are numerous unknown factors affecting ease of spread and individual response to H1N1 flu. Individual immunity is a principal factor, which is why very young and very old individuals are at greatest risk of mortality from ordinary flu. To this date, it is still not certain if humans possess any immunity to H1N1 flu. The CDC has
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Image: Electron microscopy image of the newly identified H1N1 influenza virus: US Center for Disease Control and Prevention
stated that older populations may have immunity against H1N1 virus, as 64% of the cases reported to the CDC are individuals aged 5-24 years. But this remains uncertain as other factors such as young people travelling more may have come in to play. A major concern is spread of the virus to developing countries in the southern hemisphere, whose populations according to Dr Chan, Director-General of the WHO “are most vulnerable” and as a result “should prepare to see more than the present small number of severe cases.” Charities such as Oxfam have repeatedly warned that these populations are at great risk due to shortage of potentially life threatening treatments. There seems to be one certainly common theme in much of our knowledge about H1N1: Uncertainty. Dr Nikki Shindo, a WHO medical health officer, may have described the current situation best: “The worst-case scenario is the virus will mutate and become Tamiflu (Oseltamivir)-resistant. The best-case scenario is that it causes only mild illness and continues to respond to Tamiflu.” It is too early to make definitive conclusions regarding the aftermath of a looming pandemic, and only time may give the answer. For the time being, however, the re-emergence of a pandemic as deadly as the Spanish flu seems like a remote scenario. Reference 1. 2.
Shetty P. Preparation for a Pandemic: Influenza A H1N1. The Lancet Infectious Diseases Vol. 9, Issue 6, pp. 339-340 June 2009. Thompson WW et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003; 289(2):179-186.
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PERSPECTIVE
From ‘Equasy’ to ‘Obesity’ Haran Sivapalan BA (Hons) Year 4 Medicine Kings College London haran.sivapalan@kcl.ac.uk doi:10.4201.lsjm/gch.002
“
Obesity exhibits the bio-psychosocial properties of a serious addiction, albeit a socially tolerated one
On 11 February 2009, the UK Home Secretary Jacqui Smith rejected suggestions from the Advisory Council on the Misuse of Drugs (ACMD) to downgrade ecstasy from Class A to Class B. Ecstasy or MDMA (3,4 methylenedioxy-N-methamphetamine), notorious for its use within the rave scene, therefore remains on the list of the most harmful drugs along with heroin and crack cocaine. Previous obduracy of the government on this matter, with its rejection of the Home Affairs Committee report in 2002 and the Runciman report in 2000, may have spurred the chairman of the ACMD, Professor David Nutt, to write an article comparing the risks of ecstasy use to that of horse-riding. Published in the Journal of Psychopharmacology, the article, entitled ‘Equasy: an overlooked addiction with implications for the current debate on drug harms, ’ served to highlight the illogicalities in society’s attitude to the harm of illicit drugs in relation to the harm of other more socially accepted activities. Extending from these notions, it may be argued that the ingestion of highly calorific, high-fat and unhealthy foods is harmful in the context of the present obesity epidemic. Would policies similar to those implemented to control illicit drugs be successful in curtailing the exigencies of the obesity trend? The classification system, stipulated by the Misuse of Drugs Act passed in 1971, discriminates drugs into three classes: A, B and C, on the basis of harm. The term ‘harm,’ however, is nebulously
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defined and Nutt castigates the system’s ‘arbitrary foundations with seemingly little scientific basis. ’ As an alternative, Nutt suggests that harm should be evaluated in three domains: physical harm, dependence and social harm. Unhealthy foods can be argued to be harmful in each of these ways. Physical Harm While high-fat foods may not be physically harmful in terms of acute toxicity, their chronic ingestion causes physical disease both directly and indirectly, through the promotion of weight gain and obesity. Obese females with a Body Mass Index exceeding 35kg/ m2 have a 93-fold increased risk of developing type II diabetes mellitus. In addition, obesity increases the risk off cerebrovascular and gallbladder disease. In terms of the direct repercussions of a high-fat diet, studies on human subjects suggest a causal role in vascular endothelial dysfunction and hepatic steatosis. In contrast to intravenous drug administration, oral ingestion of food is not associated with any serious secondary harm. Dependence Applying the concept of dependence to foodstuffs remains abstruse, but there is a burgeoning body of evidence suggesting obesity has psycho-physiological commonalities with drug addiction. Administration of calorific foods and drugs has both been shown to activate mesolimbic dopaminergic reward networks in the brain. Similarly, relatively low striatal D2 dopamine receptor
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PERSPECTIVE densities may subserve a ‘reward-deficient’ state in both obese individuals and drug addicts that drives compulsive eating and drug use respectively. Furthermore, dysregulation in the orbitofrontal cortex and other prefrontal areas may form a common neuronal substrate underlying food and drug craving behaviours. Repeated use and craving are two fundamental features of psychological dependence, such as that seen in long-term users of cannabis. Chronic ingestion of high fat foods, however, does not induce a physical dependence typified by withdrawal symptoms. Social Harm The social ramifications of obesity primarily include considerable economic costs. Obesity generates direct costs, such as those of diagnosis and treatment, as well as latent costs, such as from lost income due to morbidity or mortality. In the USA, such costs amounted to $68.8 billion for the year 1990 illustrating that this public health problem is of similar economic magnitude to drug addiction. Other societal harms may possibly comprise damage to psychological wellbeing. Unlike other drugs, notably alcohol, high-fat foods do not exert social damages through the effects of acute intoxication. There are other conspicuous differences between obesity and drug addiction. Food is necessary for survival, whereas drugs are not. The composition of what is deemed ‘unhealthy food’ is subject to more heterogeneity than the specific active substance of a drug. Given the parallels between drug addiction and excessive caloric dependence, however, the question arises whether public health policies used to regulate the supply and demand of drugs can be applied efficaciously to tackle obesity. A renewed and energetic public education campaign could be used to reduce the demand for unhealthy foods. This would involve the dissemination of information about their associated health risks to schools, places of employment and through the media. The potency of this method has precedence in smoking cessation campaigns, which have been effectual in reducing nicotine use. Despite this, educational strategies require long periods to evoke change and it is questionable whether this strategy alone would abate an obesity epidemic.
cost to the consumer and generate a disincentive to smoke or drink. A similar system of tax on unhealthy foods could favourably modify dietary choices. Additionally, as food has a lesser propensity to cause dependence in comparison to nicotine, demand is likely to be more price elastic. While simultaneously dissuading unhealthy food consumption, revenue created from these schemes can be used to fund healthcare. Alternative economic strategies involve placing minimum prices on unhealthy foods. One major criticism of applying these policies is that they penalise poorer people far more than those with higher disposable incomes. Conclusion Clearly, obesity exhibits the bio-psychosocial properties of a serious addiction, albeit a socially tolerated one. Whereas the Equasy example questioned the aggrandisement of drug-related harm compared to other socially accepted harms, a parallel issue is the relative leniency granted towards unhealthy foods. With the prevailing obesity epidemic, a period of cultural upheaval in the attitude toward these foods is required. High-fat, calorific, ‘junk’ foods are reinforcing drugs that drive compulsive eating and as such must be subjected to stringent social, economic and legal policies. If the obesity problem is to be solved, the state, producers and consumers of food must all grant credence to the notion of obesity as an addiction. Reference List •
•
• •
•
Nutt DJ. Equasy – An overlooked addiction with implications for the current debate on drug harms. Journal of Psychopharmacology 2009; 23 (1): 3-5. Nutt DJ, King LA, Saulsbury W, Blakemore C. Development of a rational scale to assess the harms of drugs of potential misuse. The Lancet 2007; 369: 1047-1053. Jung RT. Obesity as a disease. British Medical Bulletin 1997; 53: 307–321. Motomura W, Inoue M, Ohtake T, Takahashi N, Nagamine M, Tanno S, et al. Up-regulation of ADRP in fatty liver in human and liver steatosis in mice fed with high fat diet. Biochemical and Biophysical Research Communications 2006; 340: 1111-1118. Volkow ND, Wise RA. How can drug addiction help us understand obesity. Nature Neuroscience 2005; 8: 555-560.
Legislation The success in tapering the prevalence of nicotine use may also stem from legislative measures. A minimum age for purchasing tobacco and, more recently, the banning of smoking in public areas, clearly limit the opportunity to indulge in nicotine use. In theory, similar measures can be applied to curb obesity. While outlawing certain foods may be construed as extreme, more moderate measures, such as nationwide restrictions on the types of food that can be sold in schools, could prove beneficial. Like the nicotine precedent, legal restraints can be imposed on advertising and may enforce the inclusion of health warnings on food packaging. Such legal schemes are, however, clearly contentious in that they present a potential affront to civil liberties and consumer freedoms. Such moves would also undoubtedly engender a powerful political lobbying and subversive response from the processed food industry, one of the most influential, wealthy and well-organised groups in our society. For licit drugs such as nicotine and alcohol, pricing is an important factor in the regulation of public usage. Heavy taxes increase the
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REVIEW
Poultry vs. Poverty: The Social Impact of HPAI on Smallholder Poultry Farming in the Developing World Peter D. Liddle BA (Hons) Year 1 Medicine, King’s College London peter.liddle@kcl.ac.uk doi:10.4201.lsjm/gch.005
The term “developing” in the context of countries and economies is employed here strictly in the statistical sense as defined by the United Nations Statistics Division (UNSD), and should not be considered as a judgement of relative development in a broader sense; or an acceptance that such comparisons are possible or useful.
For the full article and references see thelsjm.co.uk.
“
Where the rooster crows, there is a village. Shambala proverb, Tanzania8
”
Although recognized in fowl for over one hundred years, and reported formally in 1959,1 Highly Pathogenic Avian Influenza (HPAI) captured widespread public attention early in 1997, spurred by the first reported human infections of the H5N1 subtype in Hong Kong.2 The emergent zoonotic properties of the virus provoked rapid mass media coverage, and 6 fatalities amongst the initial 18 laboratory confirmed cases fed urgent speculation of an impending human pandemic. Whilst the Hong Kong outbreak was contained and controlled with relative rapidity, subsequent human infections in other regions of China were reported throughout 2003/4, and in January 2005 the World Health Organization (WHO) modelled a best case pandemic scenario, projecting excess global deaths ranging from 2 – 7.4 million.3 Since this alarming analysis, however, it has become apparent that HPAI viruses, including the H5N1 subtype, have the propensity to bind deep within the lungs, in contrast to more common seasonal influenza viruses which attach to cell linings in the nose and throat.4, 5 This seems to impede human uptake of the virus, both in terms of zoonotic and human-human transmission.2 As a result, whilst occurrences have spread geographically throughout South East Asia, Africa and Europe, the most recent WHO update reports a much smaller figure than predicted: 407 laboratory confirmed cases of human H5N1, 254 of which have resulted in fatality.6 Due in part to comprehensive media coverage of the concerns of public health specialists, the general academic and public perception of HPAI was initially one of understandable apprehension. The vast majority of literature throughout 2004/5 concerned risk assessment, damage limitation, and containment strategies in the first instance; followed by financial and industrial economic analyses as costly public health measures were employed
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REVIEW in South East Asia and Africa. However, as human HPAI has yet to approach pandemic levels, public opinion seems increasingly to consider the virus to be the latest in a string of unjustified public health scares, following variant Creutzfeldt-Jakob Disease (vCJD) and Severe Acute Respiratory Syndrome (SARS). Unfortunately, this apparent reduction in concern is not representative of the lessening global significance of HPAI, and undermines a vast array of social and economic impacts which have yet to be assessed to the necessary degree. The fundamental importance of smallholder poultry farming in the context of diet, development, poverty alleviation and gender equality throughout non-Western countries is broadly recognized,7, 8, 9, 10, 11 and compels a more holistic analysis of the negative effects of HPAI and associated containment measures. The Global Importance of Poultry The International Food Policy Research Institute estimate that 30% of animal protein consumed globally is derived from poultry products, representative of a 10% increase since 1990.12 Furthermore, this figure is expected to increase to 40% before the year 2015, and meeting this demand has rendered poultry production the fastest growing element of the global meat industry.9 In the context of avian influenza, it is important to recognize that a huge proportion of this production and consumption occurs in the regions of Asia and Africa: economies within which the overwhelmingly predominant farming system is that of rural smallholder poultry rearing in local communities. Family Poultry (FP) is defined by the International Network for Family Poultry Development (INFPD) as the extensive or semiextensive rearing of poultry in small numbers, through non-salaried family labour.11 This form of poultry production accounts for 84% of Africa’s poultry flock13; some 1.17 billion birds8; whilst surveys in Kenya14 and Malawi15 indicate that chickens are kept by 90% and 95% of the populace respectively. Similarly, more than 90% of households in a survey conducted in Western India16 and 89% of households in rural Bangladesh17 keep family poultry. These statistics demonstrate the ubiquitous nature of smallholder poultry rearing throughout the developing world, and bring the negative impact of HPAI and associated control measures into perspective. Family Poultry as a Means of Poverty Alleviation Whilst United Nations Millennium Development Goals (MDGs) aim to have halved extreme hunger globally by 201518 recent figures estimate 792 million individuals continue to suffer malnutrition.19 Branckaert and Guèye (2000) assert that sufficient intensification of agriculture has not developed in Low-Income Food-Deficit Countries (LIFDCs) to feed growing populations, and thus larger tracts of land will have to be reallocated to staple food crops in these nations. As arable land is a finite resource, this in turn will ultimately be prioritised over pasture and fodder, negatively impacting livestock populations. As a result, many development projects have recognized the importance of poultry as a livestockderived protein resource and a means of financial stability that does not require arable land to rear. It is widely supported that alternatives such as these must be developed if MDGs are to be achieved.11, 19, 20
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Why poultry is such a crucial tool for poverty alleviation and international development10, 21 • poultry is a near ubiquitous resource in developing countries • relatively low cost technology and low initial financial investment • often delegated to marginal groups, such as women, children and the elderly • land is not required for successful poultry production
Many family poultry schemes have already been successful in the developmental context. Chitikuro and Foster22 calculated that in Central Tanzania, an average flock size of 5 chickens increases the income of women by US$38/yr, representative of a 10% income increase. An alternative study conducted in N’Djaména, Chad23 revealed that profit from sales of poultry related produce was spent variously between clothing, food, medicine, soap, and reinvestment, suggesting that economic benefits are widespread and generate income in excess of self-sustenance. Kabatange and Katule24 demonstrate that one chicken laying 40 eggs at 50% hatchability will, in subsequent generations, produce more meat over 5 years than a range-fed cow, which itself will not reach slaughter weight for 5-7 years. Given the significance of global malnutrition, and the apparent viability of FP poverty alleviation models, it follows that the true threat of HPAI may lie not in the human pandemic, but the jeopardising of poultry-based development initiatives, and the insurance and economic stability achieved through smallholder poultry farming internationally. Women, Children and Chickens: Gender Equality through Poultry In the context of FP production, it is highly significant that poultry farming is a realm of agriculture which, throughout Africa and Asia, is traditionally associated with at-risk groups: primarily women, children and the elderly7, 8, 11, 25 and within which economic contributions from women are often deemed more acceptable.26 For this reason, FP development programs are, in some cases, able to address the issue of gender inequality. One particularly lauded example of this approach is an initiative termed The Bangladesh Poultry Model.26 The Bangladesh Poultry Model (BPM) is derived from the Bangladesh Smallholder Livestock Development Project, first implemented in 1991.27 It specifically targeted women in rural areas, enhancing productivity of poultry rearing in the Dhaka region of Bangladesh. Through poultry skills, education and the organization of upstream and downstream enterprises (e.g. training of chick rearers, feed mixers and poultry healthcare workers) the project both improved poultry production in the region, and increased the confidence and financial stability of the women involved.27 The BPM and similar development schemes are of invaluable benefit to their communities, and are jeopardised by HPAI and associated control measures.
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REVIEW References The Social Impact of HPAI 1.
Whilst the direct risk posed to human health by H5N1 is undoubtedly a reality, the current lack of human HPAI uptake ought not to imply a reduction in impact, especially in the related academic literature. It is clear that; in light of the broad and complex role played by poultry in the developing world both at the community and household levels; the “participatory, holistic, trans-disciplinary approaches” advocated by Guèye8 and others are entirely necessary, particularly in the realms of poverty mitigation and gender equality. In Soth East Asia, countries hardest hit by avian influenza include Cambodia, Indonesia, Thailand and Vietnam,28 whilst Nigeria, Burkina Faso, Cameroon, Cote d’Ivoire, Djibouti, Egypt and Sudan represent the current course of the virus in Africa.8 In the Vietnamese example, studies29 show production in smallholder poultry farms to have decreased by 57% in 2004; the first year of avian influenza outbreak; whilst sales of smallholder poultry suffered a 150% decrease in the same year. Furthermore, the biosecurity measures recommended by public health organizations are heavily reliant on widescale avian depopulation9 resulting in a direct 10-15% loss of annual income for Vietnam’s poorest families – a figure that is likely to increase to almost 50% when accounting for the fact that such families are unable to consume their own produce.11 Worse still, these impacts are not limited to the short term, but potentially extend far into the future, as the implementation of new biosecurity and confinement measures, stringent licensing and inspection effectively favour commercialization, and drive smallholder poultry underground.31
2.
3.
4.
5.
6.
7.
8.
9. 10.
Food and Agriculture Organisation of the United Nations. Avian Influenza. EMPRES Transboundary Animal Diseases Bulletin. 2004;25:1-9. World Health Organisation. H5N1 Avian Influenza: Timeline of Major Events [monograph on the Internet]. 2007 [cited 2009 Feb 11]. Available from: http://www.who.int/csr/ disease/avian_influenza/Timeline_07_Aug27.pdf World Health Organisation. Avian Influenza: Assessing the Pandemic Threat [monograph on the Internet]. 2005 [cited 2009 Feb 11]. Available from: http://www. who.int/csr/disease/influenza/H5N1-9reduit.pdf Shinya K, Ebina M, Yamada S, Ono M, Kasai N, Kawaoka Y. Avian Flu: Influenza Virus Receptors in the Human Airway. Nature. 2006;440:435-36. Van Riel D, Munster VJ, de Wit E, Rimmelzwaan GF, Fouchier RA, Osterhaus AD, et al. H5N1 Virus Attachment to Lower Respiratory Tract. Science. 2006;312:339. World Health Organisation. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO [monograph on the Internet]. 2009 [cited 2009 Feb 11]. Available from: http://www.who.int/csr/disease/avian_influenza/ country/cases_table_2009_02_11/en/index.html Guèye EF. Gender Aspects in Family Poultry Management Systems in Developing Countries. World’s Poultry Science Journal. 2005;61:39-46. Guèye EF. Evaluation of the Impact of HPAI on Family Poultry Production in Africa. World’s Poultry Science Journal. 2007;63:391-400. Mack S, Hoffman D, Otte J. The Contribution of Poultry to Rural Development. World’s Poultry Science Journal. 2005;61:7-14. Permin A, Pederson G, Riise JC. Poultry as a Tool for Poverty Alleviation: Opportunities and Problems Related to Poultry Production at Village Level [monograph on the Internet]. Australian Centre for International Agricultural Research; 2000 [cited 2009 Feb 11]. Available from: http://www.kyeemafoundation.org/ rural_poultry/content/SADC_Workshop/pr103chapter29.pdf
In the context of the extensive and hugely positive impact of smallholder poultry rearing throughout the developing world, the true extent of the threat posed by avian influenza becomes apparent. Whilst current preventative or curative measures have the propensity to cull and contain, these practices in isolation may severely undermine, if not destroy the contributions of smallholder poultry rearing to international development. Furthermore, restrictive legislation could potentially commercialize poultry production to the extent that rural smallholders could be effectively encouraged to rear poultry in clandestine, concealing outbreaks of HPAI, and increasing the danger of a human pandemic.11, 31 In Thailand, studies have shown that qualitative analysis of local attitudes, and the provision of culturally-contextualized information regarding HPAI has stimulated locally derived control measures. In addition, although costly for governments, financial compensation for rural farmers also makes concealment of HPAI outbreaks less likely, and mitigates economic losses to some extent. Such culturally and locally contextualized measures, it appears, are able to influence poultry rearing practice in smallholder environments, and thus, in conjunction with carefully planned biosecurity measures, may provide an avenue through which both the public health and broader social impacts of HPAI can be more effectively minimized.
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ARTICLE
Chikungunya Cholan Anadarajah
Year 4 Medicine, Barts and the London ha06199@qmul.ac.uk doi:10.4201.lsjm/gch.001
Source: Wellcome Images
For the full article and references see thelsjm.co.uk.
Overview Chikungunya is a viral haemorrhagic fever caused by an alphavirus, which belongs to the Togaviridae family.1 This single-stranded RNA virus is also known as ‘Buggy Creek virus’ due to it causing boggy and creeky joints, as well as other arthralgic symptoms.2 It is transmitted via the Aedes aegypti (yellow fever mosquito). Recent research shows that the virus may have mutated slightly by altering its genotype, thus enabling the Aedes albopictus (Asian tiger mosquito) to also be a vector.3 Outbreaks have taken place in tropical countries, more recently creating an endemic in India, Sri Lanka and the Maldives. In 2006 34% of the population (about 265,000 people) on Reunion Island caught this virus and of those 237 people died. However, this rare disease is generally not fatal.4 The Chikungunya virus (CHIKV) causes high fever, pain in the joints and rashes on the body. All these symptoms are also characteristic of Dengue – also transmitted via bites from the same type of mosquitoes – leading to difficulty in achieving a definitive diagnosis. Therefore, all other possibilities must be eliminated before diagnosing chikungunya.5 History The first known outbreak of chikungunya took place in 1952 at the border between Tanganyika (now Tanzania) and Mozambique, where the illness was named in the local Makonde language literally meaning “that which bends up” due to it causing the sufferer to maintain a stooped posture.6 It was first described in 1955 by Marion Robinson and WHR Lumsden.7
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The first outbreak in India was in 1963 in the state of Calcutta, followed by outbreaks in 1964, 1965 and 1973. However, the genotype of the CHIKV has mutated and now displays the African genotype as opposed to the original Asian genotype. Through 2006 the epidemic has spread to the neighbouring countries of Sri Lanka, Maldives and the Reunion island.8 Chikungunya virus CHIKV is a positive-strand RNA virus surrounded by a lipid-containing envelope with 2-3 surface glycoproteins that mediate attachment, fusion and penetration. The virus is spherical, 60 to 70nm in diameter, and displays icosahedral symmetry. The nucleocaspid is about 40nm in diameter.9 The complete genome of the CHIKV is 11824 nucleotides long. The partial sequences of NS4 and E1 genes have been analysed phylogenically to reveal three different CHIKV phylogroups. These were samples from:10 • • •
West Africa Asia East, Central and Southern Africa (ECSA)
The original type of CHIKV that caused the Indian Ocean outbreak belonged to the Asian phylogroup. However, two mutations to the E1 envelope protein, caused it to change to the West African phylogroup. This made the virus more likely to enter mosquito cells and replicate after the insect has fed on the blood of an infected person, causing the re-emergence of the disease.10
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ARTICLE Vector Chikungunya is transmitted by mosquitoes belonging to the Aedes genus, found in tropical and subtropical zones. ‘Aedes’ is derived from the Greek for unpleasant due to the fact that it acts as a vector for many diseases, including dengue and yellow fever. The life span of a typical adult mosquito is 15 days, and they occupy human habitats (living rooms, offices etc).11
Thus treatment for chikungunya mainly consists of symptomatic relief, with analgesics, antipyretics and fluids. Paracetamol is given to relieve the symptoms of fever and joint pain. Bed rest is essential and mild exercise may improve stiffness and joint pains.13 Rudraksha healing (involving spiritual meditations) also touted as a potential homeopathic treatment. However, again there is no conclusive evidence to substantiate this.14
The initial vector for chikungunya was the Aedes aegypti mosquito responsible for transmission in the Asian and ECSA phylogroup. However, it was noticed that chikungunya still developed in areas where these types of mosquitoes were not present. Aedes albopictus, was then discovered to be a vector for CHIKV. This mosquito is more commonly associated with the West African phylogroup.3 It should be noted that only the female mosquitoes suck blood from humans (undertake hematophagy) and thus the males are not disease vectors. Females need blood to support the development of their eggs. They mainly bite humans, usually 3-4 times a day for a satisfactory meal, injecting saliva which acts as an anticoagulant in the human.12
Prophylaxis Vector control is the most effective way to prevent disease.13 One way of eradicating mosquitoes is to eliminate their habitat stagnant water at homes, schools and work places. Mosquitoes will then not be able to breed and eventually die off.13
Signs and Symptoms On becoming infected there is usually an incubation period of about 3- 12 days when no symptoms are evident, followed by a sudden onset of various symptoms.2
Prognosis Chikungunya is an illness from which most people recover completely. However some, especially tourists, develop joint pains that can last for a few months. 12% of patients will have chronic arthralgia three years after disease onset.1
Most of these symptoms will last a few days, if not a few weeks. However, research has shown that some patients may have obdurate joint pains for many months. Especially in cases with tourists becoming infected in a tropical country, but still suffer joint pain after returning home.13 Signs and Symptoms3 • high fever up to 39˚C • rashes around the limbs and trunk • headaches • infection of the conjunctiva (potential photophobia) • erythema • flagellate pigmentations on face & extremities • ulcers over scrotum
Futher prophylaxis can be achieved by long-sleeved clothing, insect repellent and the use of mosquito nets at night. Public Education matters. Many may not know how to prevent acquiring disease. It is therefore the responsibility of governments and Non-Government Organisations to educate and also to supply the necessary equipment to ensure disease prevention.
The very few associated deaths are mainly due to poor preventative measures, inappropriate use of antibiotics or lack of resources to treat symptoms. It also has not affected the Western world as yet, though the virus could mutate further and impact the rest of the world. Referencing 1.
2.
3.
Diagnosis Following a full history and examination, it is important to exclude Dengue as a differential, often done by the presence of haemorrhage. However, the definitive method for diagnosing chikungunya is to undertake an Enzyme-Linked ImmunoSorbent Assay (ELISA) to see if Immunoglobulin M (IgM) is present in the blood.1
4.
Treatment There is no specific treatment for chikungunya. Although vaccine trials took place in 2000, a lack of funding halted research due to a number of factors. Firstly, although many people were being infected by CHIKV, very few people actually died as a result. Furthermore, most infected individuals were in third world countries which led to a lack of initative amongst “Big Pharma” to invest in research and development. One drug that is being looked into is chloroquine, used in the treatment of malaria. Clinical trials are being conducted to see its use as an antiviral agent against the CHIKV. However, the results are not yet conclusive.3
7.
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5.
6.
8.
9.
10.
McMorran J, Crowther DC, McMorran S et al. chikungunya haemorrhagic fever [online] 2005. Available from: http://www.gpnotebook.co.uk/simplepage. cfm?ID=1523580948 [accessed 2/3/2007]. CBWInfo. Chikungunya fever: essential data [online] 1999. Available from: http://www.cbwinfo.com/Biological/ Pathogens/CHIK.html [accessed 2/3/2007]. Martin E (2007). “EPIDEMIOLOGY: Tropical Disease Follows Mosquitoes to Europe”. Science 317 (5844): 1485. Charrel RN, de Lamballerie X, Raoult D. Chikungunya Outbreaks – The Globalization of Vectorborne Diseases. The New England Journal of Medicine. 2007;356(8):769-771. Carey DE. Chikungunya and dengue: a case of mistaken identity?. Journal of the history of medicine and allied sciences. 1971;26(3):243-262. Joint UKBTS/NIBSC Professional Advisory Committee. Chikungunya Virus [online] 2006. Available from: http:// www.transfusionguidelines.org.uk/docs/pdfs/position_ statement_09_2006_07.pdf [accessed 2/3/2007]. Robinson M, Lumsden WHR. An epidemic of virus disease in Southern Province, Tanganyika Territory, in 1952-53. II. General description and epidemiology. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1955;49(1):33-57. Yergolkar PN, Tandale BV, Arankalle VA et al. Chikungunya outbreaks caused by African genotype, India. Emerging Infectious Diseases [serial on the Internet]. 2006;12(10). Available from: http://www. cdc.gov/ncidod/EID/vol12no10/06-0529.htm [accessed 2/3/2007]. International Committee on Taxonomy of Viruses. Chikungunya virus [online] 2006. Available from: http://www.ncbi.nlm.nih. gov/ICTVdb/ICTVdB/00.073.0.01.007.htm [accessed 2/3/2007]. Schuffenecker I, Iteman I, Michault A et al. Genome Microevolution of Chikungunya Viruses Causing the Indian Ocean Outbreak. PLoS Medicine. 2006;3(7):1-13.
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REVIEW
Is it time to put the lights out on sleeping sickness? Camus Nimmo BA (Hons) Year 4 Medicine, University College London c.nimmo@ucl.ac.uk doi:10.4201.lsjm/gch.004
For the full article and references see thelsjm.co.uk.
Introduction Human African Trypanosomiasis (HAT), more commonly known as sleeping sickness, is classified as one of the worldâ&#x20AC;&#x2122;s neglected tropical diseases (NTDs). The World Health Organisation (WHO) currently recognises 15 NTDs which until recently had received very little attention from both the worldâ&#x20AC;&#x2122;s media and scientific communities.1 The incidence of HAT has followed a very interesting path. At the end of the colonial era in Africa (around 1960), the disease had been all but eradicated in most countries due to vigorous control policies put in place by the incumbent powers. However, following independence, new African governments had other priorities and many of these policies fell into disarray. By 1997, new cases had reached a peak of 35,000.2 This coincided with a recrudescence of international political interest in NTDs in general, and over the following 10 years the incidence has been more than halved to around 15,000 new cases in 2006 (Figure 1).3 With such a promising decline in cases, over the last 10 years, is it reasonable to hope that a further 10 years can see the complete elimination of the disease? And what lessons can we learn from HAT that apply to other infectious diseases worldwide? About HAT HAT is caused by a single-celled protozoa from the Trypanosome genus. It is transmitted within human populations and between humans and animals by the tsetse fly vector. There are 2 major species affecting humans: Trypanosoma brucei gambiense and Trypanosoma brucei rhodesiense. The major features of each are summarised in Table 1. Both types have a significant impact on human health as well as an economic - caused by the infection of livestock. In the first stage of the disease the parasites infect the blood and lymph. In the second stage they cross the blood-brain barrier and affect the CNS. The treatment options for HAT are limited and old-fashioned. The options at each stage are shown in table 1. Past Successes and Failures Almost complete control of HAT was achieved across Africa by 1960 by the previous colonial administrations. At the beginning of
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the 20th century this involved simple measures such as evacuating people from epidemic areas. By the middle of the century methods had advanced through using blood-based tsetse traps to spraying of dichlorodiphenyltrichloroethane (DDT) after its discovery during World War 2.4 Use of rigorous dedicated surveillance and control teams finally drove down the number of new cases to being virtually undetectable by the late 1960s. Post independence, most African countries did not see the dedicated HAT teams as worth continuing due to high running costs and the apparent elimination of the disease.4 Sadly, ensuing social upheavals over the next 40 years allowed further epidemics to occur, and infection to spread once more. Current Successes Between 1995 and 2006, a leading factor in the falling incidence of HAT was the reduction in hostilities in countries that had suffered ongoing civil wars for long periods, particularly Democratic Republic Congo, Angola and Sudan. These changes have allowed WHO-sponsored programmes to develop in these countries over periods where they can begin to have an impact.3 There are significant differences between factors involved in control of gambiense and rhodesiense HAT. Gambiense is well controlled using tools targeted at infections in the human population, and most of the drop in HAT cases over the last 10 years has reflected a decrease in gambiense infection. However, rhodesiense HAT is less well controlled by these measures as it has a large animal reservoir as well. Between 1995 and 2006, there has been a 26% reduction in rhodesiense cases, but with an even larger increase in the interim. This compares with a 69% decrease in gambiense cases.3 Challenges for the Future Of the 36 countries classified as endemic for HAT, it had been eradicated or almost eradicated in 20 by 2006. An informal WHOsponsored meeting in 2007 involving representatives from these countries concluded that it was an eradicable disease.5 The way forward for eradication involves continuing increased surveillance and monitoring, which is best carried out using a combination of primary health care infrastructure and specialised teams.6
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REVIEW Diagnostic Techniques New diagnostic mechanisms are sorely needed to if the downward trend experienced over the last 10 years is to be maintained. Diagnosis of gambiense relies on a blood spot card agglutination test, followed by microscopy to look for parasites. Diagnosis of rhodesiense is more challenging, as the card agglutination test does not work and relies on access to skilled staff and equipment, which may often not be available. Neglect in Drug Development In terms of drug development, HAT suffers the same fate as other NTDs - an area of medicine which with far fewer drug advances than almost any other. The latest drug to be licensed for second stage gambiense HAT was eflorinthine 19 years ago involving multiple daily iv infusions, which carry a significant burden in terms of cost, infrastructure and availability.8 It is safer than melarsoprol which causes fatal encephalopathy in 10%9 and has regional pockets with substantial resistance. The advantage of melarsoprol is that it can be administered as a simple injection,8 and is still the only drug that can be used for second stage rhodesiense HAT. Clearly neither drug is ideal, and further research is needed. Unfortunately, there are no drugs currently being investigated after phase III clinical trials for pafuramidine maleate were stopped in 2008 following safety problems,10 after receiving over US$35m from the Bill and Melinda Gates Foundation.
The epidemiology of HAT is well understood, as shown by the effectiveness of simple control measures put in place initially over 50 years ago when political will was present. I see no reason why this should not be implementable in the future, and be able to lead to the control of HAT once more. However there is always a risk of return, it is important that research into HAT continues in the meantime. The main challenges for the future are to develop better monitoring techniques so that cases can be easily identified. Hopefully the past will emphasise to us the importance that HAT does not suffer from the problems of its own success and be made a lower priority for funding and international effort. References 1. 2.
3. 4.
5.
Vector Control Currently methods for control of the tsetse fly vector include aerial spraying of low concentrations of pesticide. This is rapidly effective but expensive and complicated to implement11. Selective spraying of insecticide onto animals on which tsetse flies feed is an effective alternative in settings where a smaller region is affected12. Potential strategies for the future involve further investigation of tsetse genomics to develop a genetically modified tsetse fly that is unable to carry Trypanosoma parasites13. However, this work is still many years off providing any practical interventions.
6.
Conclusion Looking at the graph showing incidence of HAT over the last 100 years makes astonishing viewing, emphasising the importance of understanding the interplay of epidemiology, medicine and politics when considering healthcare.
10.
7.
8.
9.
WHO List of Neglected Tropical Diseases [cited 2009 Mar 7]. Available from: http://www.who.int/neglected_diseases/diseases/en/ WHO Report on Global Surveillance of Epidemic-prone Infectious Diseases. p95-106. Available from: http:// www-tc.iaea.org/tcweb/abouttc/strategy/thematic/pdf/ presentations/tsetse_flies/WHO_Report_Diseases.pdf Weekly Epidemiological Record. 2006 Feb 24;81:69–80. de Raadt P. The History of Sleeping Sickness. Fourth International Cours on African Trypanosomoses, Tunis. 2005 Oct 11-28. Available from: http://www.who.int/ trypanosomiasis_african/country/history/en/index.html Report of a WHO Informal Consultation on Sustainable Control of Human African Trypanosomiasis [cited 2009 Mar 7]. Available from: http://whqlibdoc.who.int/ hq/2007/WHO_CDS_NTD_IDM_2007.6_eng.pdf Samarasekera U. Margaret Chan’s vision for WHO. Lancet 2007;369:1915-1916. Deborggraeve S, Claes F, Laurent T, Mertens P, Leclipteux T, et al. Molecular dipstick test for diagnosis of Sleeping Sickness. J Clin Microbiol 2006;44:2884-2889. Balasegaram M, Young H, Chappuis F, Priotto G, Raguenaud ME, Checchi F. Effectiveness of melarsoprol and eflornithine as first-line regimens for gambiense Sleeping Sickness in nine Médecins Sans Frontières programmes. Trans R Soc Trop Med Hyg. 2009 Mar;103(3):280-90 Blum J, Nkunku S, Burri C. Clinical description of encephalopathic syndromes and risk factors for their occurrence and outcome during melarsoprol treatment of human African trypanosomiasis. Trop Med Int Health 2001;6:390-400. Press release: Immtech Focusing On New Infectious Disease Programs Following Discontinuation of Development of Pafuramidine. Released 2008 Feb 22 [cited 2009 Mar 7]. Available from: http://www. immtechpharma.com/documents/news_022208.pdf
Table 1: Features of gambiense and rhodesiense HAT T. b. rhodesiense
Geographical spread
West Africa
East/South Africa
% of all HAT cases
90
10
Disease specificity
Mainly humans
Humans and wild/ domestic animals
Time frame
Chronic
Acute
Acute symptoms (weeks to months)
Few
Swelling at bite site Occasional headaches Irregular fevers Pruritis Adenopathies
Chronic symptoms (months to years)
Severe headaches Sustained fever Sleep disorders Altered mental state
n/a
Drug treatment
Stage 1
Pentamidine
Suramin
Stage 2
Melarsoprol Eflornithine
Melarsoprol
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Figure 1: HAT cases reported annually 1937 - 2006
Number
T. b. gambiense
Year
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ARTICLE
A short introduction to the human papilloma virus and a consideration of the implications of global vaccination Polly Jordan BSc in Adult Nursing Year 2 Medicine, Barts and the London pollyredman@googlemail.com doi:10.4201.lsjm/gch.003
Cancer of the cervix is the second most common cancer among women worldwide, with an estimated 471,000 new cases (and 233,000 deaths) in the year 2000.1 Almost 80% of cases occur in developing countries, where in many regions it is the most common cancer among women and responsible for about 15% of all new cancers.2 Cervical cancer often affects younger women and the disease has significant emotional and financial cost implications.
For the full article and references see thelsjm.co.uk.
Source: Wellcome Images
Persistent infection with high-risk human papilloma virus (HPV) is the primary cause of cervical pre-cancer and cancer.3,4 HPV 16 and 18 are high risk types as they are most commonly linked with cervical cancer, although several other HPV types are also carcinogenic.5 HPV 6 and 11 are known as low-risk HPV types as they are uncommonly found in malignant lesions but are causative agents of ano-genital warts, recurrent respiratory papillomatosis, and in rare cases, have been associated with cancers of the larynx, vulva, penis and anus.6,7 Image: HPV in cervical epithelium
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Prophylactic HPV vaccines are now available for clinical use. The two licensed vaccines are Cervarix (bivalent), which is active against HPV types 16 and 18, and Gardasil (quadrivalent) which is active against HPV 6, 11, 16 and 18. Meta-analysis shows HPV vaccine efficacy of both vaccines to be high, with significant reduction in the risk of infection from HPV16 and 18 in vaccinated cohorts.8 The question that now needs to be addressed is to whom the vaccine should be given to in order to gain maximum effect. The current vaccines are projected to prevent 75-80% of cases of cervical cancer.4
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ARTICLE Cervical cancer is uncommon in countries with planned, population based screening programmes such as the UK and Norway, which have two of the most effective programmes in the world. However, cervical cancer is common in Eastern Europe and in developing countries due to insufficient cervical screening. This results in many patients presenting with advanced lesions at the time of diagnosis, as demonstrated by studies from Uganda.9 The highest impact of prophylactic vaccination would be observed in countries without screening programmes. Successful implementation in developing countries would depend on resource availability (the current cost of the vaccine is likely to be prohibitive) as well as overcoming significant obstacles such as conservative views on teen sexuality, lack of understanding regarding HPV, relatively low school attendance and geographical barriers to vaccine delivery. Initial cost-benefit analyses of HPV vaccination suggest that vaccination of boys would not be cost-effective as prevalence would be low following comprehensive vaccination of girls.10 However, vaccination of males would boost ‘herd immunity’ through reducing the pool of disease. Additional benefits include protection against genital warts and some cancers of the perineum and anus. Homosexual men are a particularly high- risk group who would benefit. Gardasil is licensed for administration to both sexes and has been shown to provide close to 100% protection against genital warts.7 Further cost-benefit analyses would be required prior to the inclusion of boys in a comprehensive vaccination programme. HPV vaccines have been shown to be effective in women who have never been infected with HPV16/18 and in those who have no current infection.11,12 For this reason, in the UK the target age group is pre-pubertal girls in order to vaccinate prior to the commencement of sexual activity. Cost-effectiveness studies of the HPV vaccine are focused on countries in the developed world, many of which have established cervical screening programmes. For example in Ireland, base-case incremental cost-effectiveness ratio was found to be €17,383/ Life year gained, suggesting that vaccinating against HPV 16 and 18 would be cost-effective.13 A Canadian study concluded that vaccinating 12-year-old girls is likely to be cost-effective, with a significant reduction in cervical cancer mortality being observed. Concurrent vaccination of 12-year-old girls with a cervical screening programme has also been found to be cost-effective in Germany, with 120 girls requiring vaccination to prevent 1 case of cervical cancer.15 In the UK, it is anticipated that there will be a 70% reduction in cases of cervical cancer and 400 lives per year saved following the introduction of the immunisation programme16. In terms of cost, Gardasil and Cervarix are both priced at £80.50 per vaccination, requiring a course of 3 injections over a six-month period1.7 A national immunisation programme for 12-year-old girls commenced in September 2008, at an estimated cost of £100 million per year18. A catch-up programme for 14-18 year-old girls is also scheduled at a cost of £200 million. A decision has yet to be made on the benefit of catch-up vaccination for women in the 18-25 year age group. The Joint Committee on Vaccination and Immunisation (JCVI) suggest that vaccinating this age group is not a cost-effective
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strategy but recognise that it could benefit some individuals.16 The national cervical screening programme is to continue in the UK at an estimated cost of £157 million per year.19 However, modifications to the existing programme are required in order for a national immunisation programme to be cost-effective.20 Modifications are likely to include increasing the age at which women first present for screening and increasing the screening interval. The benefit to women in developing countries without established screening programmes or the resources available for effective treatment of premalignant and malignant disease of the cervix would surely be even greater. The difficulty lies in the cost of the immunisation programme and the infrastructure and compliance needed to deliver the course of the vaccine (3 vaccines over a 6 month period). A cheaper alternative to a worldwide vaccination programme would be identifying and targeting sub-populations at high risk of infection. The difficulties of this strategy have been highlighted as there is no threshold number of risk factors that predicted HPV infection with sufficient specificity or sensitivity.21 In conclusion, evidence supports the vaccination of women across the world. A population based programme, rather than an opportunistic programme, would provide maximum effect. When the emotional and social benefits (e.g. reduction in working days lost) are included, the case for investing in HPV vaccination becomes even stronger. References 1. 2.
3.
4.
5. 6.
7.
8.
9. 10.
Parkin, D.M. Bray, F.I. Devesa, S.S. (2001) Cancer burden in the year 2000. The global picture. Eur J Cancer, 37(Suppl 8): S4-S66. IARC (2005) IARC Handbooks of Cancer Prevention: Cervical Cancer Screening. Volume 10. Lyon: International Agency for Research on Cancer. Wallboomers, J.M. Jacobs, M.V. Manos, M.M. et al. (1999) Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol, 189: 12-19. Bulk, S. Berkhof, J. Bulkmans, N.W. Zielinski, G.D. Rozendaal, L. et al. (2006) Preferential risk of HPV16 for squamous cell carcinoma and of HPV18 for adenocarcinoma of the cervix compared to women with normal cytology in the Netherlands. British Journal of Cancer, 94(1): 171-175. Pagliusi, S.R. Teresa, A.M. (2004) Efficacy and other milestones for human papillomavirus vaccine introduction. Vaccine, 23(5): 569-578. Greer, C.E. Wheeler, C.M. Ladner, M.B. Beutner, K. Coyne, M.Y. Lang et al. (1995) Human papillomavirus (HPV) type distribution and serological response to HPV type 6 virus-like particles in patients with genital warts. J Clin Microbiol, 33(8): 2058-2063. Lacey, C.J.N. Lowndes, C.M. Shah, K.V. (2006) Burden and management of non-cancerous HPV-related conditions: HPV 6/11 disease. Vaccine, 24(Suppl 3): S35-341. La Torre, G. de Waure, C. Chiaradia, G. Mannocci, A. Ricciardi, W. (2007) HPV vaccine efficacy in preventing persistent cervical HPV infection: A systematic review and meta-analysis. Vaccine, 25(50): 8352-8358. Makokha, T. (2007) Pilot study of human-papilloma-virus vaccine in Uganda. The Lancet Oncology, 8(5): 372-373. Newall, A.T. Beutels, P. Wood, J.G. Edmunds, W.J. MacIntyre, C.R. (2007) Cost-effectiveness analyses of human papillomavirus vaccination. The Lancet Infectious Diseases, 7(4): 289-296.
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EDITORIAL
The unhealthy and unlawful face of medical technology: a story of India For centuries in India, infant selection has included “neglect, strangulation, suffocation, and poisoning”.1 One reason for India’s steadfast adherence to these practices is the fact that it has conventionally been a patriarchal society.2 Infant sex-selection has increased further in the past few years due to the wide array of pre-natal sex selection technologies that are available on the market, conveniently allowing one to choose the sex of a child before birth.3 Some of the techniques used to determine the sex of an unborn child are sperm-sorting, pre-implantation genetic diagnosis and sex selective abortion facilitated by ultrasonography, amniocentesis and chorionic villus sampling. In a booklet compiled by the United Nations Population Fund (UNFPA) and Indian representatives, it was reported that the normal sex ratio for children aged between 0 to 6 years is 940-950 girls per 1000 boys.3 However, according to the booklet, the 2001 census showed only 927 girls per 1000 boys in India and it is reported that the ratio stands at a mere 770 in the Kurukshetra district of Haryana, 836 in Ahmedabad, and 846 in the South West district of Delhi – despite the fact that these regions are amongst the most prosperous in the country.3 In fact, The Lancet shockingly reported that in the past 20 years, some 500 000 female foetuses have been aborted every year in India, which amounts to 10 million missing girls from India’s population.4 Though there are no specific data to suggest that the above figures have been contributed by female foeticide using sex selection technologies, rather than the age-old practice of female infanticide, according to UNICEF, “A report from Bombay in 1984 on abortions after pre-natal sex determination stated that 7,999 out of 8,000 of the aborted fetuses were females”.5 If in 1984 itself female foeticide in India was pretty rampant, with the number of girls per 1000 boys having declined from 962 girls in 1981 to 945 girls in 1991 to an all-time low of 927 girls in 2001,3 it can be submitted that the increase in the latest sex selection technologies has made sex determination a significant contributor to the adverse child sex ratio in India.3 Furthermore, the fact that the child sex ratio has consistently declined though many awareness campaigns have been conducted nationwide in the past few decades, clearly indicates that increased awareness about the value of women as equal stakeholders in the society has not had any significant impact on the societal behavior of Indians when it comes to son preference. In Indian law, Section 4 of the Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of Sex Selection) Act 1994 states that pre-natal diagnostic techniques can only be employed to detect chromosomal abnormalities, sex-linked genetic diseases and congenital anomalies and section 6(c) further provides that ‘no person shall, by whatever means, cause or allow to be caused selection of sex before or after conception’. More importantly section 5(2) provides that ‘no person including the person conducting’ the sex selection procedure shall ‘communicate to the pregnant woman concerned or her relatives or any other person the sex of the foetus’ in any manner. Section 18(1) of the Act provides that no genetic counselling centres, laboratories or clinics can be opened after the commencement of the PNDT Act unless they are registered under the Act. The question however is, can healthcare professionals who are working in genetic counselling centres, laboratories or clinics be blamed for the problem of adverse child sex ratio in India? To put it crudely, the obsession for son preference in India has made the practice of sex selection a very lucrative business for Indian medical professionals.2 Therefore, Chander in his paper claims that the above legislative prohibitions encourage doctors to do little more than fake their reports and covertly engage in sex determination’.2 Where corrupt medical professionals and son-crazed parents and relatives are in collusion with each other, it becomes virtually impossible to investigate the underlying reasons why pre-natal diagnostic techniques are employed in many cases. In fact, a Delhi doctor admitted that doctors usually employ code phrases like ‘the sky is blue’ and ‘you are in the pink of health’ to indicate male and female foetuses respectively, despite the legislative prohibitions in place.6 The undesirable behaviour of genetic healthcare professionals highlighted above can easily be classified as the height of all unhealthy healthcare behaviours. As the next upcoming generation of healthcare professionals, we should bear in mind the integral clause of the Hippocratic Oath that above all we should do no harm. We should also be aware that though the child sex ratio in England is nowhere close to the ones in countries like India and China’s.3 1ZA and IZB of the Human Fertilisation and Embryology Act 2008 provide that sex selection is not allowed except for medical reasons. Therefore, as future healthcare professionals, we should do everything in our power to abstain from selfish and irresponsible behaviours that have the potential to contribute to crises like the adverse child sex ratio in India. Rani Preatarshini Subassandran Section Editor for Health Law and Ethics
References 1. 2.
Illustration: Robert Hare
3. 4. 5. 6.
Andrea Krugman “Being Female Can be Fatal: An Examination of India’s Ban on Pre-Natal Gender Testing” 6 Cardozo J. Int’l & Comp. L. 215 (1998) at pg 221 Vineet Chander “It’s (Still) a boy… : Making the Pre-Natal Diagnostic Techniques Act an Effective weapon in India’s Struggle to Stamp out Female Feticide” 36 Geo. Wash. Int’l L. Rev. 453 (2004) at pg 455 “Missing: Mapping the Adverse Child Sex Ratio in India” India, Office of the Registrar General and Census Commissioner, June 2003 Shirish S Sheth, ‘Missing Female Births in India’, The Lancet, Vol. 367, Issue 9506, 21 January 2006, pg 185 – 186 Zeng Yi et al, ‘Causes and Implications of the Recent Increase in the Reported Sex Ratio at Birth in China’, Population and Development Review, 19:2 (June 1993) p. 297 Alison Wood Manhoff, “Banned and Enforced: An immediate answer to a problem without an immediate solution- How India can prevent another generation of Missing Girls,” 38 Vand. J. Transnat’l L. pg 889
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NEWS All authors are panellists of LSJM Health Law and Ethics
Greece bans smoking Marilena Smyrnioti A recent study of the European Commission placed Greece on the top of the list as the country with the highest percentage of smokers. The country’s Ministry of Health has been pushing to implement a ban outlawing smoking in all public places that will take effect from July 1st, 2009. Previous relevant laws had been widely ignored. Additionally, unlike most European Union countries, there has been no age limit on the purchase of tobacco – a policy that has been in the spotlight. In the face of the new deadline, the smoking debate has heated up. Smoking has been increasingly transforming from a primarily unhealthy behaviour to one that is deemed unethical: am I allowed to expose non-smokers to the harmful effects of cigarette smoke? Is it ethical to allow people to continue harming themselves with a known harmful substance? This is a debate that could go even further if we start wondering about the ethics of the banning campaigns: is it ethical to ban someone from a public place due to a ‘bad habit’? Is it ethical to force someone to change a habit? Whatever the view of the individual, more and more countries are introducing smoking bans and our minds are being made up for us. Torture and the medical profession at Guantanamo Bay Dhupal Patel The release of prisoners from Guantanamo Bay has been a primary objective in Barack Obama’s presidential campaign. The camps are infamous for their harsh conditions, deemed incompatible with human rights. Recent investigations carried out by the International Committee of the Red Cross surrounding the medical personnel at Guantanamo, have brought the institution into further disrepute. It is thought that members of the medical profession were witness to some of the forms of torture. Their role was to advise whether certain ‘treatments’ could continue or whether they ought to be stopped, based on the detainee’s medical statistics and observations. The example of ‘waterboarding’ is particularly contentious and refers to a particular form of torture that simulates drowning. In this instance, medics were on hand to measure the patient’s oxygen levels, using this as a guide as to whether the practice could continue or not. These findings have inevitably provoked outrage as such behaviour ultimately goes against the ethos of medicine which according to Hippocrates can be summed up as ‘to do good or to do no harm’. However, as more details emerge about the atrocities at this camp, it is likely that we will discover more practices that go against the very principles society should be abiding by.
There is now a new dilemma with respect to pharmaceutical companies and advertisement. The European Commission is proposing a law to allow drug companies to provide health information and advertise their products in the media to the general public. Although there was a resounding ‘no’ in the European Parliament when the law was first proposed in 2002, some feelings have since changed. The proposed main argument for the change is based on giving patients as much information as they want regarding their medications, therefore giving them the autonomy to make their own decisions. Critics also speculate that there is a change of opinion within the EU as the European pharmaceutical industry is falling behind the USA and Japan. Their opinion is that if we increase the information provided then we increase the demand for the products therefore giving the industry a boost. However many are against changing the law arguing that the information provided can never be independent or reliable. The fear is that if doctors and pharmacists can fall into the trap of being bribed to buy a product then there is a danger that consumers may also be bribed by such companies. After all, there is a difference between giving people information and trying to influence their decision making and promoting a product. Assisted suicide with Dignitas Rebekah Robson Dignitas is a Swiss euthanasia group that run the Dignitas Clinic near Lake Zurich in Switzerland. Founded in 1998 by Swiss lawyer Ludwig Minelli, it is rumoured that nearly 900 people have died at the clinic, 100 of which have been British. With the news of the assisted suicides of Peter and Penelope Duff (who both had terminal cancer) at the controversial Dignitas clinic, and with the former health secretary, Patricia Hewitt, calling for clarification in the law on assisted suicide, this debate has been pushed back onto the front pages. It is also rumoured that Lord Joffe is planning on introducing a new bill on assisted dying this year. Under the previous bill, only those with months to live would be given the privilege to choose to die, and so one wonders, even if a new bill were to become law, how many people would continue to end their lives at Dignitas nonetheless?
Proposed European relaxation of ban on advertisement of prescription drugs in the media Jennifer Davies There has been much debate in the media over the past few years There has been much debate in the media over the past few years about drug representatives using gifts and financial incentives to reel prescribing doctors and pharmacists into buying their company’s products. The overruling feeling was that it is unethical for doctors to be persuaded by drug companies into prescribing a drug and the decision should be made based on evidence from various reliable trials and studies.
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REVIEW
Allocating Organs: Two bodies, one heart Aziz Ahmed BSc (Hons) Year 3 Medicine, St. Georgeâ&#x20AC;&#x2122;s University of London m0601115@sgul.ac.uk doi:10.4201.lsjm/hle.003
Organs are a scarce resource, particularly non-regenerative organs such as the heart. There are currently around 8,000 patients on the UK organ transplant list with around 400 annual deaths due to a lack of organs.1 With such a limited resource in such high demand it is imperative to establish the optimum methods of allocation for both the donated organ and the potential recipients. A limited resource
The ethical implications of using cadavers as an organ source are similar to those found in xenotransplantations. Again, are we going against natural law by removing organs from one individual and placing them in another? There are also some religious objections for example, followers of the Japanese religion Shinto believe that it is a crime to injure a dead body, leading to a refusal to donate or receive organs from cadavers.2
The UK currently has an opt-in system meaning an individual has to volunteer to be registered on the NHS organ donor register. There are currently 10,926,428 people listed in the UK as organ donors.1 Nearly eleven million potential donors seems like a lot, however most of these individuals will not die in conditions that allow for their organs to be used. There has been much controversial discussion recently about the introduction of an opt-out system, where individuals are automatically listed as potential donors. This system is already used in several countries, including France, Spain and Belgium.
Live donors are another possible organ source, such as a person donating one of their kidneys whilst retaining their other kidney. Live donations have significant clinical advantages in terms of survival rates with fewer complications and rejections.3 One of the most serious ethical considerations is the issue of non maleficence where it is the duty of the clinician to do no harm. Are doctors contradicting this central tenet of medical ethics by removing organs from a healthy donor?
Source of organs The three main sources of organs are animals, cadavers and live humans. Research into animal organs as a source for transplantation (xenotransplantation) is subject to many ethical and practical questions. The issues to consider with xenotransplantation (such as pig heart valves), include conflict with religious beliefs, immune rejection and the possible risk of diseases (e.g. porcine endogenous retrovirus) crossing the species barrier and infecting humans. Research into this remains inconclusive, however the possibility of disease transmission cannot be underestimated as patients undergoing organ transplantation are susceptible to infectious diseases due to the use of immunosuppressive drugs. Other issues to consider include respecting the animalâ&#x20AC;&#x2122;s rights and whether we are violating natural law by placing non-human organs inside patients. A significant problem when instigating discussions about xenotransplantation is the initial shock that it can elicit.
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With live donations also comes a more sinister problem, how do we ensure the donor is making a voluntary decision and is not being coerced? Financial coercion is already a problem in many third world countries where organs are sold to wealthy individuals. Transplantation tourism is now a considerable problem with patients travelling from industrialised countries to third world countries in order to purchase organs. The Human Organ Transplants Act 1989 was introduced in the UK to prevent organ trafficking. The act states organs cannot be exchanged for payment and donations must be voluntary, it also recommends psychological counselling for both parties. Organ allocation is important as we have a limited number of organs, so we must decide which patient receives an organ and which patient does not. Once organs are obtained, they must be allocated amongst the hundreds of potential recipients. Current UK practice takes into account the urgency, length of time waiting and the quality of the match in terms of size and tissue matching.
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REVIEW This will also vary dependant on the organ type being transplanted. There are many principles used in organ distribution - Dosseter et al4 classifies these into eight main principles: The urgency principle - this is often used in life threatening situations, priority is given to patients with the greatest need, for example those at immediate risk of death are given the highest priority. The urgency principle has been criticised as it can overwhelm rational thinking in situations that are emotionally charged. The urgency principle selects patients that are at immediate risk of death. This can then lead to the allocation of organs to patients who might not utilise the organs to their full capacity. Therefore, an organ that may have kept a chronic patient alive for 5 years is instead allocated to a patient in acute distress but even with the organ can only expect to survive 5 months. How do we establish which patient can most benefit from or utilise an organ? There are many factors that influence how well a patient utilises an organ. Perhaps the most important factor is graft success. According to Guttman et al,5 patients in critical care often have lower rates of graft success, thus not utilising the organs full potential. The urgency principle has been criticized for lacking fairness; patients with chronic diseases may be on a waiting list for several years, whilst another patient with acute injuries may receive an organ immediately because of their life-threatening situation. An apparent lack of fairness could have an adverse effect on public perception as equal treatment of patients is seen as one of the most important factors in organ transplantation and its management. The utility principle - also known as the medical efficacy principle is based around optimising the health outcome of the patient. It uses physical factors such as the patients age, HLA matching and type of illness to allocate organs. These factors are associated with the health outcome, for example a close HLA match between patient and donor means there is less chance of organ rejection. The lottery principle - this system is based on random selection and disregards clinical information. According to Dossetor, patients would accept this principle whereas clinicians would not as it ignores their professional expertise. Irrespective of how much we debate and discuss organ allocation there will always be a sense of unfairness. However, with the lottery principle all patients have an equal chance of selection. The lottery principle has potential uses in situations where fair judgement cannot be reached. The queuing principle - perhaps the simplest principle, it is based on allocating organs based upon time spent on the waiting list for an organ. In its purest form clinical factors are ignored, and the organ is offered to the patient who has spent the most time on the list. Clinicians and patients have been known to take advantage of this system by applying to multiple transplant schemes, so it is important to integrate different waiting lists and prevent patients from applying to multiple lists. The queuing principle can be viewed as the fairest and least discriminative, however it also has several limitations such as its inflexibility: the queuing principle does not make considerations for patients in medical emergencies that require immediate organ transplants. The financial principle - is based on market forces of supply and demand of organs. Here affluent patients have an advantage and
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are able to gain priority, an occurrence especially prevalent in the developing world. The ability to pay is seen all over the world, even in developed countries such as the UK where transplant programmes are government run. Here the ethical implications are clear: ideally, organ transplantation should be fair and accessible to any patient, if money is involved the process might be subject to abuse. Again we have to balance this against an individual’s autonomy. Today’s society places great emphasis on the rights of individuals to choose what happens to their own bodies. Following this line of thought, it can be conceivable for an individual to sell one of their own organs, not only would this respect the individual’s autonomy but it might also increase the number of donor organs available. Whatever one thinks of the financial principle, the selling and buying of organs is a fact and one that will likely be around for as long as organs are a rare commodity. The social worth principle - Rescher6 identified this controversial method of allocation, which takes into consideration a patient’s social worth. This is measured by various factors including the patient’s social situation, their previous usefulness to society and their future potential. Should we favour a 25 year-old doctor who could help hundreds of patients over a 25 year-old vagrant? This type of approach is seen to be unacceptable in countries where the organ transplant programme is publicly funded, however it has been utilised most notably in Seattle where the programme was introduced in the 1960s with the initial development of dialysis treatment. Selection criteria were developed due to the high expense and limited availability of treatment, they included questions such as value to community and number of dependants. How do we define social worth? Who has the right to decide what is socially worthy? The societal approach can be seen to reduce an individual to a socioeconomic entity, in turn leading to discrimination against patients that are from lower socioeconomic groups. The needs of the programme policy - this is an offshoot of the utility principle (the medical efficacy principal), where decisions are based on clinically relevant information such as HLA matching and disease prognosis. However, the main difference between the utility programme and the needs of the programme policy is the clinician’s primary concern. Clinicians using the needs of the programme policy are seen to secure the future of the programme, sometimes at the detriment of patient health. Financial security is achieved through continued success of operations so the clinicians select patients that are at low risk using the utility principle criteria. Macroallocative public policy - this is the nation-wide approach to health care used by the government to dictate health care policies. Factors are usually non-clinical, the most important usually being monetary and availability of organs, these are factors not sensitive to individual needs. The eight principles mentioned all have their advantages and disadvantages, so which principles should we use to allocate organs? Perhaps a points system might be the solution, where we integrate the different principles and develop a universal answer to the dilemma. One such points system exists in kidney transplantations called the European transplant algorithm. Here clinicians use a number of algorithms to assign points to patients and eventually allocate organs, each algorithm takes a different aspect of organ allocation into consideration for example HLA
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REVIEW Conclusion matching and age. The points a patient accumulates from different algorithms are combined to give each patient an overall score, which determines where on the waiting list a patient is placed. Another advantage of using a points system is that we can now undertake objective research into how we allocate organs and we can compare allocation systems on a nation-wide or global basis.
To use only one ethical approach for organ allocation leads to a perception of unfairness. How we define patients suitable for organ allocation should take into account the medical, social and emotional viewpoint, thus perhaps using an algorithm to integrate the aforementioned ethical ideas would be the optimum way of doing this.
The introduction of an algorithm system in the USA illustrated the biased allocation that was prevalent under the old system. Research demonstrated a bias of kidney transplants in the USA towards men over women, the young over the elderly and white patients over black patients.7 The main advantage of using a points system is the transparency of the process. Removing the ambiguity around the issue makes the process more systematic and less subject to bias. By using such systems, we can develop centralised policies that are open to inspection. We also alter the patient-doctor relationship by removing individual clinicians from the allocation process. As physicians are no longer expected to allocate organs to individuals, this should improve the patient-doctor relationship leaving clinicians to fulfil their role as impartial advocates for all their patients.
References
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1.
2. 3. 4. 5. 6. 7.
Organ Donation Facts [information sheet online] NHS online 25/11/2007 [25/03/2008]. Available from http://www.nhsdirect. nhs.uk/articles/article.aspx?articleId=562&sectionId=34 Namihira, E. Shinto concept concerning the dead human body. Transplantation proceedings. 1990; 22(3): 940-1. Nicholson, M. Kidney transplantation from asystolic donors. British Journal of Hospital Medicine. 1996; 55(1/2): 51-56. Dossetor, J. Ethics issues in organ allocation. Transplant Proc. 1968; 20:1053-1058. Guttman, T and Land, W. The ethics of organ allocation: The state of debate. Transplantation Reviews. 1997. 11, 197-207. Rescher, N. The Allocation of Exotic Medical Lifesaving Therapy. Ethics 1969; 173, 178-79. Veatch, R. Transplantation ethics. 2002; Georgetown University Press; 118-137.
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PERSPECTIVE
Promoting IVF: The (un)hidden effects of playing God Chantal Bohren Year 4 Medicine, St. George’s University of London m0401801@sgul.ac.uk doi:10.4201.lsjm/hle.004
For the full article and references see thelsjm.co.uk.
Introduction On the 25th of July 1978 the first baby conceived in vitro was born.1 The world’s press went into overdrive in a race to break the news. The hyperbolic headlines screaming “BABY of the century” and “Test Tube Baby”2,3 announced the birth of Louise Brown. The Time magazine sensationally described the palpable expectation of the newborn as “the most awaited birth in perhaps 2000 years”.2 The scientific breakthrough in reproductive biology of human species by means of in vitro fertilisation (IVF) was heralded by some commentators as a miracle of modern medicine. However, few advances in medicine sparked off such far-reaching controversy, as the intervention in the act of procreation. With repercussions on ethical, moral and social aspects of human life, creation of life outside the womb could be interpreted as usurpation of God’s powers. Was the interference into God’s domain the opening of the Pandora’s Box? This article will first provide the contextual background of this issue. Subsequently, economic, political and religious aspects as key drivers affecting public and private sector policies, as well as societies’ views and attitudes, will be explored. Though the issues will be considered in the aforementioned order, the problems, concerns and questions surrounding this subject are tightly interlinked. Screening IVF With an estimated 4% – 14% of all couples in the reproductive age being affected by infertility,4 it is not surprising that reproductive medicine has mushroomed over the past few decades. Since the birth of Louise Brown, approximately 3.5 million newborns were delivered as the result of eggs and sperms being introduced to each other in a Petri dish.5 In the UK, around 35,000 women had IVF treatment in 2006, resulting in more than 10,000 live births.6 The average success rate varied significantly across age groups, ranging from 31% for women under 35 to 4% for women above 44 years of age.6 More than one fifth of all treatment cycles resulted in multiple births.6
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IVF treatments are still tremendously expensive. According to the latest figures by the Human Fertilisation and Embryology Authority (HFEA), the cost for undergoing the therapy in the UK ranges between £4000 and £8000.6 The NICE1 guidelines affords each couple a maximum entitlement of three state funded IVF cycles;7 a vast majority of care trusts pay only for one.5 As a result, in 2005, two thirds of the provided treatment cycles were paid for privately.5 Compared to most Western European countries, the current funding scheme in the UK is more taxing on patients.5 In contrast, the most extensive state subsidies for IVF are provided in Israel. In fact, irrespective of marital status and sexual orientation, Israeli women can repeat the treatment cycles “as many times as needed” until two children have been born.8,9 To pay or not to pay? If governments were to ask a Homo economicus whether statesubsidised IVF was a viable business proposition, the answer would most probably be in the affirmative. In fact, the body of research concurs that if a long term perspective is taken into account, it is profitable for governments to fund IVF treatments.10,11,12,13 However, IVF services are available to less than a quarter of all the 191 member states of the World Health Organisation (WHO).14 Strikingly, even in industrialised nations of the West, utilisation of IVF is far below the optimal level.4 The key reason for the lack of governments’ funding is the elevated costs associated with the IVF therapy.3, 4,15,16,17 As a result, in most countries patients have to pay part or all of the treatments cost out of their own pockets, reinforcing the notion that only affluent people can purchase superior products and services. The current predominantly selffunded system discriminates against people who cannot afford the treatment. Some observers suggested that inadequately funded procreation programmes effectively result in a form of financial eugenics.18 In fact, researchers discovered that people benefiting from IVF treatments primarily share a few key attributes, namely race, age, education and financial status.4,15 Consequently, the ethical concern is that IVF treatment, or access to it, does not benefit people in society equally.
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PERSPECTIVE With IVF’s unsatisfactory permeation in society, the elicited question is whether there are more cost effective birth increasing measures at governments’ disposal? According to the finding of a comparative study benchmarking IVF against the provision (or increase) of child benefits, funding test-tube babies is more cost effective.19 In the current climate where most western countries are faced with sub-replacement fertility rates, economic rationale would strongly suggest an increase in state subsidies for IVF treatments.19
IVF and the NHS – a brief introduction.
Myopic regulation? In liberal societies the reproductive realm has historically been a private affair. However, by opening a new frontier through IVF, one more bastion has fallen under governments’ remit. Given the many nations’ different stance to ethical questions on reproduction and health care services, it is understandable that legislation introduced across these countries are conflicting and competing.20,21 For instance, egg donations are treated very differently in different countries. Whereas Germany and Switzerland prohibit such procedures, the US allows them.21 In the UK eggs can only be donated, but not sold.20 A further example is the provision of infertility treatments in most Western European countries, whereby only heterosexual couples and pre-menopausal women are allowed receive such treatments.
• 28% for women under 35 years of age, • 24% for women between 35-37 years of age, • 18% for women between 38-39 years of age, and • 11% for women between 40-42 years of age.
By and large, as a result of legal restrictions and prohibitions applied in certain countries, people with purchasing powers fulfill their desires in jurisdictions that allow the purchase of the required services and products.21 Some observers have described this international market phenomena as reproductive tourism.4,20,21 The ethical merit embodied by such a commercial system is questionable, as the cost of international exchange is also carried by societies which are opposed to assisted reproductive procedures.22 Therefore, the question of whether the result of a self-regulated marketplace is more advantageous might be raised? The key benefit of such an arrangement is the inherent flexibility in responding to emerging technological advances without the need to issue new legislation whenever new procedures become available.21 However, relying on the invisible hand of free markets to take the decisions, might potentially open the doors for abuse. It is not hard to imagine that exuberant demands of parents coupled with the inquisitive nature of scientists would establish, or fast-track, the concept of “Designer babies” with boundless procedural permutations. Corroborating this reflection is the recent announcement by a fertility clinic in the renowned liberal state of California. The US clinic revealed that it extended the array of reproductive options, offering prospective parents the choice of traits like eye and hair colour for their future offspring.23 Potentially, the ethical middle ground between the consequences of an inconsistent prohibitive market and the vagaries resulting from a free market might be a regulated market.20,22 At a macro level, international laws restricting the ethically most severe occurrences of commercialism would need to be passed.20 At a national level, guidance could be provided by an independent organisation. Following the HFEA’s well devised structure and function, the organisation would license fertility clinics, monitor and approve procedures for assisted reproduction, enforce a Code of Practice, inform the general public and monitor research initiatives.22
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IVF (In-Vitro Fertilisation) is a method for assisted conception where an egg is fertilised with sperm outside the body. The most notable variable that affects the success of IVF is age: younger women tend to have healthier eggs. Because of this women over the age of 45 are not recommended for IVF as the success rates are too low and conception using older eggs is more likely to result in chromosomal abnormalities, birth defects and miscarriage. The NHS1 quotes the success rates as follows:
The NICE2 guidelines state that 3 cycles of IVF treatment is offered if: ∑ the woman is between 23 and 39 at the time of treatment AND ∑ one or both of the couple have been diagnosed with a fertility problem OR ∑ there has been at least 3 years of infertility. There are many risks associated with the treatment including multiple births and ectopic pregnancies. For more information on this please use the websites from which the above information was obtained. These are: 1. 2. 3.
NHS choices website. Accessed 19th April 2009. http://www. nhs.uk/Conditions/IVF/Pages/Introduction.aspx NICE guidelines. Accessed 19th April 2009. http://www.nice. org.uk/guidance/CG11/publicinfo/pdf/English HFEA website. Accessed 19th April 2009. http://www.hfea.gov.uk/index.html
Against God? And God blessed them, saying, Be fruitful and multiply, and fill the waters in the seas, and let fowl multiply on the earth.24 - Holy Bible: Genesis 1:28 Adhering to the divine instruction, initially given by God to Adam and Eve, has historically been easy and enjoyable for the human species. However, the process of generating new life in the natural way eluded a minority but increasing part of the population. The availability of new technologies has imposed on various religious leaders the challenge of providing guidance to their devout followers. The Roman Catholic branch of Christianity opposes IVF because it separates the procreative purpose of the marriage from its unitive purpose.25 “Playing God” by means of assisted reproductive technologies is considered improper human arrogation of the divine power. In Italy and many Latin American countries, the Roman Catholic Church applied pressure on legislators to restrict or prevent access to IVF treatments.4,26 In contrast, imitating God by acting in ways of “beneficence, mercy and compassion” is encouraged in Judaism.22 Henceforth, the IVF policy in Israel is very liberal and strongly supports pronatalism.8,9 Similarly, Islamic faiths support and welcome assisted reproduction,22 though only insofar as the family’s genetic lineage is retained.4,27
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PERSPECTIVE References The analysis of ethical questions surrounding IVF is subjected to varying principles, values and priorities embodied by religious communities. Therefore, it is comprehensible that different conclusions can be drawn, each with its content-specific ethical merits. However, arguing what is best for a liberal society, based on ethical instructions derived from religious prescriptions is a rather daunting and dubious task to fulfill.28
1.
2.
3.
4.
Conclusion Understanding all the implications of promoting IVF is extremely difficult, and is most likely impossible. The availability and accessibility of IVF treatments is the intricate product of economic, political and social forces, manifesting themselves in public and private sector policies, as well as religious and cultural principles and instructions. Ethical reflections and public debate about how IVF is changing Life in its broadest sense are paramount. At a personal level, the stories painted by the world of assisted reproduction, with IVF as the magic token, are touching and often tragic. However, stretching societal principles and values to accommodate the desires of individual parents and inquisitive scientists is an uncharted and critical path to walk. In some interpretations of the Pandora’s Box, the opening of the jar did not release evils, ills and plagues, but rather the golden light of Creation. In the case of IVF, the opened jar released the miracle of new Life though it raises many ethical questions.
5.
6. 7.
8.
9.
10.
TIME. Test-Tube Baby: It’s a Girl. TIME. [Online] August 7 1978. Available from: http://www.time.com/time/magazine/ article/0,9171,948239,00.html [Accessed 5th March 2009]. TIME. The First Test Tube Baby. TIME. [Online] July 31 1978. Available from: http://www.time.com/time/magazine/ article/0,9171,946934,00.html [Accessed 5th March 2009]. TIME. Frenzy in the British Press. TIME. [Online] July 31 1978. Available from: http://www.time.com/time/magazine/ article/0,9171,946938,00.html [Accessed 5th March 2009]. Nachtigall, R. International disparities in access to infertility services. Fertility and Sterility 2006; 85: pp. 871–875. The Economist. No IVF please, we’are British. The Economist. [Online] July 17 2008. Available from: http:// www.economist.com/world/britain/displaystory. cfm?story_id=11750879 [Accessed 5th March 2009]. Human Fertilisation and Embryology Authority (ed.). The HFEA Guide to Infertility. London: HFEA; 2007. National Collaborating Centre for Wonem’s and Children’s Helath. Fertility: assessment and treatment for people with fertility problems. Clinical Guideline. London: Royal College of Obstetricians and Gynaecologists; 2004. Birenbaum-Cermeli, D. and Dirnfel, M. In Vitro Fertilisation Policy in Israel and Women’s Perspectives: The More the Better?. Reproductive Health Matters 2008; 16(31): pp. 182–191. Birenbaum-Cermeli, D. “Cheaper than a newcomer”: on the social production of IVF policy in Israel. Sociology of Health & Illness 2004; 26(7): pp. 897-924. Svensson, A., Connolly, M., Gallo, F. and Hägglund, L. Longterm fiscal implications of subsidizing in-vitro fertilization in Sweden: A lifetime tax perspective. Scandinavian Journal of Public Health 2008; 36: pp. 841–849.
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ARTICLE
The dangers of multiple births: the Octuplets’ story Jessica Whitehead
Year 3 Medicine (GEP), St. George’s University of London m0600174@sgul.ac.uk doi:10.4201.lsjm/hle.002
Introduction The birth, in California, of the world’s second set of live-born octuplets on 26 January 2009 (and the only set to all have survived for more than a week), has caused a great deal of controversy in the media.1 The case has also raised many questions about the motives of the doctors involved, as well as the ability of the mother to care for her children. The six boys and two girls were born at 30 weeks’ gestation, to 29 year-old Nadia Suleman, who already has six children through In Vitro Fertilisation (IVF). In this pregnancy, it appears that she had six embryos transferred, two of which later split into two pairs of identical twins. At the time of writing, all of the babies are stable, with very few requiring oxygen, and there do not seem to be many health concerns.2 Multiple births are a common outcome of Assisted Reproduction Technologies (ART), of which IVF is probably the best known. However, this is an extremely unusual outcome. Many pregnancies of quadruplets, triplets or even twins result in long-term problems for the babies themselves and their families and therefore use a lot of resources.3 Because of the real dangers to mother and babies from a multiple pregnancy, several methods are used to try to ensure that only a singleton, or, at worst, a twin pregnancy results. These include limiting the number of embryos transferred, or
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reducing a multiple pregnancy to one or two foetuses. This article will discuss the problems of multiple pregnancies, as well as embryo transfer and some of the ethical issues relating to pregnancy reduction.
For the full article and references see thelsjm.co.uk.
Some dangers of multiple pregnancies Despite the fact that 66% of couples undergoing IVF who were surveyed by the British Fertility Society and “Child” (a UK infertility self-help organization) felt that having twins would be an ideal outcome,4 there are many reasons why multiple pregnancies are not encouraged. Prematurity is one of the greatest dangers facing multiples, with twins on average being born at 37 weeks, triplets at 33.5 and quadruplets at 31.5.5 Infant mortality increases as prematurity increases, as shown in a report of preterm birth and mortality rates produced by the Office of National Statistics.6 In 2005, figures for England and Wales showed a 85% mortality in the 283 infants born at 23 weeks. At 26 weeks the percentage of deaths was lower; 24% of 704 live births. And by 31 weeks the infant mortality rate was 3% of 1935 live births. However, this is still 15 times higher than the 0.2% mortality rate for infants born between 38 and 40 weeks.
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ARTICLE Premature infants who survive are at increased risk of many longerterm complications, compared to term infants. For example, retinopathy of prematurity was found in 66 % of infants born weighing less than 1.25 kg. 7 In addition, the EPIPAGE study found that half of babies born between 24 and 28 weeks had a cognitive or motor impairment at 5 years, compared to a third of children born between 29 and 32 weeks.8 There are other health problems associated with being one of a set of multiples; these include twin to twin transfusion, polyhydramnios and Central Nervous System disability. The increased risk here is independent of prematurity. A common example is the three to seven-fold increase in cases of cerebral palsy amongst twins which has a background risk of 0.2% in singletons9 and a ten-fold increase among triplets.10 The immense publicity and lack of privacy which higher order multiples are subjected further adds to the stress faced by such pregnancies. The current media attention on the octuplets is likely to be long term and very intrusive. Ethical issues surrounding the care of extremely premature neonates The ethical issues in this case will now be discussed according to Beauchamp and Childress four principles.11 These are; the requirement to do good (beneficence), to not do harm (nonmaleficence), to respect autonomy and to consider the justice of different options. The potential outcomes of acting which in many infants is in the form of aggressive treatment measures often appears to be in their best interests. For a few babies, particularly ones born at the extremes of viability or who are very ill, the clinician’s view may be that such intervention will fail to save the child’s life and hence futile. Alternatively it may be that the resulting quality of the child’s life would be so poor that he or she should be allowed to die.12 In these situations to continue to treat the child aggressively might actually be doing harm. Autonomy is a difficult concept when considering very young children, as they are often unable to indicate their wishes or lack an understanding of ensuing consequences. This is perhaps even more difficult when our actions result in a child who will be developmentally disabled such that he or she will never be autonomous. The mother often represents the infant’s interests in these cases. The issue of justice is particularly relevant when discussing resource allocation, as it involves considering the impact of any decision on other patients, the community and the population as a whole. Premature babies may sometimes require long in-patient stay conjuring the image of “bed blockers”. 13 The health service unfortunately has limited resources and this raises questions whether heroic interventions such as the resuscitation of extremely premature neonates is appropriate when these babies are likely to suffer significant disability, and therefore increase demand for already limited. In 2006, the United States health service spent $26 billion on the care of infants born preterm.15 The issues discussed often become abstract when faced with actual families and the clinician’s concern will usually be for the individual neonate condition and prognosis.
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Methods used to avoid high-order multiple births For the reasons already discussed, it seems desirable to try to reduce the number of multiple births without affecting the number of IVF successes. Reduced number of embryos transferred Medically, the best outcome from IVF treatment would be one baby resulting from the transfer of one embryo. Although a small chance of this embryo splitting into twins exists, the likelihood of higher order multiple births would be negligible.16 Elective single embryo transfer has been suggested.17 To increase the chances of successful implantation two or more embryos are usually transferred. In the UK, the Human Fertility and Embryology Act Code of Practice 2007 governs the number of embryos per cycle.18 The HFEA permits women under 40 using their own eggs, and all women using donor eggs, the transfer of two embryos per cycle. For women over 40 using their own eggs, three embryos can be transferred. Failure to comply with this Code can lead to the institution losing its license and the individual doctor being disciplined. The Code also states that if any woman who fits the criteria for single embryo transfer has more than one embryo transferred, the reason should be documented. In the United States there are no legal restrictions on the number of embryos which can be transferred. However, guidelines published by the American Society for Reproductive Medicine (ASRM) give a list of situations where the prognosis is favourable (for example, in the first cycle of IVF or if there are good quality embryos). 19 In these situations, one cleavage stage (three-day old) embryo could be transferred in a woman under 35, two in a woman aged 35-37. These recommendations provide guidance only and there is no legal requirement to follow them. The only repercussions may be expulsion from professional organizations and the inability to obtain insurance.20 Although audits by the ASRM and the Centre for Disease Control (CDC) encourage clinicians to comply, many may feel that these guidelines take clinical autonomy away from them. In an article by the Associated Press, it was noted that reports filed by clinics with the CDC showed that less than 20% of clinics were following these guidelines. 21 Despite this, it seems that it is very unusual to need to transfer six embryos in a single cycle, especially as, in the case of Nadia Suleman, she had already been successful several times. Her doctor may be investigated for this by the ASRM.22 Selective reduction of fetuses This is an option offered to a woman who is pregnant with two or more foetuses. The decision is normally made relatively arbitrarily about which foetus(es) to destroy, and the procedure is then performed, usually by the injection of potassium chloride into one or more of the foetus(es). The risk of premature birth and other complications in the surviving foetus(es) can be reduced by selective reduction, For example, reduction from a triplet to a twin pregnancy reduces the risks of birth before 28 weeks from 8.5% to 3%, and increases the percentage of babies born and taken home from 79% to 93%.23
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ARTICLE However, selective reduction carries its own risk of miscarrying all of the foetuses, with a loss rate of 4.5% for triplets, 8% for quadruplets and 11.5% for quintuplets.24 The ethics surrounding foetal reduction are interesting particularly because there are two patients (or in the case of a multiple pregnancy, three or more). When considering beneficence, one has to look at the best interests of the mother and all of the foetuses. The mother’s best interests may be in remaining healthy and therefore selective reduction. This is because selective reduction lowers the obstetric risks to the mother posed by higher order multiple pregnancies. However the psychological impact of destroying one or more of much-wanted babies must not be underestimated. The parents and surviving siblings may feel lasting guilt, although research has shown that most couples felt that selective reduction had been the right choice for them. This suggests that the parents tend to value the autonomy they are given by making the decision for themselves. 25,26 In opposition to the best interests of the mother and surviving infants however, are the interests of the foetus(es) which are selected for destruction. This raises all of the issues surrounding termination of pregnancy, including the rights of the mother compared to the rights of the foetus. Currently only the mother has any legal rights before the delivery of the baby.27 Reports suggest that Nadia Suleman refused selective reduction.29 This is not an unusual reaction, and is a decision supported by many pro-life groups arguing that every foetus has an equal and intrinsic right to life from the moment of conception.30 Failing to reduce the number of foetuses can result in a worse outcome than with the Suleman babies. Mandy Allwood, in 1996 decided to continue with her octuplet pregnancy sadly all the babies were born too prematurely to survive.31 Conclusion Current reports suggest that Nadia Suleman’s octuplets are clinically stable with no medical problems at present. However, the long-term sequelae of prematurity may take years to become apparent. They are also likely to face the challenges experienced by multiples, such as lack of individuality and increased demands for parental attention.
Referance 1. Tedmanson S. Woman gives birth to Octuplets in California. The Times Jan 27 2009 Available from: http://women. timesonline.co.uk/tol/life_and_style/women/families/ article5596036.ece [Accessed 8th April 2009] 2. Tedmanson S. Woman gives birth to Octuplets in California. The Times Jan 27 2009 Available from: http://women. timesonline.co.uk/tol/life_and_style/women/families/ article5596036.ece [Accessed 8th April 2009] 3. Mistry H, Dowie R, Young TA, Gardiner HM; TelePaed Project Team. Costs of NHS maternity care for women with multiple pregnancy compared with high-risk and low-risk singleton pregnancy. BJOG. 2008 Feb;115(3): p 416. 4. Murdoch AP. How many embryos should be transferred? Human Reproduction, 1998, 13: pp 2666–2669. 5. Macfarlane AJ. Early days. In: Botting BJ, Macfarlane AJ, Price FV, (eds). Three, four and more; a national survey of triplet and higher order births. London, HMSO, 1990: pp 80–98 6. Moser K, Macfarlane A, Chow YH, Hilder L, Dattani N. Introducing new data on gestation-specific infant mortality among babies born in 2005 in England and Wales Health Statistics Quarterly Autumn 2007, Office of National Statistics, London 7. Allin M, Rooney M, Cuddy M, et al; Personality in young adults who are born preterm. Pediatrics. 2006 Feb;117(2):pp 309-16. 8. Larroque B, Ancel PY, Marret S, et al; Neurodevelopmental disabilities and special care of 5-year-old children born before 33 weeks of gestation (the EPIPAGE study): a longitudinal cohort study. Lancet. 2008 Mar 8;371(9615):pp 813-20. 9. Stanley FJ, Blair E, Alberman E. Cerebral palsies: epidemiology and causal pathways. London: Mac Keith, 2000. 10. Petterson B, Stanley F, Henderson D. Cerebral palsy in multiple births in Western Australia. American Journal of Medical Genetics, 1990, 37: pp 346–351.
Despite the media circus, however, it is vital to remember that these are eight new individuals, and whatever actions the adults in their lives have taken, they have the same right to individuality, happiness and privacy as any other children.
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Baby shambles? Katie Honney BSc (Hons) Year 4 Medicine, University College London k.honney@ucl.ac.uk doi:10.4201.lsjm/hle.001
For the full article and references see thelsjm.co.uk.
Adolescent pregnancy has long been a contentious topic, but in the past decade, this issue has become one of the most frequently cited examples of the perceived societal decay in the United Kingdom. In 2007, 40,298 adolescents under the age of 18 became pregnant.1 Analysis of these statistics and trends indicate that teenage pregnancy is not an exponentially growing phenomenon in Britain. Nonetheless, the number of births to teenagers is considered unacceptable. The complexities surrounding the issue of teenage pregnancy are widespread, some of which extend beyond the scope of this article. Rather, the concept of parenthood, the implications for both young parents and their children and the subsequent impact upon primary care and society have provided the focus for this discourse. In addition, whilst most studies found in the literature focus on the antecedents and consequences of teenage pregnancy in relation to young women, research that directly examines the contributions of the men involved is scant. Thus it is also important to explore the role of the adolescent father and broaden the discussion of these significant issues. Parenthood The quality of parenting is a crucial factor in the healthy growth and development of a child. Parenting involves both the care and affection of the child, and the natural desire to raise them in a way that facilitates them to succeed in life.2 The transition to parenthood can be a stressful time for many, regardless of age or background. For teenage parents, such stresses are likely to be compounded by their typically underprivileged backgrounds as well as the addition of the normative changes throughout adolescence, such as identity and relationship formation. Whilst adolescent parents may well have desirable intentions for their children, several research studies report that the majority of teenage pregnancies are unplanned, and the outcomes for the parents and their child in terms of life chances are negative.3 Implications for young parents Teenagers who give birth during their adolescent years tend to function less effectively in numerous areas than their peers who delay childbearing4. This recent research has indicated that many of the negative outcomes of adolescent parenthood, such as low educational achievement and poverty, precede rather than stem from
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early parenthood. Nevertheless, it states that teenage pregnancy adds to the limited prospects of the already disadvantaged adolescent. These outcomes include poorer psychological functioning, lower rates of school completion, reduced levels of marital stability and additional non-marital births, less stable employment, higher rates of poverty, and slightly greater rates of health problems for both the mother and child as compared with peers who postpone childbearing.4 In addition, there are a number of long-term negative health outcomes for young mothers. Teenagers usually go to their doctors much later in pregnancy than older women,5 meaning they often miss out on preconception and first trimester healthcare, such as folic acid supplementation, to help prevent neural tube defects. Almost half of all teenage mothers smoke during pregnancy, with health and economic consequences for both mother and baby.6 There is some evidence of higher rates of pregnancy complications and maternal mortality for teenage mothers.6 Forty percent of teenage mothers have an episode of depression within one year of childbirth, and postnatal depression may be up to three times more common in teenage mothers than their older counterparts.6 In addition, questionnaire data from a Department of Health study highlighted that teenage mothers were significantly more likely than older mothers to: receive means-tested benefits; not have worked recently; not to have school or university qualifications and to be in social housing7. However, when adjustments were made for factors at baseline associated with teenage pregnancy such as poverty, living in social housing, lone parenthood, and leaving school before 16, the teenage mothers in the study were no more likely than the older mothers to have poor outcomes.7 This confirms the view that social exclusion may be implicated by teenage pregnancy but does not necessarily cause it. Having said this, not all teenage parents have parenting problems and it is vital that generalisations are interpreted as generalisations only. Further research will prove invaluable in exploring variations in adaptation to early parenthood. The forgotten father Reviewing the social and psychological literature of the 1970s concerning adolescent childbearing, Chilman cited the problem of
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PERSPECTIVE “insufficient attention to the attitudes and behaviours of males in respect to adolescent parenthood” as one of the major problems in the conceptualisation of teen pregnancy.8 From the information available, it is generally agreed that fathers tend to be two or three years older, on average, than teenage mothers. However, in the recently publicised case of Alfie Patten he was two years younger than girlfriend Chantelle Steadman, a fact that has caused much concern among policy makers. Like teenage mothers, male adolescents tend to be from lower socio-economic classes, are often continuing an intergenerational practice (many are from families who experienced teenage childbearing and receive welfare), and have low educational achievement.9 Having said this, research would suggest that young fathers do not fit the stereotype once applied to the “putative” father. Many desire involvement with their children: Furstenberg and Talvite found that 90% of the fathers of babies born to adolescent women remained involved with their children for at least one year after birth.8 A study executed in Rochester, New York found that 68% of teenage fathers were happy when they learned of the pregnancy, although it was unplanned in almost all cases.10 Nonetheless, the study also revealed that less than half the teenage fathers were coping well with the situation. Infact, clinical depression was common and nearly half required referral for psychotherapy.10 Most prospective fathers are under a phenomenal amount of stress, regardless of their age. Teen fathers must learn to cope with the stress and uncertainty of fatherhood alongside the already difficult events of adolescent development. During adolescence, the individual gradually moves toward emotional, social and financial independence. Teenage years are typically characterised by rebellion against adult values, narcissism and self preoccupation. Such normative adolescent changes conflict strongly with the emotional and financial responsibilities of fatherhood. Difficulty in resolving such conflict accounts for the frequency of depression in teenage fathers and indicates their need for psychological services.11 Quinlivan and Condon undertook a cross-sectional cohort study to compare levels of psychological symptomology in fathers in the setting of teenage compared to non-teenage pregnancy. The results revealed that significantly more fathers in the setting of teenage pregnancy met the criteria of having ‘Hospital Anxiety and Depression’ (measured using a sub scale that analyses anxiety and depression in hospital patients), when compared to older fathers.11 Negative reactions from parents and social exclusion among peers can deepen such depressive symptomology within young fathers and lead to subsequent long-term health implications.12 Such research highlights that teen fathers have unrecognised psychological symptomology that requires appropriate services along with teen mothers. Implications for the children of adolescent parents New research has made substantial advances into the effects of early childbearing on the functioning and well-being of young parents. However, the same level of attention is yet to be directed towards the study of the children of teenage parents. Having said this, a number of small-scale studies have examined the cognitive and behavioural functioning of children of adolescent mothers compared with older mothers. Few differences were found in infancy, however, in the pre-school years delays in cognitive development emerged. Pre-school children of teenage mothers also began showing behavioural problems, including higher aggression
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levels and lower impulse control, than their peers born to older mothers.9 Further discrepancy between children born to teenage mothers compared with older mothers, is evident in adolescence too. Higher rates of grade failure, delinquency, early sexual activity and pregnancy have been recorded.9 However, these studies are now considerably outdated and more recent research, since the introduction of improved support for teenage parents and their children, is required to accurately comment on such issues. Obstetric and neonatal outcomes of teenage pregnancy also have negative associations compared to those born to older mothers. In a retrospective case-control study executed over five years at a tertiary care teaching hospital, teenage pregnancy was found to be associated with higher pregnancy induced hypertension, preeclamptic toxaemia, eclampsia, premature onset of labour, fetal deaths and premature delivery. Increased neonatal morbidity and mortality were also seen in babies delivered to teenage mothers.13 Such findings introduce a complex argument based on the concept that children born to teenage mothers are at risk of significant health complications and thus begs the question as to whether there should be more of a duty to prevent such morbidity from occurring at all. Implications for primary health care Teenage pregnancy and motherhood have implications for several different aspects of primary health care. The pregnant teenager is considered a high-risk obstetric patient given the increased risk of maternal and infant mortality apparent in teen pregnancy.13 Primary Care Trusts (PCTs) will be required, on an already overstretched budget, to provide care for these higher risk patients. Finally, and perhaps even more significantly, there is the implication of care required to deal with longer-term adverse health consequences associated with teenage pregnancy. For example, primary care physicians will have a duty to recognise the increased prevalence in vulnerability of parents to clinical depression and depressive symptomology in the year after delivery.15 The provision of health education and contraceptive services is relevant to the prevention of unplanned teenage pregnancy. More needs to be done allow appropriate support both ante and post-natally to be provided for teenage parents and their children. Implications for society Teen pregnancy obviously has a major impact on the lives of the people directly affected, yet it also has broader implications for society. With regards to the broadly publicised Alfie Patten and Chantelle Steadman case, in which a 12 year old boy and 14 year old girl conceived a child, Ed Balls, the Secretary of State for Children, Schools and Families said: “It’s not right – it looks so terrible. It has got to be sorted out. I want us to do everything we can as a society to make sure we keep teenage pregnancies down.”16 The case reignited concerns about the rate of teenage pregnancies and the sexualisation of children at increasingly early ages and condemnation resonated across the political spectrum. Although there are several health risks and biological problems related to teenage pregnancy, some of the strongest concerns for policy makers are the social and economic consequences that result from young parenthood. The high costs that come with having a new baby combined with a lack of income and support
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PERSPECTIVE for adolescent mothers can have very disparaging effects on the socio-economic status of teenage-headed families. Experts do not agree over what should be done about teenage pregnancy. Many of its problems are due to how it is regarded by society. Social disapproval may mean that young women avoid health care and may not complete their education while pregnant or return to education after the birth of their child. In recent decades, in Britain at least, teenage pregnancy has become labeled alongside cardiovascular disease, cancer and mental health as a major public health problem.17 However, arguments do exist that propose teenage pregnancy should not be conceptualized as a public health problem but rather a reflection of what is considered to be—in this time and place—socially, culturally and economically acceptable.18 Nonetheless, there are profound socioeconomic consequences of teen pregnancy which must receive timely intervention so as to avoid setting a social precedence. Teenage pregnancy is a significant global challenge and the health, social and economic issues that it raises are of deep concern to all those people involved in the care of young people. It is important to establish the issues and implications of teenage pregnancy for all parties involved. In so doing poverty, deprivation, poor educational achievement and low expectations have all been identified as key factors ontributing to the high rates of teenage pregnancy.1 It is widely recognised that teenage pregnancy and early parenthood are, in certain circumstances, associated with a number of negative consequences, including poor educational achievement, poor physical and mental health, poor employment prospects, and poor housing. In turn, these factors are inherited by the children of teenage parents, predisposing them to the same risk factors and outcomes. It is clear that reducing the rate of teenage conceptions and improving outcomes for teenage parents, could make a significant contribution to the overall reduction of social and health inequalities in the UK.19
Consent is at the heart of medical practice, obtain it and treat patients, flunk it and face the consequences, says MPS writer Sara Williams
References
This does not mean that you have to repeatedly ask for patients’ explicit consent for every minimally intrusive activity. If a patient complies with a request – “Would you hold out your arm please so I can bandage it?” – you can assume that you have their consent by implication.
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2. 3.
4. 5.
6.
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8. 9. 10.
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Department of Health. Office for National Statistics and Teenage Pregnancy Unit Teenage Conception Statistics 1998-2007. London: 2009 McWhinney I. A Textbook of Family Medicine. 2nd Ed. New York: Oxford: Oxford University Press Inc; 1989 Department of Health.Teenage Pregnancy Research Programme – briefing: Long term consequences of teenage births for parents and their children London: March 2004 Coley RL and Chase-Lansdale PL. Adolescent Pregnancy and Parenthood. American Psychologist 1998;53(2): 152-66 Simms M. and Smith C. Teenage mothers: late attenders at medical and antenatal care. Midwife, Health Visitor and Community Nurse 1984;20:192-200 Botting, B., Rosato, M. and Wood, R. Teenage mothers and the health of their children. Population Trends – Office for National Statistics 1998;93: 19-28 Department of Health (2007). Teenage Pregnancy Research Programme: Teenage Parenthood and Social Exclusion A multi-method study. London; 2007 Tuttle J. Adolescent Pregnancy: Factoring in the father of the baby. Journal of Paediatric Health Care 1988;2:240-244 Coley RL and Chase-Lansdale PL. Adolescent Pregnancy and Parenthood. American Psychologist 1998;53(2): 152-66 Elster AB, Panzarine S. Unwed teenage fathers: Emotional and health educational needs. Journal of Adolescent Healthcare 1980:1;116-120
A 22-year-old mother died recently after giving birth to twins. A Jehovah’s Witness she was reported to have refused a vital blood transfusion.1 Doctors can be confronted by these cases at any time and it’s important to remember the powers of a doctor are conferred by those they treat, so if the patient is a competent adult, where there’s no consent there can be no treatment. In the same vein, care can only be given if the person consents to it. Any procedure from the simplest taking of blood pressure, to the more complicated repairing of an aortic aneurysm requires consent.
Is written the same as verbal consent? Verbal consent is just as valid as written consent, except in circumstances where the law requires written consent, such as some forms of fertility treatment. So view consent as a process rather than a signature on a form; it results from open dialogue between you and your patient, so the sooner you get into this habit the better. Where there are disputes over whether valid consent was given, the key is not whether a patient signed a form, but whether they were given all the information they needed to make an informed decision. This should be documented in the medical record alongside evidence of the procedural risks and warnings discussed as well as any fears expressed by the patient.
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SHORT CASE
No consent, no defence
Consent is at the heart of medical practice, obtain it and treat patients, flunk it and face the consequences, says MPS writer Sara Williams
Competence New rules have recently come into force in England and Wales under the Mental Capacity Act 2005, which clarifies the assessment of a patient’s capacity and treatment of patients who lack capacity. An assessment of a patient’s capacity should be based on their ability to make a particular decision. Assume that they have the capacity unless it is demonstrated that they have not. Some patients, for example, need help to communicate a decision, but this does not mean that they lack capacity. There is a two-stage test to apply when deciding whether a patient has the capacity to consent to treatment: 1. Does the person have an impairment or a disturbance in the functioning of his/her brain or mind? 2. If so, does it mean that the person is unable to make a specific decision when they need to?2 What if consent is not taken? Many MPS clinical-negligence claims are settled because valid consent was not obtained, or the evidence for it was missing from the notes. In theory, where harm has befallen the patient and valid consent was not obtained, the doors are open for allegations of professional misconduct and even criminal charges of assault or battery, although these are extremely rare. You need to be familiar with GMC guidance and follow it. Otherwise if there is a complaint your professional conduct could be called into question. So communicate effectively with your patients from the outset and protect yourself and your practice. Case study While working in A&E, Foundation Year 1 Dr Y saw an elderly patient who was experiencing nausea and vomiting. She took appropriate steps to start treatment including the insertion of a Venflon in the patient’s arm.
A couple of hours later, the patient’s family arrived and became alarmed about the extensive bruising around the Venflon which had been used. The patient alleged that Dr Y had inserted the IV cannula incompetently and without her consent. The patient’s family complained to the hospital and to the GMC. Dr Y rang MPS and was immediately put in contact with a medico legal adviser who gave her advice and support throughout the subsequent investigations. She was able to meet her adviser and eventually, after numerous exchanges of correspondence and scrutiny of the case notes, the GMC referred the matter back to the hospital. A meeting was arranged by the hospital complaints officer between Dr Y and the patient, in which Dr Y acknowledged that although she had told the patient she was inserting a Venflon, she did not warn her about the pain and bruising it might cause, and apologised. Outcome The patient accepted the apology and was assured that the doctor would always fully explain her actions in the future. The issue here was that Dr Y failed to obtain valid consent because the patient did not have all the relevant information. The GMC expects patients to be given all information material to their decision. “It is not justifiable to withhold information on the grounds that it may prove worrying or generate anxiety.”3 Useful links • General Medical Council • Department of Health guidance on consent – www.dh.goc.uk/policyandguidance • MPS guidance • MCA code of Practice 1. 2. 3.
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Mother dies after refusing blood 5 November 2007 BBC News DCA, Mental Capacity Act 2005: Code of Practice, 2007, p. 45 General Medical Council, Seeking Patient’s Consent: The Ethical Considerations, November 1998, para. 10.
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CAREERS
The recent GMC attempt to define ‘unhealthy behaviour’ has placed medical students firmly under the spotlight. In a story picked up by the mainstream press, the BMA have urged caution over these new criteria, which seem to threaten professional censure for ‘bad behaviour’ even before students have qualified. In our inaugural issue, we take a closer look at the new obligations outlined for medical students, and ask what do they mean for healthcare students in general? Those who support the guidelines argue that medical students – and indeed all healthcare students – are afforded specific responsibilities which other students are not, and along with those rights of access and authority comes the added responsibility of early professional behaviour. In a hierarchical system where training consists, in part at least, of a sort of apprenticeship, patients may not be able to distinguish students from healthcare professionals. Thus students should be able to ‘act-up’ in terms of their attitudes and behaviours. Yet how comfortably does this sit with the traditional work-hard, play-hard stereotype of doctors-in-training and nurses-to-be? Critics fear the medical regulators risk “using a sledgehammer to crack a nut.” The GMC is at pains to emphasise that these guidelines are just that, and that they have little jurisdiction over medical school admissions. The hope then has to be that these guidelines are used discerningly by medical schools and universities who hold the careers of thousands of students in their hopefully not-so-heavy hands. Personal and professional attributes are also high on the agenda for those who have just received their F1 allocations. We look at how the system has worked this year and hear from students who have just gone through the process. Did the new weighting of academic achievements disadvantage those in the 1st academic quartile? For the first time it was possible to link your application with a friend or partner but how was this done and what assurances were there? There is also talk of a national qualifying exam being used as a future differentiator of foundation allocations. To unearth the background and issues surrounding this controversial idea don’t miss issue two of the LSJM. Bringing professional attitudes to their training may be less of an issue for those who come to the healthcare sector via a more circumlocutious route. Increasingly, graduate places are being offered on healthcare courses, and a former advertising executive explains why she made the jump from promotion to physiotherapy. We also compare the training of graduate medics at home and away – and look at whether the Australian graduate admissions model, now adopted at some schools in the UK is succeeding in attracting candidates to healthcare. Without a doubt career pathways in all healthcare professions have always been a moveable feast. We anticipate that this will continue. LSJM Careers hopes to guide you through the myriad options that face you from the moment you start studying, and continue throughout your careers. By keeping you up to date with the latest developments in the healthcare sector, and offering tips and insights into paths less trodden as well as the more popular career choices, we hope to make your training time more enjoyable and worthwhile. Illustration: Robert Hare
Rob McGuire and Sonia Damle Section Editors of Careers
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Fitness to Practise - What does it mean for students? Matko Marlais*, Aneurin Young Year 4 Medicine, Imperial College London doi.10.4201.lsjm/car.001
What does fitness to practise mean to you? We all know that committing crimes or engaging in unprofessional behaviour can get us thrown out of medical school, but the remit of fitness to practise spreads much further than that. You may steer clear of drugs, avoid violence and respect confidentiality, but many other issues could call your fitness to practise into question. Can you honestly say that you have never been rude to a colleague, engaged in patient contact without making it clear that you are a student, or embellished your CV a little? These and many other actions could affect your fitness to practise. In addition, illness could strike any one of us and this guidance sets out new ways of dealing with those whose health threatens their ability to be a medical student. In the past, fitness to practise policies have been set entirely by individual medical schools, without clear guidance from external bodies. That is about to change. It has been increasingly recognised that unstandardised procedures threaten to treat students unfairly or to fail in their attempts to protect patients from those who are not fit to practise. As a result the General Medical Council (GMC) and the Medical Schools Council (MSC) has released new guidance: “Medical students: professional values and fitness to practise.”1 Here we explore how these new guidelines could affect you. The GMC aims to “protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.”2 As part of this mission, it defines and polices fitness to practise issues for doctors and has offered the following definition of fitness to practise: “To practise safely, doctors must be competent in what they do. They must establish and maintain effective relationships with patients’ respect, patients’ autonomy and act responsibly and appropriately if they or a colleague fall ill and their performance suffers.” “But these attributes, while essential, are not enough. Doctors have a respected position in society and their work gives them privileged access to patients, some of whom may be very vulnerable. A doctor whose conduct has shown that he cannot justify the trust placed in him should not continue in unrestricted practice while that remains the case.”3
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Whilst it is recognised that students are not doctors, as medical curricula start to include patient contact at an earlier stage it becomes apparent that guidance, similar to that for doctors is necessary. Set out below are some of the main ways in which students might compromise their fitness to practise: Criminal Offences These are some of the more obvious reasons for which a student’s fitness to practise may be questioned. The new guidance gives some examples: assault, theft and financial fraud to name a few. Whilst it is obvious that violent behaviour is unacceptable for a student doctor, other offences such as financial fraud may not be so clearly linked to fitness to practise. Any behaviour which compromises the trust placed in us by patients is potentially a fitness to practise issue. University life provides a vast array of criminal temptations! Medical schools are famed for their culture of drinking and high jinx. But when does this behaviour cross the line into criminality? Many of us have done things we regret after a heavy session at the union, but as medical students we must always be mindful that when jovial pranks turn into violence, criminal damage or theft, our careers are threatened. Unprofessional Behaviour Some examples of unprofessional behaviour in the new guidance include: poor time management, breach of confidentiality, rudeness and poor communication skills. Whilst some may feel it is excessive to review a student’s fitness to practise because of poor communication skills, the new guidance emphasises that it is not just the seriousness of an offence but also repetitiveness of offences which may bring about a fitness to practise review. Hospitals are stressful places and students are constantly placed under pressure to perform. In this context it would be easy for a student to fail to obtain proper consent for a procedure, to become habitually rude to those around you or to fail to maintain the appropriate boundaries between a medical professional and a patient. As doctors-in-training it is our duty to keep in mind the importance of treating patients with respect and acting professionally towards colleagues. Failure to do so could bring into question your suitability for a career in medicine.
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PERSPECTIVE What actions can be taken against students? Formal Warning: This is the first option available to the fitness to practise panel. The warning would be placed on record and would have to be disclosed when applying for registration as a qualified doctor. In addition, the student would be placed under supervision so that their progress can be monitored by the medical school. Conditions: This option obliges the student to take defined actions and observe limitations on his or her practise. These conditions aim to protect patients and provide a means by which the student can be supported and guided to becoming fit to practise, either by addressing poor behaviour or returning to good health.
Probity This is an important and under-recognised part of the GMC’s key guidance, Good Medical Practice4. Probity encompasses all aspects of integrity which are essential for doctors to maintain the trust placed in them by patients. As career progression in medicine becomes ever more competitive, the temptation to dishonestly enhance your CV grows. Have you ever considered forging a signature in a logbook, exaggerating your achievements in a CV or application form, or falsifying research to enhance your chance of getting published and earning a few vital MTAS points? Any of these actions would call into question your probity. A few white lies on an application form may not seem like a big deal, but any dishonesty calls into question your integrity. Health The inclusion of health as a fitness to practise issue is a strength of the new guidance. Whilst it is made clear that very few disorders would automatically require a fitness to practise review, there is a broad range of conditions which could potentially impact on a student’s graduation and subsequent fitness to practise. The guidance emphasises the requirement to seek appropriate medical advice at an early stage and encourages medical schools to support students through health problems by making reasonable adjustments. Each student would be assessed individually for the impact that their health problems might have on their ability to practise. This new guidance emphasises the duty students have to listen to medical advice which aims to allow them to practise safely and to observe any limitations which must be placed upon them. For instance, students who are infected with HIV or hepatitis B will usually be allowed to continue in their education as long as they carefully observe the guidance which is given to them to avoid exposure-prone procedures and protect patients. Protecting Students, Safeguarding Patients Fitness to practise policy must balance two important factors: firstly the GMC’s overriding duty to protect patients from poor medical practise, and secondly the need to treat students fairly. As set out in the council’s purpose statement above, these guidelines are formulated to ensure that vulnerable patients are protected from those whose fitness to practise has been called into question. In order to safeguard patients, the guidelines must provide strong tools which schools can use to address concerns or to prevent students from continuing to see patients if the concerns cannot be resolved.
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Temporary Suspension: A temporary suspension from medical school with a resulting delay in graduation can be imposed if it is felt that this period will allow the student to address his or her behavioural issues or health problems. Permanent Expulsion: If the transgression is exceptionally grave or if it is felt that no other measure will sufficiently protect patients, a student can be permanently expelled from medical school. This may be employed in response to serious offences including sexual offences, exploitation of a patient, gross disregard for a patient’s safety or a failure to understand and comply with concerns which have previously been dealt with using less severe measures.
In light of the power of fitness to practise procedures, standardised procedures aim to ensure that students are treated fairly. In line with recent recommendations for doctors and other medical professionals, this guidance incorporates ways to resolve fitness to practise issues without resorting to expulsion from medical school. This is a vital shift of focus, allowing fitness to practise procedures to help students with problems to learn, develop and become better doctors. This guidance integrates with other documents, especially Good Medical Practice, the Doctors’ Guide to Good Practise, and Tomorrow’s Doctors,5 which sets the standards for the expected knowledge, skills, attitudes and behaviours of students. This unified approach provides a firm foundation for students to better understand what is expected of them as a student and when they qualify. Patients, students and medical schools all benefit from clear, effective and fair fitness to practise procedures. This guidance significantly improves and standardises those processes. Very few of us will ever undergo formal hearings, but it is important that we are all aware of the range of problems which could influence our fitness to practise, and how we can expect to be treated if our suitability for a career in medicine is called into question. Reference List •
• • • •
General Medical Council, Medical Schools Council. Medical students: professional values and fitness to practise. 11-3-2009. Ref Type: Report General Medical Council. Role of the GMC. 2009. Ref Type: Internet Communication General Medical Council. The Meaning of Fitness to Practise. 2009. Ref Type: Report General Medical Council. Good Medical Practice. 2006. Ref Type: Report General Medical Council. Tomorrow’s Doctors. 2003. Ref Type: Report
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Career Change Gemma Webb Physiotherapy student, Kings College London
Towards the end of my first degree I studied the psychology of advertising and persuasion, and after a week’s work experience in a media agency, I was hooked. Five years down the line, three agencies and a few promotions later my passion had somewhat evaporated. There I was, working well into the night - talking to target audiences to sell products for other people, yet somehow still penniless at the end of the month. So what’s new you say? Surely, it’s inevitable to feel like this when you spend so much time at work? Well, if you spend an average of 50 hours in the office each week as I did, your working week quickly becomes half your waking week! This excludes the time spent thinking about all the things you have to do on the way to work. In effect, it equates to an awful lot of time in an okay career that no longer excites you. This is how I felt two years ago. After a particularly busy period at work I was knackered, bad-tempered and run down. Over Christmas I thought deeply about whether this was the career path for me. On the plus side, it paid reasonably well, and if I continued to work hard I could have worked my way up the company. However, I looked at my bosses - all overworked and trying to keep numerous work and personal plates spinning - and decided it simply wasn’t for me. I spent time thinking about the aspects of my job that I enjoyed; working in a team, solving problems, negotiating, talking to people. And then there were the things I didn’t like so much; stuck behind a computer, writing powerpoint documents, balancing budgets and sitting in endless meetings. I considered switching to a job in marketing, but would that be any different? It may have offered temporary relief to my situation, but the lack of fulfillment would have inevitably returned. At school I had enjoyed biology at A-level but had been put off pursuing it. My teachers spent their time focusing on the alreadyfuture doctors and vets in the group instead of giving those who needed that extra bit of help to do well. Oddly enough, an interest in human biology had remained, and I had a pile of free New Scientists by the side of my desk at work that I would read for my own pleasure. I’d also taken up running three years earlier to combat stress at work had become interested in training effects on the body and optimising my performance. Could I develop the things I enjoyed into a whole career?
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At school physiotherapy had been something I had looked at but the high grades had put me off. I am not now and never have considered myself as particularly academic. However, I decided to look into retraining to become a physiotherapist. I assumed that I would need to take science A-levels to be considered eligible to apply, fully appreciating that I may have to do this at night school while continuing to work. To my surprise I learnt that there were a handful of accelerated physiotherapy courses for those who already had a science-based degree. So instead of the traditional three year course I could be qualified within two years and my fees would be covered. Things were looking up. But what about the financial aspects? The accelerated course was full-time so I would have to leave my job. My boyfriend and I had a flat we owned so there would be a mortgage to pay, as well as the balance of my first student loans that I still had to pay off. I had the usual credit card and overdraft debts and no savings to speak of. At this point some might be discouraged, but I did not let this put me off. With the support of my boyfriend and my family, I worked out a realistic plan, focusing on reducing my debts and putting some money aside each month that would help me cover my living costs. I also found out that I would be able to apply for a means-tested bursary which, though not a substantial amount, would at least offset some of the costs. I was lucky because my parents offered to help each month. I also planned to ask my then-employer if I could continue working one day a week. Despite knowing that it would be difficult financially, I remained optimistic and tackled each challenge one step at a time. I did some work experience, I was accepted on to the course at King’s College, London, in March 2007. It gave me the same high as when I completed my first marathon in 2005. Two years later, it is still tough. Whilst in advertising, I had become used to a certain standard of living and three holidays a year. These are all now a thing of the past, and even my student discount won’t justify the monthly shopping trips I used to make! I started to bike to work, I took my lunch in every day, much to the amusement of my colleagues. When I finished work and started at university I negotiated to do a day a week at my old agency. I started babysitting for my friends and I signed up for focus groups. I’ve always been fiercely independent, preferring to pay my own way, but I’ve accepted that for the time being I should accept others generosity.
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PERSPECTIVE *Details correct at time of going to press.
Sources of Funding: A Sunday afternoon surfing the web is time well spent. There is a wealth of financial support available. Here are just a few suggestions to get you started.* 1. The NHS Bursary: What is it? An annual payment which is either income assessed (your own, parents’ or partner’s earnings), or non-income assessed depending on the course you are studying. It includes payment of tuition fees. It will normally be made in equal instalments over 12 months, you will then be required to re-apply if your course is over a year long. Eligibility? To access this, you must have been offered an NHS-funded place on a full or part-time course in an area such as medicine, dentistry, physiotherapy, radiography, speech and language therapy, nursing or midwifery. How much do I get? If you are on an income assessed course it depends. The basic rate for courses in 2008/09 for those living in London is £3,306 and £2,287 for those outside London. However there is a helpful online bursary calculator which can help you get an idea of what you may be entitled to on the website. Pros & Cons: + There doesn’t seem to be a downside! f you are successful at getting a place on an eligible course you should definitely apply for this as they will help towards things like placement costs. Those of you who have children or dependents may be eligible for ‘top-ups’. To find out more visit http://www.nhsbsa.nhs.uk/students 2. Career Development Loan (CDL) What is it? A bank loan for those wishing to retrain or develop skills in their existing career. It will help you fund up to two years of education. The loan is an arrangement between the Learning Skills Council (LSC) and three high street banks. The LSC pays the interest on the loan whilst you are training and then for a month after you’ve stopped training. You then repay the loan over an agreed term at a fixed rate of interest. The loan can help cover cost fees and living expenses.
One of the challenges of going back to studying is accepting that you are starting a career and that you may be treated differently by some. In my previous career I was a senior member of my team, I managed a couple of people. Nowadays I am supervised by senior physiotherapists who are often younger than me. In the early days this was hard for me to accept. I felt that it ignored all I had given up. It’s important to accept that when starting a new career you have a lot to learn and you have to start at the beginning again. However I feel that my age and experience has also benefited me in many ways. In my new career, connecting with people and effectively communicating with them is core to my practice, my previous experience has been invaluable and my supervisors often comment on the ability of older students to establish relationships with patients.
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How do I get it? You must be over 18 and a UK resident. If you qualify for a nonmeans tested bursary or receive a student loan you will not be eligible. Check the CDL website to see if your course is eligible for this product. How much can I get? You can borrow between £300 to £8,000. Barclays, the Cooperative Bank and the Royal Bank of Scotland all offer career development loans. Pros & Cons: + The loan is interest free whilst you study. — However, it is still a loan and you will have to start paying it back a month after you qualify (with interest) so you need to think about the monthly repayments and whether you can afford them. The loan is for courses that are up to two years long. If your course is longer, you can still apply, but be aware that you will need to start paying back the loan whilst you are still studying, (and therefore perhaps not earning). To find out more visit http://www.direct.gov.uk/en/ index.htm and search for “career development loan”. 3. Part Time Work What is it? This could either be work in your former guise, work in your newly chosen industry, or something completely unrelated. How do I get it? Try to stay on your former employer’s good side! You could approach them for part time or freelance work, either on a regular basis or during university holidays. Make use of any contacts Try to find paid employment in your new career sector, for example as a healthcare assistant, or in an administrative role. Upskill before leaving your previous career! Short courses such as sports massage or sports training might be useful services that you can offer, whilst studying. Pros & Cons: + This option will not only provide valuable income, but may also increase your experience of your new work environment. — Remember though, that your course may be extremely demanding at times, so be realistic about how much you will be able to work on top of this. Universities often discourage students from having part time jobs, so be careful if you are asked about how you will be funding your course when being interviewed for a place!
When I left my first career the economy was doing well and it wasn’t until the following summer that things began to slide. I guess despite it being tough financially for me with hindsight I made the right decision at a good time. As my colleagues tell me getting your first physiotherapy NHS post may be competitive but once achieved I‘m hoping that my occupation will be recessionproof. My old colleagues continue to work long hours. Although I’m told business is good the pressure is greater than ever to do what it takes to keep their clients’ businesses afloat, and no doubt salary reviews will be harder than ever to negotiate. Had I not taken this chance, I would have been in a similar position, with similar responsibilities and undoubtedly with more cash in my pocket, but I would still be stressed-out, unfulfilled and frustrated. Don’t be afraid to change an average career into something better. Take that first step, and who knows? It may just be the beginning of an exciting new life.
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INTERVIEW
Rebecca McConnell, BA (Hons) Year 3 Medicine (GEP), Nottingham University What preparation did you undertake for the GAMSAT? I have A-levels in biology and chemistry and also a degree in physiology. I bought an A level chemistry revision book, a physics GCSE book and the revision papers from GAMSAT (which were really worthwhile).
Describe two positive experiences of your course. - I really liked problem based learning. It forced me to study at home in preparation for a session. - The relationship between GEM students and the teachers was much more adult to adult than my first degree.
To what extent did you find your undergraduate background useful in the GAMSAT? My degree incorporated biochemistry, neuroscience, endocrinology and renal physiology. These subjects are very relevant to medicine but in terms of the GAMSAT they really only helped with the biology questions. Before I did the GAMSAT I had been working for charities for about 10 years and the experience I gained in the marketing and fundraising departments helped a lot towards the essay writing section of the exam.
Describe 2 negative experiences of your course. - Some of my colleagues not quite being the “mature” students that we are supposed to be. - The fear of practical exams. I always hated someone watching me do something.
Did you feel that your prior academic learning and life experience were helpful in the problem solving, critical thinking and writing skills that the GAMSAT is supposed to test? I believe that my prior academic and work experience have given me problem solving and critical thinking skills but I am not sure if they were fully tested in the GAMSAT. Is the GAMSAT in your view a useful appraisal tool for entry into graduate entry medicine (GEM)? I think the science part of the GAMSAT probably helps people who haven’t done science before learn some basics before they start the GEM course. As for the comprehension and essay sections, I guess they test your level and understanding of English but I am not sure what else.
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Do you believe that you will be ready to practice at the end of your course and if not, why? I think we will be well prepared to be doctors. In terms of practical and clinical experience, GEM students get the same amount of exposure as the undergraduates. Our added “life experience” can help with the understanding of social and communication issues but may also make us more cautious doctors, which is not necessarily a bad thing. What sort of reactions towards your graduate medicine degree have you had? From undergraduate students the reaction was really good. They were very curious when we all merged together and seemed glad to have someone with questions they can ask. Both junior and senior health care staff seemed curious about GEM and what we did before. I haven’t really come across any of the stereotyped old consultants who think that graduate students don’t do enough Anatomy.
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ARTICLE
Graduate Entry Medicine
Amit Verma*, Ajai Verma Year 3 Medicine, Monash University, Australia amit_verma5@hotmail.com Admission into medicine is traditionally a highly competitive challenge. The ferocious struggle to gain entry has intensified in recent times as institutions seek candidates who are well-rounded and compassionate as well as academically gifted. Such a shift in thinking has meant that many traditionally qualified candidates have missed out, as medical schools seek to test candidates’ abilities through entrance examinations such as the Graduate Australian Medical Admissions Test (GAMSAT) and the Undergraduate Medicine and Health Sciences Admission Test (UMAT). As graduate entry into United Kingdom (UK) medical programs in particular increases1, there has been a similar trend towards supporting these models as a method of establishing the worthiness of candidates. It is paramount that the value of these models in producing multifaceted and balanced doctors is examined, before such a practice is firmly established in the United Kingdom. Since 1997, the intake onto medicine degree courses has increased by more than 60 per cent in the UK.2 This growth is particularly in evidence when looking at the rise in numbers of graduate entry places. This fact alone offers reason to scrutinize the effectiveness of the GAMSAT process in delivering the best potential doctors to medical schools. The GAMSAT is an exhaustive examination designed to test candidates’ problem solving and critical reasoning in the physical and social sciences, as well as written communication.3 While in theory this test is designed to distinguish deserving candidates, there is a stream of evidence, such as a study by Groves et al that suggests that performance in the GAMSAT is not significantly indicative of performance later in medical school.4 This finding is endorsed by a similar study in the United States by Mitchell et al which found that the Medical College Admission Test (MCAT) predictive scores were only slightly higher in Medical School than high school.5 When considering this evidence, however, it must be kept in mind that the study by Groves et al only takes into account candidates who achieved above the required GAMSAT score threshold, so that this data may not be completely indicative of the general population. Studies relevant to the United Kingdom have gone as far as to show that measures of knowledge, such as A-levels, are in fact more predictive of performance than tests of reasoning aptitude.6 However, this may be due to an under-exploration of the personal and emotive factors needed of doctors combining with this finding.7 Such findings reflect the tendency for tests such as the GAMSAT to potentially discriminate against undergraduate candidates, and restrict the talent pool of potential future doctors.1 The recent proposal of a lower age restriction1 upon entry into UK medicine has been rejected as unrealistic due to workforce demands and the pressures of staff turnover. Ironically, this rejection of such a limitation may, in fact, serve to decrease the skill set of
prospective doctors. Evidence showing more mature-aged candidates with prior degrees and a diverse range of life experiences are more suitable for entry juxtaposed against recent school-leavers1, underscores the usefulness of the GAMSAT in this regard. In addition, post-graduate entrants have been shown to demonstrate a high level of inquisitiveness and more emotional maturity than their less experienced counterparts.1 A recent study has also shown that students from non-biological science backgrounds are not at any grave disadvantage to their colleagues and are just as likely to succeed in their graduate medicine programme.4 In fact, it is of note that several clinicians have found teaching and interacting with junior doctors who may be several years older than themselves a daunting experience.8 Despite this possible drawback, the GAMSAT has drawn praise from several sources in its ability to discriminate between candidates, though the level and scope of this differentiation between different regions is unclear.1 The intake of medical students continues to rise throughout the UK and around the world – over seven undergraduate and postgraduate medical programmes have been established in Australia over the past nine years. Before that, no new programmes had been created since the 1970s.9 Such an increase in the number of graduate programmes means the need for entrance examinations which can accurately determine a candidate’s ability in a wide range of reasoning, interpretive and interpersonal domains must be continually reassessed rather than accepting current practices which may not necessarily identify the best candidates. Overall, when seeking validation for the introduction of the GAMSAT based on Australian findings, it is important that selectors keep in mind that the program is still in its infancy overseas9, and that evaluation over a longer period of time will yield more significant and useful results. References 1.
2. 3.
4. 5. 6.
7.
8. 9.
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Rushforth, B. Life in the fast lane: graduate entry to medicine. BMJ, 16 Oct 2004. http://careers.bmj. com/careers/advice/view-article.html?id=479 Bligh J. More medical students, more stress in the medical education system. Med Educ 2004;38: 460-462. Kulatunga-Moruzi C, Norman G. Validity of admissions measures in predicting performance outcomes: the contribution of cognitive and non-cognitive dimensions. Teach Learn Med 2002; 14: 34-42 Groves M., Gordon J, Ryan, G. Entry tests for graduate medical programs: is it time to re-think? MJA 2007; 186 (3): 120-123 Mitchell K, Haynes R, Koenig J. Assessing the validity of the updated Medical College Admission Test. Acad Med 1994; 69: 394-401 McManus IC, Powis DA, Wakeford R, et al. Intellectual aptitude tests and A levels for selecting UK school leaver entrants for medical school. BMJ 2005; 331: 555-559. Lievens F, Coetsier P. Situational tests in student selection: an examination of predictive validity, adverse impact and construct validity. Int J Selection Assess 2002; 10: 245-257. McCrorie P. Graduate students are more challenging, demanding, and questioning. BMJ 2002;325: 676. Lawson K., Chew M., Van Der Weyden M. The new Australian medical schools: daring to be different. MJA 2004; 181 (11/12): 662-666
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ARTICLE
European Working Time Directive Jennifer Turner
Year 4 Medicine, St. George’s University, London m0400240@sgul.ac.uk doi:10.4201.lsjm/car.002
This summer, the NHS is slated to achieve full compliance with European legislation, limiting working time to 48 hours week. The Department for Health is currently considering appeals for the special dispensation of 52 hours to “local services where there remain special difficulties”. Even allowing for such concessions, trainee healthcare professionals are likely to be effected by these new regulations. A recent national news story about the European Working Time Directive (EWTD) and how it may affect the training of junior doctors quoted a trainee orthopaedic surgeon. Speaking anonymously for fear of jeopardising his career, he said did not feel experienced enough in the surgery he will soon be expected to perform solo, as a result of the reduced number of hours he can work under the new legislation. While his blacked out face and actor-disguised voice smacked of sensationalism, his concerns about the impact on professional training and patient safety are shared by many. The issue of working hours and the potential impact on trainee doctors is by no means new. In 1998, Britain finally signed up to the European legislation after much resistance from the previous government throughout the 1990s. Management of the Health Service is becoming increasingly centralised. The European Working Time Directive is set to protect all workers within the European Union from being compelled to work too many hours, and aims to guarantee the amount of rest they get and minimum annual leave requirements. Proponents of the new legislation claim that the new rules will benefit business as well as the individual - as the workforce become increasingly tired, productivity falls. The magic number of 48 hours was determined to be the perfect balance between quantity and quality of work and a contented workforce. Despite the theory, the directive has remained a hotly debated topic, and the implications of this new piece of legislation have already been far reaching. Since signing up to the agreement, all UK employees cannot be compelled to work more than 48 hours a week. Following Government negotiations, which led to a 12 year preparation period, a few exceptions were made. For the moment, doctors and doctors-in-training were permitted to be contracted for longer hours. However, since the legislation was agreed, the NHS is slowly being brought into line. Since 2003, the maximum contract for a trainee became 56 hours. As of this August, the training week
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will be further reduced to 48 hours. But at what cost? Has the Government used their 12 years of easing in time well enough to prepare hospitals for such drastic changes? Most importantly, will the changes ultimately be of benefit to healthcare professionals and those who use healthcare services? As always, arguments have been put forward on both sides of the fence. Stories of junior doctors working for more than 100 hours a week have passed into professional folklore, and even with the aid of rose-tinted glasses, it is unlikely that anyone will claim the old system as perfect. In fact, working conditions for juniors often became so extreme some gave up on their career. Family life became a distant memory, as work began to consume their every being. Working upwards of 80 hours a week led to an overtired population of juniors, who were undoubtedly making mistakes simply through lack of sleep. Nonetheless, many hospitals relied on the huge number of hours put in by the junior doctors to get through the inevitable workload. Some members of the profession consider these unearthly first few years a rite of passage to be endured, however others, often most vehemently, would disagree. It used to be such that time spent on-call was not included as work if you were not actively seeing patients, however any amount of time you are on these duties under new legislation all counts towards the 48 hour limit. This means that for many, there will be lost opportunities to undertake activities such as audits, clinical based education and taught courses with proportionally more time dedicated to non-training duties. It is clear, therefore, that in the same length of time, doctors employed under these new rules will not have had the training that their senior colleagues have benefited from. Many juniors have reported having to undertake training in their free time in order to achieve even the basic competencies expected of them. This is something that has been a particular issue for surgical trainees. Anecdotally, I’m sure many trainees are consistently working over their 48 hour requirements. Reduced hours do not mean fewer patients, and surely cannot mean a reduced level of care? One foundation doctor said “any doctor worth his salt will not leave work as the clock strikes five if there are still patients to attend to”. It’s an attitude commonly echoed, and one instilled from student level onwards. However, overtime that was previously was paid for will no longer being thanks to the curtailment of the working week. A BMA postal survey of showed that 50% of respondents have felt pressure to work beyond their contracted
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INTERVIEW
hours without recompense. Over half of them felt that the reduced hours would be a good thing for both their health and social life. However 64 per cent agreed it would a negative effect on training. Many of those surveyed also believed that trainees should be able to opt out of the directive, that long hours can sometimes be dangerous for patients under their care and that the overall duration of training should be increased to ensure competence before qualification. This clearly means ever-increasing postgraduate training time, but is something that the UK needs to prepare for if we want our doctors to be of the highest standard. How this legislation will affect patient care remains to be seen. More alert, happier doctors can only be a good thing. However, potentially more protected teaching time and increasingly restricted hours will mean fewer doctors in the hospital at any one time. NHS reforms attempting to mitigate this, such as the introduction of nurse practitioners, remain too recent for evaluation. An opt-out scheme seems viable, but would some trainees feel pressured by their employer, or their training demands to do so? Would such an option risk undermining the spirit of protection with which the legislation was adopted in the first place? With the NHS aiming to be fully compliant in less than three months, one thing is clear. Whatever the advantages and disadvantages of the legislation, the directive is here to for the foreseeable future. Changes to postgraduate training are needed fast in order to ensure both short and long-term patient care is not compromised.
Nicolas Smoll, BA, MSc Year 2 Medicine Gippsland Medical School, Monash University Australia What preparation did you undertake for the GAMSAT? I completed the Des Oâ&#x20AC;&#x2122;Neill training course, which is a series of workshops and booklets that you can do at home. This course helped a lot and it was extremely useful in the exam. To what extent did you find your undergraduate background useful in the GAMSAT? My background is in physiology, pathology, chiropractic clinical skills and 2 years of radiology. I found this virtually useless for the GAMSAT. Did you feel that your prior academic learning and life experience was helpful in the problem solving, critical thinking and writing skills that the GAMSAT is supposed to test? Not really because the focus of my last course was on research and clinical reasoning. I didnâ&#x20AC;&#x2122;t find that the exam tested it too well which was surprising since research requires good writing skills. If I were to take a course specifically to prepare for the GAMSAT I would have majored in Organic Chemistry and English Literature. Is the GAMSAT un your view a useful appraisal tool for entry into graduate medicine? I think perhaps, but only because it is a hurdle. Describe two positive experiences of your course. As a whole, the course was well organized. The resources available are extensive. Describe 2 negative experiences of your course. Unlike the rest of the course, the problem based learning groups lacked organization. Do you believe that you will be ready to practice at the end of your course and if not, why? I am sure I will be fine. What sort of reactions towards your graduate medicine degree have you had? The undergraduate students were sometimes apprehensive about having post-graduate students on their course and the senior health care staff were always interested in our backgrounds.
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PERSECTIVE
The Blame Game Nick Lelos Year 4 Medicine (GEP), St. George’s University of London Litigation culture is on the rise, with record payouts and higher profile cases hitting the headlines. What can you do to minimise the risk of it happening to you? In the past decade, healthcare practitioners and doctors in particular have seen the rise of a new phenomenon: the tendency of patients to litigate. The targets of litigation tend to be the providers of healthcare, about perceived damage caused to patients following the intervention they had, or indeed had not, received. Litigation in all employment areas particularly healthcare seems to be rapidly on the rise in the UK,1 though it has not quite reached the status quo of the US.2 There are several reasons for this increase. One reason is because the mystique and glamour of the doctor that older patient generations may have been enthralled by has been worn down substantially through the media. A blame culture is also becoming more prominent, where unmet expectations can be expected to lead to formal complaints. The younger generations have also been raised in a culture where the customer is always right, and healthcare is perceived as a right, extrapolated from the Human Rights Act 1998. The increased emphasis on a patient-centred approach is another factor not to discount. Media effects have been wide-ranging, such as the popularisation of medical jargon and knowledge through television series, by the loss of respect and public trust through scandals in the press and by the well publicised, high damages awarded to successful litigants as seen by the tripling of money awarded to litigants for obstetric cases between 1996 to 2001 to £1.6 billion, or money awarded even forty years after the incident itself, such as in Norfolk with Mr O’Brien.4 An important difference is the technological aptitude of the public. The younger population of patients is more ‘claim conscious’, and also more knowledgeable in how to access information from the internet.2, 3 Perhaps the reason for the rise of litigation against doctors is simply that medicine has become a victim of its own success. Many patients’ now have unrealistic expectations of the power of medicine. As well as this, the number of investigations and tests that can be offered to patients renders the detection of abnormalities almost unavoidable. 5 The end result is that the more expert doctors are, the more likely they are to be sued if something is not detected, when considered in retrospect. An area rich with such examples is the field of antenatal testing which, by improving drastically over the years, has seen a drastic rise in litigations.2 It is almost inevitable to detect abnormalities, and there are also false negatives or false positives possible with every test to consider. With hindsight, the patient can to question the care they received, and if they feel so inclined, sue. While such lawsuits are not yet as successful in the UK as in
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the USA, their numbers are increasing, with certain specifics specialities standing out as prime targets: General Practice, Obstetrics & Gynaecology, and Paediatrics.3 The key to all such litigation claims relies on the medico-legal concept of negligence. In order to prove that a doctor has been negligent, the plaintiff has to establish that there was a duty of care owed to them, which was breached by not achieving the standard of care required, which then led to the damage brought forward by the complaint.5 This is proving particularly harrowing for junior doctors, who may be unsure or not as confident as an understandably worried or anxious patient would like them to be. This in turn may lead to perceived lack of quality in the care they receive. This all begs the question – what can be done to protect oneself as a medical student or junior doctor? Perhaps defensive medicine is the answer. Carrying out medical practices in order to avoid a law suit, as opposed to acting in the patients’ best interest, can have serious consequences. Patients can face unnecessary tests and procedures, at considerable financial cost to the healthcare system, and at increased risk of harm to the patient. Alternatively, difficult or high risk patients may be avoided by nervous physicians. Superfluous radiography, lumbar punctures or unnecessary operations are among the procedures more commonly overordered.2 The irony is that the development of this type of practice, primarily to protect oneself, can be construed as negligence in itself.3 To recognise this fact, and the effect of law suits on doctors’ morale as well as their medical practices is vital, as the fear of litigation can lead to discontent and quitting the profession. 1 If defensive medicine is not the answer, the question remains – what can be done? The answer is simple enough, though trite: candour and communication. Act in the best interests of the patient at all times, use your clinical judgement and if uncertain, always consult colleagues and seniors.6 The current healthcare system in the UK distributes responsibility equally and jointly within healthcare teams. Mistakes are easily made as they are part of human nature and the learning process of medicine. Of course, the stakes are high when considering an individual’s health, but when mistakes are admitted and apologies freely offered, a great deal of anger and a betrayal of trust can be avoided. References: 1.
2. 3. 4. 5.
Mulcahy, L. 2003, Disputing doctors: the socio-legal dynamics of complaints about medical care, MaidenheadPhiladelphia, Open University Press. Pp. 30-149. Jauhar, S. 2008. “Eyes Bloodshot, Doctors Vent Their Discontent.” July 18 2008 THE NEW YORK TIMES Harpwood, V. 2007 Medicine, Malpractice and Misapprehensions, New York: Routledge-Cavendish. Sources: http://news.bbc.co.uk/1/hi/england/norfolk/3216151. stm, http://news.bbc.co.uk/1/hi/health/7033658.stm Harpwood, V. 2001 Negligence in Healthcare: clinical claims and risk, London, InformaUK Limited, pp. 5-64. Capsticks, J.B. 2004 Making amends—the future for clinical negligence litigation, BMJ 328:457-459 (21 February), doi:10.1136/bmj.328.7437.457
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PROFESSIONAL BRIEFING
Professor Nigel Leigh, BSc, PhD, FRCP (UK), FMedSci Professor of Clinical Neurology; Director, King’s MND Care and Research Centre; Co-Director, MRC Centre for Neurodegeneration Research, King’s College London As an undergraduate, getting your head around neurology is no mean feat. As well as a detailed anatomical knowledge of that most complex of organs – the brain – as well as the whole network of nerves and synapses leading to and from it, a proper understanding of this system also requires a certain talent for logic, deduction and detective work. Is it a fascinating discipline, with many research opportunities and diagnoses to determine, or is it more often a case that’s too hard to crack? For award-winning consultant neurologist Professor Nigel Leigh, who has spent a lifetime trying to unravel the mysteries of Motor Neuron Disease, it is clearly the former. And he has some advice for students who suffer from a little documented, but well-known condition that he terms “neurophobia”. “There is a core and basic set of skills to learn in Neurology”, He says, rather reassuringly. “Once you have that, and you have disposed of your fear, you have the makings of a very interesting subject.” Professor Leigh is a world renowned specialist in motor neurone diseases (MND), a group of disorders in which motor neurones – which control muscle activity such as movement, walking, speaking, swallowing and breathing – are progressively destroyed. These disorders have held his interest for more than a quarter of a century. But what inspired him to pursue neurology in the first place? “The brain is the most interesting organ in the body”, He said. “Neurology includes the mind and the whole gamut of nervous system disorders, and all aspects are fascinating.” The Professor’s curiosity began at an early age, and he comes from a dynasty of neurology giants. The eponymous Leigh’s Disease – a rare neurometabolic disorder – was discovered by his father, who was also a neurologist. “When I was growing up we had books, phrenological heads and skeletons around the house and so I developed a young and unhealthy interest in the human brain”, he said with a twinkle in his eye. In 1986, Professor Leigh became particularly interested in MND. He said that there was “pitifully little” in terms of treatment available before the 1990s. “In hospital a diagnosis would be made and then there would be a big black hole. The patient would just be handed back to their GP”, he said. When a colleague voiced the same concern to him over coffee, he decided that there was a need for change in the way that MND patients were treated. Alongside an already burgeoning clinical practice, a research career was born. When it comes to research, the Professor admits to thinking “big and ambitiously”. Today, as well as being Professor of Clinical Neurology at King’s College Hospital, he is also Director of the King’s MND Care and Research Centre and until recently Deputy-Director, MRC Centre for Neurodegeneration Research, also at King’s. Together with his teams, he continues to explore MND at a clinical and molecular level. “Developing an understanding the neurofilaments and structural proteins of the nervous system is a step towards to finding different treatments – and perhaps one day a cure – for MND,” He said optimistically, before being careful to qualify his statement. “We are nearer to finding a cure, if you can believe any cure is possible, but we are still not close.”
He spoke passionately of his research. The latest includes a large randomized controlled trial for Parkinson Plus Syndrome and Riluzole treatment he carried out, which was published in the journal Brain last January.1 He said: ”It was a big trial, which involved follow up of blood, DNA sampling and collecting and analysing over 100 brains.” The trial took place in France, Germany and the UK. Leigh is also preparing a large scale drug trial looking at the effects of lithium treatment on the progression of the disease. With so many irons in the fire, he admits that balancing the demands of home and the office is sometimes tricky. “It’s a difficult one,” He said, sounding momentarily troubled, but any doubt was swiftly swept away by an enthusiasm and energy for his patients, which is easily evidenced. A lot has changed since he began his career. Professor Leigh talks of a revolutionary change in the attitude towards neurology as a whole. While there remain few cures for many of the neurological conditions suffered by patients, greater emphasis is now placed on appropriate patient care. He believes that this can make a real difference to the quality of people’s lives. “Palliative care and multidisciplinary teamwork is highly valued within neurology today. Not only is a team essential for good patient care, but as a consultant you have to have a good team to support you in the work you do.” In determining the appropriate course of care for often terminally ill patients, he often finds himself having to make difficult decisions. He gives an example of the constant round of choices which dramatically influence a patient’s quality of life. “To give you an example, most weeks we’ll have to weigh up the pros and cons of using a PEG (percutaneous endoscopic gastrostomy) compared with a non-invasive technique.” The PEG enables patients to have a fluid diet through a tube that is placed directly into the stomach via the abdominal wall. It prevents anxiety and difficulties the patient may have with swallowing food and it also reduces the risk of aspirating food into the lungs. However, Professor Leigh points out: “Just because there is a gizmo or technique available, it is not always the best decision to go ahead and use it. To have the PEG can be painful and when a patient has 3 months to live it might be better that one is not inserted.” He added, “Palliative care is all about death with dignity”. He explains that although patient autonomy is an ideal concept, it is not always as simple as asking the patient what they want. Often the patient will not want to think about the situation or be the one to make the final decision. He added, “The patient and family will always be given a proper consultation but often the decision is pushed back on to you. You cannot run away from those decisions.” Despite the difficult decisions, he remains positive about his patients, and finds that his patients remain optimistic also. “Working with MND you do get terribly tragic situations, but by and large patients are very positive, courageous and grateful. “I can never remember a time when I didn’t want to do neurology.” Laura James Year 3 Medicine, King’s College London Currently intercalating in medical journalism References 1.
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http://brain.oxfordjournals.org/cgi/content/full/132/1/156
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PERSECTIVE
UK Foundation Programme Anna Mead-Robson Year 4 Medicine, St George’s University of London m0502048@sgul.ac.uk
“ This summer will see the UK Foundation Programme enter its fourth year; having negotiated an updated online application system, over 7,000 medical students have now been allocated to F1 programmes around the country. In previous years, criticism of the allocation system has arisen from both technological difficulties and controversy around the suitability of ranking candidates ‘by computer.’1 However, while some students this year may naturally have been disappointed by the outcome of their application, the process seems to have run more smoothly and to have attracted fewer objections than in the past. As in previous years, a candidate’s score and subsequent placement depends on several factors: their academic ranking whilst at medical school, other academic achievements - such as additional degrees, national awards and publications - and their answers to a series of questions that aim to assess the personal attributes necessary to become a foundation medic, as laid out by the GMC’s Tomorrow’s Doctors.2 Such attributes include good communication skills, the ability to prioritise and work effectively as part of a team, the ability to cope under pressure and, above all else, the recognition of the importance of patient-centred care. This year, changes made to the online form meant that, for the first time, candidates were able to link their application with someone else’s – such as a partner or close friend – although this option is not without pitfalls: the foundation school to which any pair are allocated is dictated by the lower-scoring candidate, and while a couple may be placed within the same deanery this does not guarantee they will be working within the same hospital. Nevertheless, the introduction of linking is likely to remain popular, especially with students in long term relationships. In addition, the weighting given to academic achievements was once again altered this year. While candidates are still divided into
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For me, medicine is a vocation ... deep down, it doesn’t really matter where I end up
”
quartiles by their medical school on the basis of exam results, their academic ranking provided a maximum of 40 points, as opposed to 45 points last year.3 The gap between higher and lower scoring medical students was also narrowed – meaning that those in the bottom quartile scored just 6 points less than those in the top. While there is still some debate around how much weight exam results should carry, especially given the lack of a national qualifying exam for all medical students4, most students seem to feel that the current balance is acceptable. ‘Technically everyone who graduates is safe to practise, no matter what their academic ranking at medical school’ said one final year student at St George’s, University of London. ‘I can see it irritating some people that you can do well academically and still get a low score, but it wouldn’t be fair to allocate people on the basis of their exam results alone. Your priority in medical school should be becoming a safe clinician – not one who excels in written exams.’ Although this year’s statistics are not yet available, in the past two years over 90% of candidates were allocated to their first choice foundation school. However, some may end up many miles from where they had hoped to work. Allocations are made on the basis of preference rather than score5; if an applicant does not gain a place in their first choice foundation school, regardless of their score they will be allocated to the next school on their list that has remaining places available – which for some candidates may turn out to be one of their last choices. The Foundation Programme website provides data from the last two years which give a rough idea of which foundation schools are the most competitive – although candidates are reminded that these figures fluctuate each year, and it is impossible to predict which schools will be oversubscribed, although traditionally the London deaneries have always been the hardest to get into.
lsjm 15 june 2009 volume 01
PERSPECTIVE Source: Wellcome Images
In the past, the overall number of posts available in the UK has exceeded the number of candidates, and in an attempt to correct this and to divert candidates to some of the less popular foundation schools, an announcement was made after this year’s application deadline that 120 posts would be scrapped across the country – including a loss of 24 posts in London. This sparked some outrage and was criticised by the BMA medical students committee, and it is likely that as a result a greater percentage of students will not be allocated to their first choice school.6 However, candidates should be reassured that there will still be enough posts to achieve a 100% employment rate, despite a recent surge in foreign applications. Nevertheless, following this year’s application round many students remain positive. ‘For me, medicine is a vocation,’ explained a final year student at St. George’s, ‘deep down, it doesn’t really matter where I end up, especially at this stage when I do not know what I want to specialise in,’ while another St. George’s fifth year medic pointed out, ‘In medicine we are very sheltered – in this current economic climate we are all lucky to have jobs – wherever they may be’. References: 1. 2. 3. 4. 5. 6.
Hawkes, N. 2006 ‘Pick a doctor by computer ‘fiasco’’ The Times, March 4th Tomorrow’s Doctors. 2003, available at: http://www.gmc-uk.org Kelley, T. and Finnigan, E. 2008 ‘Foundation Programme 2009’ sBMJ; 16:398-399 Kelly, C. and Burke, K. 2008 ‘Should UK medical students sit a national qualifying exam?’ sBMJ; 16:184 FP 2009: Foundation Applicant’s Handbook. 13th October 2008, available at: http://www.foundationprogramme.nhs.uk Lelos N. 2008 ‘120 Posts Axed’ Medical Student Newspaper, December
lsjm 15 june 2009 volume 01
Box 1: 2008: foundation school rankings Most oversubscribed... 1. North West Thames 2. South Thames 3. North Central Thames Most under subscribed... 1. North Yorkshire and East Coast 2. Northern 3. East Anglia
Box2: Foundation Programme applications – Top Tips 1. Refer to the Foundation Applicant’s handbook for advice – it becomes available online each October. Visit http://www. foundationprogramme.nhs.uk/pages/home/key-documents for more details. 2. Most universities will offer some sort of support in the form of lectures or one-to-one guidance – ask for help if you need to. 3. Make sure that you read each question very carefully. Be prepared to spend time forming considered and relevant answers – it may take several hours before you are satisfied with your response to a question. 4. Get a friend or tutor to proof-read your answers – poor spelling or grammar can result in a poorer score. 5. Remember to save your answers as you work your way through the form. 6. Don’t leave applying to the last minute!
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MEET THE TEAM
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lsjm 15 june 2009 volume 01
ABOUT US About the LSJM The London Student Journal Medicine (LSJM) is a student initiative started by students from St. George’s University of London, Kings College London, University College London and Imperial College London with the oversight of Professors and doctors at these institutions. It is a quarterly student journal that publishes substantiated peer and expert-reviewed research in all fields of clinical science and global health, along with topics relevant to undergraduate medical education and interdisciplinary interest. The LSJM is a platform for formal discussion of insightful research and include the practical interpretation of topical and upcoming news written from the perspective of the healthcare student/ practitioner. The journal will be freely available as an electronic journal with printed copies open to subscription. Our Name? The name “London Student Journal of Medicine” was chosen to unite healthcare training in London. The LSJM was founded in London and its core publishing team comprises of students from the five London medical schools. The journal will however host articles and be opened to readers globally. The LSJM provides an umbrella under which Students can educate each other and extend their knowledge to newly qualified professionals and the general public. Thus provide an opportunity for students to contribute to the evolving course of medical education. The Journal will also encourage students to formally address issues pertaining to healthcare provision. Health promotion and disease management form the principle focus of medicine as a discipline. Medicine as an art can thus only be successfully effected through interdisciplinary healthcare collaboration. The LSJM highlights the importance of interdisciplinary collaboration by uniting students from the different allied professions in the production of its articles. Honorary Patrons Professor Joe Collier Dr Deborah Bowman Professor Parveen Kumar Founders The Founding Committee of the LSJM was established with representation from all the University of London Medical and Allied Health Institutions. The committee worked to ensure a reputable academic journal, and as an executive, selected the editorial board for the inaugural edition of the LSJM.
lsjm 15 june 2009 volume 01
Chairs Kevin Owusu-Agyemang Nana Seiwaa Opare Committee Mukhtar Bizrah (SGUL) Sonia Damle (KCL) Oluwadamilola Haastrup (KCL) Jonathan Hyer (SGUL) Sinan Khadouri ( Barts & the London) Jasmin Lee (UCL) Matko Marlais (ICL) Rob McGuire (SGUL) Toby Mitchell (Barts & the London) Helen Pickburn (UCL) Charlotte Spelman (Kingston) Omair Shariq (ICL) Claire Smyth ( Kingston) Sian White (Kingston) Special Thanks Mr Patrick Musami, Miss Philippa Tostevin, Professor Macallan, Dr David Winterbourne, Dr Scarpa Schoeman, Mr Elikem Tamaklo, Dr Velislav Batchvarov, Mr Ray Hsu, Maataa Opare, Charlotte Roberts. Executive Committees The individuals on these committees ensure the continual running of the journal. They are responsible for the design, marketing, legal aspects of the journal. Other committees ensure the journal remains true to its goals by having a fair interdisciplinary representation and contain sufficient educational material of relevance to the undergraduate healthcare student. Education: Rob McGuire, Matko Marlais, Sinan Khadouri, Jonathan Hyer Marketing/ Public relations: Jasmin Lee, Charlotte Spelman, Omair Shariq, Sonia Damle Finance: Helen Pickburn, Mukhtar Bizrah, Sinan Khadouri Legal: Sonia Damle, Rob McGuire Design: Jonathan Hyer, Robert de Niet, Robert Hare, Ella Beese, Elaine Parker, David Rawaf, Elaine Parker, Paul Feakins, Adrian Ellis, Nathalie Epperlein, Allied health: Geraldine Dutta-Gupta, Claire Smyth, Jasmin Lee, Kristian Lane, Alan Truman, Charlotte Spelman Donations/Sponsors Thanks to the Medical Protection Society, Work the Worlds, Royal Society of Medicine, Mr & Mrs Owusu-Agyemang and Dr. & Hon.Mrs Opare for their financial support.
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