Oxford Medical School Gazette Issue 63(1) by Oxford Medical School Gazette

PAIN...

OMSG 63 (1)

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WHEN DOES PAIN BITE? 8

EMPATHY 18

EXTREME PUSHY PARENTING 11

ACUPUNCTURE 20

PAIN AND CONCIOUSNESS 14

ERASING MENTAL PAIN 24

PALLIATIVE CARE 17

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OXFORD MEDICAL SCHOOL GAZETTE COMMITTEE 2012 Editors: Joshua Luck, Barnabas Gilbert Sub-editors: Nicholas Aveyard, Alexandra Barry, Clare Buffery, Alexander Deng, Nick Denny, Miriam Hillyard, Thomas Hine, James Kennedy Original Research editor: Benjamin Stewart Book Review editor: Edward Chesney Design Editors: Rosalie Brooman-White, Hannah Thompson, Giles Neal Design team: Alix Brasier, Maira Hameed, Simone Paulson, Alexander Slaney, Shaun Thein, Richard Sykes Patron: Professor Sir John Bell, Regius Professor of Medicine Honorary Treasurer: Mr Stephen Kennedy Senior Members: Dr Tim Lancaster, Dr Peggy Frith, Dr Sue Burge and Dr Vanessa Venning OMA Liaison: Dr Peggy Frith

readers to subsidise production. If you are able to contribute in any way, all donations, either SUBMITTING ARTICLES TO THE GAZETTE The Gazette welcomes submissions from students, alumni, clinicians, other health professionals and members of Oxford University academic staff. Articles do not need to amend any copy received, following discussion with the author. If you would be interested in contributing please contact the editors at editors@omsg-online.com. SUBSCRIBING TO THE GAZETTE To subscribe directly to the Oxford Medical School Gazette please contact the editors by email at editors@omsg-online.com or by post at the address below. To subscribe to the Gazette through membership of Oxford Medical Alumni (OMA), please contact jayne.todd@ medsci.ox.ac.uk ACKNOWLEDGEMENTS The editors would like to thank the members of the senior committee, Jayne Todd, Karen thanks to Robin Roberts-Gant from the Medical Informatics Unit who has, as ever, given tremendous support in producing this issue of the OMSG. ILLUSTRATION AND PHOTOGRAPHY Many of the images used in OMSG are produced by members of the medical school and we thank all those involved in the modelling, photography, and illustration of this issue. Images COMMUNICATION Hospital, Oxford OX3 9DU. PRODUCTION Medical Informatics Unit, NDCLS, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU. Telephone +44 (0)1865 222746 COPYRIGHT NOTICE © 2012 The editors of Oxford Medical School Gazette (OMSG) and the contributors to OMSG. All rights reserved. The contents of this publication may not be reproduced in whole or in part without the express prior written permission of the editors.

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28 Oxford Medical School Gazette (OMSG) is the oldest medical school journal in the world. OMSG is produced by the students of Oxford University Medical School for the enjoyment of students, doctors, alumni, academics and any other interested readers.

ACROSS 1 People from the North of Spain love to sunbathe, we hear (6) 4 Ferrous woman roofs cottages (8) 9 Craftsman may work with parts of stone (5) 10 Ratty’s friend, whose acting was initially over the top, ended up on a medical drama (5) 11 Forbid sheep to speak before heading North (3) 13 Russian revolutionary known to slide downhill slower than a cantering horse (7) 14 Mad blood-sucking insect chased the Moon (7) 16 Confused, we are alone without a Ms. Rigby (7) 18 At the end of his trip to Dortmund, the man from Copenhagen proclaimed it “dull” (7) 19 Mr. Jones is in a right state (7) 20 Spaceship Captain begins by handling things alone (3,4) 22 In the end, all cardiological problems can be solved rationally (7) 26 Assess partly to make sure you have the right gauge (7) 28 So sad it could stop a horse (3) 29 Concern with his shoe by the sound of it (5) 30 The sea is acting odd once again (5) 31 Small animal doesn’t like to share bushes (8) 32 Mad parrot is a fast-talking bird of prey (6)

DOWN 2 Brotherly love does not make the heart beat (7) 3 These bones are not halfway to the centre of a circle, but they are close! (5) 5 Telephone after you get to the Idaho inn (5) 6 Italian city famous in the manufacturing sector (5) 7 Monks wear clothes as a matter of routine (5) 8 Diabetic parrot may make your ears wet – he goes a lot! (8) 9 Some married men see her as a deranged woman Hitler (6-2-3) 12 5 cents for the cinema to watch children’s TV (11) 15 Mountains belonging to Andrew (5) 17 Fictional Arab was not one of the forty thieves; he had evidence he was elsewhere (5) 18 It is not possible for one to touch this rapper (1,1,6) 21 Oh, don’t push your way into the hospital department, even though it is very grand (7) 23 As a starter, Gordon Ramsay eats every dessert, what voracity! (5) 24 Either a very hot or a very cold country (5) 25 Cowboy ropes himself a girl, oh! (5) 27 Sweet smell of a Roman’s sandals (5) Crossword created by Edward Warren, a fourth year medical student at St John’s College

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Reading medicine Matthew Hutchison examines the issue of writing pain

Bing Tseu listens to one patient’s personal experience of living with multiple sclerosis to uncover what she feels is important

When does pain bite? Foetal termination and the Law Alex Barry considers foetal pain and the implications for abortion legislation

Pushy parenting to the extreme Wendy Teo explores the ethics of selecting a child’s characteristics pre-birth

Animal Wrongs

Sports medicine: a proactive approach to public health

The development of palliative care

Classical pain

A beginner’s guide to medical etymology

Pain without a cause...

The practicality of puncturing pain

Alice Buchan investigates if this could actually be neuropathic pain

Mindfulness in medicine

Pain: separated by a culture gap?

Thomas Frost addresses why microglia might just hold the key to chronic neuropathic pain

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Erasing mental pain Sophie McManus explores the future of PTSD treatment

A painful imbalance

Out of Africa

Dying and getting away with it

Andrew Dooley explores access to pain relief in the developing world

George Chapman and Elizabeth Morris reveal what you’ll see on elective

Professor Michael Marsh responds to Angela Sheard’s look at near death experiences

The nocebo effect: placebo’s not so insignificant twin Sam Bilton addresses the role of the doctor in minimising the negative outcomes of clinical interventions.

Book reviews

Original Research

Do you really feel my pain?

From our archives

Crossword

Emily Arch explores whether medical students are as empathetic as they believe

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Abbie Taylor advocates the use of mindfulness approaches

Shirley Yick discusses how different cultures respond to pain

Zoon Tariq considers the potential benefits of acupuncture

Chronic pain: Immune modulation gone wrong?

Isobel Barling considers the presentation of pain in Homer’s Iliad

Edward Chesney takes us on a heroinaddled, botox-ridden, formicating ride from erotica to evidence based medicine

Nicola Kelly looks into the history of the palliative care movement

Calum Miller argues that the commonly held view that animals experience morally relevant pain may be mistaken

Elspeth Cumber considers the importance of sports and exercise medicine in the NHS

Pain perception in altered states of consciousness Laura Munglani considers how to assess pain perception in vegetative state and minimally conscious state patients

Did you want to climb mountains?

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A Note from Design Welcome to the first issue of 2013. This issue saw a new design team take over. We would like to thank all those who have contributed illustrations or photographs to this edition. If you have any queries, or would like to get involved, do not hesitate to get in touch at: design@omsg-online.com

- Rosalie Brooman-White, Giles Neal & Hannah Thompson design@omsg-online.com

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63(1) EDITORIAL

ain continues to resist simple characterisation. Both medicine and literature have attempted – with varying degrees of success – to define and understand the universal experience of suffering, in all its forms. Meaningful dialogue between these two spheres is often scarce and frustratingly inadequate. With the help of Philip Roth’s The Anatomy Lesson, we open with Matthew Hutchison’s thoughts on how our theme might be approached from both perspectives, as he explores the complex relationship between the pen and the stethoscope. We’ll then traverse the ethical minefield surrounding issues at the start of life. Whilst Alex Barry considers foetal pain and its wider implications for abortion legislation, Wendy Teo evaluates thoroughly the moral credibility of pre-genetic diagnosis. And what about end of life issues? In an interview with Professor Mary Baines, Nicola Kelly explores firsthand the development of palliative care in the UK and further afield. Laura Munglani’s assessment of pain perception using functional MR imaging in the comatose patient also makes for essential reading. Beneath the pain umbrella lie enshrouded a number of bizarre, ill-explained phenomena. Be sure to pause at Sam Bilton’s examination of the ‘nocebo’ effect, by which pessimism is thought to correlate with poor clinical outcomes. As for neuropathic pain, Thomas Frost addresses why microglia might just hold the key to the therapeutic armoury that researchers have for decades been trying to unlock. There’s a further side to the clinical management of pain that merits consideration – the actual manner of delivery. Here, Emily Arch brings into question the empathy of the medical profession – do we really feel a patient’s pain? And, perhaps more importantly, should we? Bing Tseu’s portrayal of one patient’s experience of living with multiple sclerosis certainly suggests so.

Pain is also interpreted differently in different cultures. As Shirley Yick identifies, social adaptations pervade our pain behaviour, making precise evaluation notoriously difficult. Of course, there may be logistical reasons for these cultural and geographical nuances. Andrew Dooley finds that access to analgesia in the developing world remains worryingly poor, largely due to doctors’ (perhaps unfounded) fears surrounding addiction. As ever, some articles stray from the thematic line. If you, like us, are ever baffled by the origins of the medical language, prepare to be mesmerised by Edward Chesney’s whistle-stop tour through medical etymology. We’ll journey back to the blood and gore of the Trojan War with Isobel Barling’s analysis of pain in Homer’s Iliad. We also publish for the first time a response to a previous article; namely Professor Michael Marsh’s consideration of Angela Sheard’s piece on near-death experiences in the 62(2) issue.

Thanks to our wonderfully diligent sub-editors, without whom we would be utterly overrun. Especial praise is reserved for our new design team (led by Rosalie BroomanWhite, Hannah Thompson and Giles Neal) who have wrestled with the most belligerent software known to man to produce the impressive magazine you now find before you. We are also incredibly grateful to Jack Carruthers and Caroline Pendleton for their saint-like patience throughout the handover period! We leave you with the celebrated words of Aristotle: “The aim of the wise is not to secure pleasure, but to avoid pain.” We hope that our first issue will provide you with plenty of the former, and rather less of the latter. Please do get in touch: we welcome any feedback you might have and letters to the Editors are warmly received.

The OMSG Editors, Joshua Luck and Barnabas Gilbert

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MATTHEW HUTCHISON examines the issues of writing pain

t’s one of those things that, having pitched this article as an English student’s perspective on pain, all the interesting questions I could think of were resoundingly medical. What exactly is pain, anyway? How does it work? Is the physical pain-process the same all over the body? What’s the correlation between physical pain and mental or emotional pain? What are the boundaries between something like grief, depression, angst and what can be medically diagnosed as ‘pain’? None of these questions I can even begin to answer, but you’ve probably got the right magazine in your hands. Then again, you medics already know the answers, don’t you?

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IMAGE/ADAPTED FROM WIKIMEDIA COMMONS

I would seek enlightenment at the feet of my medic housemates, blessed as I am with three of them, but it’s a daunting prospect. Occasionally this year I have chirped up with beautiful childlike innocence, asking “why do we cough?” or “what happens when we fall asleep?”, and spent the next half an hour flattened to the back of my chair by a torrent of meticulous scientific analysis of the oesophagus, or rapid eye movement, neuron-firing,

etc etc. After the Battle of Asculum in 279 BC, King Pyrrhus of Epirus gazed at the corpsestrewn battlefield and remarked to a comrade that another such victory, and they’d be utterly undone. After a medical question is successfully answered in my house, I know how he felt. It might not surprise you to learn that it’s rare, during these flurries of scientific shop talk, that anyone turns back to me and asks, “but what does literature have to say about all this?” There doesn’t seem to be an obvious overlap between literature and medicine. Put another way, there’s not much of a conversation going on between the two worlds. And it’s a shame. Back in the days when everyone at Oxbridge read Classics and took it from there, there was none of the disciplinary divide we have now, when students of some degrees may as well be speaking a different language from the rest of us (especially - punchline! - if they’re a language student). It may be a caricature to suggest that your average Victorian gentleman alternated between astronomy and

WE COULD DO WITH A FEW MORE EXAMPLES OF THE REVERSE JOURNEY FROM MEDICINE TO LITERATURE, OF THE STETHOSCOPE BEING CAST ASIDE FOR THE PEN

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WE CAN DO OTHER SENSATIONS LIKE HEAT OR COLD, BUT WHERE’S OUR UNIVERSAL LANGUAGE OF PAIN?

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lyric poetry, or that he catalogued a few more African insects between chapters of Bleak House; but he would have had far more cohesive, all-round intellectual pursuits than we do today. Tennyson naturally included references to the latest scientific discoveries in his greatest poems - “Nature red in tooth and claw” and all that - while On the Origin of Species itself became ‘Literature’ in a way that Richard Dawkins dreams about. George Eliot structured Middlemarch in part around the travails of a young doctor struggling to make his way in the world, opening up the medical profession as a fit subject for literature - and Middlemarch is Great Literature. Gray’s Anatomy reached Dickensian levels of popularity when first published in 1858. Essentially, the literary and medical worlds had something to say to each other. But somewhere along the line the position of the author shifted from action hero and public figure - Lord Byron charging around with pen in hand and woman on arm, or Dickens’ celebrity prestige - to that of the outsider looking in. Broadly speaking, Modernist writers of the twentieth century were more concerned with representing the experience of the inner life. The objective certainty of the outside world was now filtered through the subjective consciousness of individuals like Virginia Woolf’s Mrs Dalloway. The more psychology and neuroscience progressed, though, the more a medical understanding of the mind came to inform literary representations of the self. We

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can see this in Jonathan Franzen’s recent novel The Corrections, where one of the main characters, worried about his mental health, has done his homework on depression: As he entered the darkroom, he estimated that his levels of Neurofactor 3 (i.e. serotonin: a very, very important factor) were posting seven-day or even thirty-day highs, that his Factor 2 and Factor 7 levels were likewise outperforming expectations, and that his Factor 1 had rebounded from an early-morning slump related to the glass of Armagnac he’d drunk at bedtime. Trying to convince himself that he is “not in the least bit clinically depressed,” this chap goes on to realise that the illumination afforded by medical science is no substitute for treatment, and eventually concedes that he needs help. Franzen recognises that we live in a world of pop science - ‘Embarrassing Bodies’, ‘10 Years Younger’ etc - which has given all of us a thin, superficial layer of medical jargon to work with. My mother no longer nags me to eat less fast food, for instance, but to banish trans fatty acids from my diet. But pain is another matter; there’s not a lot we can say about pain. Indeed, most conversational usage of the word slides past its primary physical meaning into metaphor: “he’s a real pain,” “she really hurt me,” “it’s too painful to talk about.” Even describing someone as physically ‘in’ pain has, on closer

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ON THE ORIGIN OF SPECIES ITSELF BECAME ‘LITERATURE’ IN A WAY THAT RICHARD DAWKINS DREAMS ABOUT

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look, a strange immersive vagueness to it, as though the pain has spread to encompass their being. And how to describe pain itself? How to put pain into words? We can do other sensations like heat or cold, but where’s our universal language of pain? Not a lot reminds us of our individuality more than being in pain. It’s a constant reminder of itself, of our own bodies and of the fact that we are, basically, fundamentally, ourselves. And being impossible to share this pain with others, it’s very easy for them to forget about our physical (and accompanying mental) discom-

fort. Which is always a relief when it’s others in pain, and a total injustice when it’s us. But what does literature have to say about all this? Can it put pain into words? As it happens, the problem of representing the un-representably individual nature of pain is tackled head-on by Philip Roth in his novel The Anatomy Lesson. Roth gives us a successful writer, Nathan Zuckerman, afflicted suddenly and mysteriously with undiagnosable back pain. Pain tends to dominate one’s thoughts anyway, so chronic pain, as Roth says, “teaches us: one, what well-being is; two, what cowardice is; three, a little something of what it is to be sentenced to hard labour. Pain is work.” The pain being undiagnosable and essentially meaningless intensifies the problem for the writer, whose job is to search for and effectively create meaning. Zuckerman’s resulting crisis gives the lie to Karl Marx’s line that ‘the only antidote to mental suffering is physical pain.’ It’s worth quoting at length from the novel, if only to give a valuable, wordcount-related insight into the typical English essay-writing process: Then the pain, so persistent as to estrange him even from the writing... every other predicament, large or small, was inconceivable: no character imaginable other than the one in pain. What prevents my recovery, what I do or what I don’t do? What

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Or this: But he was not a sick man - he was fighting the idea of himself as sick. Every thought and feeling ensnared by the selfness of pain, pain endlessly circling back on itself, diminishing everything except isolation - first it’s the pain that empties the world, then it’s the effort to overcome it. He refused to endure one day more. So Zuckerman’s great solution (admittedly reached under the influence of drink, drugs and aforementioned pain) is to ditch the novels and enrol in medical school. Getting out of his own head, getting out of the “selfness” of pain and the “selfness” of writing and becoming a doctor: someone “so busy diagnosing everybody else there’s no time to overdiagnose yourself. The unexamined life - the only one worth living.” Whether Zuckerman gets there in the end or not, you’ll have to read the book to find out. But I like the pain-prompted transition between the medical and literary worlds, and I like the idealised literary conception of doctors as too altruistic and outward-looking to have time for introspection. As someone who spent most of his first year writing about the ‘self’ - solid 2:1 in Mods, thank you very much - while my medic friends actually

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help, you know, actual people, I have a certain sympathy with this view. However, we could do with a few more examples of the reverse journey from medicine to literature, of the stethoscope being cast aside for the pen. Fortunately though, as I think I’ve said before, you’ve probably got the right magazine in your hands. Full references available at: www.omsg-online.com

Matthew Hutchison is a third year English student at St Hilda’s College All Roth quotations (and the Marx one) taken from Philip Roth, The Anatomy Lesson (Vintage, 1983 [2005]). The Franzen quote taken from Jonathan Franzen, The Corrections (Vintage, 2001).

IMAGES/ROSALIE BROOMAN-WHITE

does this illness want with me anyway? Or is it I who want something from it? The interrogation had no useful purpose, yet the sole motif of his existence was this hourly search for the missing meaning. Had he kept a pain diary, the only entry would have been one word: Myself.

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When does pain bite? Foetal Termination and the Law ALEX BARRY considers foetal pain and the implications for abortion legislation

ILLUSTRATION/SIMONE PAULSON

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he 1990 Human Fertilisation and Embryology Act reduced the abortion limit from 28 to 24 weeks following evidence of increased foetal viability and growing controversy surrounding foetal awareness. More recently, Health Secretary Jeremy Hunt caused a stir when he favoured a reduction to a 12 week abortion limit. His public views on abortion were met with outrage from pro-choice and women’s rights groups. Shadow health minister Dianne Abbott described Hunt’s views as a “sustained ideological attack on the science and the rights that British women and families have fought for” [1]. Only 11% of foetuses born before 24 weeks survive to discharge, often with severe disability, and there is little evidence of significant improvement in the survival of preterm foetuses in the last 20 years [2]. Current late termination practice in the UK involves foeticide, inducing cardiac asystole by intracardiac injection of potassium chloride [3]. This

avoids potential signs of life when labour is induced, but some advocate the use of analgesia, arguing that this invasive procedure causes foetal pain [4]. NEURODEVELOPMENT OF PAIN

Pain experience demands an intact system of nociceptive transmission from the peripheral to the central nervous system (CNS) [5]. Immature nociceptors, vital for pain experience following tissue damage, are not unequivocally present until 17 weeks [6]. These newly formed nociceptors can signal tissue damage but signal intensity is much weaker than in the adult and nociceptor presence alone is insufficient for experiencing pain [7]. Although a foetus withdraws from a needle at 18 weeks [8], spinal reflex actions are not indicative of foetal pain, since lack of cortical involvement precludes conscious perception of noxious stimuli [9]. Spinothalamic connections are necessary but not sufficient for foetal pain and thalamo-cortical connections arguably form the minimum necessary anatomical pathways for pain experience. The crucial role of the cortex in pain perception is seen in robust cortical activity in preterm neonates exposed to noxious stimuli [10]. Cortical synapses, suggestive of active neuronal circuitry, are present from 23 weeks [11] though the specific developmental timing for pain circuits in the cortex remains unexamined. Newer tech-

niques, such as water diffusion anisotropy magnetic resonance imaging (MRI), have revealed specialisation of cortical architecture at 26 weeks [12]. However, the presence of neural material does not indicate functional circuitry and cannot account for the content of any presumed pain experience. PHYSIOLOGICAL & BEHAVIOURAL RESPONSES

Anand and colleagues cite the activation of the hypothalamo-pituitary-adrenal (HPA) axis in the foetus, a ‘stress response’ similar to that seen in neonates and older children, as evidence for foetal pain [13]. Their work on preterm neonates promoted the concept of foetal analgesia amid concerns that, if preterm neonates can feel pain, then foetuses of similar gestational age must also be able to. Intrahepatic vein (IHV) blood sampling in a transfusion procedure was associated with increased foetal plasma cortisol and β-endorphin levels as early as 18 weeks, independent of maternal responses [14]. Use of fentanyl, an opioid analgesic, reduces foetal β-endorphin release [15], further linking stress response and pain. However, assessment of β-endorphin as a pain experience biomarker in mice found β-endorphin release following both noxious and non-noxious stimuli, though noxious stimulation generated longer responses [16]. The HPA axis is a subcortical system, so how perception is achieved with2013 63:1

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IMMATURE NOCICEPTORS, VITAL FOR PAIN EXPERIENCE FOLLOWING TISSUE DAMAGE, ARE NOT UNEQUIVOCALLY PRESENT UNTIL 17 WEEKS

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out cortical involvement remains questionable. Glover and Fisk undervalue the dynamic relationship between hormones and pain: adult stress responses can increase under general anaesthesia with analgesia [17] and, during organ-harvesting of brain-dead individuals, the response is not negated with analgesia [18].

age of the foetus ‘crying’ and moving away from a needle in utero to suggest pain perception but there is no scientific evidence that these actions are anything more than unconscious reflexes. 4D ultrasonography aids diagnosis of foetal abnormalities [20] but provides no information on foetal pain.

Anti-abortion groups have long used behavioural indices as evidence of foetal pain, but without the recollected experience of being a foetus, interpretation is sentimentally biased. Studies in preterm neonates have examined behavioural responses to noxious heel lancing. Gibbins et al found immediate facial actions (measured with the Neonatal Facial Coding System) following heel lance in neonates below 28 weeks gestation, with similar responses for 23 – 25 weeks and 26 – 28 weeks. No specific alterations in physiological or body movement changes were noted, leading the authors to postulate facial actions as the most prominent pain indicators [19]. However, the neonate is not the foetus, and vital differences could mean that extrapolation between the two is inaccurate.

The crucial perceptual element of pain experience implies consciousness is required for any foetal capacity to feel pain. Edelman describes consciousness as the organisation of sensory experience into a coherent scene for higher order reflection and general consensus establishes the cortex as the seat of consciousness [21]. Substantial postnatal cortical development has been used as an argument against foetal consciousness development [22], but postnatal development gives no real indication of foetal developmental status.

Recent developments in 4D ultrasonography have enhanced ultrasound examination of the foetus. Pro-life groups use foot-

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Electroencephalography (EEG) has been the main method used to gauge when the foetus reaches the minimum consciousness necessary for pain perception. EEG is arguably uncontentious as a close link exists between genuine conscious behavioural evidence and electrical activation in the cortex. Studies in preterm neonates demonstrate EEGs at 24 weeks gestation

THE PRESENCE OF NEURAL MATERIAL DOES NOT INDICATE FUNCTIONAL CIRCUITRY AND CANNOT ACCOUNT FOR THE CONTENT OF ANY PRESUMED PAIN EXPERIENCE

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FOETAL CONCIOUSNESS

are only active for 2% of EEG recording time, implying lack of consciousness. Somatosensory EPs can also be recorded in premature infants from 25 weeks [23], although these are largely undefined, diffuse and provide no indication of specific pain consciousness. Assessment of foetal pain is complicated by the psychological aspect of consciousness; some argue that neural tissue alone cannot support pain experience at any stage, since pain is multidimensional [24]. Consciousness development may be irrelevant in foetal pain as the foetus is maintained in a sleep-like state throughout gestation. Using an implanted Plexiglas window, Rigatto observed only quiet and rapid-eye-movement (REM) sleep states in a sheep foetus under electrocorticography (ECoG) monitoring. Though evident postpartum, no signs of foetal wakefulness occurred in utero. Birth has therefore been described as awakening from a profound inhibitory state [25]. Vibroacoustic stimulation in foetal sheep caused ECoG changes similar to the dynamics of spontaneous sleep transitions [26], providing evidence that noxious stimulation in utero does not cause foetal wakefulness, although cortical arousal may occur. Regardless, certain physiological differences between sheep and humans question the validity of extrapolation. Rigatto used the absence of in utero eye opening as evidence of a lack of wakefulness. However, reflex eye opening is witnessed in the foetus from 18 weeks [27], with blinking visible by 4D ultrasound from 24 weeks [28]. In the human foetus mid-gestation, a discontinuous EEG pattern is observed with coherent states suggestive of sleep. Cortical pain responses in preterm infants are significantly greater 9

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when awake, indicating reduced awareness of noxious stimulation in sleep [10].

Extrapolation of preterm neonatal evidence to the foetus is undermined by the uterine environment which suppresses foetal cortical activation on detecting invasive stimuli, such as occur in foeticide. Warmth, fluid-cushioning of tactile stimulation and maternal, placental and foetal neuroinhibitory chemicals preserve continuous sleep-like unconsciousness in the foetus. Foetal responses to the hypoxia of apnoea are those of profound unconsciousness (cessation of movement and a shift to hypometabolic EEG [29]), in contrast with the rapid onset of behavioural activity seen in the neonatal response [30]. Correlation between these states may therefore be inappropriate due to the effect of intense tactile stimulation at birth. IMPLICATIONS FOR ABORTION LEGISLATION

Foetal pain underpins arguments for the use of foetal analgesia in late-term abortions. Studies on foetal anaesthesia have used physiological and behavioural responses as evidence of reduced foetal awareness, though the main aim in these studies was not foetal pain alleviation but immobilisation for surgical procedures. Arguments that it is prudent to avoid the possibility of pain during gestation ignore the unnecessary risks to the mother that accompany inappropriate intervention. Recent reports by the Royal College of Obstetricians and Gynaecologists and the House of Commons Science and Technol-

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THE UTERINE ENVIRONMENT: DIFFERENCES BETWEEN FOETUS & NEONATE

PRO-LIFE GROUPS USE FOOTAGE OF THE FOETUS ‘CRYING’ AND MOVING AWAY FROM A NEEDLE IN UTERO TO SUGGEST PAIN PERCEPTION

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ogy Committee reject any need for legislative change [31]. It appears that the British government will stick to their legislation for the foreseeable future, with influence at last spreading to Northern Ireland where the first Marie Stopes private abortion clinic opened in Belfast in October 2012 [32]. While an overlap between abortion and premature birth presents many ethical issues, these should not undermine the scientific evidence that foetal pain is not possible before 24 weeks gestation. Full references available at: www.omsg-online.com

Alex Barry is a fifth year medical student at New College

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ILLUSTRATION/RICHARD SYKES

Pushy parenting to the extreme

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DISABILITIES Julian Savulescu argues that prospective parents should not only be allowed to se-

not being born at all. This is, in essence, a consequentialist argument based on John Stuart Mill’s premise that freedom can only be restricted when there is harm inflicted on others. However, Sarah Stoller of New York University disagrees. She argues that “in the area of procreation, when we focus solely on consequences, we ignore key components of our sense of morality” and “fail to capture all the relevant facets of the issue” [3]. Stoller contends that it is better to tackle these thorny issues using deontology and virtue ethics. Expressivist objections state that allowing Pre-implantation Genetic Diagnosis (PGD) to be used for certain illnesses may amount to “reinforc[ing] prejudice, stigmas, and unjust social discrimination against persons” living with those diseases, suggesting that a life with a certain disability is not worth as much as a fully healthy person’s life [4]. According to Asch and

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Medical advancements in the field of reproductive medicine have brought intriguing scientific possibilities but, as ever, have been surrounded by a heated debate on where the moral boundaries should lie. Central to this debate is the question whether parents should be allowed, or even morally required, as Oxford Professor of Ethics Julian Savulescu believes, to use medical assistance to select or alter the traits of their children pre-birth [1]. There is tension between what is best for the parents and what is best for society as a whole; for many, this is heightened by the fear of eugenic implications. Nevertheless, a balance must be struck. It might be reasonable for parents to select or alter the characteristics of children pre-birth when it concerns disabilities or ‘saviour siblings’, but not to select for sex or trivial characteristics.

PUBLIC OPINION DOES NOT SUPPORT LEGALISED SEX SELECTION

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neglect’. Following this approach, parents are morally obliged to prevent their children suffering from disabilities but are not obliged to ‘enhance’ non-disease traits such as intelligence or height. This reasoning is in line with current UK law, which makes exceptions on ‘therapeutic grounds’ in the most compelling cases. Other commentators, including John Harris, a distinguished British bioethicist, support the view that parents should take preferential action where possible to avoid bringing people with disabilities into the world [7]. So what about the expressivist objections to the use of PGD in any form? Professor Allen Buchanan of Duke University rebuts

SAVULESCU ARGUES THAT PROSPECTIVE PARENTS…ARE MORALLY OBLIGED TO SELECT CHILDREN WITH THE GREATEST CHANCE OF LEADING THE BEST LIFE

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lect or alter the characteristics of children pre-birth, but are morally obliged to select children with the greatest chance of leading the best life [2]. This is known as the theory of Procreative Beneficence. Savulescu also supports reproductive autonomy and argues that, to discover what the best prospects are, couples must have freedom to act on their own value judgment. Thus, parents should be allowed to select a deaf child, for example. Savulescu argues that there is no harm done to the child since the only alternative to being born deaf is not being selected and thus

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Wasserman at Yeshiva University, “a policy that promotes selection against embryos with disabling traits conveys the strong impression that the problem is the disability itself rather than the society that could do so much more to welcome and include all its members” [5]. Jess Hammond advances a more modest and palatable perspective [6]. Unlike Savulescu who argues for general duty to select for both ‘therapeutic’ and ‘enhancement’ reasons, Hammond argues that the parents’ duty is limited to avoiding ‘genetic

such objections by pointing out that they fail to recognise the difference between judging a disability and judging a disabled person [8]. As Hammond points out, “it is perfectly consistent to say that a person with disability is utterly wonderful while saying that her disability is unfortunate for her”. In a similar vein, Oxford Law Professor Jonathan Herring notes that there is a difference between saying that a life with a certain characteristic is one not worth living at all, and saying that it would be better not to have the characteristic [9]. Hence, Hammond’s view is perhaps the most bal-

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anced perspective of them all. SAVIOUR SIBLINGS ‘Saviour siblings’ refer to cases in which the parents of a sick child wish to have another child whose tissue can be used to treat the condition of their sick sibling. Following the ruling by the House of Lords in the Quintavalle v. HFEA case of 2005, the 2008 Human Fertilisation and Embryology Act (HFEA) permits embryo testing to ensure an implanted embryo may function as a ‘saviour sibling’. However, the criteria remain stringent; PGD is restricted to sibling cases and is forbidden whenever a whole organ is required. Opponents claim that bringing a person into existence for the sole purpose of assisting another infringes the principle that people should not be used solely as a means to an end. Martin Delatycki from Murdoch Childrens Research Institute points out that the child might suffer from psychological harm, particularly if their sibling could not be saved [10].

SEX SELECTION Some have argued that reproductive autonomy entails the right to decide the sex of the child. However, an HFEA report has revealed that public opinion does not support legalised sex selection and that parents should love their children regardless of sex. Indeed, HFEA 2008 will not accept sex selection on social grounds.

children with a certain hair type do not have lives worth living, or be an expression of a prejudicial attitude, in the way that a decision based on disability could be perceived [8]. Likewise, Harris thinks that such choices can be left to parents [7]. If important, these traits should not be left to chance; if not important, why not let parents choose?

If implemented, sex selection may have demographic consequences, with a skewed ratio between males and females. Moreover, if legalised, it would be difficult for the UK to object to the procedure in other countries such as India and China where, for cultural and historical reasons, it may be more likely to be used in an unacceptable manner.

However, Dr David King, editor of GenEthics News, argues that techniques like PGD transform the relationship between parent and child into a ‘consumerist’ model in which children become “products, expressing, in part, their parents’ aspirations, desires and whims” [12]. Since this may indirectly harm the child, it is difficult to argue, based on Mill’s ‘no harm’ principle, that parents’ decisions should be autonomous.

TRIVIAL REASONS Although PGD can establish the presence or absence of certain genes and the sex of the embryo, the technology does not yet enable us to select or alter characteristics such as intelligence or sporting ability pre-

It seems like yesterday that Quigley and colleagues at Manchester University were debating whether everyone had a right to reproduction [13], yet already the spot-

PGD TRANSFORMS THE RELATIONSHIP BETWEEN PARENT AND CHILD INTO A ‘CONSUMERIST’ MODEL

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By contrast, Merle Spriggs from the same institute argues that to save the life of one’s sibling is beneficial to the donor, or at least does no harm [11]. Herring notes that the ‘saviour sibling’ may feel overjoyed to be able to save or attempt to save its sibling’s life [8]. Perhaps Harris is right and the potential emotional harm for the saviour sibling does not justify denying treatment that could save a life [7]. Hence, in my view, parents should be allowed to use medical assistance to select or alter characteristics of children pre-birth if they are to be ‘saviour siblings’.

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birth. Nevertheless, as scientific advance continues and the ‘impossible’ continues to be redefined, we would be foolish to confine the prospect of ‘designer babies’ to the realms of scientific fiction. Various philosophers have spoken in support of selecting ‘trivial characteristics’. In his elaboration of Procreative Beneficence, Savulescu suggests that parents should choose the most intelligent embryo which has the greatest chance of leading the best life; i.e. intelligence promotes well-being. Herring points out that the parents’ selection of a hair type could not suggest that

light has shifted to focus on niche ethical questions, including the issues surrounding PGD. Given the rapid rate at which reproductive technologies are developing, it comes as little surprise that the ethical debate is struggling to keep up. Full references available at: www.omsg-online.com

Wendy Teo is a fifth year medical student at Keble College The author would like to thank Professor Jonathan Herring for his help in preparing this article.

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Pain perception in altered states of

CONSCIOUSNESS LAURA MUNGLANI considers how to assess pain perception in vegetative state and minimally conscious state patients

Nociception is a physiological response to noxious stimulation. In contrast, pain – and the suffering associated with it – necessarily involves conscious experience. Using functional magnetic resonance imaging (fMRI), a distinction may also be made between brain areas involved in pain perception and those involved in suffering, the latter often integrated with those areas associated with prior exposure and meaning.

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The question of whether such patients suffer or not will have a profound effect on how they are treated and how they are allowed to die. Therefore it is crucial to examine whether those patients diagnosed as being in a VS or a MCS are “conscious”. The definition of VS precludes being conscious, whereas MCS patients are thought to have fluctuating episodes of consciousness. However these behavioural scales are not standardised and it is suggested that misdiagnosis rate may be as high as 40% [2]. It is also worth noting that VS and MCS are

behavioural descriptors, without strict pathophysiological description. Studies have shown important differences in brain function and possible states of consciousness between the two populations using PET scanning techniques [3]. Owen’s team used fMRI to show that a woman in VS had many features associated with consciousness[4]. In 2010,Owen’s team also reported on a 24-year-old male classified as being in VS (following a road traffic accident 5 years previously), but using a selective mental imagery paradigm was able to correctly answer 5/6 verifiable ques-

DEFINITIONS: COMA– a state of total lack of arousal and behavioural unresponsiveness i.e. a lack of consciousness. VEGETATIVE STATE (VS) – a state of responsiveness and wakefulness (periods of preserved behavioural arousal) without conscious awareness of self and environment. They demonstrate no language production or comprehension. MINIMALLY CONSCIOUS STATE (MCS) – show reproducible but minimal and fluctuating signs of consciousness but are unable to communicate effectively.

IMAGE/ROSALIE BROOMAN-WHITE

ith improvements in intensive care protocols, many patients survive severe brain injury but are left with deficits of consciousness and information processing. At any one time, it is estimated that 1000 patients are kept alive in the UK in the hope that they may one day regain consciousness. These patients may awaken from their coma but still show no signs of awareness; and are often described as being in a vegetative state (VS), or a minimally conscious state (MCS) [Box 1]. To what extent are these patients able to feel pain? Currently there is little convincing research and almost evenly divided medical opinion, with 56% thinking these patients can[1].

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If Owen’s estimate that 1 in 5 people in VS are indeed “conscious” and able to communicate using brain activity [5] is right, then such patients may feel pain.However VS patients are able to demonstrate aversion-type responses (such as grimaces, tachycardia, and posturing), causing some to suggest that they are able to perceive pain [2]. Current understanding suggests that awareness of pain is thought to occur at the cortical level whilst nociceptive responses – grimacing and crying –are subcortically mediated. Studies done under general anaesthesia indicate that motor responses and autonomic signs (e.g. respiratory

FMRI CAN BE USED TO MEASURE CONSCIOUSNESS

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tions [5].This landmark study showed it was possible to exchange information with someone in VS and the team inferred that he was aware, with many other higher cognitive functions largely intact.However, critics argue that fMRI is only an indirect measure of consciousness.

1 IN 5 PEOPLE IN VS MAY BE CONSCIOUS

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frequency, heart rate, blood pressure) are not reliable measures of consciousness or pain perception [6]. Though the precise cortical and related subcortical nuclei involved in the emergent sensation of pain have yet to be conclusively defined, a lateral and a medial pain system has been postulated. One study using PET to measure brain activation during noxious electrical stimulation of the median nerve supported the conclusion that patients in MCS have sufficient neural pathways required to experience –or at least to allow for awareness of – nociceptive stimuli, but that patients in VS might not [3]. In VS patients, painful stimuli may not reach the threshold to become consciously experienced, even if there some cortical processingwas evident [2]. The question arises whether those in MCS or VS, even if they consciously perceive pain, are likely to have the same sort of experience of the pain and suffering as experienced by otherwise fully conscious individuals?

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withdrawal of active feeding and hyTHE LAW ALLOWS dration approaches may lead to intense ACTIVE FEEDING suffering. In Mr Bland’s seminal 1993 AND FLUID THERAPY case, relatives won the right to withWITHDRAWAL draw treatment to allow him to die – a FOR VS PATIENTS, so-called “mercy-killing” [8]. In this inCAUSING DEATH BY stance, Mr Bland was thought to be in DEHYDRATION a more extreme form of VS – with one judge in the case stating that Bland was In November 2012 Owen, using fMRI, just a “shell”. fMRI may be able to help asked 39-year-old VS patient Scott Rout- distinguish the level of consciousness ley, if he was in pain at that moment in – and perhaps pain – in those patients time. Through selective mental imagery who challenge simple bedside categoriRoutley answered no! [7]. Importantly sation. though, there is likely to be enormous In conclusion, the detection of pain heterogeneity in the patient groups dis- perception in VS and MCS patients recussed. In particular, the varying types mains a challenging but crucial task in of injury that lead to coma, VS and MCS the management of patients recovering make it likely that there will be differ- from coma, where behavioural responsences in patterns of brain activity, pre- es to nociception cannot be accurately cluding gross generalisations from indi- assessed. Though new scales to assess vidual cases. The most recent evidence, nociception response are being develwith the exception of Mr Routley, sug- oped [9], it seems that fMRI may progests that a cautious approach needs to vide a window into the world of such be taken if indeed patients can feel pain, patients. Perhaps then by communicatwith fMRI being used to direct analgesia ing with patients and asking them if and use. how they feel pain, steps may be taken to

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However with end of life care a more improve their quality of life. ethically demanding scenario arises. Full references available at: Currently the law allows VS patients www.omsg-online.com to have active feeding and fluid therapy Laura Munglani is a fourth year withdrawn to allow them to die, hastenmedical student at Balliol College ing dehydration as the terminal event. Recent fMRI studies suggest that such

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The development of palliative care

“Life is pleasant. Death is peaceful. It’s the transition that’s troublesome.” – Isaac Asimov, novelist (1920-1992) Saunders gave up her studies at Oxford and moved to London to train as a nurse. Whilst a social worker, she describes “meeting a young Polish Jew who had an inoperable cancer” as the turning point that led her to realise that “we needed not only better pain control but better overall care. People needed the space to be themselves” [3]. Following medical training at St Thomas’ Hospital, Cicely obtained a research scholarship to study pain and terminal illness at St Joseph’s Hospice, also in London. Through diligent observation and documentation of over a thousand patients with terminal cancer, she conducted the THE HISTORY OF PALLIATIVE CARE first ever research project in palliative care With the first modern hospice, St Chris- [4]. Her research included investigation topher’s, set up in 1967, the history of ‘Pal- into the use of opioids for long term pain liative Care’ might be deemed fairly recent. relief, leading to therapeutic developments However, this specialty arguably repre- considered by many to be the most imporsents the most primitive of medical inter- tant in end-of-life care. However, Cicely ventions: supporting all aspects of an in- advocated the adoption of a more holistic dividual’s life; and providing symptomatic view of pain. She coined the term “total relief when a cure is unavailable. In the 19th pain” to describe a concept encompassing century, ‘homes for the dying’ were inde- the “physical, spiritual, psychological, and pendently set up in France, Ireland, the US, social pain” experienced by the dying – asand the UK, primarily by Christian groups. pects of pain that she felt “must be treated” Despite lacking the specialist treatment [3]. available in today’s hospices, these homes were able to provide care for sufferers THE BEGINNING OF THE HOME which fulfilled many of the WHO criteria CARE SERVICE that define palliative care today [2]. The pioneering hospices were primarily inpatient centres; the potential to return THE WORK OF CICELY SAUNDERS home was hindered by the reluctance of At the outbreak of World War II, Cicely general practitioners to maintain the high WHAT IS PALLIATIVE CARE? The World Health Organisation (WHO) defines palliative care as an approach that “intends neither to hasten [nor] postpone death” for “patients whose disease in not responsive to curative treatment” [1]. Symptomatic relief, most crucially from pain, allows patients to maintain an active and fulfilling lifestyle for as long as possible. The psychological and social support provided is equally valuable, helping patients to see death as a normal process and supporting families as they come to terms with the prospect of bereavement.

1948 The NHS is founded

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1952 Cicely Saunders (CS), aged 33, begins medical studies

1967 St Christopher’s, first ‘modern’ hospice, opens in South London.

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MARY BAINES, Emeritus Professor at St Christopher’s, shares her thoughts on Palliative Care: Why did you move to St Christopher’s? “I had been a medical student with Cicely Saunders and she persuaded me to join her when she opened St Christopher’s.” What do you think are the most important skills a Palliative Care consultant can have? “A combination of an analytical mind trying to diagnose and treat difficult symptoms and an understanding and compassion for emotional and spiritual suffering.” What do you think is the greatest challenge facing the Palliative Care movement today? “To offer the level of care given in hospices to all dying people whether they are in hospital, home or care home.” What are the best and worst things about working in Palliative Care? “Great satisfaction in enabling the majority of patients to die well, with relief of their pain and emotional distress. No worst things!”

1969 The home care service is introduced at St Christopher’s.

1975 The first Macmillan nurse posts are established

1980 The International Conference on Terminal Care

1982 World Health Organization Cancer Pain and Palliative Care Programme initiated

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it is clear that the domiciliary service has been a success. A survey by the National Audit Office, however, found that whilst between 56 and 74% of the British public expressed a wish to die at home, only 19% currently do so [6]. Clearly, there is still room to improve the provision of home care in many regions. THE MOVEMENT GLOBAL

GOES

Cicely Saunders aimed to care not only for patients at St Christopher’s opioid doses implemented within but to “change the world’s view the hospice, for fear of addiction. of dying” [4]. In Romania, where The demand for home care led to cancer is the second leading cause the start of the St Christopher’s of death [7], significant barriers to domiciliary service that has funda- opioid use have prevented adequate mentally changed the way hospice pain control in terminally ill pacare is carried out. The service, tients. Many doctors continue to which provides 24 hour care, was adhere to a maximal opioid dose of launched in October 1969 by Mary 60 mg and, until 2007, there existed Baines, a doctor who had trained a maximum prescription duration with Cicely at St Thomas’, alongside of three days that could only be exa nurse called Barbara McNulty [4]. tended by special authorisation. In Mary Baines emphatically describes 2007, pressure on the government hospices “not as buildings filled led to a policy change that allowed with beds but as a way of caring for specialists and non-specialists with dying patients” [5]. St Christopher’s “certified training” to prescribe opitoday is certainly more than a build- oid analgesics “for 30 days with no ing – with just 48 inpatient beds limit to dose”. These changes have and 850 patients cared for at home without doubt improved the lives of

1987 Palliative Medicine is granted sub-speciality status

1990 World Health Organization defines “palliative care”

1991 430 hospice services are now in operation in the UK

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Similarly, developing countries have struggled to provide adequate palliative care, including opioid pain relief, to their populations. This is due principally to a low number of doctors per capita and the challenges of providing medical care to isolated rural populations. Anne Merriman, a Liverpudlian doctor who has spent 28 years of her working life in Africa, introduced the palliative care movement to Uganda in 1993 after founding “Hospice Africa” [9]. Indeed, Uganda has been the first country to implement laws allowing nurses to prescribe morphine [10]. In the context of the UK health system, some might consider this decision irresponsible. However, in Uganda, a country with 0.08 doctors per 1000 people, a context dependent approach must be applied to universalise access to medical care [11]. For developed and developing countries alike it seems that the palliative care movement will continue. Context dependency on both a small and large scale underlies how this will take place. Concerning the former, healthcare professionals must treat patients as people and take into ac-

2001Liverpool Care Pathway recognised as Best Practice

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IMAGE/CICELY SAUNDERS INTERNATIONAL

many suffering from pain associated with chronic disease [8].

Dame Cicely Saunders

count the “total pain” they suffer from. Regarding the latter, the global development of palliative care must ensure that the programme put in place reflects the needs, available resources, and region-specific challenges of each country. With the global spread of the Palliative Care movement, it seems that Cicely has succeeded in her dream to “change the world’s view of dying”. Full references available at: www.omsg-online.com

Nicola Kelly is a third year medical student at The Queen’s College The author would like to thank Professor Baines for her interview in this article

2008 Liverpool Care Pathway recommended in the End of Life Care Strategy

2010 20.8% of deaths are ‘at home’

2012 New NICE guidelines on the use of opioids in advanced disease

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Amitriptyline and other tricyclic antidepressants are often first-line therapy [3], but tend to produce known side effects (including arrhythmias and anxiety [5]). Jessica’s current treatment is with anticonvulsant medication: “I had tried gabapentin pills…but they didn’t work so well. Unfortunately, it is a bit trial and error when it comes to relief for neurological pain.” [2] Indeed, only certain anticonvulsants – such as pregabalin, carbamazepine and gabapentin – demonstrate some level of efficacy [6], whereas others – including phenytoin and clonazepam – do not [7]. Often, drugs are used in combination, allowing a lower dose of each to be used and side effects minimised. However, there is little evidence to indicate which combination regimens are the most effective [8]. If the pain is refractory to two or three types of drug, more invasive treatment such as nerve or spinal cord stimulation may be considered [9]. New agents under investigation include cannabinoid- and capsaicin-based drugs. Sativex (containing ∆9-THC and can-

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could actually be neuropathic pain

Underlying the development of neuropathic pain is the inherent plasticity of neurons [3]. This allows abnormal circuits to be set up during chronic pain episodes, which may then remain active after resolution of the disease [4]. Neuropathic pain typically results from damage to central or peripheral nerve fibres, either due to the pathology itself or therapeutic intervention. In addition, new nerve fibres have been found in the ectopic tissue that characterises endometriosis [4]. Since there is no overt disease to treat, and analgesics have little effect, other drug classes have to be used. Perhaps surprisingly, these include antidepressants and anticonvulsants.

PAIN WITHOUT A CAUSE…

veryone experiences pain, but there are myriad possible causes. The usual approach involves providing pain relief with analgesic drugs – including paracetamol, ibuprofen, or opiates – whilst the underlying cause is treated medically, surgically, or sometimes simply by waiting it out. Defined as “pain caused by a lesion or disease of the somatosensory nervous system” [1], neuropathic pain is difficult in more ways than one. In addition to being hard to treat, the root cause may be hard to find or have already been treated. This can be frustrating for both doctor and patient, and happened in the case of Jessica. She was diagnosed with the gynaecological condition endometriosis, where endometrial tissue is found outside the uterus. Despite surgical removal of the offending ectopic tissue, her pain failed to resolve in tandem: she is now “100% free from endometriosis, but since they cleared an area full of nerves, some of these nerves were irritated and/or damaged… the neurological pain is still here.” [2]

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THESE NEW TREATMENTS COULD CHANGE THE LIVES OF NEUROPATHIC PAIN PATIENTS

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nabidiol) is already prescribed for the pain and spasticity associated with multiple sclerosis [10]. Moreover, cannabinoid receptors have been shown to dimerise with delta-opioid receptors – potentially facilitating allosteric modulation of opioid receptor activity [11]. It appears that neuropathic pain increases expression levels of both cannabinoid-1 receptors and delta-opioid receptors in the brain [11]. Similarly, the active ingredient found in chilli peppers, capsaicin, is being developed for topical use [12]. Whilst long-term low doses have shown little effect, research suggests a high dose transdermal patch may relieve pain through signal blockade of fibres with TRPV1 receptors [13]. Another avenue being explored focusses on cytokine modulation, since inflammatory processes are involved in the onset and maintenance of neuropathic pain. Aberrant cytokine production in both peripheral and central nervous systems may prove to be therapeutically malleable [14]. For example, the pro-inflammatory cytokine IL-6 has been shown to be significantly elevated in dorsal root ganglia after spinal cord injury. Promisingly, an IL-6 neutralising antibody appears to delay the onset of allodynia in murine models [15]. These new treatments could change the lives of neuropathic pain patients. They are sorely needed, because in Jessica’s words: “endometriosis is still ‘ruling’ my life, even if it is not inside me anymore!” Full references available at: www.omsg-online.com

Alice Buchan is a third year medical student at Balliol College. Names have been changed to protect patient confidentiality.

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The practicality of puncturing pain “There must be something to acupuncture. After all, you never see any sick porcupines.” Bob Goddard (Columnist,St. Louis Globe-Democrat, 1940s)

oes the above quote reflect a genuine, measurable benefit of acupuncture, or simply a high sickness threshold of porcupines? Wit aside, it begs the question: What is the evidence for the efficacy of acupuncture, particularly in the treatment of chronic pain? Acupuncture is a traditional Chinese therapy involving stimulation of body acupoints with cutaneous insertion and mechanical manipulation of needles [1]. It revolves around the belief that illness occurs from disruptions to the flow of Qi (the energy of life) along set “meridians” (channels around the body) [2]. Legend has it that the idea was sparked when a soldier’s frozen shoulder regained full range of motion amidst battle after being struck by an arrow [3]. The West was first exposed to acupuncture during the 16th century with the return of travelling missionaries from China [4].George Soulié de Morant, a French consul, worked tirelessly to advance the practice of acupuncture in the West, and was nominated for the Nobel Prize in Physiology or Medicine in 1950 [5]. In 1979, the World Health Organization(WHO) proclaimed acupuncture as a “clinical practice” [6] and, in 2003, reported a list of conditions for which acupuncture had either been deemed “an effective treatment” or a potential therapy for which “further proof is needed” [7].

IMAGE/ROSALIE BROOMAN-WHITE

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Acupuncture is a highly tailored act. It is the responsibility of a competent acupuncturist to communicate effectively with the patient and to assess which acupoints should be targeted [8], by inquiry (cf. taking a history) and by palpation (cf. physical examination). Unfortunately, some practitioners do not follow this methodology and inadvertently perform what might be termed “sham acupuncture” – essentially needling the body without a coherent strategy [9]. 2013 63:1

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THE PREACHING PORCUPINE SHOULD BE FOUND INNOCENT UNTIL PROVEN GUILTY

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Given the emphasis on individuality in acupuncture, its administrator necessarily impacts patient outcome. The success of acupuncture perhaps depends on communication above all else; therefore, it is essential that the patient should feel entirely comfortable with their acupuncturist. But does acupuncture really work? Ultimately, the hype surrounding acupuncture comes down to its therapeutic efficacy. Many clinical trials investigating acupuncture employ variations of a non-invasive “sham acupuncture” procedure as a control: needling random points on patients without penetrating the skin. Recently it was found that although true acupuncture may show some effect when compared to no acupuncture treatment, it does not “significantly outperform sham acupuncture” [10]. The efficacy of acupuncture thus could be due to so-called placebo effects. However, it is also possible that the act of needling itself, or other factors involved in true acupuncture, may have therapeutic effects [10]. For chronic back pain, a Cochrane metaanalysis showed that acupuncture was no more effective than conventional therapies, although a combination of acupuncture and conventional interventions appeared superior to standard therapy alone [11]. However, ‘conventional therapy’ for osteopathic complaints – typically painkillers with physiotherapy – shows limited and unpredictable benefits, arguably inflating the reported efficacy of acupuncture. Nonetheless, the National Institute for Health and Clinical Excellence (NICE) now recommends acupuncture in the treatment of back pain. In short, acupuncture may provide relief to at least a subset of patients. Clinicians and patients alike should be encouraged to treat acupuncture as a conceivable adjunct therapy, lifting it from the much-maligned fringes of ‘alternative medicine’. The underlying mechanism of action of acupuncture is still not known. With regard to Qi, one suggestion is that these reflectneuronal signals in the body: the meridians 2013 63:1

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thus corresponding with nerves [12]. However, such speculation has failed to survive scientific scrutiny. Yet dismissing acupuncture as a simple placebo is equally unsatisfactory. While it may be that acupuncture stimulates endogenous opioid production, a 2010 paper in Nature proposed an alternative mechanism. In mouse models needled around the knee’s “Zusanliacupoint”, a local rise in adenosine was believed to suppress pain sensation via A1 receptor signalling [13]. This finding is consistent with the knowledge that tissue damage is often associated with increases in extracellular nucleosides. It is likely that acupuncture does not act by one mechanism alone. Its efficacy may lie in its modulation of the limbic-paralimbicneocortical network (the brain’s “emotional” system) [14]; reduced inflammation via release of vascular factors [15]; and/or altered local microcirculatory characteristics [16]. Elucidating the specific pathways involved may be of pharmacological benefit, possibly allowing downstream messenger cascades to be appropriately increased or suppressed with targeted agents. The reality is that chronic pain is one of the largest medical health problems in the developed world, affecting about 13% of the adult UK population[17] and costing Europe as much as €200 billion/year. While chronic pain management is further limited by individual variation, perhaps acupuncture’s greatest strength is that it focusses on treating the person, not just their illness. Cost effective (at roughly£25-50/session [18]), the argument that it would be “worthwhile to add solid needles to the armamentarium of hollow needles in the treatment of chronic pain” [19] is gaining momentum. An increased emphasis on holistic medicine further makes a case for acupuncture in the Court of Science: the preaching porcupine should be found innocent until proven guilty. A paucity of evidence in favour of its innocence is insufficient cause for a conviction.

Full references available at: www.omsg-online.com

Zoon Tariq is a third year medical student at Jesus College The author would like to thank Mr Andrew Zamore, Mr Christopher Poh, Miss Anam Baig, and Miss Laura Munglani for their time and input.

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CHRONIC PAIN: IMMUNE MODULATION GONE WRONG?

IMAGE/WIKICOMMONS

THOMAS FROST addresses why microglia might just hold the key to chronic neuropathic pain

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hronic pain has become the silent epidemic of our time. Despite statistics showing that moderate-to-severe chronic pain affects nearly one in five people in Europe, we have only an incomplete and at times rudimentary understanding of the mechanism behind it [1]. Worse yet, chronic pain is notoriously difficult to treat, with painkillers often having little to no effect. At the most fundamental level, chronic pain represents a change in the balance of excitatory and inhibitory impulses in the nociceptive nerves of the spinal cord, lowering their threshold of activation to a hyperalgesic state in which pain signals become over-exaggerated [2]. Likewise, weaker non-nociceptive inputs that are received and ordinarily interpreted as touch or heat

of “strong” opioids to treat their pain [1]. Experiments in microglia have investigated why opioids have such poor efficacy in the treatment of chronic pain. The results are remarkable. It appears that microglia express a toll-like receptor which opioids can bind to and activate, resulting in an increase in P2X4 receptors on the membrane surface [9]. In other words, by treating chronic pain patients with opioids, doctors could well be inducing both analgesic and hyperalgesic effects. These two effects would likely countersuppress one another, offering a plausible explanation as to why opioid use can often have diminished effects when treating chronic pain. Recent studies have begun to implicate this mechanism in the development of opioid tolerance following prolonged use [10].

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THE OBSERVATION OF MICROGLIAL ACTIVATION FOLLOWING PERIPHERAL NERVE INJURY HAD BEEN OVERLOOKED BY MANY AS A MERE EPIPHENOMENON

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begin to activate the nociceptive nerves instead, and are sent on as pain signals. Allodynia is the perception of these non-painful stimuli as painful, and normally occurs at the site of an injury. Recently, the P2X4 receptor (P2X4R) has been identified as likely having a critical role in producing and maintaining chronic neuropathic pain. Within the spinal cord, P2X4Rs are predominantly found in microglia. The observation of microglial activation following peripheral nerve injury had been overlooked by many as a mere epiphenomenon. However, experiments in mice with induced neuropathic pain have shown that blocking P2X4R causes rapid relief of pain behaviour [3]. Further, a temporal relationship has been demonstrated between the upregulation of P2X4R expression and onset of allodynia [4]. Pain behaviour of P2X4R knockouts has also been shown to fall significantly following peripheral nerve injury, as compared with normal mice under the same conditions [5]. These experiments illustrate a role for P2X4Rs in maintaining neuropathic pain. However, P2X4R upregulation within microglia has also been indicated in initiating neuropathic pain. When P2X4R-stimulated microglia were injected into the spinal cords of uninjured rats, mechanical allodynia developed soon afterwards [3]. Here, the role of brain-derived neurotrophic factor (BDNF) is thought to be significant. By causing a shift in the neuronal anion gradient, pain signals to both noxious and non-noxious stimuli are amplified [4, 6-8]. This recent evidence suggests that P2X4Rupregulation in microglia is a critical component in the pathogenesis of chronic neuropathic pain. Almost half of all patients with chronic pain in Europe have at some point chosen to switch to stronger pain medication; 12% of chronic pain patients report the use

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This research offers exciting new possibilities for the treatment of chronic pain sufferers. Drugs that suppress the expression of P2X4Rs would be worth investigating clinically. Further, inverse opioid agonists (e.g. naloxone) and opioid antagonists (e.g. naltrexone) have been shown to be effective in reducing pain when applied intrathecally in conjunction with standard opioid administration [9, 10]. These drugs could well be streamlined into clinical trials within two years. As things stand, large areas of the microglial activation mechanism are yet to be explored and important questions linger. Is this activation mechanism different from that triggered during an immune response? If so, what other differences could exist between normally and dysfunctionally activated microglia? Crucially, can these differences be exploited clinically? Although much of this territory remains unchartered, the discovery of microglial involvement in pain modulation over the past five years marks a resounding leap forward in our understanding of chronic pain. Researchers now find themselves face to face with multiple treatment pathways that target microglial activation. Their goal is clear; for if successful, their work could greatly accelerate the effective palliation of chronic pain. Full references available at: www.omsg-online.com

Thomas Frost is a first year medical student at Lincoln College The author would like to thank Dr Norman Marcus for his support and advice.

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ERASING MENTAL PAIN SOPHIE McMANUS explores the future of PTSD treatment

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n the wake of tragedies such as the Sandy Hook shootings, post-traumatic stress disorder (PTSD) is a topical condition. Apart from the obvious immediate horror of such a scenario, a more insidious effect is the psychological scarring often experienced by survivors. People who witness traumatic events may be left with debilitating symptoms of PTSD, ranging from unexplained pain to night terrors [1]. Fear conditioning occurs in the brain’s limbic system; stimuli previously perceived as neutral are associated with the traumatic event. A sudden sound or the odour of burning becomes a potent conditioning stimulus that triggers symptoms of PTSD, including vivid, uncontrollable flashbacks. These can blight the sufferer’s life to the extent that normal day-to-day conduct becomes impossible and the condition is termed disabling [2]. In a recent survey, PTSD was estimated to affect up to 1.8 million British adults [3]. Evidently, PTSD is a condition in need of careful attention. Patients are commonly victims of rape, combat or terrorism. Indeed, the type of trauma affects the likelihood of contracting PTSD; up to 40% of survivors of ter-

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IN A RECENT SURVEY, PTSD WAS ESTIMATED TO AFFECT UP TO 1.8 MILLION BRITISH ADULTS

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rorist attacks go on to exhibit classic signs [2]. Counselling is often used to manage PTSD [2], but for many patients this is not enough. In the case of young children with PTSD, for example, it can be difficult to explain the incident or to detail the associative fear they may feel. Similarly, victims of sexual abuse are often reluctant to talk about their experiences [2]. In recent years, scientists have sought to better understand PTSD to help relieve the terror described by patients. Today’s research takes a radical approach: exploiting the pliable nature of memory.

MEMORY MODIFICATION A multitude of potential options now exist for tackling PTSD. In 2005 Margaret Altemus and colleagues at Cornell University began a study in PTSD subjects using the beta-blocker propranolol [2]. This drug appears to block neurotransmitters involved in memory formation. A phase II clinical trial in which war veterans are given beta-blockers to help alleviate flashbacks is currently underway at Yale [4]. Similar research is ongoing in Canada: in 2008, work by Dr Alain Brunet attracted the interest of America’s Department of Defence. Subsequently, research teams in the USA and Canada were awarded US military funding of approximately $7 million [5]. Research into PTSD memory blockers could be lucrative – in 2004 the PTSD treatment market was valued at $4.3 billion [6]. In 2007 the putative role of the enzyme PKMzeta in memory formation became a subject of investigation by Dr Todd Sacktor.

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In a study performed in New York, PKMzeta was chemically blocked in the insular cortex of rats, a brain region associated with taste. The animals had been taught to reject saccharin, as researchers had paired it with lithium to cause sickness. When a drug called ZIP was administered, PKMzeta activity was blocked. From then on, the rats appeared to have forgotten their previous association between saccharin and nausea.

VICTIMS OF SEXUAL ABUSE ARE OFTEN RELUCTANT TO TALK ABOUT THEIR EXPERIENCES

Nonetheless, such concerns must be weighed up against contributions from PTSD patients. One patient is quot-

The memories had been totally erased and the effect appeared permanent [7]. Sacktor suggested a role for PKMzeta block in treating PTSD, hypothesising that traumatic memories could be selectively blotted out in these patients. This work therefore built on the less fine-tuned effect of propranolol. Most recently, dopamine receptor agonists have been suggested as an option for PTSD treatment. Although they do not destroy memories, these drugs may prevent spontaneous recall of aversive memories [8]. The most prominent study involved the D1 receptor in the medial prefrontal cortex. Having received D1 agonist infusions, rats presented with an olfactory aversive stimulus did not exhibit their usual fear response. Associative aversive memory production had effectively been dampened by interfering with dopaminergic transmission. What is most promising about this work is that the integrity of the memory was not compromised, but spontaneous recall was still prevented. This is a marked advantage over proprano-

IN 2004 THE PTSD TREATMENT MARKET WAS VALUED AT $4.3 BILLION

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lol or a PKMzeta antagonist, as modulation of PTSD symptoms in this instance would be more subtle. With this method of treatment, traumatic memories would remain stable, but the characteristic ‘flashback’ element of PTSD could be controlled. We note, then, a certain progression in this field; propranolol resembles something of a pharmacological ‘hammer’ compared to the more nuanced approach of recent studies.

WHERE ANGELS FEAR TO TREAD? Although many people blighted by PTSD would welcome advances in treatment, proposed therapies pose major ethical and legal concerns. The modification of a sufferer’s memory raises concerns pertaining to the possible abuse of treatment. Ethical implications are well summarised by Dr Paul McHugh of the

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Johns Hopkins University: “If soldiers did something that ended up with children getting killed, do you want to give them beta blockers so that they can do it again? Psychiatrists are once again marching in where angels fear to tread.” [2]. Fear of PTSD treatment being used as a ‘get-out clause’ is not unique to Dr McHugh; when the President’s Council of Bioethics convened in 2003 to discuss implications of potential memory alteration in PTSD patients, the Council was, for the most part, sceptical of the merits of memory dampening [6]. Some even foresee a dystopian future in which memory-blockers are used to crush natural responses to suffering, create a ‘false sense of happiness’ and tamper with the concept of human identity.

PSYCHIATRISTS ARE ONCE AGAIN MARCHING IN WHERE ANGELS FEAR TO TREAD

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ed as saying: “I have PTSD and would sell my soul to the devil himself to be rid of my hellish 24/7 flashbacks and night terrors” [6]. It is clear that PTSD can represent an enormous obstacle to daily living; therapeutic modulation may bring a new lease of life to many such patients.

SCIENCE OR FICTION? In the film ‘Eternal Sunshine of the Spotless Mind’ a quirky couple seek to ease the pain of their break-up by paying for complete memory erasure. This outlandish premise makes for an engaging story, but by the end of the film the conclusion proposed is that ‘scrubbing out’ memories is a childish, shortterm solution to an underlying problem. The technologies mentioned in this article are hardly as heavy-handed as total memory obliteration; the aim is to lessen psychological trauma rather than erase it altogether. However, some researchers believe that the potential use of technology to snuff out PTSD symptoms could in reality be more damaging than PTSD itself. Their argument is that PTSD is a natural way in which the brain deals with trauma or grief. Using drugs as ‘psychological painkillers’ could do more harm than good in the long term. The question is not whether scientific progress in PTSD treatment is achievable, but whether the moral conundrums facing trauma intervention can be suitably addressed. Full references available at: www.omsg-online.com

Sophie McManus is a second year Biomedical Sciences student at Magdalen College

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lindfolded, hands tied and head held on a chopping block, dissatisfied medical students terrorised their ‘unpopular’ teacher. With the falling axe simulated by a swishing broom and a wet cloth dropped on his neck, the man died on the spot [1]. This phenomenon, whereby negative expectations lead to actual consequences, was later termed ‘nocebo’ (Latin for I will harm) by Walter Kennedy in 1961 [2]. Although the nocebo effect has struggled to escape the shadow of its more celebrated twin, it has potentially serious implications within the clinical setting. Many powerful illustrations come from randomised control trials, particularly when placebo subgroups report comparable side effects to those encountered within the intervention cohort. For example, metaanalytic data assessing neoteric anti-convulsant agents demonstrate equivalent anorexia, memory disturbances, paraesthesia and upper respiratory tract infections in both the treatment and placebo groups [3]. Such retrospective analyses suggest that negative expectations can be translated into genuine adverse outcomes. Intuitively, a potential means of avoiding the nocebo effect is to reduce initial negative expectations. The use of the hormonal therapy finasteride in benign prostatic hyperplasia (BPH) has well known unintentional outcomes, including decreased libido, erectile dysfunction and ejaculatory problems. BPH patients were randomised into two groups: one informed of potential side effects and the other not. Reported side effect incidence was 30% higher in the informed group [4]. Similar results have been seen in studies assessing the efficacy of local anaesthesia, where the positivity or negativity of comments from the administering clinician acted as a reliable predictor of the level of pain relief subsequently achieved [5].

These studies raise a pertinent question: Can the power of negative suggestion have real effects on clinical outcomes and therefore be manipulated therapeutically? The ability to avoid side effects by minimising negative suggestion in the clinical setting provides us with an ethical dilemma.

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SAM BILTON addresses the role of the doctor in minimising the negative outcomes of clinical interventions

The nocebo effect: placebo’s not so insignificant twin CAN THE POWER OF NEGATIVE SUGGESTION HAVE REAL EFFECTS ON CLINICAL OUTCOMES AND THEREFORE BE MANIPULATED THERAPEUTICALLY?

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While the notion of informed consent requires us to disclose all relevant information – both good and bad – we are also compelled to minimise the potential harm of therapeutic intervention [6]. Whilst it may be unreasonable to completely ignore predictable side effects, consent may be sought while lessening nocebo-related outcomes. In one study, patients given a standard influenza vaccine were either informed of the percentage of patients free of side effects (positive framing), or of the percentage reporting side effects (negative framing). Those receiving positive framing described significantly fewer complications, highlighting the importance of language used by doctors [7]. Authorised concealment has also been considered an alternative. In this approach, patients are asked for permission to allow details of potential side effects to be withheld [6]. The patient must, however, still be briefed about severe and/ or irreversible complications. The challenge then lies in correctly identifying which issues merit full disclosure, and which may be withheld. Whilst the nocebo effect is a real, everyday phenomenon, its effects on patients can certainly be altered. Careful management of verbal communication and a reassuring, empathetic approach is therefore key in adverse risk reduction. However, the full scope and severity of the nocebo effect – and the potential benefits obtained by minimising its influence – has yet to be conclusively explored. Full references available at: www.omsg-online.com

Sam Bilton is a third year medical student at Brasenose College.

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Do you really feel my pain? EMILY ARCH explores whether medical students are as empathetic as they believe

Pain is a very personal experience, making it a tricky starting point. It has multiple components, but importantly can be boiled down to either “pain” or “no pain”. Perhaps showing that an individual feels their own pain when observing another’s is enough to support the existence of empathy? Neuroimaging studies show just that. If you put someone in an MRI machine and imply that their partner is in pain, some of the regions activated are identical to when they themselves are in pain (namely the posterior anterior insula (AI) and mid-anterior cingulate cortex (ACC)) [1]. These same regions are also activated when viewing images of pained faces [2]. Subjective reports of feeling

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T BETWEEN EMPATHY AND SYMPATHY

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empathetic appear to correspond to increased activity within the AI and ACC, while specific lesions within these structures inhibit the ability to recognise painful expressions in others [3]. These shared neural representations could reflect the emotion felt by the subject and invoked in the observer: the shared emotion or “empathy” between people. However, these shared regions do not represent the whole pain experience. Empathetic pain does not involve somatosensory areas so is arguably not “felt” (at least in the same way). Equally, these are both well-established integrative regions in the brain; it is possible that they are merely coincidental processing pathways rather than necessary components in the neural signature of pain. Still, studies imply that empathetic pain is, at least qualitatively, similar to personal pain. A subject’s own pain experience is enhanced by the feeling of empathy; for example, mice watching their cagemates writhe around in pain have significantly reduced tolerance to pain themselves [4]. However, it is problematic to assume that the mouse actually experiences empathy. It could be that just observing another mouse’s pain behaviour leads to the

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expectation of pain, and therefore an increased pain response. Human studies have the advantage that subjects are able to report how they actually feel. Additionally, various techniques can be employed to encourage high empathy states – such as using an actor to recount touching personal stories to participants. When this actor is then subjected to pain alongside these participants, those who reported feeling empathetic declared their own pain to be both more intense and more unpleasant [5]. What does this all mean? Well, for the medical profession, when you have someone screaming the ward down in the emergency department, it’s possible that their empathetic neighbours may end up in more pain themselves. More clinically, pinpointing the source of empathy could help to understand conditions where it is lacking; ranging from the social difficulties encountered in the autism spectrum disorders (ASDs) to the psychopathic Hannibal Lecters of the world. This may be true for alexythmia, a personality disorder characterised by the inability to identify and describe emotions in the self. The low empathy scores seen in this condition appear to be strongly correlated with reduced AI activity [6]. Someone who cannot identify their own emotions therefore struggles to empathise with others’. It again seems that empathy requires the same neural pathways as a given first person emotion, and that we really do understand another’s pain by “feeling” at least an element of it ourselves. This all seems to point to the fact that you have to already ‘know’ an emotion or feeling to empathise with it. In this case, this brings to mind the rare but well-described group of people with a congenital insensitivity to pain and whether they are capable of true empathy. A recent New York Times interview would suggest not. One paininsensitive teenager has “studied the expressions other people made and learned to cringe when someone described something painful” but was incapable of describing pain beyond the con-

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mpathy: the ability to share the feelings of others; the Holy Grail to a medic. We all assured tutors that we were brimming with it in interviews, but how sure are we that empathy objectively exists? Do we really feel another’s pain, or do we just recognise it and try to help them anyway?

ARE WE ALL DESTINED TO BECOME COLD,

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cept of “that must really hurt” [7]. She has learned the correct social response to another’s pain but is unable to define the “hurt” she assumes people are feeling. She doesn’t feel empathy – as she has no meaningful concept of what these people are experiencing – but is certainly capable of the same associated prosocial responses. Anecdotal evidence doesn’t hold strong in academic circles but this certainly supports the existence of a shared emotion/ feeling in empathy. This raises the question of how well one needs to know another’s pain to empathise with them. Do you need to have experienced exactly the same pain stimulus before, or is an awareness of pain as an experience enough? Worryingly for us self-confessed “empathetic” medics, one study suggests that you can be desensitized to pain stimuli by associating them more frequently with other brain states. For example, acupuncturists lack the activation of pain regions when viewing needles being inserted into another’s body. Instead they associate the normally painful experience with concentration, activating regions hypothesised to be important for emotional regulation and executive functions [8]. It is possible that medics lose the ability to empathise with patients once accustomed to performing routine procedures on them. If so, are we all destined to become cold, heartless ‘House-esque’ doctors? More importantly, should we even be worried about this? The inbuilt ability to down-regulate our own empathetic response could certainly be useful. Arguably the best doctors are those who are able to treat their patients, no matter how upsetting that may be, as opposed to those who break down at your bedside. There’s a crucial difference between feeling every emotion your patient does (empathy) and caring that they feel a certain way (sympathy). While sympathy certainly has a place in medical practice, less empathy could be seen as a blessing in disguise. It seems like it could be time to stop looking for this elusive “empathy” in medical school applicants; it’s probably not that useful in a medical context and they’re most likely going to lose it anyway. Perhaps the cold-hearted consultant shouldn’t be criticised for their matter-of-fact attitude at the end of the bed. Just as long as their name’s not Dr. Lecter, we can stop judging them by their ability to empathise and focus on their practice instead. Full references available at: www.omsg-online.com

Emily Arch is a fourth year medical student at Brasenose College.

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Did you want to climb mountains? BING TSEU listens to one patient's personal experience of living with multiple sclerosis to uncover what she feels is important "I'm afraid I'm going to have to give that one a bit of thought," Sylvia begins, shifting gently in her chair before letting out a wry laugh. "Typical. All these years of talking to doctors and I haven't got an answer for the first thing you throw at me." Sylvia sits in silence, resting her head on the tips of her fingers as she carefully considers her response. Little flashes of sadness play across her ageless face, but it's not long before she breaks through with a triumphant smile. "I have an answer," she continues gingerly, "but it's a bit of

over and over again." She grimaces slightly before finally putting the cup to her lips. "When it strikes, well, the agony just makes everything seem so unimportant in comparison. I can't think straight, let alone hold a polite conversation." She sighs, allowing the teacup to find home in its saucer. "I remember this one time; I was out in the park with my son. This was many years ago," she continues, gesturing towards a series of faded photos on the wall, turned sepia by the sun. "He was six then. You wouldn't think it from looking at him

THE HARDEST PART IS HOW MUCH IT HURTS; AND JUST HOW HELPLESS IT MAKES ME FEEL

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a cop-out and so you might not like it… What I find worst about having multiple sclerosis really changes depending on when you ask me." "There's something really quite awe-inspiring about having a relapse. They say that everyone with MS has a different experience and I have to say that trying to describe it to someone else has always been difficult." Sylvia reaches for her nearby teacup, but carries on before taking a sip, holding it steady in front of her as though for comfort. "During some of my relapses, I get these episodes of neuralgia. It's this intense, unforgiving pain. I think the best metaphor I have for it is like being quickly dipped into boiling water

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now, but he was such a chubby little boy. I suppose he had to be that cute to get away with being as naughty as he was," she says, chuckling softly with her nostalgia. "He was my little tornado." "It was a nice day so we went out for a walk. Just the two of us. He ran off a little bit ahead, like he always does, and when I jogged to catch up to him, my legs just gave way and I felt this awful pain go shooting up both my legs. I'm not sure how long it lasted - pain like that really changes your sense of time - but what I do remember is having my son standing above me crying and begging me to get up and stop playing around." Sylvia frowns and cradles her hands in her

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lap before carrying on. "At that time, all I wanted to do was to hold my son's hand and whisper in his ear that everything would be alright." She shakes her head from side to side in solemn exasperation. "But I couldn't. The horrible thing about moments like that is that the pain really isolates you from everything else. It's just you and the disease having some quality time together whilst you're begging for someone to make it stop."

and I think it's awful that all the grief and misery it has caused doesn't get more attention than it does." Sylvia furrows her brow, “I suppose it’s all quite hard to talk about, and especially not with my doctor. He doesn’t get very much time. He has so much to do and I can’t expect him to waste his life chasing after the hopes and dreams of every patient who stumbles in.” Looking resignedly at the ground she continues. “I don’t get

THE PAIN REALLY ISOLATES YOU FROM EVERYTHING ELSE

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"So," she continues, pausing as though to add to the finality of her conclusion, "to go back to your original question, if you were to ask me about MS during, or even just after a relapse, the hardest part has to be how much it hurts; and just how helpless that makes me feel." Sylvia takes the time to brush back her long black hair behind her ears before following her train of thought. "The rest of the time, however, MS gets to me in an entirely different way. I've been very lucky with the way my MS has progressed: it's been almost 15 years and right now I can still walk around quite happily," she wiggles her legs for emphasis, "but that doesn't stop it from hanging over me all the time." "It's so much more than the threat of having a relapse. Over the years my MS really has dictated a lot of my decisions and, to tell you the truth, that really does depress me sometimes." Sylvia stares out of the window as she continues: "our family moved into this flat so that I could use the elevator to get upstairs for when my legs finally give in. MS has made me retire from a job I loved and has stopped me from doing so many of the things which I enjoy. It has shaped my life since the beginning

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to talk about it much – even with the students. I get wheeled in by my doctor to talk to them every now and again, the bright young things. They sit attentively, taking notes and listening to me ramble on, but when they get to ask the questions, they can be so clinical. I suppose that’s ironic, really. They’ll ask about my relapses; whether I have trouble getting around the house; what kind of treatments I’ve tried.” She sighs again, slowly and deeply. “I hardly ever get asked the questions I’d like to hear. ‘Are you happy?’ ‘How do you feel?’ ‘Did you want to climb mountains?’” “I guess it would just be comforting to be reminded that doctors are still human enough to recognise that I'm a human being too. It's just that there is so much more to us patients than our symptoms. Our disease hurts us in so many ways.” Full references available at: www.omsg-online.com

Bing Tseu is a fourth year medical student at Christ Church College

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ANIMAL WRONGS CALUM MILLER argues that the commonly held view that animals experience morally relevant pain may be mistaken

It seems obvious to many people that animals feel pain. The almost unanimous response of incredulity towards scepticism suggests that there is some very commonsense, universal intuition at stake here. But is this intuition well-founded? I hope to demonstrate that it is not as clear as might seem to be the case, and that sceptics ought to be taken seriously – or at the very least, not seen as intellectual or moral monsters. Of course, it should be perfectly plausible that not all lower forms of life feel pain. After all, most of us don’t consider bacteria or simple multicellular organisms to be conscious. At the very least, it’s unclear where pain - or any consciousness at all - kicks in, evolutionarily speaking. This should suggest to us that the question of which animals feel pain is a serious and rightly controversial one. Even if our intuitions that bacteria do not feel pain and that chimpanzees do were correct, we would still be left with some far from obvious cases: what about snails, stick insects or tapeworms? Even if we set aside these grey areas, however, there is good reason to doubt our intuition and rigorously question the supporting arguments behind it. By far the

most common of these is that animals exhibit “pain behaviour” – they nurse wounds, yelp when kicked, retract from “painful” stimuli and avoid “painfullooking” objects or creatures. But clearly it’s possible that they do all this without actually feeling pain; indeed, we know that certain organisms exhibit some kind of “pain behaviour” without the emergent sensation itself. Bacteria, for example, retract from noxious substances, but no one infers that they feel pain when they come into contact with them. So there is no strictly logical inference to be made solely from pain behaviour. Might pain behaviour nevertheless provide evidence for the view that animals feel pain? Again, this is not obvious. Given evolution, we would expect pain behaviour even if animals didn’t have a conscious experience of pain. Evolution selects for organisms better adapted to living and reproducing, and pain behaviour helps in these respects. Just as bacteria retract from noxious substances, animals have evolved to do the same in their respective macroscopic ways. An animal with an unconscious pain withdrawal reflex is less likely to be harmed by dangerous substances, and an animal that nurses its wounds is less likely to die from them – both promoting survival. Pain behaviour therefore seems equally likely whether or not they actually feel pain, and so it is hard to see how observable behavioural motifs can be used as evidence at all. Indeed, if the hypothesis that animals feel pain gives us no more predictive power than evolution alone, is

IT’S NOT OBVIOUS THAT IT’S WRONG TO CAUSE PAIN TO SOMEONE IF THERE’S NO UNPLEASANTNESS ASSOCIATED WITH IT

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GIVEN EVOLUTION, WE WOULD EXPECT PAIN BEHAVIOUR EVEN IF ANIMALS DIDN’T HAVE A CONSCIOUS EXPERIENCE OF PAIN

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it not an unnecessary addition to be dissected by the sharp edge of Occam’s razor? Certainly, there is a case to be made here. The deceptive power of pain behaviour might be made plainer by considering known instances where such behaviour may seem to indicate pain, only for us to later find out that there was no plausible underlying conscious experience leading to it. I have already alluded to such an instance in the case of the pain withdrawal reflex – while looking at a human withdraw their hand from a hot surface, we intuitively judge that the human must have felt pain. However, reflection on the timing of such scenarios makes it very unlikely that conscious pain led the hand to withdraw; indeed, more rigorous studies have confirmed that the pain behaviour is initiated before any conscious experience [1]. Similarly, a series of experiments by James Grau and others has demonstrated that much of the pain behaviour of rats, while seeming to be mediated by conscious experience of pain, can be explained by complex patterns in the spinal cord alone. For example, rats still have paw withdrawal and tail-flick reflexes even when spinalized at birth. Moreover, more complex trained responses, like keeping a paw up in the air to avoid shock, can also be learned in spinalized rats [2]. So we know that not all apparent pain behaviour is mediated by conscious experiences of pain – and perhaps none of it is. The “morally relevant” clause in my opening question may seem perplexing at first, but recent developments in neuroscience show that there can indeed be kinds of pain which are not necessarily morally problematic. Studies suggest that there are at least two quite different pain processing pathways: discriminatory, through the ventroposterolateral nucleus of the thalamus and onto somatosensory cortex, and affective, thought to run through the intralaminar nuclei of the thalamus to anterior cingulate and prefrontal cortex. The discriminatory pathway relays information regarding site and modality of sensory input, while the affective pathway mediates the feeling of “badness”.

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This distinction can plausibly be seen as paving the way for a kind of pain which is not morally relevant. Consider pain asymbolia, a condition where patients are able to report pain intensity and location, but do not associate it with an overarching unpleasant feeling. This most frequently occurs as the result of a cingulotomy or lobotomy. Some reflexive avoidance is retained in such patients, but they claimed not to be bothered by, or afraid of, the pain. It’s certainly not obvious that it would be wrong to cause this kind of pain, since there is no sense of emotional aversion associated with it. It seems then that negative affect may be required for a morally relevant kind of pain. Might there be other necessary components – that the pain is “owned” by a person and attributed to themselves, for example? What if a patient attributed their pain to someone else, or to no one in particular? Perhaps a clear sense of self-identity and self-attribution of sensory experiences is necessary. While this may seem abstract and perhaps absurd, there are hints at the possibility from certain other disorders. Somatoparaphrenia is a disorder arising predominantly from parietal lesions, where patients deny ownership of a limb or a whole side of their body, usually (if not always) in conjunction with unilateral neglect. Dissociative identity disorder and out-of-body experiences are wellknown, though controversial. Split-brain patients

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NOT ALL APPARENT PAIN BEHAVIOUR IS MEDIATED BY CONSCIOUS EXPERIENCES OF PAIN - AND PERHAPS NONE OF IT IS

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seem to be more peculiar than originally thought: Ramachandran presents one patient whose left hemisphere is an atheist while his right hemisphere is a theist [3]. This raises all sorts of questions about identity, but the one which concerns us here is whether it is possible for some people (and, most relevantly, animals) to feel pain without attributing it to themselves. The suggestion that morally relevant pain requires the pain to be “owned” by a particular person in this sense ought to be taken seriously. Do animals have enough of a sense of self-identity for their pain to be morally relevant in this way? Another requirement for morally relevant pain might be the continuity of consciousness – in the sense that painful experiences must be remembered or otherwise effect subsequent conscious life. Some drugs (e.g. scopolamine) have the ability to keep a patient conscious during a procedure, while erasing their memory. Imagine this was administered during an operation, along with a paralysing agent. Patients would presumably feel pain during the operation, but would have no recollection of it once the operation was over. Is there much of a moral difference between using this combination compared to a normal anaesthetic? If there is, it is by no means obvious. Certainly, if one was told in retrospect of an operation that this had been done to them, it would not be

clear that they should feel hard done by. It is plausible that a relevant kind of continuity is necessary here. The final common argument for the animal pain thesis is the similarity of human and animal nervous systems. While similarity can be granted for the most part, it is essential to note that the affective component of pain is mediated partly by the prefrontal cortex, which is precisely the part of the central nervous system which differs most substantially between humans and other animals [4]. While we might be reasonably confident that animals work similarly and have similar experiences to us in other respects (those based on “lower” structures in the central nervous system), the prefrontal cortex is the most important locus of significant development in the human brain, and cannot reasonably be assumed to be similar between humans and other animals. Since the affective component of pain is partly located here, this gives us very good reason to be hesitant about affirming the animal pain thesis. In sum, there is significant reason to doubt the common sense view that animals feel pain in a morally relevant sense. The reasons commonly offered in support of the view are wholly unpersuasive, and it is clear that a comprehensive account of morally relevant pain allows for significant disagreement over whether animals are victims of such. There is substantial room for empirical confirmation of one view or the other, and we should wait to see the results of such investigation before investing too much confidence in intuitive dogmas. Full references available at: www.omsg-online.com

Calum Miller is a fourth year medical student at St Hugh’s College.

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The views and opinions expressed in this article are the author’s own.

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Sports medicine: a proactive approach to public health

xercise is good. Of course, not everyone is going to be an Olympic athlete, but attempting to raise your heart rate a few times a day has multiple beneficial effects on your health - some more unexpected than others [1-3]. In 2004, the World Health Organisation (WHO) highlighted diet and physical activity as a worldwide health priority [4]. Here in the UK, an important part of the London 2012 Olympic bid was the emergence of one of the newest medical specialities: sports and exercise medicine [5, 6]. Despite this – and a growing number of clinical and public health guidelines [7-9] – the majority of UK medical schools offer only limited teaching on the benefits of sports and exercise, with little attention given to how they might be better integrated into various medical specialities [10]. If we are to encourage an active lifestyle, we must adequately prepare physicians both to be able to prescribe exercise, and to deal effectively with the physical stresses on the body that this can cause. This may require better integration of physiotherapists into the NHS care pathway, particularly in areas of the country where provision remains inadequate.

SPORTS INJURIES, PHYSIOTHERAPISTS AND THE NHS In many cases of sports-related injury, a physiotherapist is the best person for the job [11]. So, what do physiotherapists actually do? As in all times of crisis, I turned to Wikipedia: “Physical therapists are healthcare professionals who diagnose and treat individuals of all ages…who have medical problems or other health-related conditions, illnesses, or injuries that limit their abilities to move and perform functional activities as well as they would like in their daily lives” [12]. I was particularly interested by the last aspect of this description as a surrogate therapeutic outcome. Too many times I have visited my GP to be told to “rest” for an unspecified period - even though the purpose of the appointment was to minimise pain and promote recovery, whilst continuing to exercise. Like any other athlete in training, I don’t want to rest unless I absolutely have to. Although cynicism with regards to physiotherapy is not uncommon, the NHS actively supports the profession [13]. We may natu-

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rally be a little sceptical about adorning various extremities with brightly coloured tape, or allowing someone to enthusiastically manipulate our limbs, but such techniques are tried and tested [14, 15] and the Chartered Society of Physiotherapy ensures a minimum standard of training for registered practitioners [16].

“ Exercise is

an essential part of public health, which needs to be promoted

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In many places, the exact role of physiotherapists in the treatment of sports injuries within the NHS is unclear. In some trusts, there is provision for physiotherapy; however, the criteria determining eligibility and the number of sessions available vary nationwide [17]. Those tenacious patients who persevere with their request to see a physiotherapist will often be limited to an arbitrary number of sessions [18], irrespective of their individual therapeutic requirements. This means that the outcome is often unsatisfactory for both patient and practitioner. The NHS has long taken a proactive approach to public health by promoting healthy living and supporting preventative medicine. However, while those who ignore public health advice are treated by the NHS for a multitude of ailments, there is relatively limited provision of care for those afflicted by sports-related injuries. Indeed, many lucky enough to be able to afford it now use private physiotherapists as a form of primary healthcare, in place of GPs. For the most part this causes no problems, although the lack of coop-

eration between NHS GPs and private physiotherapists raises the possibility that a potential medical issue may not be appropriately escalated. SPORTS AND EXERCISE MEDICINE: THE WAY FORWARD? In Oxford, we are in the privileged position of having a specialist centre for sports medicine [19]. Local GPs are typically all aware of the facility and its role and, as a result, their referral is far more pleasing to the ears: an appointment at an NHS-funded centre that deals specifically with sports-related injury. Based at the Nuffield Orthopaedic Centre, OxSport is a dedicated centre for sports and exercise medicine. This speciality has only emerged in the last decade, in tandem with London’s Olympic bid and the Olympic legacy [5, 6]. It is not just for elite athletes, but predominantly aimed at “active people trying to stay active” [20]: OxSport currently treats individuals aged between 8 and 90! The multidisciplinary team there comprises physicians, physiotherapists, orthotists and radiologists, amongst others. The close interaction between these specialities provides comprehensive care for a tremendous range of injuries, from “biomechanical assessment” to accurately locate the cause of pain to “innovative treatments for tendon disease” [21]. I spoke to Dr Natasha Jones, a consultant in sport and exercise medicine, and Simon Wood, the senior sports physi-

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It is not to say that advances aren’t being made. OxSport is just one of several centres across the country (including Manchester, Loughborough and London [19]) which is beginning to expand what was previously an underappreciated branch of medicine. How this could be translated into less well subsidised areas remains a difficult problem, but I urge you to consider this: if we wish to promote a healthy lifestyle, we should be providing some service for when it leads to injury. So, at a time when allocation of funds is increasingly challenging, can a speciality dedicated to sports and exercise be justified? Should the taxpayer have to pay for treatment of injuries sustained by someone choosing to engage in an “above average” level of exercise? I suggest that (should provision be further expanded) the majority of patients seen would not be elite competitors,

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but – for the most part – active laypeople. Despite a shorter referral time than most other specialities [20], the time taken to complete initial screening tests and commence treatment may still be too slow for the highestlevel athletes. In addition, many sports teams provide the opportunity to see medical and physiotherapy professionals privately. Thus, it is more likely that improved sports medicine facilities would mostly deal with individuals trying to maintain a more modest level of exercise, in line with what the NHS and government currently advocate.

dedicated to sports and exercise medicine be justified?

“

otherapist at OxSport. It soon became clear that, despite my interest in both sports and medicine, my knowledge of their combined speciality was very limited. Diet and physical activity have been named WHO public health priorities since 2004 [4], yet their full benefit is often not comprehensively reflected in medical teaching [10]. I’m sure we all know exercise reduces the risk of cardiovascular disease, but how many of you were aware of the evidence for exercise as beneficial in both prevention of and recovery from cancer, and in patients with chronic kidney disease [3, 22]?

Can a “speciality

Exercise is an essential part of public health, and its promotion is important to help prevent disease and its costly sequelae. The question we must ask is whether extra investment in facilities and teaching will bring about both measurable benefit to the health of the nation and outweigh the overall financial cost of inactivity. To my mind, the answer is a resounding yes. Full references available at: www.omsg-online.com

Elspeth Cumber is a fourth year medical student at Green Templeton College. The author would like to thank Dr Laurence Leaver for his encouragement and support in the preparation of this article and Dr Natasha Jones and Simon Wood for their valuable insights. If this article has sparked your interest, Dr Natasha Jones of OxSport has said anyone is welcome to visit and spend some time with her and her team. Email: Oxsport@ ouh.nhs.uk

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Classical Pain

ISOBEL BARLING considers the presentation of pain in Homer's Iliad Society today shows intolerance towards physical pain, apparent in our blasĂŠ and liberal use of drugs to suppress it. In this respect, we have a similar attitude towards physical pain as the Iliadic heroes. But the connection ends there; due to our unfamiliarity with physical pain by avoidance, it has become something to dread and fear, a mindset alien to the heroes of the Iliad. Pain is a main theme in some Classical myths; Marsyas the satyr was famously flayed alive by Apollo for daring to challenge him in a singing contest and Prometheus had his liver eaten daily by an eagle. Yet it could be argued that even the Underworld punishments bring psychological, rather than physical torment to the transgressor. At the end of Sophocles' Oedipus Rex, Oedipus, having

discovered that he killed his father, slept with his mother and that his children are also his siblings, gouges out his own eyes. The resultant physical agony is left untold, and it is possible that Oedipus blinds himself to distract, through physical affliction, from the far more painful psychological suffering he undergoes. Physical pain is even less prominent in the Iliad. Words describing pain seldom appear, usually derived from the Greek words for anger or sorrow, the two emotions most frequently expressed. Homer is occasionally curious about types of physical pain: in Book 11 Agamemnon's wounded arm is unexpectedly compared to "when a woman in labour is taken with the sharp stab of piercing pain sent by the Eileithyiai, daughters of Hera, who bring bitter pangs of childbirth"(11.269-72). Elsewhere physical pain is only mentioned with regard to medicine; medicine being the greater point of interest. The soldier Idomeneus informs Nestor that "A healer is a man worth many others, for his skill to cut out arrows and spread wounds with soothing medicines" (11.514-5). At the end of Book 11 an example of elementary surgery even occurs when Patroclus tends to Eurypylus. Elsewhere, however, physical pain is of little consequence. It is hardly ever mentioned at the fatal moment itself. Death is not romanticised in the Iliad; on the contrary, the poet's desire to convey the violence of the battlefield often results in some horrifically detailed descriptions. To give an example: "Idomeneus stabbed Erymas in his mouth with the

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Cowards might fear pain, but we see very few of them in the Iliad; valour is, after all, one of the heroic virtues pitiless bronze. The bronze spear passed right through and up under the brain, smashing the white bones. His teeth were knocked out and both his eyes flooded with blood" (16.345-9). We see guts and bowels gushing to the ground, spattered brains, and heads hanging by the skin. As a device to emphasise the incredible speed of a hero, occasionally a victim continues to entreat his victor for mercy even after his head has been severed. But the physical pain is irrelevant, an inconvenience to the practical function of the fighting hero. This is evident in Book 11 when, wounded, Agamemnon "shuddered in horror" but "kept plying his attack... as long as the blood still gushed warm from his wound. But when the wound started to dry and the flow ceased, then sharp pains began to overcome his strength of spirit" (11.254-68). It is what happens to the body after death that matters. The mutilation of his corpse, should it fall into enemy hands, is one of a hero's greatest fears as it would bring post mortem dishonour. A common taunt uttered by a victor before striking the killer blow is that his victim will 'make sport for the dogs and birds of Troy'. Receiving proper burial rites was a prime concern in Iliadic society, overwhelming any fear of pain. It was believed that the shade of the deceased would linger forever on the banks of the Styx if denied burial. Hector's death in Book 22 demonstrates these cultural priorities: "flesh showed... at the gullet, where a man's life is most quickly destroyed. Godlike Achilles drove in there with his spear...and the point went right through his soft neck, but... did not cut the windpipe, so that Hector could still speak" (22.324-9). Hector seizes the opportunity to beg Achilles not to let his corpse be mauled, which Achilles refuses, and we see the dead Hector's beautiful head dragged along the dusty ground, attached to Achilles' chariot through his ankle tendons. In the second part of his appeal Hector had asked for a proper burial. Nowhere in this climactic scene - the duel between the two greatest heroes - is physical pain mentioned. Compared with other concerns, it

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is considered too trivial to record. Cowards might fear pain, but we see very few of them in the Iliad; valour is, after all, one of the heroic virtues. It is death itself and its aftermath that is feared by the Iliad's heroes, and even then only if death comes before they have attained sufficient kleos (glory) and timÄ&#x201C; (honour). Hence Achilles, with his abundance of kleos, is utterly fearless of the preordained brevity of his life. The most substantial passage in the Iliad on the subject of physical pain occurs, surprisingly, in the immortal sphere. The mortal hero Diomedes has stabbed the goddess Aphrodite and there is no doubt that physical pain is hence described: Aphrodite is "in terrible affliction... in an agony of pain, her lovely skin darkening with blood"; "I am in agony with a wound which a mortal man dealt me" (5.352-61). But Aphrodite enjoys an immediate recovery. Dione has merely to "wipe away the ichor from her daughter's hand: the hand was healed, and the heavy pains soothed away" (5.416-7). Athene likens Aphrodite's wound to a scratch from a dress-pin (425). The god Ares is also wounded by Diomedes, and Ares reflects in horror how he could have been "lying there suffering long in agony among the grim dead" (5.885-7). But "Paieon spread pain-killing medicines on him and cured him, since he was not of mortal make" (5.900-1) - this is key. Pain is easily remedied for the gods, and death is out of the question. Homer uses pain here to illustrate the gulf that lies between mortals and immortals, and so generate pathos. The gulf is mortality, not pain. The formula for when a young hero dies in battle is: "and his soul fled down to the house of Hades, lamenting its fate, leaving youth and manhood behind"; the soul itself is reluctant to die so prematurely. It is the inescapable finality and immediacy of death for mortal heroes that is emphasised; pain implies lingering and the hope of recovery. It is significant that, in punishment for causing pain to an immortal, Dione predicts death for Diomedes and the grief of his family, not reciprocal physi-

cal pain (5.406-15). Before duelling, Achilles taunts Asteropaios not with the physical pain he is about to undergo but with the warning, "misery comes to the parents of those who face my strength"(21.151). The Iliad's main concern is thus with emotional pain, and could be termed more appropriately a tragedy than an epic. For Homer's characters, unbearable sorrow is far more painful than pain itself. In the Odyssey, too, emphasis is given to mental over physical torment: "Helen... had a happy thought. Into the bowl in which their wine was being mixed, she slipped a drug that had the power of robbing grief and anger of their sting and banishing all painful memories" (Odyssey 4.219-32). The anodyne, possibly some sort of opiate, is used not as a treatment for physical pain but as a cure for depression; Helen gives her sorrowful guests sweet oblivion - the perfect hostess! The characters in Homer are therefore indifferent to physical pain, regarding it as an incidental companion of death. The culture, beliefs and practicalities of the society we see in the Iliad meant that death still posed a threat where pain did not. It is difficult to determine how far Homer's Iliad reflects the realities of war for the individual who was not Achilles, for whom physical pain would have been a natural and involuntary dread, regardless of cultural values. Explained from a literary aspect, Homer's concern was to express emotional rather than physical pain in his text, but the astoundingly steadfast mentality of the Iliad's heroes might still reflect some reality of the attitude of Homer's contemporary society. All in all, we make a pretty soft bunch in comparison. Full references available at: www.omsg-online.com

Isobel Barling is a fourth year Classicist at Trinity College The texts used in this article are Martin Hammondâ&#x20AC;&#x2122;s translation of The Iliad, Penguin Classics, 1987 and E.V. Rieuâ&#x20AC;&#x2122;s translation of the Odyssey for Penguin Books, 1984.

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Medical Etymology A beginner’s guide

EDWARD CHESNEY takes us on a heroin-addled, botox-ridden, formicating ride from erotica to evidence based medicine Pain is the theme of this issue of the Gazette and so pain is where we’ll start. The word “pain” is derived from the old French word peine, which is from the Latin word poena, which in turn came from the Greek word ποινή (poine). ποινή can be translated as price paid, penalty or punishment [1], and is also the root of the word pine. Pining is something you will do if you are in pain, perhaps for some morphine, a word with a much more captivating effect, sound and etymology. Morphine is named after Morpheus, the Greek god of dreams [2]. He inhabited the underworld in the form of a winged demon, and had the ability to change – or morph – into any human form. He was the son of Hypnos, the god of sleep, whose name has given us the words “hypnotic” and “hypnosis”. The two gods share the poppy as their symbol, which is not only the source of morphine, but also its derivative, Heroin. Heroin, also known as smack, skag or brown, is a trademark for diacetylmorphine. It was first synthesized by the chemist C.R.Wright in 1874 [3] during his quest for a non-addictive substitute for morphine. The German company Bayer believed he had succeeded, and marketed the new drug as an over-the-counter analgesic and cough suppressant. A clever marketing ploy led to the name “Heroin” being chosen due to the drug’s perceived euphoric, or ‘heroic’ effects (from the Greekk ἥρως (heros) meaning “demi-god”) [4]. The name “Heroin” first appears in the Lancet in 1898 [5]. A lancet is a surgical knife or scalpel, derived from the Iberian word lancea meaning light “javelin” which, having made its way though Latin and old French, entered the English lexicon in the 14th century [6]. “Lancet” was chosen as the title for the journal in 1823 as it also refers to the lancet arch, a sharp-pointed window that metaphorically illuminates the medical profession to this day [7]. From lancet arches to archery. The Greeks used to fight with poison arrows, and as a result, their word for bow τόξον (toxon) has given us the word “toxin” [2]¬. Botulinum toxin, a treatment for cervical dystonia, has had its name shortened to the more chic ‘Botox®’, a name which has made the toxin more amenable to being injected into Simon Cowell, Gordon Ramsay and assorted footballers’ wives’ foreheads by men in pinstripe suits. As well as taking them away, botulism still makes headlines; as recently as last July the HPA identified a dodgy jar of olives containing the toxin, which led to the admission of one Oxfordshire resident to the John Radcliffe [8]. In 1817, Justinus Kerner published a paper entitled Vergiftung durch verdorbene Würste [9] which translates roughly as ‘Poisoning by spoiled sausages’. In it, he describes what is now known as botulism. However, rather than naming the substance something snazzy like Würstoxin, Kerner chose the Latin word for sausages, botulinum. It wasn’t until 1897 that the bacteria producing the toxin were finally isolated: the University of Ghent’s Professor of Bacteriology, Emile Pierre van Ermerngem, found the bacteria in a suspect batch of ham after it had killed three guests at a wake, and named the species Clostridium botulinum [10]. Digoxin, a portmanteau of digitalis and toxin, is a purified extract from the foxglove, or digitalis plant [11]. Rather than originally com-

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It is hopefully not an unfathomable leap from fairies to mystical butterflies, because that’s where we’ve landed. In the mid-2nd century, a Numidian Berber called Lucius Apuleius wrote one of the only complete and surviving Latin novels, The Golden Ass. One of Apuleius’ stories is the tale of Cupid, the god of desire, and Psyche, the goddess of the soul, who was depicted as a butterfly. The two lovers had a daughter called Hedone, the goddess of sensual pleasures whose name has given us the words hedonism and anhedonia. Cupid’s Greek alter ego was Eros whose name gave us more erotic words such as erotogenic, erogenous and erotica. Historically, psyche was used synonymously with the word soul, and was adhered to the Greek word for release, ἀνάλυσις (analysis) by Freud, to produce the term psychoanalysis, literally translating as ‘soul-release’ [2].

ARTICLE DESIGN/LARA HIBBS

ing from Latin, digitalis is in fact a modern translation into neo-Latin of the German word Fingerhut, meaning thimble. The name foxglove, meanwhile, is thought to be derived from “folk’s (a now obsolete term for fairies) gloves” [2].

It was once believed that if a soul needed to re-enter its body in time for resurrection it would enter the most sacred of bones, the sacrum. This is perhaps because the sacrum is one part of the body likely to escape postmortem disintegration [12]. However, an ornithologist’s soul – being of a contrary disposition – might pick the coccyx, which Galen decided resembled a cuckoo’s beak (from the Greek κόκκυξ (kokkus) meaning “cuckoo”). Falling from the lofty heights of the os sacrum, we must delve down into depths of formication. Formication, not to be confused with fornication, is the sensation of bugs under the skin. This creepycrawly word is a lot less sinful and is derived from Latin word for ant, formica. There are many things which bug me, and along with clichéd conclusions and forced links between paragraphs, the poor use of language is common annoyance. My inner pedant is not only aghast at the amalgamation of Greek and Latin in the word parasuicide, but is also irked by the euphemism and lack of clarity it conveys. The word “service-user” seems to have infiltrated psychiatry to replace the term patient. It is derived from the Latin word patiens, meaning suffering, is therefore supposedly demeaning [13]. However, the majority of service users prefer their original label [14, 15]. Evidence based medicine (or EBM for those at the forefront of etymological barbarity) seems to be the replacement for more stylish and succinct words such as empiricism. The term was coined in 1992 and proclaimed as some sort of new paradigm [16] despite being logically indistinguishable from the word medicine [17]. To this day, its mantra is now unfortunately sung like a call to prayer from the ivory towers of various leading editorial offices around the world. Like a vagabond, vagrant or the vagus nerve, my editors complain that I am liable to roam, (Latin: vagus) and make my articles too complex (Latin: plexus, meaning braid or network, w h i c h also gives us brachial plexus and perplexed). This article may at least provide a small stash of anecdotes for those who are otherwise as culturally barren as the average medical student with an interest in orthopaedic surgery. Incidentally, the term orthopaedics was coined in 1840 by the French physician Nicholas Andry who specialised in straightening (Greek: ὀρθός (orthos)) out wonky c h i l dren (Greek: παιs (pais)) [18]. Full references available at: www.omsg-online.com

Edward Chesney is a fifth year medical student at New College. The views expressed in this article are the authors own.

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Mindfulness in Medicine Imagine telling a patient with chronic pain that it would hurt less if they stopped taking it so seriously. This seemingly uncompassionate approach is actually the message of mindfulnessbased therapy, which advocates paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally. Mindfulness teaches us to see painful thoughts and feelings not as something we need to 'get rid of', but rather to 'welcome' into our consciousness. Ironically, paying more attention to our thoughts and feelings can help us be less affected by them. [1] In 1979, a Professor at the University of

Massachusetts, Jon Kabat-Zinn, used principles from Buddhism to help patients manage chronic pain with a technique known as Mindfulness Based Stress Reduction, or MBSR. As well as reducing the physical symptoms of a number of conditions (ranging from cancer to fibromyalgia [2]), an 8-week course of MBSR appeared to reduce anxiety and promote a more positive worldview [3] [4]. Recognising this, some British psychologists interested in the prevention of psychiatric relapse synthesised the mindful approach with conventional psychotherapy to form Mindfulness Based Cognitive Therapy [5]. MBCT is now recommended as a

cost-effective intervention by the NICE guidelines on recurrent depression. Mindfulness lies at the core of Vipassanā meditation, a tradition with a rich heritage extending back over 3000 years. So why has it only been adopted by secular Western medicine in the last three decades? Perhaps it is due to the growing realisation that we live in a stressed-out world. No amount of wealth can combat the dramatic rise in suffering arising from chronic disease and depression. Doctors are only now coming to terms with what practising monks have known for millennia: that suffering is universal and inevitable, and a change in our

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perception is necessary to minimise the pain encountered. The emergence of new neuroimaging technologies in tandem with this growing awareness has fused 'ancient wisdom' with modern science, giving mindfulness a convincing evidence base and affording it credibility beyond the 'hippy' image of meditation [6]. Kabat-Zinn now teaches stress reduction in the workplace for corporate organisations, and smartphone apps such as Headspace On-The-Go target busy commuters desperate to fit moments of calm into their daily lives. Neuroimaging studies of subjects who practice regular mindfulness consistently show increased activity in the left prefrontal cortex and greater development of corticolimbic systems involved in emotional regulation [7]. We know that attention and appraisal of sensations is important in determining pain perception, but it is also thought that a reduction in stress and hypothalamic activation might have knock-on effects for the immune system [8]. This might explain why mindfulness practice decreases medication use and symptoms in surprising conditions (such as HIV and psoriasis) as well as in mental illness [9] [10]. In fact, it seems the more chronic

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and the more treatment-resistant the condition, the better the outcome of mindfulness-based therapies [11]. This directly challenges the notion that a more difficult problem necessarily requires a more complex solution. So why are we not all using it? For a start, mindfulness is easier said than done â&#x20AC;&#x201C; as the first teachers of MBSR cautioned, learning stress reduction is stressful! Battling to control one's own mind is not the serene, peaceful process we might imagine meditation to be. In MBCT, the onus is very much on the patient taking responsibility for their own problems, in contrast to the paternalism that characterises psychotherapy for example. A commitment to daily 'homework' is an essential component of the programme â&#x20AC;&#x201C; as with physiotherapy, poor compliance with these 'exercises' severely limits the usefulness of mindfulness in ambivalent patients. I have to admit that the idea of giving painful thoughts my undivided attention sounded less than appealing, and my first encounter with MBCT did not do much to allay my reservations. I found myself sitting cross-legged in a room that smelt of incense and herbal tea, whilst a softly-spoken yoga teacher instructed me to follow my breath to

places my respiratory physiology did not allow! I came out of each session feeling more stressed than when I arrived. I discovered that it is possible to fall asleep in the full lotus position. My first attempt at mindful walking was brought to an abrupt end by a collision with a lamppost.

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My first attempt at mindful walking was brought to an abrupt end by a collision with a lamppost

Nonetheless, with a bit more practice, mindfulness has given me an incredibly powerful tool to observe my thoughts and emotions with an element of scientific curiosity, rather than being absorbed and defined by them. In the sleep-deprived, chronically stressed state of most students and clinicians, a mindful approach could be invaluable in maintaining concentration and building compassionate relationships with oneâ&#x20AC;&#x2122;s patients, colleagues and self. Mindfulness training should be made much more widely available to both patients and doctors, and I would not be surprised if it is introduced into medical school curricula in the near future. Full references available at: www.omsg-online.com

Abbie Taylor is a fourth year medical student at Green Templeton College

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Pain: separated by a culture gap? SHIRLEY YICK explores the role of society in pain perception and expression

diversifying workforce, encounters between patients and health care workers of different cultural backgrounds are becoming increasingly frequent. The effect of culture on communication with patients

and pain management clearly must be addressed. Describing pain is hard enough without

a language barrier – Virginia Woolf once wrote that even a “schoolgirl, when she falls in love, has Shakespeare and Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.” [4] Despite being a sensation that is experienced by nearly everyone, pain is private, subjective and poorly defined. To complicate matters further, virtually all cultures have their own unique ways to communicate the notion of injury or suffering – arguably, the lexicon of pain may be sufficient to shape the phenomenon itself. So while an Englishman might be forced to endure ‘throbbing’, ‘stabbing’, ‘burning’, ‘tearing’ or ‘crushing’, the Sakhalin Ainu of Japan suffer from the heavy footfalls of a “bear headache”, the lighter beats of a “deer headache”, or the rattling of a “woodpecker headache”. All three are of the same intensity but exhibit unique descriptive characteristics [5]. Moreover, what we might collectively classify as pain in one language may encompass more than one concept in another. For example, the Thai language has two semantically different terms for pain: one that signifies a visible, measurable injury, and the other referring to a more subjective, ill-defined

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Few things are common to people from all cultures, but pain is one such universality. However, it has long been observed that different cultures respond to pain with distinct patterns of behaviour. In the 1950s, an influential study looking at different groups in the United States noted that, whilst Jewish and Italian Americans tended to react to pain emotionally, Protestant (English and Irish) Americans showed relatively milder responses [1]. Scandinavians and Asians have also been thought of as stoic with high pain tolerances [2]. These early studies catalysed a great deal of interest, prompting questions from the overlapping spheres of medicine, anthropology and philosophy: Why do different groups seem to react so differently? How do they express themselves? What does it mean for treating individuals of different cultures? So far, studies comparing pain thresholds of different ethnic groups have produced conflicting findings and there is no clear consensus. These are but a few of the issues needing to be resolved. Ethnic minorities now make up approximately 10% of the UK’s population [3] and the patient population comprises individuals from all social backgrounds and age groups. Together with a

"Let a sufferer try to describe a pain, and language at once runs dry" - Virginia Woolf

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Our reactions to pain are governed by what is socially acceptable

malady [6]. The match between words and feelings is inherently imprecise – every language and culture necessarily relies on idiom and experience. Physiological and psychological distinctions may be lost or misconstrued when a patient tries to communicate through a second language, and it is hard to quantify how much meaning is lost in translation or unfamiliar metaphor. The vocabulary of pain may highlight other confounding influences on expression and behaviour, particularly with regard to religious and spiritual beliefs. Pain is interpreted by many cultures as a punishment for sins or a way to atone for past transgressions: indeed, the English “pain” comes from the Latin “poena”, meaning punishment. Medical practice and the understanding of disease processes have been indelibly marked by the religious context of their infancy. For example, the Bible says “I will greatly multiply your pain in childbearing; in pain you shall bring forth children” (Genesis 3:16), and gives us the phrase “bearing one’s cross.” In the 19th century, Queen Victoria’s use of ether during childbirth was considered to directly challenge the precepts of the Bible [7], whilst the agony of gout was often viewed as a penalty for upper class indulgence [8]. The medicalization of pain, detached from beliefs and stripped of meaning, is a relatively modern development. However, many cultures continue to see pain as a test of one’s beliefs or a means of achieving higher spiritual status. In Buddhism, tolerating pain without undue distress is one way of achieving superior states of being – consequently, such beliefs may render patients more accepting of their pain and less likely to expect pain medication [9]. Despite the fact that this can present a management issue, religion and spirituality can be equally advantageous coping mechanisms. Those holding religious beliefs have been found to have lower pain scores and more positive symptom attitudes [10]. These conclusions are consistent with both Melzack’s gate control theory of pain and the neuromatrix theory of pain.

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In each, multiple neurological pathways involving cognition, emotion and behaviour influence the ascending nociceptive signal, thereby increasing or decreasing a person’s subjective experience at any given moment. Our reactions to pain are also governed by what is socially acceptable. In East Asian cultures for example, strong values exist for self-conduct and not drawing attention to one’s personal problems. The high status awarded to doctors and nurses may further bias pain reportage, although this phenomenon appears to be in decline [9]. For others, the taboo of death (and the association of pain with mortality) may further limit the ability to openly discuss personal suffering [8]. In contrast, other cultures appear to actively encourage overt displays of affliction. In Latin America, crying out in agony is socially acceptable and viewed as a means to relieve pain. Interestingly, nurses tended to interpret such vocal distress as indicative of a lower pain threshold, although pain extroversion shows no meaningful correlation with subjective experience [11]. Thus, how we expect others to behave in pain is necessarily affected by the cultures to which we are accustomed and our impressions of particular groups of people. In the context of healthcare, this has wideranging and serious outcomes. Although there is no reliable evidence to suggest credible pain perception disparities exist across different ethnic or racial groups, clinicians have been observed recommending divergent treatment options to patients presenting with the same primary complaint [12]. Why this is remains puzzling, but together with the communication problems and underreporting discussed above, this means that certain ethnic minorities may repeatedly have their pain underestimated. Indeed, one study found frequent and serious under-provision of analgesia within minority demographics during various cancer treatment regimens [13]. In another study, Asians, Blacks and Hispanics were prescribed significantly

less pain relief than Whites. However, the introduction of patient-controlled analgesia eliminated apparent clinician-imposed variation, and no difference in the amount of self-administered narcotics was recorded between patient sub-groups [14]. The significance of this issue remains unquantified, although such data may only hint at the scale of the problem worldwide. Alternatively, these findings may reflect other unknown factors beyond the perceptions of medical staff. However, in the diverse communities of today, substantial cultural mixing and assimilation means that ethnicity is not a simple surrogate marker for culture. ‘Social class’ further confounds the issue, superimposing additional cultural differences onto groups perhaps previously well defined by antecedent criteria (such as ethnicity). Studies from the UK and Sweden have shown both that different social classes report varying levels of chronic pain [15], and that clinicians perceive patients from lower social classes to have a higher perception of pain (despite no evidence in support of this belief) [16]. Despite being one of the most common medical symptoms and a crucial quality of life determinant, pain remains notoriously difficult to characterise. Complex personal, emotional and cognitive components cloud simple expression and interpretation of such subjective experience. Culture is but one of many variables in this Gordian picture. Fixed stereotypes linking pain and culture are probably unhelpful to the point of being counter-productive - ultimately, it is important to recognise that pain is experienced by an individual, not a group. Only by recognising this can we begin to bridge the culture gap. Full references available at: www.omsg-online.com

Shirley Yick is a fourth year medical student at Magdalen College

19/06/2013 15:24:22

A painful imbalance

Andrew Dooley explores access to pain relief in the developing world The 2010 earthquake that struck Haiti was a natural disaster of such scale that any health service in the world would have struggled to deal with its consequences. Haiti, according to the International Monetary Fund (IMF), is the poorest country in the Western Hemisphere. Prior to the dis-

The World Health Organisation (WHO) considers morphine an essential medicine [2]. The WHO three-step model for pain relief makes it clear that opioids are required to treat moderate-to-severe pain [3], yet the Global Access to Pain Relief Initiative (GAPRI) estimates that of the 7.3 million people

prevent severe pain. However, a 2011 investigation into palliative care by Human Rights Watch (HRW) found that this was often the only pain relief received by cancer patients in developing countries [7]. In truth, it is unlikely the cost of the opioids themselves that limits their use; morphine

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MORPHINE IS NOT UNDER PATENT, SO IMPORTED MORPHINE TABLETS COST LESS THAN $1

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who die in moderate-to-severe pain from HIV/AIDS or cancer each year, 2.9 million die with their pain untreated. Further, 99% of these deaths with untreated pain occur in low- and middle-income countries [4]. Of course, there are limitations to GAPRI's approach to calculating the need for morphine. Records of the cause of death will always be inaccurate; this is especially true in developing countries [5]. However, their conclusion that there is a vast unmet need for analgesia in the developing world is a view shared by WHO and by the medical community at large [6]. Paracetamol or weak opioids will not

is not under patent, so imported morphine tablets cost less than $1 for a daily dose [8]. Moreover, morphine and other opioids are produced from the cultivation of Papaver somniferum – a poppy of which there is no global shortage [9]. Instead, the inability to access adequate pain relief is often secondary to fundamental problems in healthcare provision and poor infrastructure. HRW reports that even when morphine is prescribed, patients often have to travel long distances, at great expense, to obtain it. HRW recommend the implementation of development programmes aimed at improving the avail-

IMAGE/ANDREW DOOLEY

aster, 40% of its population lacked access to basic healthcare and a similar proportion suffered from malnutrition and a lack of clean drinking water. The earthquake caused over 200,000 deaths and thousands of injuries that required emergency surgery, primarily in the form of emergency limb amputations. One of the first surgical teams to arrive after the disaster described how amputations were carried out without anaesthetic or post-operative analgesia [1]. Whilst natural disasters of this magnitude are mercifully rare, poor access to pain relief is all too common throughout the developing world.

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OF THE 7.3 MILLION PEOPLE WHO DIE IN MODERATE-TO-SEVERE PAIN FROM HIV/ AIDS OR CANCER EACH YEAR, 2.9 MILLION DIE WITH THEIR PAIN UNTREATED

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Further difficulties can arise due to misconceptions about pain relief amongst clinicians and patients. HRW found that an attitude of 'once you get better, the pain will go away' was common amongst healthcare staff throughout the developing world, particularly in India [7, 10]. With no curative treatments available for many diseases, this approach results in unacceptable pain for many patients. There is also a paucity of teaching in palliative care and pain management in many medical schools across the developing world. This may be accompanied by an exaggerated fear of opioid addiction, although this is a rare occurrence when used for pain relief [11]. The WHO guidelines state that chronic pain relief should, where possible, be administered in oral form [3]. However, oral morphine is scarcely available in many parts of the developing world. In Pakistan, for instance, oral morphine can only be found at a handful of pharmacies; in Iran, it is not a registered medicine and is thus unavailable [7]. There may, however, be reason for hope. Figures from the International Narcotics Control Board (INCB) show that Vietnam's consumption of opioids increased eight-fold between 2005 and 2008. Palliative care was improved by relaxing the regulations limiting the prescription of morphine and through the support of the US President's Emergency Plan for AIDS Relief (PEPFAR) [12]. A similar story has been reported in India; Kerala state has fewer restrictions to morphine prescription than other states, giving more patients access to appropriate analgesia [10]. Legal barriers are fundamental in preventing access to pain relief; if obtaining morphine is illegal, then the relevance of other

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factors preventing its access plummets. The UN 1961 Single Convention on Narcotic Drugs and the UN 1971 Convention on Psychotic Substances are the key international treaties which lay the foundation for national drug laws [13]. Signatories have a dual obligation: to ensure adequate availability of opioids for medical and scientific purposes, whilst preventing drug abuse. Known as the 'Principles of Balance' this is the prevailing international standard in formulating opioid drug policy [14]. It is the INCB that oversees implementation of these treaties and sets quotas for the quantities of narcotics that each country can import. In 2011, Hamid Ghodse, the

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ability of morphine in local hospitals and clinics [10].

AN ATTITUDE OF 'ONCE YOU GET BETTER, THE PAIN WILL GO AWAY' WAS COMMON

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then President of the INCB, admitted that they had got the balance wrong. In that year's annual report, he stated that 'equal emphasis has not been placed on ...ensuring that illicit controlled substances are available for medical and scientific purposes' [15]. The 1961 Convention does allow countries to continually revise their annual estimates, as seen in Vietnam between 2005 and 2008 [12]. It is claimed, however, that the system lacks sufficient flexibility to allow many developing nations to arrive at satisfactory estimates. Countries tend to estimate their requirements based on the previous year’s consumption, rather than using epidemiological studies to calculate the actual requirement [13]. It could be that individual countries prefer to set low quotas due to concerns over addiction or the potential diversion of supplies for illicit use. However, there is no empirical evi-

dence that significant diversion occurs [16]. Why the INCB accepts such low quotas is unclear, given that they are responsible for ensuring that each country receives an adequate supply of opioids for medicinal purposes. Regardless of how small the quota for medical opioids is, it remains legally binding. If an aid organisation supplements morphine therapy beyond this quota, they are breaking the law. A week after the 2010 earthquake, the INCB encouraged donors to send morphine even though no authorisation had been given by the Haitian Government. However, the 1961 Single Convention states that import authorisations are required, even in emergencies. This put the INCB in the ludicrous position of urging organisations to breach the Convention it exists to uphold, since enforcing it would have prevented access to analgesia when the Haitian people needed it most [13]. Since 1961, the demand for pain relief has increased; HIV/AIDS has emerged, and the incidence of cancer has continued to rise. True, the fear of drug addiction may have motivated the 1961 Convention [17], but our understanding of addiction has vastly improved in the half-century that has followed. Patients treated with opioids for pain relief rarely become addicts, yet this remains a great fear amongst doctors and regulators in the developing world [16]. It is primarily for this reason that the Convention remains unchanged, leaving millions of people in the developing world to die in unnecessary pain.

Full references available at: www.omsg-online.com

Andrew Dooley is a fourth year medical student at St Catherine’s College

19/06/2013 15:27:09

Out of Africa

morbidity and mortality in a rural Zambian hospital What you'll see on elective – a medical student's perspective

IMAGE/GILES NEAL

All admissions, diagnoses and deaths from a rural, 80-bed hospital in northern Zambia were recorded by staff throughout 2010. Using this data, this report aims to give prospective elective students a feel for the atmosphere on the wards, and thus an idea of what you might experience during a medical elective in a rural African hospital. During a 4-week elective placement on the two adult wards, a medical student can therefore expect to see these conditions in the quantities shown. Of note, the five most prevalent infectious diseases: HIV, tuberculosis, respiratory infections, diarrhoeal illnesses (predominantly infectious) and malaria are responsible for 61.5% of all adult admissions. Despite this obvious prevalence of infectious diseases, the data also shows the marked heterogeneity of conditions seen on the adult wards. This is further emphasised by the 26.1 admissions per month not attributable to any other diagnostic category. Interestingly, snake bites, responsible for approximately one admission per fortnight, are sufficiently common to warrant an independent category. Despite the unusual nature of many admissions, more familiar diagnoses such as diabetes, hypertension and cardiovascular disease still account for 8.1% of adult admissions.

Figure 1: Average number of adult admissions per month, categorised by diagnosis at time of discharge or death. Data shown is from the two adult wards (male and female) in the period from January 2010 to December 2010. Total number of adult admissions in 2010, n = 2,232. Abbreviations: PID – pelvic inflammatory disease, HTN – hypertension, RTA – road traffic accident, TB – tuberculosis, UTI – urinary tract infection, HIV – human immunodeficiency virus, AIDS – autoimmune deficiency syndrome.

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The greater prominence of HIV/AIDS in mortality data versus admissions data is clearly evident. 149 admissions and 48 deaths in 2010 were attributed to HIV/AIDS, giving a mortality rate per admission of 32.2%. The role of HIV as a comorbid factor in deaths attributed to other conditions, and indeed the role of other conditions in association with HIV mortalities are difficult to accurately establish from this data. Malaria, by contrast, was responsible for 3 mortalities from 197 adult admissions, a mortality rate of 1.5%. Also of note, meningitis and poisoning are responsible for relatively few admissions, with proportionately much greater representation as causes of mortality. Before drawing comparison between paediatric and adult admissions data, it is important to note that paediatric admissions are outnumbered approximately 2:1 (2232:1187) by adult admissions (excluding maternity data). The three most common causes of admission to the paediatric ward were: malaria, respiratory 2013 63:1

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LES NEAL

infections and diarrhoeal illnesses. Together, these accounted for 80.8% of all paediatric admissions and therefore a significant proportion of the paediatric workload. Trauma and burns account for 13.8 paediatric admissions per month, effectively double the incidence in the adult population (12.0 admissions per month, but in approximately double the number of total admissions). Malnutrition is another common cause of childhood morbidity, with an average of one admission every four days. Malnutrition undoubtedly also contributes to adult admissions, but is not recognised in this dataset as an independent diagnostic category in the adult population.

Figure 2: Total number of mortalities in 2010 from the adult wards, classified by diagnosis. This data excludes mortality associated with term pregnancies.

Throughout 2010 paediatric outcomes varied with age. Probability of death during an admission to the paediatric ward was 0.066 (i.e. 6.6%) in the under 5 age group and 0.018 (i.e. 1.8%) in those aged 5 to 16 years. The odds of a paediatric patient dying during their admission were 3.27 times greater (95% confidence interval: 1.47 â&#x20AC;&#x201C; 7.26 p = 0.002, X2) for children under the age of 5 than those aged 5 to 16 years. This marked difference is noticeable during a placement on the paediatric ward, where older children seem able to tolerate a much greater medical insult than their younger counterparts. The maternity ward cares for all expectant mothers and infants less than 28 days of age. The number of inhospital deliveries in 2010 totalled 1,299; of these, 1,253 were live births (96.5%). Infant mortality was 3.5%, approximately 1 in 28 deliveries. There were 5 maternal deaths, giving an in-hospital maternal mortality of 0.38% (approximately 1 in 260 mothers). How closely this data reflects infant and maternal mortality in other centres, or indeed the community, cannot be established from data collected in-hospital. In addition, of the 1,299 deliveries in 2010, 115 (8.9% of the total) were delivered by caesarean section. Prevention of mother-to-child transmission of HIV, in the form of anti-retroviral treatment, was offered, after testing, to 143 of the 1,299 (11%) mothers admitted for delivery. Data from a rural Zambian hospital are reported here in the hope of giving medical students a feel for rural African medicine. What conditions will you find on the wards? What familiar elements are there? What level of morbidity and mortality can you expect? And most importantly of all, what might you find yourself in charge of? Full references available at: www.omsg-online.com

Figure 3: Average number of admissions per month to the paediatric ward, categorised by diagnosis at time of discharge or death. Data shown is from January 2010 to December 2010 and includes patients aged 28 days to 16 years at time of admission. Total paediatric admissions in 2010, n = 1,187. 2013 63:1

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George Chapman & Elizabeth Morris are previous Oxford medical students and are now Foundation Doctors The authors would like to thank their host hospital for their kind permission to use this data

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Dying â&#x20AC;&#x201C; and getting away with it? Congratulations to Angela Sheard for successfully writing about near-death experiences (NDE) in the 62(2) issue [1]. That was a formidable undertaking, given that the field sports 'fringe theorists' and medically-qualified people willing to go down the parapsychological/mystical pathway. With few empirical data, is it true â&#x20AC;&#x201C; she asks - that neuroscience cannot explain this intriguing phenomenon? That was the problem facing me ten years ago when I began exploring this subject for a D.Phil [2]. From my derived perspectives, we can usefully explore some of Angela's queries. First, it is not certain how often NDE occur, since they are not all formally collected. Does Angela's mention of 'consistency'refer only to regularity of occurrence, or perhaps to subjects' uniformity of reportage? Ring noted that there is no "thanatomimetic core sequence" encapsulating every NDE [3]. A close reading of the many reports should make that clear, despite persistent attempts from many quarters, including the popular press, to perpetuate that erroneous caricature into the public mind. Drab's meta-analysis, for example, showed that

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tunnels occur in only ~10% cases [4]. I was amused by one NDE subject who, having just watched a relevant TV programme, declared herself unable to relate to the experiences under discussion! Neither does Ring's 'depth' idea fare any better. His data showed that only a progressively dwindling cohort successfully gains access to every 'core' feature that he listed. A so-called 'deep' NDE could, more simply and more sensibly, relate merely to duration, and not to increasing "mystical" significance, as he uncritically alleged. That is, the longer the event, the more phenomenological bits and pieces are randomly cobbled together by the brain. Therefore, we can all safely conclude that NDE are personally idiosyncratic, related solely to each individual's historic, geographic and personal circumstances. Bede's account (c.800 AD) of the nobleman Drychthelm illustrates well the mediaeval cultural influence. That likewise establishes an inevitable, major cerebral contribution to the experiences undergone: brainbuilt personal memories and cultural influences clearly deter-

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mine the idiosyncracy. There is no escaping that conclusion. But a second point. No authors have criticised the semantic content of subjects' reportage, thus to reveal its bizarreness, illogical sequences, and impossible foundations – even its sheer stupidity and banality (read some of the stuff on offer – and draw your own conclusions). Here, the similarity with the brain-directed mentation of dream-states provides important neurophysiological parallels. There is, however, one further consistent feature of NDE never previously noticed. All NDE cease abruptly as consciousawareness is regained. That time-point is not only enormously significant, but of critical, objective value. First, because the phenomenology obviously occurs during those final moments when consciousness is being re-established. Second, word counts (employed by dream researchers) suggest that NDE last only seconds - or a minute or two at most. Third, the event is remembered and later recalled. But "dead brains" (note: nobody actually dies during NDE) do not put down memories. Therefore, these events cannot occur when the brain is non-functional, but only during the ascent to full conscious-awareness, directly analogous to vivid hypnopompic dream awakenings. Fourth, it follows that NDE are not vague celestial day-trips, nor the result of mind, soul or consciousness 'escaping' from their physical confines (a dreadful Cartesian slip), but brainengineered phenomena conjured up during the recovery from antecedent metabolic stress (cardiac arrest: haemorrhage or cardio-vascular collapse: inhalation of a "dissociating" agent such as nitrous oxide, etc). There is good empirical evidence underpinning my assertion, from suicide attempts off the Golden Gate Bridge [5], medical students purposely inducing fainting attacks [6], and military aircrew centrifuged to unconsciousness [7]. Here we have a series of varied awakenings, but from a preceding state of reduced conscious-awareness, and over (laboratory) measured time-frames, during which the phenomenology experienced hardly differs from NDE. When later interviewed by psychiatrists, suicide subjects recounted evocative episodes of being in the light, and at peace with themselves. Moreover, the investigating military physiologists emphasised how pilots' brains, within such a very short period (<40 seconds), were able to conjure emotionally-charged scenes of great beauty and warmth, and to set them into memory. Clearly, mnemonic function returned very quickly while these subjects' brains were recovering from each precipitating circumstance (and despite post-centrifugation confusion). Anoxia, carbon dioxide narcosis, endorphins, or ketamine2013 63:1

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induced hallucinations do not explain NDE phenomenology, although the naloxone case-report underlines the profound influence of drugs on cerebral function. Further neurological explanation is offered by disturbed vestibular functioning, accounting subjectively for "tunnels", weightlessness (negative utricular graviception), or bodily movements, accelerations or gyrations (semi-circular canals and brainstem connections). Olaf Blanke (Geneva) [8] and Peter Brugger (Zurich) [9] have written extensively on out-of-body experiences, autoscopy, heautoscopy and the sensing of (invisible) presences. Their combined work – lamentably ignored by NDE enthusiasts - indicates that neurological processes (normal and abnormal) contribute understandings about the relationship between body-image and environment, and how medical crises cause temporary break-downs in this important brain system, resulting in many subjective misperceptions about one's body in space (or below the ward ceiling). Angela's mention of Britton & Bootzin greatly aids neurological correlation [10]. NDE subjects, compared with 'controls', seemingly reveal evidence of sub-clinical temporal lobe dysfunction – the result usually of minor head trauma, neonatal or childhood pyrexias, abuses, or other varied environmental impacts. While these brains are predisposed to NDE, the subsequent alterations in personality seen after an additional major metabolic insult could rest on that antecedent sub-clinical brain damage. The NDE is simply an epiphenomenon, but triggered in a compromised brain. This important distinction explains why only ~10-15% subjects have NDE. The remaining subjects with 'normal' brains would therefore never be expected to have an NDE during a medical crisis nor, crucially, to have a later change of personality. I hope that these brief remarks are helpful. Remember that the more a neurophysiological explanation is offered, the more the NDE community is obliged to return a reasoned, empiricallybased rebuttal. We have not seen much of that, and I suspect that the type of argument put forward here, for example, is unlikely to be followed by other well-reasoned counter-arguments. For me, I suggest it's all in the brain: and that seems to make good sense. But well done, Angela! Full references available at: www.omsg-online.com

Professor Michael Marsh is a Research Fellow at Wolfson College

19/06/2013 15:27:27

Epigenetics – How environment shapes our genes Richard Francis £11.99

Understanding Pain Fernando Cervero £17.95

Reviewed by Tom Stewart

Reviewed by Rebecca Rewbury

Epigenetics has broken into the popular science literature. This book, Epigentics: How environment shapes our genes, offers a broad and engaging introduction to the field. It starts with an explanation of how antenatal starvation can predispose offspring to obesity and goes on to discuss topics as diverse as colour blindness and cancer. With these examples, Francis certainly succeeds in providing a comprehensive, yet accessible, overview. The book is highly readable: its short chapters allow many examples of epigenetic inheritance to be covered concisely. However, all chapters could have been read alone – perhaps highlighting a lack of cohesion between topics. A better integration of the general theme throughout might have made for a more engaging approach. The book's best feature is that it provides extensive experimental evidence to support the examples considered. Seminal studies are well described and integrated neatly into the stories that form the introduction of each chapter. Coupled with the extensive reference list, this provides a great starting point for further reading. A balance has also been achieved by explaining complex scientific concepts from an unexpected perspective. Aimed at a lay audience, it is certainly accessible though, at times, to the detriment of detailed mechanistic explanations. The science then, while accurate, extends little beyond the grasp of a competent A-level biology student. Similarly, the stories and anecdotes at the beginning of each section prove a little unnecessary. While they offer some much needed padding to the otherwise brief chapters, they add little to the overall discussions of the book. Epigenetics has a large theoretical potential for treatment or prevention of a plethora of conditions. This is the most exciting area of epigenetics and underlies its growing popularity. An assessment of the future therapeutic targets would have added some context to the historical evidence of epigenetic modification presented in this book. As a whole, Epigenetics is undoubtedly a great introduction: it is extensively referenced, and offers a starting point for those wanting to gain a better understanding of this interesting new field. A very worthwhile read.

Charles Sherrington concluded that pain "remains a biological enigma, a mere curse." Nearly a century later, Fernando Cervero is optimistic that this statement no longer holds true. However, while significant advances have been made in the arena of nociception, particularly with regard to protective reflexes and inflammatory pain, we are far from unraveling the intricacies of the complex pain experience. The story of this mysterious sixth sense addresses the components of the pain pathway: from the level of the nociceptor, through the spinothalamic tract of the spinal cord and onto the brain. The journey explores the numerous interacting factors that influence and modulate pain perception at each level, both within and between individuals. Interestingly, Cervero discusses what happens when these processes malfunction and pain becomes a disease, for which our approach is unsatisfactory. Drawing on his vast personal experience and with a sprinkling of historical anecdotes, Cervero strikes a careful balance between explaining the theory and pondering the philosophical aspects; in doing so, he enables the reader to question what pain really is and what it means. What Cervero doesn’t do, however, is provide many answers. Pain as a symptom is at least a component, if not the prime reason, for the majority of clinical presentations. Chronic intractable pain represents a huge burden on society and society strives for a more painless existence. Yet, despite relentless interest, scientists are unable to connect laboratory results to real human experience. In reality, research methods have progressed remarkably little and clinicians are still without an objective measure to quantify pain. That said, attitudes towards pain are changing and there are glimpses of hope for the future, particularly with respect to novel imaging techniques. As popular science, this is a very readable and entertaining summary, although perhaps a little too focused on the molecular and anatomical details for the lay audience. For the curious student about to delve into this fascinating yet frustrating subject, I would certainly recommend it; the book manages to provide a concise and all-encompassing perspective, which is too often sorely missed.

Tom Stewart is a second year medical student at New College Rebecca Rewbury is a fifth year medical student at New College 54

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ORIGINAL RESEARCH

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Information provision for breast reconstruction patients Rebecca Dyar, David Coleman

ABSTRACT The incidence of breast cancer in the UK is increasing. 40% of breast cancer patients undergo mastectomy; 21% of these women opt for immediate reconstruction. This study was designed to examine the provision of information and support for women undergoing breast reconstruction in the Oxford University Hospitals (OUH). A questionnaire was generated following consultations with patients. Fifteen patients were interviewed, and a further eleven patients responded to the questionnaire by post. Both pre- and post-operative patients were included in the study. There were no statistical tests performed on the results. 18 of 26 patients sought additional information following their consultation. 18 of 26 patients were shown pictures of the potential results of breast reconstruction. 10 of 26 patients spoke to a previous patient; 12 of 16 patients who did not have this opportunity would have wanted it. All 26 patients felt sufficiently informed by their surgeon and involved in the decision-making process. 8 of 26 patients were unhappy with a particular aspect of their care. 20 of 22 post-operative patients would make the same decision again regarding their choice of treatment. Over two thirds of patients sought additional information following their consultation, reliable sources of extra information should therefore be developed. A third of patients were unhappy about an aspect of their care. Appropriate communication routes should be in place to facilitate patient reporting.

INTRODUCTION The incidence of breast cancer has been increasing since the 1970s. Close to 50,000 new cases of breast cancer are now diagnosed each year in the UK [1]. 40% of women with breast cancer undergo mastectomy and 21% of these women opt for immediate reconstruction [2, 3]. The decision for breast reconstruction and the subsequent patient journey is a long and difficult one, compounded by the fact that each patient has to confront an often-recent cancer diagnosis. A shift towards a more patient-centred approach in the practice of medicine has brought to light the importance of patient reported outcomes (PROs) and patient experience data for guiding best practice in breast cancer patients [1, 2]. This study was designed to examine the provision of information and support to women undergoing breast reconstruction in Oxford University Hospitals. In additon, it provided an avenue through which patients could report successes or shortcomings in their care. METHODS Questionnaire development At the time of this study, there was no validated questionnaire

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t t t t t t t t t t t t t

Figure 1 | Questions presented to patients experiencing breast reconstruction

Age Please describe your experience so far During which consultations were you given detailed information about the various types of reconstruction available to you? Were you given an information booklet about the types of breast reconstruction available to you? During your consultation, were you shown any pictures of potential results of the various treatments available to you? Did you talk to anyone that had experienced breast reconstruction before? Was the information given to you by the doctors and health care professionals sufficient to inform your decision about which treatment to pursue? Did you look elsewhere for information? When you came to your pre-operative consultation, were there particular things you wanted to know? Were these addressed in your consultation? Do you feel you were involved as much as you wanted to be in the decisions made about which procedure to pursue? Have there been any aspects of your care so far that you have been unhappy about? If you had any questions or concerns at any time, were you given the name or contact number of someone to talk to? Having experienced the entire procedure, do you think you would make the same decision again? 2013 63:1

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for assessing the patient experience of breast reconstruction. A questionnaire was generated, following consultations with patients, that sought to ask questions which would elicit readily quantifiable answers (fig. 1). To allow a complementary, and potentially valuable qualitative approach, commentary boxes were included in the postal questionnaires. Study timeline This study was conducted in two phases: the first phase involved interviews with patients, guided by a model questionnaire. One interviewer recorded patient answers in view of the patient. Fifteen patients were interviewed in the plastic surgery outpatient clinic in Oxford. Verbal consent was obtained prior to starting each interview, and patient information was anonymised. To reduce the impact of interviewer bias, thirty patients received postal questionnaires with a covering letter addressed from the patient’s plastic surgeon (according to Oxford University Hospital Trust requirements for patient correspondence). The project was registered (no. 1802) with the Patient Surveys Coordinator, Oxford University Hospitals NHS Trust. Under their guidance, no ethics approval was required for this survey. The principal inclusion criterion was the decision to opt for a breast reconstruction. Both pre-operative and post-operative patients were included, to assess for any variation in responses from these two patient groups. The only exclusion criterion was non-English speaking. Data analysis Data from twenty-six questionnaires were analysed. 23 patients were post-operative, 3 pre-operative. The survey was completed by women of an age range 28-74 years, mean 50 years. Both immediate and delayed reconstruction patients completed the survey, and patients described experiences of a variety of breast reconstruction procedures, including transverse rectus abdominis muscle (TRAM) flap, latissimus dorsi flap and implant-based reconstruction. A few patients also described adjustments to previous reconstruction including scar revision, lipofilling and nipple-areola construction. The number of years since diagnosis of malignant breast disease was only sparsely reported, ranging from one to fourteen years. Due to the small number of results to be analysed, no statistical tests were performed on this dataset. There were insufficient pre-operative patient numbers to generate meaningful data for comparison between the pre and post-operative patient groups. RESULTS Information provision 21 out of 26 patients were given an information booklet [3, 4], 17 of whom found it helpful. Out of the 4 patients not given one, 3 would have liked to receive one. It is not known why this group of patients were not given an information booklet. 2013 63:1

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18 of 26 patients (69%) sought additional information following their consultation. The most frequently used source of information was the internet (15 of 18 patients). Other sources included friends, books, and magazines. All 11 patients who responded to the postal survey reported that they were given contact details of someone to talk to if they had questions or concerns at any time. 18 of 26 (69%) patients were shown pictures of potential reconstruction results. Out of the 18 shown pictures, 17 (94%) patients found this experience valuable. 5 of 8 patients not shown pictures would have liked this opportunity. 10 of 26 (38%) patients talked to a previous patient who had undergone breast reconstruction, of whom 9 (90%) found this a valuable experience. Of the 16 who did not talk with a previous patient, 12 (75%) would have liked to, and 4 (25%) would not (fig. 2). One patient described the need to have her questions answered by a patient who had been through a similar experience, and reported that she found this valuable. Making the decision about which operation to pursue All 26 patients indicated that the information provided by surgeons and healthcare professionals was sufficient to inform them about which treatment option to pursue. All 26 patients indicated that they were sufficiently involved in the decision about which procedure to pursue. Unsatisfactory aspects of care 8 of 26 (31%) patients were unhappy about an aspect of their care. Issues ranged in severity and differed in the points in the care pathway at which they were experienced. A negative encounter with the on-call nursing service: “I have never been able to speak to her when I am concerned or anxious, I have had to leave a message on an answer phone, with days and days[of] delay; or in fact no response at all!” A negative experience of ward nursing staff: “When in hospital for one week it was striking how uncaring the nursing staff appeared to be, they were efficient and knowledgeable but not ‘caring’” A negative experience in follow-up clinic: “Came for my post op consultation – the consultant was not there. Seen by a registrar who was not present at my operation. My notes were not at clinic and the registrar didn’t know I had had surgery or what I had done so not able to answer my questions. A waste of my time, the Dr’s and had to take time off work.” Many women took this opportunity to praise the healthcare professionals who were involved in their care: “medical staff etc. were very patient and positive” and “my care has been just brilliant!”. One woman wrote of her breast care nurse: “always helpful and also able to contact people on my behalf”. Study timeline This study was conducted in two phases: the first phase in-

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volved interviews with patients, guided by a model questionnaire. One interviewer recorded patient answers in view of the patient. Fifteen patients were interviewed in the plastic surgery outpatient clinic in Oxford. Verbal consent was obtained prior to starting each interview, and patient information was anonymised. To reduce the impact of interviewer bias, thirty patients received postal questionnaires with a covering letter addressed from the patient’s plastic surgeon (according to Oxford University Hospital Trust requirements for patient correspondence). The project was registered (no. 1802) with the Patient Surveys Coordinator, Oxford University Hospitals NHS Trust. Under their guidance, no ethics approval was required for this survey. The principal inclusion criterion was the decision to opt for a breast reconstruction. Both pre-operative and post-operative patients were included, to assess for any variation in responses from these two patient groups. The only exclusion criterion was non-English speaking. Data analysis Data from twenty-six questionnaires were analysed. 23 patients were post-operative, 3 pre-operative. The survey was completed by women of an age range 28-74 years, mean 50 years. Both immediate and delayed reconstruction patients completed the survey, and patients described experiences of a variety of breast reconstruction procedures, including transverse rectus abdominis muscle (TRAM) flap, latissimus dorsi flap and implant-based reconstruction. A few patients also described adjustments to previous reconstruction including scar revision, lipofilling and nipple-areola construction. The number of years since diagnosis of malignant breast disease was only sparsely reported, ranging from one to fourteen years. Due to the small number of results to be analysed, no statistical tests were performed on this dataset. There were insufficient pre-operative patient numbers to generate meaningful data for comparison between the pre and post-operative patient groups. RESULTS Information provision 21 out of 26 patients were given an information booklet [3, 4], 17 of whom found it helpful. Out of the 4 patients not given one, 3 would have liked to receive one. It is not known why this group of patients were not given an information booklet. 18 of 26 patients (69%) sought additional information following their consultation. The most frequently used source of information was the internet (15 of 18 patients). Other sources included friends, books, and magazines. All 11 patients who responded to the postal survey reported that they were given contact details of someone to talk to if they had questions or concerns at any time. 18 of 26 (69%) patients were shown pictures of potential re58

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construction results. Out of the 18 shown pictures, 17 (94%) patients found this experience valuable. 5 of 8 patients not shown pictures would have liked this opportunity. 10 of 26 (38%) patients talked to a previous patient who had undergone breast reconstruction, of whom 9 (90%) found this a valuable experience. Of the 16 who did not talk with a previous patient, 12 (75%) would have liked to, and 4 (25%) would not (fig. 2). One patient described the need to have her questions answered by a patient who had been through a similar experience, and reported that she found this valuable. Making the decision about which operation to pursue All 26 patients indicated that the information provided by surgeons and healthcare professionals was sufficient to inform them about which treatment option to pursue. All 26 patients indicated that they were sufficiently involved in the decision about which procedure to pursue. Unsatisfactory aspects of care 8 of 26 (31%) patients were unhappy about an aspect of their care. Issues ranged in severity and differed in the points in the care pathway at which they were experienced. A negative encounter with the on-call nursing service: “I have never been able to speak to her when I am concerned or anxious, I have had to leave a message on an answer phone, with days and days[of] delay; or in fact no response at all!” A negative experience of ward nursing staff: “When in hospital for one week it was striking how uncaring the nursing staff appeared to be, they were efficient and knowledgeable but not ‘caring’” A negative experience in follow-up clinic: “Came for my post op consultation – the consultant was not there. Seen by a registrar who was not present at my operation. My notes were not at clinic and the registrar didn’t know I had had surgery or what I had done so not able to answer my questions. A waste of my time, the Dr’s and had to take time off work.” Many women took this opportunity to praise the healthcare professionals who were involved in their care: “medical staff etc. were very patient and positive” and “my care has been just brilliant!”. One woman wrote of her breast care nurse: “always helpful and also able to contact people on my behalf”. Retrospective views 20 of 22 (91%) post-operative patients indicated they would make the same decision again regarding their choice of treatment. DISCUSSION The majority of women who reported their experience in this study were satisfied with the overall level of care they received. However three specific areas have been highlighted as priorities for improvement in the future.

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Firstly, the provision of information for patients considering breast reconstruction. The large number of patients looking for information beyond their consultation, particularly on the internet (58% patients), suggests that it may be worthwhile developing an area of the OUH trust website where reliable information can be stored for easy access at the patient’s leisure. This will be pursued in a future project developing a patient video diary to be made into a DVD for patients and their relatives to watch at home. The results demonstrated that patients place a high value on knowing about the patient experience and likely outcomes before they make their decision to pursue the operation. In contrast to the national average (79.1-81.1%), only 69.2% of patients in Oxford were shown pictures of potential breast reconstruction results [5]. Nationally, there is a large discrepancy in satisfaction with information provision in patients who were shown pictures (84.3% satisfaction) compared to those who were not (52.9% satisfaction) [5]. This suggests that all patients should be offered the opportunity to see photographs during their consultation. An intradepartmental collection of photographs of the various stages of breast reconstruction is being developed for this purpose. A large proportion of patients valued meeting a previous patient (81%). In response to this, a Breast Reconstruction Awareness (BRA) group has been set up in Oxford to provide potential patients with the opportunity to meet those who have undergone breast reconstruction. The second area identified as warranting improvement was service provision. This study highlights the need for patients to be able to communicate any issues with their care, preferably at the time of occurrence. The Enhanced Recovery Programme - a procedure-specific, goal-oriented care plan that involves more frequent monitoring and expediting recovery from major surgery has recently incorporated breast reconstruction patients [5]. This study also highlights the need to address the issues raised by patients, namely organization of notes and clinic attendance, interactions with nursing staff, and availability of contacts for patients. The third area of importance is patient generated data. This is likely to be enormously valuable in shaping practice in the future [1]. This questionnaire was not validated, and thus has limited reliability. Further work should develop a validated

questionnaire specifically for breast reconstruction patients, which addresses their unique experiences. The European Organisation for the Research and Treatment of Cancer (EORTC) have developed a Quality of Life core questionnaire module (QLQ-C30), with many supplemental modules specific to each cancer type [6, 7]. The Breast Reconstruction module is currently under development [8], and the international trial to assess reliability is due to start this year. Limitations of the study include its small size and small catchment area for patients. The small number of pre-operative patients did not allow for comparison between the pre and post-operative patient groups. The questionnaire had not been validated, thus limiting the reliability of the results. The interview phase of the study did not involve audio-recording; though this was deemed unnecessary due to the ‘tick-box’ format of the questionnaire. All patients in this study felt sufficiently informed about breast reconstruction by their surgeon. Despite this, over two thirds of patients sought additional information following their consultation. Healthcare providers have a duty to provide patients with accurate and reliable information. The value of specific sources of additional information should be considered, for example the Breast Reconstruction Awareness group, a patient video diary, and an information page accessible from the trust website. Nearly a third of patients were unhappy about an aspect of their care. There should be established routes of communication available to patients for the purpose of reporting any areas of their care warranting improvement. The increased intensity of care in the Enhanced Recovery Programme should contribute well to this. Conflict of interest The author reports no conflict of interest. Full references available at: www.omsg-online.com

Rebecca Dyar is a sixth year medical student at Brasenose College, University of Oxford Mr David Coleman is a consultant in Plastic and Reconstructive Surgery, John Radcliffe Hospital

REFERENCES

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the National Cancer Institute 1993; 85(5): 365–76.

1. Winters ZE, Benson JR, Pusic AL. A systematic review of the clinical evidence to guide treatment recommendations in breast reconstruction based on patient- reported outcome measures and healthrelated quality of life. Annals of surgery 2010; 252(6): 929–42.

4. Breast Cancer Care. Breast Reconstruction 2012. http://www.breastcancercare.org.uk/breast-cancerinformation/treating-breast-cancer/surgery/reconstruction [Accessed online 28/5/2013]

7. Sprangers MA, Groenvold M, Arraras JI, Franklin J, Te Velde A, Muller M, et al. The European Organization for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire module: first results from a three-country field study. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 1996; 14(10): 2756–68.

2. Lee C, Sunu C, Pignone M. Patient-reported outcomes of breast reconstruction after mastectomy: a systematic review. Journal of the American College of Surgeons. 2009; 209(1): 123–33.

5. Jeevan R, Sheppard C, Pereira J, Caddy C. Report: National Mastectomy and Breast Reconstruction Audit, Fourth Annual Report 2011. http://data.gov. uk/dataset/national-mastectomy-and-breast-reconstruction-audit/resource/94c8f928-138f-44728829-2b76e4a02b7e [Accessed 28/5/2013]

3. Macmillan, Cancer Backup. Understanding Breast Reconstruction 2011. http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/Treatmenttypes/Surgery/Breastreconstruction/Breastreconstruction.aspx [Accessed online

6. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. Journal of

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8. Thomson HJ, Winters ZE, Brandberg Y, Didier F, Blazeby JM, Mills J. The early development phases of a European Organisation for Research and Treatment of Cancer (EORTC) module to assess patient reported outcomes (PROs) in women undergoing breast reconstruction. European journal of cancer 2013; 49(5): 1018–26. 59

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s e v

h c r

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The following book review is taken from our Hilary 1963 issue: Growth and Development in Childhood. A. Bogden. 1962. Tutorial System Publications. 3s. 6d. Dr. Bogden has presented in this booklet a system for teaching students about the normal growth and development of children. He stresses the facts that no two children are alike, and that both growth and development may vary widely from one child to another, facts which medical students often fail to appreciate. The idea of the booklet’s good, but unfortunately the notes give the impression of having been put together hurriedly, without regard to the best and clearest way of wording sentences, to grammar or even occasionally to spelling. A few of the statements are so ambiguous that it’s almost impossible to decide what the author really means. Here and there, one wonders whether a word or sentence has been misprinted; if it has, then the proofs should have been more carefully corrected. For example, under the heading Urine and Bladder Function, he says; “At 10p.m. even when no longer fed, an infant may still be persuaded to use the pot, and if this is successful, he must be able to remain dry until morning at 18 months of age.” He surely did not mean ‘must’. Students may find some of the facts mentioned, including the list of milestones, useful for revision purposes. M.H.

It’s perhaps at times like this that we medical students might give thanks to our trusty Cheese & Onion! If only it cost three bob and sixpence…

IMAGE/ROSALIE BROOMAN-WHITE

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