Monday, 5 August 2013

How to die without dying

Have you ever watched someone die? Almost everybody has. Ok, so not in real life but on TV or in a film? Deaths are used by writers to make us laugh or cry, but I've watched two this week which, well, irritated me. Instead of being sucked into the emotional tragedy unfolding before me, I sat muttering ”well that wasn't very realistic”. Now, I am the queen of suspending disbelief- I've watched Neighbours for over 25 years, my Freeview recorder has 169 episodes of Murder, She Wrote on it (Angela Lansbury makes me want to be old) and I believe that Jack Bauer really could do all that AND MORE in 24hrs. But even my imagination couldn’t keep me in TV land when faced with Queen Eva's death in Once Upon a Time this week. I was sucked out of the story and spat out onto the sofa by the absurdity of it. An immaculately beautiful woman imparted an eloquent, heartfelt message before dying in a neat, quick and quiet way. You could almost feel her holding her breath. No death rattle for Queen Eva.

But that was a fairy-tale, she was poisoned, maybe magically cursed people do die just like that. (The Oxford Handbook of Clinical Medicine was no help in this matter). But Queen Eva wasn't the only irksome death of the week- I felt just as bothered by the departure of Raj from 90210. Yes, my name is Catherine and I watch 90210…it’s like the crack of TV, so bad, yet you just can’t stop it, and your husband doesn't understand why you keep going back to it. Anyways, there I was, enjoying my fix of emotional highs and lows delivered by the beautiful people. Raj was in hospital looking a little hungover. We know he’s close to death, purely because we've been told so, but he's chatting away, being witty, romantic and thoughtful. Then his girl pops out for a second and returns to find him dead. We know he's dead because his eyes are shut and she drops a glass of water. Again it’s neat, quick and quiet. Bothersomely so.

You see people in TV land, like Raj and Eva, die without dying. In the real world, death is an event, but dying is a process. Noisy, irregular breathing, semi-consciousness, confusion, a dry mouth, restlessness- these are often very normal parts of dying.

Yet we don’t often see this on TV, despite the fact that a LOT of people die in soaps. A study of soap characters in the BMJ found that “standardised mortality ratios for characters were among the highest for any occupation yet described”. The authors noted that “Their lives are more dangerous even than those of Formula One racing drivers or bomb disposal experts”. But despite this obsession with death, TV hates people dying. Perhaps because it’s too upsetting? Yet, think of a soap wedding- we expect it to be upsetting, we KNOW there are very few happily ever afters in soap land. TV expends a huge amount of effort in creating drama and wringing every ounce of emotion from an audience. So it seems strange that dying a soap death is as simple and sanitized as you could hope for. Does this suggest dying, more than death, is a taboo too shocking for TV?

I know that reality isn't what these programmes are made for, but they are based firmly in our world. Music we know plays in the pub, there are frequent references to Facebook and everyone in Ramsay Street has an ill-disguised mac book. These shows tell stories about people and they're watched by millions. That means they have incredible potential to influence our expectations of what normal is. Is TV making us think it’s normal to die without dying? If so, a lot of us are ill prepared for when death forces its way from our screens and into our lives.

Think back to the last time you watched someone die in TV or film land. Did you really watch them die, or just see a death?

Monday, 6 May 2013

Poo, glorious poo

C. diff. Courtesy of Marcus007 at de.wikipedia [Public domain], from Wikimedia Commons
 When is it medically advisable to eat some one else's poo? When you need a poo transplant.
Poo transplants could be the solution to one of the biggest problems facing the NHS today- the bacterial infection Clostridium difficile. C.diff, as its known to its friends, infects about 18,000 people in England and Wales every year and is involved in the deaths of about 2000 people.
C.diff typically arises due to imbalances in your normal gut bacteria. You see your gut is like a city, a city with about 100 trillion bacterial residents happily munching away on a banquet of bowel contents. The average person has about 1000 different types of bacteria in their gut, and about 3% of healthy adults have C.diff in that mix. The C.diff doesn't cause them any problems because its numbers are kept in check by the other gut bacteria. However treatment with broad spectrum antibiotics can disrupt this happy community, killing off vast swathes of bacteria but crucially not the C.diff which is particularly hardy. Given free rein the C.diff multiplies rapidly and produce toxins which damage the gut. In some people this causes mild diarrhoea and abdominal pain, in others it can lead to torrential diarrhoea, perforation of the colon and death.
Traditional treatment involves stopping the broad spectrum antibiotics and prescribing antibiotics which specifically target the C.diff. However C. diff is becoming resistant to these antibiotics and about 22% of patients who are treated then relapse. This can result in a cycle of illness and hospital admission which is costly to the patient and the hospital.

So it's time to start thinking outside of the box. Cue the poo transplant. The thinking goes like this- if the cause of the problem is disruption to the normal community of gut bacteria, why not just pop those bacteria back in to crowd out the C.diff? Simples. Practically, the first step is to identify a donor, usually a close relative of the patient, and screen them for a range of infectious diseases and parasites. You should also make sure they haven't recently consumed anything the intended recipient is allergic to, before asking them to make their "donation". You then pop it in a household blender, adding salt water or milk to achieve a slurry consistency and blitz it down. Next you need to strain your concoction to remove large materials- one medic in the UK uses coffee filters. Top tip. Then you're ready to administer it- about 25ml from above (via a tube into the stomach), or 250ml from below.
Now, its important to note that poo transplants are experimental. To date only small case studies have been carried out, but with 200 total reported cases, an average cure rate of 96% and no serious adverse events reported to date, it's worth carrying out a large trial to assess it thoroughly.
So, poo transplants-the ideal treatment for a cash strapped NHS. Its cheap, plentiful and it seems to work. We just have to convince people to consume someone else's poo....or, let us pop it in their bums. Bottoms up!

Sunday, 3 March 2013

A Medical Mystery for Mother's Day...

I'd like to tell you a curious story. Jane was a 52 year old woman in need of a kidney transplant. Thankfully she had 3 loving sons who were all very happy to give her one of theirs. So Jane's doctors performed tests to find out which of the three boys would be the best match, but the results were surprising. In the words of Jeremy Kyle, the DNA test showed that Jane was not the mother of two of the boys... Hang on, said Jane, childbirth is not something you easily forget. They're definitely mine. And she was right. It turns out Jane was a chimera.

Chimerism is the existence of two genetically different cell lines in one organism. This can arise for a number of reasons- it can be caused by medics, like when someone has an organ transplant, or be naturally occurring. In Jane's case, it began in her mum's womb, with two eggs that had been fertilised by different sperm creating two embryos. Ordinarily, they would develop into two non-identical twins. However in Jane's case the two balls of cells fused early in development creating one person with both cell lines.


Thus when doctors did the first tissue typing tests on Jane, just by chance they had only sampled the 'yellow' cell line which was responsible for one of her sons. When they went back again they found the 'pink' cell line which had given rise to the other two boys.

This particular type of human chimerism is thought to be pretty rare- there are only 30 case reports in the literature. (Though remarkably both House and CSI's Gil Grissom have encountered cases.) What happens far more frequently is fetal microchimerism- which occurs in pregnant women when cells cross the placenta from baby to mum. This is awesome because we used to think the placenta was this barrier which prevented any cells crossing over. Now we've found both cells and free floating DNA cross the placenta, and that the cells can hang around for decades after the baby was born. Why? As is often the case in medicine we're not sure but one theory is that the fetal cells might have healing properties for mum. In pregnant mice who've had a heart attack, fetal cells can travel to the mum's heart where they develop into new heart muscle to repair the damage.

Whilst we're still in the early stages of understanding why this happens, we already have a practical application. In the United States today, a pregnant woman can have a blood test which isn't looking for abnormalities in her DNA, but in that of her fetus. The DNA test isn't conclusive enough to be used to diagnose genetic conditions in isolation, but it is a good screening test for certain conditions including Down's syndrome.


Now, we started with a curious tale, so let's close with a curious fact and one that's appropriate for Mother's Day: This exchange of cells across the placenta is a two way process. So you may well have some of your mum's cells rushing through your veins right now. In my case they're probably the ones that tell me to put on sensible shoes and put that boy down...


This post is based on a presentation I gave at the 2013 FameLab regional finals.

Sunday, 2 December 2012

This is my truth, now tell me yours

Image: Fir0002/Flagstaffotos

My truth is a tale of smoke and cynicism, power and death, and a glimmer of fiery, fragile hope.

I tripped up the stairs, clutching a clipboard and breathlessly reciting the signs of chronic obstructive pulmonary disease (COPD)- tar staining, cyanosis, hyperinflated chest, wheeze. Suddenly my train of thought was derailed. There was a cigarette butt wilfully loitering on the steps. Even here. I felt a stinging slap of hopelessness- my little nicotine nemesis was so beloved that it was able to sit bold as brass on the steps to our respiratory ward. I gave it a vicious look, trudged onwards and started a new list. Bed 4, end stage COPD- clutching a Venturi mask to her face, every inch of her body exhausted by the effort of gas exchange, breathing as hard as a marathon runner, knowing it wouldn't stop until she died. Bed 7, query lung cancer- his awake bronchoalveolar lavage the single most horrific procedure I'd ever seen. A sort of iatrogenic water boarding that had failed to provide any information on the large mass dominating his chest X-ray. My list, and most of the people on our ward, were testimony to the power and horror of tobacco.

The tendrils of tobacco's power reached beyond the respiratory ward. I could take a history anywhere in any hospital and when someone described themselves as a smoker, my heart would sink a little at their increased risk of heart disease, hypertension, stroke and cancer. As a medical student my inner optimist would enquire about smoking cessation, but the barrage of polite declines slowly eroded this optimism and by the time I was qualified the question was almost a formality.

Sadly, my blossoming cynicism followed me out of the hospital and all the way home. One of my friends was a smoker and philosopher who somersaulted his way through arguments. We debated life, the universe and smoking. As a scientist I would hurl statistics at him- 100,000 people die every year in the UK from smoking related illnesses. 8 in 10 non-smokers live beyond age 70, but only half of long term smokers do (1). I'd outline the dangers of second hand smoke and give graphic descriptions of how people suffocate over weeks and months thanks to emphysema. Nothing phased him. He knew the risks, it was his choice. He felt my desire to dissuade him bordered on the unethical because it insulted his autonomy. The reality was I had no real ability to change it. And perhaps I was being a dictator to even try. Certainly my friend wasn't alone, British society accepted smoking, what right did I have to disagree? People have free will, let them exercise it.

Then two events shifted my perspective: the death of a loved one and a political triumph.

Coffins are small. They house a body, but they can never hold a person. My cousin baked the most amazing biscuits I'll ever eat, she loved music and had unending patience for jigsaws. She was kind and generous and irreplaceable. These things, the things that made her who she was, live in my heart and in every person who was lucky enough to know her. She died in her forties from lung cancer.

34,859 families stood over coffins because of lung cancer in 2010 (2). Being one of those families has completely dissolved any qualms I had about impinging on people's ability to smoke. My philosopher friend may want his autonomy, but on balance I think the world would be a better place with fewer cigarettes and fewer coffins. Sod your right to inhale tar and cyanide and die gasping.

I realise my opinions may offend, so let us turn to a safer subject: politics. I come from Scotland, a wild country that is famed for its whisky and which offers a plethora of pubs to drink it in. I never hoped we would be able to ban smoking in these pubs, yet in March 2006 Scotland did exactly that with a ban on smoking in enclosed public places (3). In 2007 Wales, Northern Ireland and England followed. The positive impact on health has been notable- air quality in pubs has improved, bar workers have better respiratory health and hospital admissions for acute coronary syndrome are down (4). Whilst I expected improvements in health, I didn't expect it to be popular. A recent survey of 12,000 British adults found that 78% supported the ban (5) .This societal support and the political will to ban smoking, stirred my comatose optimist and gave me a glimmer of hope.

This year, my optimist was brought back fighting by the Australian government. 2012 was the year that Australia passed a plain packaging law to standardise cigarette packets (6). Goodbye camels and cowboys, hello disease addled eyes and cancer ridden lungs on a murky green background. Lest we forget who is responsible for selling these deadly wares, companies can put their name on the packet in a dull, diminutive font. It has been said this will have no impact on smoking, but the tobacco companies' reactions tell a different story. British American Tobacco, Imperial Tobacco, Philip Morris and Japan Tobacco all took legal action against the Australian government, claiming the law violated the companies' intellectual property rights. Philip Morris also asserted the law would contravene a bilateral trade agreement with Hong Kong that would leave the government liable to pay Philip Morris huge amounts in compensation (7). Thankfully the Australian High Court ruled that the laws were sound and they will come into force in December 2012. The perfect Christmas present for Australian hearts and lungs.

With the return of my fiery, fragile hope, I've come to find my truth. Trying to stop people smoking wasn't thinking too big, it wasn't thinking big enough. We can't take on tobacco one smoker at a time, it's like trying to stop malaria by catching every mosquito in the world with a pair of chopsticks. We need to be murderously ambitious. We need to suffocate the tobacco industry. The World Health Organisation (WHO) have defined the elimination of leprosy as a prevalence of less than 1 case per 10,000 of the population (8). Using this definition, I believe it's realistic to eliminate tobacco smoking in the UK in my lifetime. Given longer I think we can eliminate it worldwide.

You may say I'm a dreamer, but if you look at the statistics of smoking we really have no choice but to make it happen. In the Lancet earlier this year, Giovino et al reported the results of the Global Adult Tobacco Survey of 14 low and middle income countries. 40.7% of men in the survey smoked a tobacco product, ranging from 21.6% in Brazil to 60.2% in Russia (9). These high demand rates are readily met by the tobacco industry with cigarettes being manufactured faster and cheaper than ever before. One of the most formidable accounts of this mass production of death was penned by Proctor this year (10). He uses the assumption that one death is caused by every million cigarettes smoked, to provide some sickening statistics.

“…the 6 trillion smoked in 1990 will cause about 6 million deaths in 2015. That's one death every 5seconds.

Cigarette companies make about a penny in profit for every cigarette sold...a tobacco manufacturer will make about US$10000 for every death caused by their products.

We can even make our own relatable statistics. Philip Morris' Richmond plant in Virginia, USA made 146 billion cigarettes in 2010. That's 146,000 deaths. The Kunming Cigarette Factory in China made just 71 billion that year, a paltry 71,000 deaths (10). Between these two factories, in a single year's production they will kill the equivalent of every man woman and child in the town I was born in. 54 times over. Don't feel left out, its a game we can all play.

Hopefully you're now asking yourselfhow do we end it? Some suggestions are well known, such as plain packaging, high taxes, restricted advertising and accessible cessation. But ours is an ambitious aim, which will require daring and innovation. Borland (11) has proposed a regulated market model, which would take mass marketing away from the tobacco companies and hand it to an agency with a harm reduction charter. Advantages of this approach would include brand control, price control and the ability to incentivise manufacturers reducing the harmfulness of the products. An equally bold idea is Daynard's suggestion that reducing nicotine levels in cigarettes to non-addictive levels could secure a smoke free future (12). While I think both of these ideas are compelling, I also find a certain radical appeal to Tasmania's2000 Smoke Free Generationidea, which would ban the sale of cigarettes to anyone born after the year 2000 (13).

All of these ideas are big and brave and massively problematic, much like taking on the tobacco industry. Together, the biggest tobacco firms make more than $1,100 of profit a second (14), so they have much to lose if smoking declines. This fact was felt by the Australian health department when they were passing the plain packaging bill through parliament. The team wereswampedby 63 freedom of information requests, 52 of which were courtesy of tobacco companies in what has been described by commentators asa specific and deliberate attempt to divert resources(15). Disappointingly, tobacco companies are being aided in their efforts to maintain power and profit by the policies of some countries. The WHO Framework Convention on Tobacco Control came into force in 2005 and was a landmark achievement in international public health. It sets minimum standards for tobacco control which are legally binding in 176 countries, covering every aspect of the industry from production to marketing and taxation. Yet, even under a Democratic President with a vocal commitment to healthcare the United States has not ratified the convention (16). Clearly there is a long way to go before my hopes are realised.

The tobacco industry has the audacity to make millions of dollars selling an addictive product which causes millions of deaths. We must be as smart, as ambitious, as bold as they are. If ever there was a man who captured all of these qualities it was Apple's visionary leader Steve Jobs. In 2005 at Stanford University he delivered the most moving and inspiring piece of public speaking I've ever heard. His advice was to “Stay hungry. Stay foolish.” This is the mantra public health needs- from smoking to obesity, from malaria to HIV, it is imperative we think big. When devising solutions we shouldn't just accept our limitations, instead we must push them, shove them, shatter them. Stay hungry. Stay foolish. That's my truth, now tell me yours.
  1. Smoking- The Facts. http://www.patient.co.uk/health/Smoking-The-Facts.htm Accessed 06/10/12