Month: January 2016

37. Hippocratic and Hippocritic oafs – spot the difference!

HippocraticOath Montage

A sculptured bust of Hippocrates and a reproduction of the original Hippocratic oath ‘manuscript’. Accessed at https://en.wikipedia.org/wiki/Hippocratic_Oath on 30 January 2016.

I formulated this title for the current blog entry prior to discovering the following after researching several of my Google hits. “Hippocratic and Hippocritic Oaths” – not quite identical, I appreciate, but sufficiently close thematically to cast doubt on my independent originality. But clearly, I have like-minded empathetic ‘friends’ out there:   I did think of the title a couple of days ago – during a dinner conversation (see later interlude of the euthanasia debate involving Elaine, Jacqueline and Linda as well as my good self), so I do have witnesses. But still, I wasn’t first, damn it!

[The Hippocratic Oath goes back a long way. One version I have seen in the past contains the line, “First, do no harm”. Sadly in recent years, accelerating with the formation of NICE and the PCTs, the oath really needs to be reworded, “First, spend no money”. The current “version” of the Hippocratic Oath used in the UK is the GMC Guidance On Good Practice. However, if you actually read what doctors are supposed to do and compare with what they actually do, you may find just a few discrepancies. There’s an old saying, “What do you call the doctor who graduated bottom of the class?” “Doctor”]

I love it!

I’ll return later to the main substance (hypocritical views) of the debate around euthanasia and assisted death, especially when it is declared ‘illegal’ in your own country (most of the world, including the UK, by the way! ). Meantime, I’ll follow up on a question I asked you all in my previous blog, “…do you want me to blog in much shorter chunks, but more frequently; or …should I carry on as I have been doing? ”, ie suiting myself how frequently and how much I write?

Well, the result is in of my informal, non-randomised, and unrepresentative sample of blog-readers and more importantly, blog responders, – a grand total of 3 ‘visitors’.  This comprised 2 females and 1 male (Variable: Sex – I refuse to use the more PC term Gender); 2 Australians and 1 UK citizen (Variable: Nationality).  Just to confuse you, here Sex and Nationality were associated variables.  So no, there weren’t 5 responses (perhaps an inference to draw from the picture below!?)  in total – just three as previously stated!

UK-Aus Montage 2

Don’t you just wish?

Accessed at https://www.google.co.uk/search?q=UK+map ; http://www.mapsofworld.com/australia/; https://www.google.co.uk/search?q=australia ; https://www.google.co.uk/search?q=UK ; on 30 January 2016

This represents 11.6% of the number of you (35) that have read the blog entry.  So, draw your own inferences.  Anyway, there was a unanimous vote (3; 100%) in favour of letting me carry on as I am currently doing – hence the three-day gap for publishing this blog entry!

What has happened since my last blog, and what on earth is that title supposed to mean, do I hear you ask? Ok then- here goes…

On Wednesday I resumed my in-door cycling routine to try to stay fit-ish! I can manage about 20 mins in ‘top gear’. My target by the end of this cycle of Chemo is 30 minutes, and that should equate to about 7 miles when I eventually get back out on the road, and I will, I promise!   In the afternoon I felt nauseous (though not actually sick) for the second day running, further proof, if proof were needed, that the 2-day treatment with dexamethasone on day 1 and 2 after the Chemo cycle really are required.

Anyway, by the evening I get over it and can resume consumption of my Cadbury’s crème eggs and whole nut milk chocolate as well as Terry’s Chocolate Orange-segments, “Segsations” (courtesy of Ellen’s boyfriend, Craig), liberally interspersed between handfuls of wine gums or midget gems. It’s marvellous what prescriptions the NHS can come up with! Unfortunately, such items are not free like the rest of my chemo or other 9 medications, but they do taste infinitely better!

Cadbury Creme Egg

Accessed at https://www.google.co.uk/search?q=cadbury+creme+egg 30 January 2016.

Thursday was a largely uneventful day for the most part for me, though we did have a visit from the company who installed our multi-fuel wood-burner (if that isn’t tautology?), ostensibly to clean its flew, 2 years now after purchase.  I’m pretty certain we were his “first or guinea-pig customer” for the guy who turned up. He knew absolutely nothing (zilch, zero, nada) about how to dismantle our Jotul F100, though we bought it from the shop where he works; and, he had to borrow our own ash-vacuum cleaning device to remove the overnight remnants of our fire so that he could commence the work.  Not a good start, or even a good look!

Jotul F100 Home

 

Our lounge – just after the Jotul F100 had been fitted (December 2013)

However, he did have some clever-fitting sweeping rods with a rotating ‘thing’ on the end that could be driven by a portable drill to ‘sweep’ the inside of the flew liner, hopefully properly, since you never get to see how good the fit is between whirly ‘thing’ and inner surface of the flew at the top of the stove. After about 20 minutes of application of the whirling device he retrieved his rods to reveal a pretty small ‘fall’ of soot and minor debris – and voila!  -we are done– £30 quid, just like that!

Elaine and Jacqueline went shopping in Cupar, mostly LiDL and Aldi, as we are, or at least have become, pretty-much cheapskate penny pinchers, though we like to think we are simply great bargain hunters!   This particular shopping spree was timed to coincide with the arrival at Cupar Railway station of our friend, Linda, from Bristol, who was also visiting and staying with us for a long weekend (she returns to Bristol on Monday). It’s all go at chez nous all of a sudden!

Elaine cooked a fabulous meal for 4, including Chicken in tomato sauce (hand-crafted from a kilo of roasted vine tomatoes, garlic and our own fresh garden herbs). Yes, our ‘backdoor’ herb garden is thriving even in a Scottish winter in Ceres!  This was followed by Brownie, as prepared by Elaine’s own fair hand again using almonds, sugar, coffee and syrup, topped with both cream and ice-cream.  And ‘cos we were still starving (obviously!) we finished off with a selection of cheeses and wholemeal rye and wheat-grained-studded cracker biscuits.  Oh, and there was starter Gin and tonics as well as wine for “swilling-down” purposes.  And that was just Elaine’s portion!   We all declared we’d… “…have the same as she was having” (allusion to Meg Ryan’s orgasmic performance in, “When Harry Met Sally”).

Meg Ryan Montage 3

The scene from Katz’s Delicatessen – in “When Harry Met Sally”.

Accessed at https://www.youtube.com/watch?v=F-bsf2x-aeE on 30 January 2016

On Friday evening/Saturday there was an overnight blizzard here in Fife, as in much of Scotland, and so travel arrangements were affected. Jacqueline left us on Saturday morning. Elaine drove her to Leuchars railway station. The Forth Road bridge was closed to all vehicles because of the snow and 60 mph gale-force winds, so car or coach travel weren’t options. We learned later that Jacqueline’s flight from Edinburgh to London Heathrow had been cancelled, and she had a long wait for a substitute. She duly arrived in her daughter’s flat at 7:30pm, having left our abode at 8:30am – some journey, eh?

So what about this Hippocratic stuff?  Well, in the course of our post-prandial discursions (new word to indicate wide-ranging discussions? ) that took us to bedtime, we waxed (at some length!) upon government policy on euthanasia and comparison of attitudes to it (See Appendix I) between the UK (and most other countries) and those like Holland, Belgium and Luxemburg where it is legal, and others such as Switzerland, Germany, Mexico and five American states where only some types of assisted suicide and passive euthanasia are legal).  Not that I was fearing (just yet) the pre-arranged ‘pillow’ that Elaine and I have agreed upon when the quality of my own life fails to meet certain thresholds – like, not purchasing second-hand books, CDs and LPs or more apposite, wiping my own bum for instance!

My point in this discussion can be put simply.  The UK, and by extrapolation most of the rest of the world, do not have a voluntary euthanasia policy because some but influential people or bodies (including majorities in the House of Lords, particularly) think they know better than others what is good for us UK citizens despite successive consultations that show otherwise.

Papyrus Hippocratic_oath._Wellcome_L0034090

Yet an even older version of the Hippocratic Oath: A fragment of the Oath on the 3rd-century Papyrus Oxyrhynchus 2547.

Accessed at https://en.wikipedia.org/wiki/Hippocratic_Oath on 30 January 2016.

We are a nation of unbelievably adamant dog or pet owners and lovers. Some of the lengths that the latter go to are inexplicable (to me anyway). These include dressing their pet in human-type clothes; ordering ‘take-away’ for them as a special treat on their birthdays; and leaving their entire inheritance or fortune to their pet rather than to any of the rest of their family, extended to however many generations to include, “absolutely all of them, deliberately!”.

Nevertheless, we are also a nation of fervent supporters of “putting down” these same pets when they are clearly suffering physically or ‘mentally/emotionally’.  “I would always know that Rex, Duke, or Megan, Lady was having a bad time – you can just tell by looking at him/her. It’s the eyes mostly that give it away, you know!”  A fair proportion of the rest of the nation might say these things or many others of similar ilk.  Now I would totally agree with these observations. We certainly have government-approved euthanasia carried out by veterinarian surgeons (Vets).  Most people, reluctantly albeit, have their suffering pet put down. We had Holly, our pet dog, Part-Retriever (87.5%) and Part-Collie (12.5%), put down when things got too bad, though even then we waited until the end of semester for both Ellen and Richard to return from university so that they could say their goodbyes. This was a much longer wait for Holly than she deserved, but we did it relutantly for our children’s sakes.

If this is good for animals why isn’t it good for humans, after all we are animals, aren’t we? Maybe (we argue) it is because we are ‘special animals, sentient beings etc’ that the same rules shouldn’t apply automatically to us?  Well, I know many pet owners, though I am not one of them, that sees ‘many-a-human trait’ in their Fido or Beauty.  “Of course she has a personality”, they say.  Now me, I don’t need this level of speculation. I am happy that Holly had a (nevertheless very strong and ‘nice’) ‘animality’, as I would call it, the equivalent trait in humans.  All the same, I do know and understand the direction towards which “these people” are leaning!  Accordingly, to me, regardless of whether humans are tending towards animals or animals are tending more towards humans, it is clear that successive UK governments, on either free or party-whipped votes, are and have denied we humans our (animal and human) rights! Why do we let them get away with it?

Naturally, governments will argue that it is not that simple.  Actually it is, of course, but let’s give them some further “wiggle room”. They (Government) point immediately to the medical (rather than Veterinary) profession and say, “Ah, but doctors themselves are not in favour of euthanasia;  they consistently vote to reject legislation to permit euthanasia, which they would be responsible for administering”.   As an aside, I’m sure they are whispering between closed lips, “and we fully agree!”.

And one of the reasons they purport or argue is that euthanasia (suicide or assisted suicide) is contrary to their sworn “Hippocratic Oath”.  Interestingly, I have recently learnt that the Oath does not now have to be sworn.  It is worth looking at the exact wording of sections of the Hippocratic Oath and its interpreted version of guidance given to doctors, the “Good Medical Practice (GMP)”, published by the General Medical Council (GMC), and which embodies many of the underlying principles of the original Hippocratic Oath.   See Appendix II for a reproduced version of these documents where I have highlighted  (lime green! ) the appropriate wording relevant to our current discussion.

In the original Hippocratic Oath statement  bullet point 2 is of primary relevance, comprising the key phrase is, “a promise of beneficence” or, translated from Latin version as, “do good or avoid evil”, as well as a promise of “non-maleficence“, towards patients.  However, the second phrase, “primum non nocere – non-maleficence”, or  “do no harm”  that is often associated with this bullet point is not actually part of the original Oath, apparently!   The third bullet point is a promise,Not to assist suicide or abortion”.   This intrigues me because many, though clearly not all, doctors (and nurses and mid-wives) routinely carry out or assist in providing abortion on demand, and without coercion.

Furthermore, for any of you who, as I have, experienced a loved-one nearing the end of their life and who has been dependent upon ever-increasing doses of morphine to alleviate pain, will know that the medical care team will approve and administer an amount of morphine that will undoubtedly hasten death.  I am not complaining, indeed I approve!  But surely, any first year student (fresher, UK or freshman, USA, Canada )  of Logic  (Logic and Metaphysics 101? )  can see as transparently as,  “le nez sur la visage”,  that this is assisted suicide (though highly justified, I might add) rather than what it may be referred to by some? It is interesting that Domain 3, bullet point 6: “Listen to and respond to their concerns and preferences.”, and bullet point 8:  “Respect patients’ right to reach decisions with you about their treatment and care.”,  seem at least a little at variance with the notion that only medical professionals should control a patient’s treatment and fate.  In summary then, is this not a case of Hippocritic Oafs practising or hiding behind Hippocratic Oafs?

Why can’t more of the UK (and global) medical profession be as honest as the Dutch, Belgians or Luxenburgians (?)  clearly are, and call a spade exactly what it is, a spade or even a shovel!  Now ignoring the fact that though the medical profession and governments will argue, often pedantically or semantically, about this latter point, aren’t they dodging the bigger issue?  In the most recent parliamentary debate (House of Lords again) there was a strong lobby against legislating in favour of assisted suicide, presumably, not because they didn’t agree with it at least in some cases, but because it would signal the beginning of a slide down a very slippery slope!

This slope would include conflicts of interest between relatives and friends who could not (necessarily) be trusted not to coerce their loved ones into wanting to hasten their own deaths.  Reasons for coercion might include: getting out of providing further continuous health care to their loved one; being motivated by being the recipient of an actually-agreed Last Will and Testament or promised inheritance upon death of the loved one; and so on…  Now leaving aside that these would be criminal offences (or should be, see Appendix I again), should we not resist any situation where a small or minority problem, (though it might be serious) should dictate practice, policy or indeed, the law?  I think so.  What about you?  Answers please, in the usual place at the end of this blog?

That’s all folks!  Appendices follow after this endearing picture of Buggsy:

BUGS001

Appendix I

Accessed at http://www.nhs.uk/conditions/euthanasiaandassistedsuicide/pages/introduction.aspx  on 1 February 2016

Euthanasia and assisted suicide

Introduction

Euthanasia is the act of deliberately ending a person’s life to relieve suffering. For example, a doctor who gives a patient with terminal cancer an overdose of muscle relaxants to end their life would be considered to have carried out euthanasia.

Assisted suicide is the act of deliberately assisting or encouraging another person to kill themselves. If a relative of a person with a terminal illness were to obtain powerful sedatives, knowing that the person intended to take an overdose of sedatives to kill themselves, they may be considered to be assisting suicide.

Legal position

Both active euthanasia and assisted suicide are illegal under English law. Depending on the circumstances, euthanasia is regarded as either manslaughter or murder and is punishable by law, with a maximum penalty of up to life imprisonment. Assisted suicide is illegal under the terms of the Suicide Act (1961) and is punishable by up to 14 years’ imprisonment. Attempting to kill yourself is not a criminal act in itself.

Types of euthanasia

Euthanasia can be classified in different ways, including:

  • active euthanasia – where a person deliberately intervenes to end someone’s life – for example, by injecting them with a large dose of sedatives
  • passive euthanasia – where a person causes death by withholding or withdrawing treatment that is necessary to maintain life, such as withholding antibiotics from someone with pneumonia

Euthanasia can also be classified as:

  • voluntary euthanasia – where a person makes a conscious decision to die and asks for help to do this
  • non-voluntary euthanasia – where a person is unable to give their consent (for example, because they are in a coma or are severely brain damaged) and another person takes the decision on their behalf, often because the ill person previously expressed a wish for their life to be ended in such circumstances
  • involuntary euthanasia – where a person is killed against their expressed wishes

Depending on the circumstances, voluntary and non-voluntary euthanasia could be regarded as either voluntary manslaughter (where someone kills another person, but circumstances can partly justify their actions) or murder. Involuntary euthanasia is almost always regarded as murder.

There are arguments used by both supporters and opponents of euthanasia and assisted suicide. Read more about the arguments for and against euthanasia and assisted suicide.

End of life care

If you are approaching the end of life, you have a right to good palliative care – to control pain and other symptoms – as well as psychological, social and spiritual support. You’re also entitled to have a say in the treatments you receive at this stage. For example, under English law, all adults have the right to refuse medical treatment, as long as they have sufficient capacity (the ability to use and understand information to make a decision).

If you know that your capacity to consent may be affected in the future, you can arrange a legally binding advance decision (previously known as an advance directive). An advance decision sets out the procedures and treatments that you consent to and those that you do not consent to. This means that the healthcare professionals treating you cannot perform certain procedures or treatments against your wishes.

Other countries

Active euthanasia is currently only legal in Belgium, Holland and Luxembourg. Under the laws in these countries, a person’s life can be deliberately ended by their doctor or other healthcare professional.

The person is usually given an overdose of muscle relaxants or sedatives. This causes a coma and then death. However, euthanasia is only legal if the following three criteria are met:

  1. The person has made an active and voluntary request to end their life.
  2. It is thought that they have sufficient mental capacity to make an informed decision regarding their care.
  3. It is agreed that the person is suffering unbearably and there is no prospect for an improvement in their condition.

Capacity is the ability to use and understand information to make a decision. Read more about the capacity to consent to treatment. In some countries the law is less clear, with some forms of assisted suicide and passive euthanasia legal, but active euthanasia illegal. For example, some types of assisted suicide and passive euthanasia are legal in Switzerland, Germany, Mexico and five American states.

Page last reviewed: 11/08/2014 (Next review due: 11/08/2016).

 

Appendix II

 

Hippocrates was a Greek philosopher and physician who lived from 460 to 377 BC. He is known as the “father of modern medicine”. [1] His work included the Hippocratic Oath which described the basic ethics of medical practice and laid down a moral code of conduct for doctors. The classical Hippocratic Oath has been translated and interpreted. [2] However, modern versions have also been proposed, using many of the basic principles of the original. Many people think that doctors still swear the Hippocratic Oath. It is not compulsory but in fact many medical schools now hold a ceremony where graduating doctors do swear an updated version. The British Medical Association (BMA) drafted a new Hippocratic Oath for consideration by the World Medical Association in 1997 but it was not accepted and there is still no one single modern accepted version. [3] In some medical schools the Declaration of Geneva physician’s oath is used. [4] In others an oath individualised by the institution is used. In the UK, the closest to a modern Hippocratic Oath are the core values and principles set by the General Medical Council (GMC), laid out as the duties of a doctor under the title “Good Medical Practice”. [5]

The classical Hippocratic Oath has been summarised as:

“A solemn promise:

  • Of solidarity with teachers and other physicians.
  • Of beneficence (to do good or avoid evil) and non-maleficence (from the Latin ‘primum non nocere’, or ‘do no harm’) towards patients. (In fact the well-known “first do no harm” phrase does not feature in the classical Hippocratic Oath.)
  • Not to assist suicide or abortion.
  • To leave surgery to surgeons.
  • Not to harm, especially not to seduce patients.
  • To maintain confidentiality and never to gossip.”

General Medical Council: Good Medical Practice [5]

The GMC is charged with the supervision of the conduct of the medical profession. This includes educational standards, ethics and behaviour. The extent to which the GMC should question personal ethics and behaviour if they do not impinge on medical practice may be debated.

The GMC publishes advice to doctors on the standards expected of them in the form of the document “Good Medical Practice”. It discusses the duties of a doctor registered with the GMC. This covers many of the principles of the original Hippocratic Oath.

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must fulfil certain duties which the GMC categorises into four domains:

Domain 1. Knowledge, skills and performance

  1. Make the care of your patients your first concern.
  2. Provide a good standard of practice and care:
  3. Develop and maintain your professional performance.
  4. Apply knowledge and experience to practice.
  5. Recognise and work within the limits of your competence.
  6. Record your work clearly, accurately and legibly.

Domain 2. Safety and quality

  1. Contribute to and comply with systems to protect patients.
  2. Respond to risks to safety.
  3. Protect patients and colleagues from any risk posed by your health.

Domain 3. Communication, partnership and teamwork

  1. Communicate effectively.
  2. Work collaboratively with colleagues to maintain or improve patient care.
  3. Teaching, training, supporting and assessing.
  4. Continuity and co-ordination of care.
  5. Establish and maintain partnerships with patients:
  6. Listen to and respond to their concerns and preferences.
  7. Give patients the information they want or need in a way they can understand.
  8. Respect patients’ right to reach decisions with you about their treatment and care.
  9. Support patients in caring for themselves to improve and maintain their health.

Domain 4. Maintaining trust

  1. Show respect for patients.
  2. Treat patients as individuals and respect their dignity.
  3. Treat patients politely and considerately.
  4. Respect patients’ right to confidentiality.
  5. Treat patients and colleagues fairly and without discrimination.
  6. Act with honesty and integrity.
  7. Never abuse your patients’ trust in you or the public’s trust in the profession.
  8. You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions

For full details and elaboration, refer to the GMC’s Good Medical Practice advice. [5]. The GMC also has further guidance on the duty of confidentiality, and on acting on concerns about patient safety (for example due to a colleague’s ill health or performance or due to inadequate premises, equipment, systems or policies). [6][7]

 

 

 

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36. Combo chemo – 7 days on and counting, and still not dead yet!

Sorry, if anyone has been left wondering, was that Glen Frey blog his last one, or not? Clearly it wasn’t. This is one of those more mundane updates – what I ate, what I ate next… you know the sort of thing! However, the interim has not been uneventful so read on if you don’t mind a preponderance of domestic-type stuff.

The administration of my Chemo cocktail went like a dream: cannula – straight in; flushing – all good; first up – the red stuff (Epirubicin), and ‘cos you can see it you know you are now less likely to die from excessive, trapped air bubbles; more successful flushing and then on to the arch-enemy, Oxaliplatin (it wins every time, by the way). I reach the last 30 minutes of the 2-hour administration and by then I need a heat pack to protect my injection site, and I’m already feeling a little queasy. Here we go again! However, before I know it out comes the cannula, Elastoplast affixed and I’m good to go. Only three hours in total expended, so we are on our way by 13:00h – yippee!

The next two days were pretty good, probably due to the 4 dexamethasone pills (strong steroid) I am given to take first thing on both mornings, ostensibly to boost my resistance to the Chemo onslaught. They seem to work! Friday morning is a little dodgier, and I’m now on my own as Elaine headed off, via Edinburgh (for more shopping), to pick up daughter, Ellen, in Glasgow to bring her ‘home’ for the weekend. They duly arrive at around 8:30pm together with a Chinese take-away for three of us. They get a shock as they suddenly realise they haven’t catered for four and yet, larger than life, there sits Brad (my best friend who had called around for a chat) sipping a nice Single Malt whilst we “right the world”, listening to Robin Trower (another blast from my 70s past). I reassure them their share of the food spoils is safe, as Brad has already eaten. Phew!

Robin Trower Montage

Robin Trower, ex- Procol Harum, and leader of his own trio.  l to r: in his young days, his later years, Live in 1974 playing “Bridge of Sighs”, a UK TV Appearance. Accessed at https://www.youtube.com/watch?v=0tLsFsGxLmE on 27 January 2016.

We were enjoying the second album, “Bridge of Sighs” from the first volume of a bargain-priced 5 album collection which was playing at the time – and very nice too. If you like your music loud and heavy (I do too!) then AC-DC is your band (“Highway to Hell” comes to mind).

AC DC 1

But if you like your guitar sounds, as I often prefer them, with “space and air” around the notes, then look no further than Robin Trower – just brilliant. And interestingly, King King seem to have adopted a not dissimilar style – hence, I suspect, they lead my favourite new Blues-Rock band of the 2010 decade, for now!

King King 2

King King, led by Alan Nimmo, lead guitar and vocals, here playing live – Kilt-rock! Accessed at https://www.facebook.com/kingkingalannimmo/ on 27 January 2016.

Returning to matters in hand – Friday Night. Eating the takeaway was put on hold and all four of us then put even more of the “world to rights” for another half hour prior to Brad leaving to re-unite with his family, most of which were now in bed and the other tapping her foot, no doubt! Afterwards we did our best to complicate sharing three main meal takeaways where Meal A and B appealed to only one person; Meal B and C appealed to another and Meal C and A looked more than attractive to the other. No-one wanted less than half of the main meal they had ordered for themselves but no one wanted any less than a proper third of the total spoils. To achieve this was some feat given that A was Chicken Chow Mein; B was Chicken Satay and C was Chicken Egg Foo Yong. And there were two portions of egg-fried rice as well as the soft noodles (from the Chow Mein) also to be shared. But we did it!

I met up with a couple of Masons (not my namesake ones) in Lodge 25 on South Street, St Andrews to be ‘screen-interviewed’ for potential membership of this very ancient lodge (25th Oldest in Scotland). The Grand Lodge in Edinburgh is Number 1 and the Kilwinning Lodge is Number 2, and so on. I am also considering the Cupar ‘O Fife Freemasons’ Lodge (Number 19), at least it is a few miles closer to home here in Ceres.

Grand Lodges ScotlandAccessed at http://www.grandlodgescotland.com/ 27 January 2016.

I have become intrigued with Masons and Freemasonry since I researched the history of my name (Blog 31). And I have subsequently bought a Mason Tartan kilt – second hand of course!

But maybe they will have the last word as two of the criteria for entry trouble me quite a bit (A belief in one’s own Universal Spirit – God (any flavour will do!) to me and you – as well as being very charitable. Now I do believe in the awesomeness of the universe, and I buy a lot of stuff from the Salvation Army, Dr Barnardo’s, The Heart Foundation, Cancer Research UK, and any number of other charity shops, but I’m sure that’s not what they mean!

The rest of Saturday was a “slob out” day – great! We were up very early on Sunday morning. Elaine was to drive to Edinburgh to pick up her sister, Jacqueline from Australia. Meantime, Ellen, Craig (her boyfriend) and I head out to the Dundee centre for the Creative Arts (DCA) to take advantage of the Sunday morning (matinee) offer of a Film, Coffee and Bacon-butty, all for £6! We have decided on Quentin Tarantino’s, “The Hateful Eight”. As ever, Tarantino doesn’t disappoint, though you’ll have to stay awake for a good three hours to reach the “piece de resistance”!

Hateful Eight

Quentin Tarantino’s “The Hateful Eight”,  Accessed at http://www.imdb.com/title/tt3460252/ on 27 January 2016.

Jacqueline is here mainly to spend time with her daughter and her family who live in London. We all meet for a late brunch at the Balgove Larder café and country produce shop, just outside St Andrews where we avail ourselves of roast beef, Dauphinoise potatoes (though most of us end up with roast ones – they ran out!) and seasonal vegetables. Despite the jet-lag, we all get the benefits of Jacqueline’s descriptions of what she has just left behind in the Antipodes: sun, sea and surf of Sydney! Lucky her, and it brings back memories.

To bring you up to date, on Monday we went back to St Andrews (more shopping) and I visited my GP (Dr M) who advised me on a couple of queries: to keep taking the stomach ulcer medicine, Omeprazole (that PPI, remember?); but to cease taking Finasteride, my medicine used to treat my enlarged prostate gland – hurray! One fewer pill to take every morning.

Finally, yesterday, Tuesday, 26 February, I attended Ninewells Hospital, Dundee for my second Computerised Tomography (CT) scan. On the way in I counted the number of “No Smoking” signs in and around the ‘fresh-air’ garden at the main entrance – no fewer than 28, by the way! Still no effect on the smokers ‘lighting-up’ whilst reading one of them, I despair! I book in and am quickly greeted by an “InHealth” staff member who takes me to a CT scanning room – actually a mobile storage container containing about a million-quid’s-worth of very sophisticated kit including very fast computers that must handle transfers of 5 MB of data per second – billions of 0s and 1s representing 1mm slices of my upper chest through to my lower abdomen. I’ll discuss the results with Dr P at our next meeting in a couple of weeks time just prior to my next round of Combo Chemo Cocktail. Got to admit- I’m excited (if tumours have gone or at least shrunk) and scared (if tumours are still there or new and/or bigger ones have appeared) in equal measure.

Walking back from the makeshift CT facility to the waiting room where Elaine and Jacqueline await I engage briefly with the “InHealth” guy, who informs me that his company is privately-owned, but that the NHS gets a much better deal from them than when the NHS funds these facilities themselves. For example, Ninewell’s waiting list for CT scans is too long for their existing complement of ‘in-house’ facilities but not so long to justify purchase of another machine, a new building in which to house it, and all the vital staffing and maintenance costs (maybe several millions of pounds’ worth of investment). Hence, Ninewells, like many hospitals including large ones like at Dundee, have to rely on ‘privatisation’ to bridge the gap.

My gut reaction is to commence a considered debate (read: have an argument!) about the merits, or otherwise, of NHS privatisation. In principle, I’m against it. However, I bite my tongue, and reflect for a while before just nodding and agreeing how daft it is that the NHS prices itself out its own markets sometimes.

Later, I recall how we had devolved budgets at all the higher education institutions where I have worked. I controlled several millions of Aussie dollars whilst I was at Deakin University in Melbourne. Also, all these universities had very long-winded, complex procedures and rules for purchasing equipment and services. These included using “preferred suppliers” and getting at least three quotations on any proposed purchase of equipment priced above a minimum threshold. Now this is a very frustrating business. Often, the preferred supplier provided the most expensive quotation, and at other times we could nearly always find a supplier via an internet quick search that was the cheapest. We were not supposed to place orders with such companies if they did not appear on the university’s preferred supplier list. How frustrating is that?

Needless to say, I went ahead and authorised purchase of what we needed, at the lowest cost to the university, regardless of our university rules! The rules were either wrong or, at best, out of date, and needed to be revised. Consequently, they deserved to be ignored. I faced the “eventual music” on more than one occasion throughout my career. But if the NHS UK-wide is tied up with similar kinds of red tape, it is no surprise that both ‘insiders’ and ‘government’ believe that there are ‘savings’ to be made in the NHS, though, whose fault it is that these can’t be made by devolving budgets fully to those that manage them on the front line, is beyond my understanding! This ‘problem’ will need to be addressed in my New NHS.

Well, that’s all folks. I promise to chunk my blogs a little more in future, if you’d rather read a little less, but a little more frequently. However, please let me know what you think – via the comments box at the end of this blog.

BUGS001

 

35. Glen Frey and Neutrophilic Granulocytic White Blood Cells (WBC) – Neutrophils

Glen Frey Montage

Glen Frey and the Eagles – early days, 1977, Playing Lying Eyes and Hotel California at The Capital Centre, LA.

Accessed at http://edition.cnn.com/2016/01/19/entertainment/glenn-frey-songs-eagles-hotel-california-feat/index.html on 20 January 2016.

What on earth is happening to us baby-boomers (1946-1966)? First it was David Bowie, then Alan Rickman (both died because of cancer) and now another of my musical heroes, Glen Frey, of my favourite Country-Rock band- the Eagles, kicks the bucket, all three of them in the space of less than two weeks. At least Glen Frey’s death was not attributable to cancer; now that would have been even scarier, given my present predicament. What do you think?   We are devastated. We have seen the Eagles, albeit in later years, 2007, at Hampden Park, Glasgow (and a long way from the stage), but also 2014, at the 02 arena in Leeds (and thankfully much closer to the stage, but also with better nay, fantastic acoustics!).

Thank goodness for those stage screens – in Glasgow, but curses on them – in Leeds, where they acted as a complete distraction when not required on that occasion. I suppose the cheap seats still needed them, but one gets fairly picky having splashed out for posh seats!  The Eagles’ Leeds concert was preceded by our visit the previous night to the same venue to experience Dolly Parton (also our second viewing – we saw her in Belfast in 2007 too – busy year prior to migrating to New Zealand in September). She was brilliant on both visits but a problem with the PA system for the first half of the concert in Leeds spoilt things even though Dolly added repeat performances of a couple “first half songs” in the second part of the show. No worries we thought, still have the Eagles to come tomorrow, and we were more than compensated!

Eagles

A later version of the Eagles.

Alan Rickman as the Sherriff of Nottingham in my favourite role of his:

Accessed at http://www.telegraph.co.uk/news/celebritynews/12099543/Alan-rickman-dead-at-69-latest.html on 20 January 2016.

Alan Rickman Robin Hood

Yes, yet another baby-boomer, Lemmy from Motorhead, is a further casualty of cancer (prostate), though a little earlier, but not by much, than the recent spate.

Lemmy Cancer Death

Accessed at http://www.teamrock.com/news/2016-01-20/lemmy-s-cause-of-death-listed-as-prostate-cancer on 20 January 2016.

 

Dolly Parton at 70

A modern version of Dolly Parton on her 70th birthday tour.

Accessed at http://themuse.jezebel.com/happy-70th-birthday-dolly-parton-lets-celebrate-with-1753849659 on 20 January 2016.

 

Dolly Parton Little Sparrow

Dolly Parton playing “Little Sparrow” – her encore at the Leeds concert!

Accessed at http://themuse.jezebel.com/happy-70th-birthday-dolly-parton-lets-celebrate-with-1753849659 on 20 January 2016.

However, Glen did die of multiple disorders including pneumonia, and this is my link between him and those vital little buggers that circulate in our blood stream: our neutrophilic, granulocytic white blood cell (WBC) (or abbreviated to neutrophil and sometimes called Poly-Morphonuclear Neutrophil, PMN, because of their multi-lobed nucleus). These cells get their name from their appearance under a light microscope at high resolution and magnification (>500x) from a combination of their staining and the presence of distinct ‘granules’ that are in fact vesicles containing packets of chemicals (eg, hydrogen peroxide) as well as highly specific enzymes that assist in the killing and elimination of bacteria associated with infections such as pneumonia.

To see one of these tremendously hard-working little gems of the blood system a small drop of freshly-drawn blood is placed upon a microscope slide (or at least it was, way back when as a haematologist I prepared my own) and a thin film is created by drawing out this drop with another slide. The blood-covered slide is allowed to air dry and then it is (was) placed in a Coplin jar for staining.

Blood film or smear

 

Blood film or ‘smear’ prepared on microscope glass slides from “Making and Staining a Blood Smear”: Accessed at https://www.uvm.edu/~jschall/pdfs/techniques/bloodsmears.pdf on 20 January 2016.

Coplin is just one of the many offerings I get from word-processor auto spellcheckers for my first name – others include colon, coin, Collin, Coppin, Copland and on and on.  A Coplin jar is a small, beautifully crafted glass vessel with an accompanying lid, containing the stain, Giemsa.  Giemsa is like a combo of  Haematoxylin (Alkaline blue dye) and Eosin (Acidic red dye). The Haematoxylin-like component is attracted to alkali-loving cell structures such as Nuclear Chromatin as well as alkali-loving components found in some white blood cell granulocyte vesicles. Eosin is attracted to acid loving components, including those in WBC vesicles or ‘granules’.

The granulocytes get their name because their granules are easily visible and distinctively coloured. All three types of these WBCs mount their attack rapidly on infectious organisms or damaged cells and tissues. In fact, the three types of granulocytic WBC are not equally represented. Alphabetically, they are the acidophil, actually eosinophil (about 5-10%), the basophil (about 0.1-2.0%) and the neutrophil (about 60-90%). Clearly the neutrophil is boss in this subcategory of WBCs. The names of all three granulocyte cell types is associated with the staining of their ‘granules’ in this dye combo: under the light microscope eosinophils have bright red-orange granules; basophils have dark blue-purple, nearly black ones, and neutrophils, you’ve guessed it, have the middle ground – they appear purple-mauve-lilac (at least they did to my eye), and are thus ‘neutral’ or between blue and red. Hence the neutrophil is named, and now finally you know what I was on about in my previous cancer blog entry.

 

WBC montage

White blood cells in a stained blood film.

Top l to r: Eosinophil (Acidophil), Basophil, Neutrophil, also known as a Poly-Morphonuclear Neutrophil (PMN); Bottom l to r: Lymphocyte, Monocyte

The other category of WBCs is the non-granulocytic population comprising round or oval shaped lymphocytes and the similarly shaped but larger monocytes. These two functionally different cell types look similar to one another in the blood-stained images seen under the microscope, partly because the lymphocyte population is diverse in size and sometimes a lymphocyte is nearly as large as a monocyte. Nevertheless, they can be differentiated (distinguished). Both types have a nucleus that occupies much of the cell volume, though the monocyte nucleus often appears indented. For better financed haematology labs fortunate to have better microscopes (such as the German Leitz, or even better, a German-again Zeiss) small ‘granules’ can sometimes be seen in monocytes. Mobilisation of lymphocytes and monocytes is somewhat slower than for granulocytes, though this can depend upon whether a person has been infected previously with the same organism, and in which case these cells can respond quicker, though again usually not as rapidly as the granulocytic WBCs mount their attack.

Complicated stuff, eh?  Just to add a little more to your headache then, neutrophils often work in close collaboration with monocytes against some infectious bacteria. Monocytes are the longest lived of the WBCs. Further, after the initial attacks, predominantly by granulocytes, breakdown products released from the devastation of battle with bacteria may attract lymphocytes to the scene and it is these cells that then initiate or kick start the immune response, and it is this and subsequent reproduction of these cells that ‘prime’ and equip us to be better armed against the specific (or sometimes related) organisms. On a subsequent exposure to the infectious organism (bacteria already mentioned, but also viruses, fungi and parasites) lymphocytes particularly get to the site of action quicker than on the first infection and further, these already ‘primed’ cells receive intercellular signals that trigger cell division, and proliferation through exponential reproduction.

The total population of lymphocytes may have different activities, particularly during this ‘second exposure’ phase of the immune response. Some, the so-called B-Lymphocytes (or B cells), produce specific antibodies against the target infection whilst T-Lymphocytes (or T cells) mount direct cell attacks on the enemy. Also, some T cells form a repository of ‘helper’ cells that also assist B cells in producing more antibody as well as helping initiate cell-cell recognition. It is the T cell lymphocyte population that is gradually destroyed in Human Immunodeficiency Virus (HIV) infections and ultimtely (without treatment) leads to Acquired Immune Deficiency Syndrome (AIDS).

Returning to granulocytes, it is eosinophils that cooperate (and often fail) with neutrophils in attempting to destroy parasites, and can be often seen in great numbers in thin sections of human tissue plus parasite-infected tissues from sampled areas of the body when viewed under a light microscope by histopathologists. Basophils often appear at the site of inflammatory reactions, and may even attract eosinophils to the action as they release histamine from their ‘granules’ – and so also can be seen, though not exclusively, at the site of a particularly resistant parasitic infections.

Once again you deserve a bonus, and I guess it was a little remiss of me not to give you my favourite Bowie track, “Golden Years” after he died. So, with apologies here he is now. You also qualify on further grounds of putting up with some more biology or biomedical science stuff. So here goes:

David Bowie Montage

David Bowie, “Golden Years”,1975.

Accessed at https://www.youtube.com/watch?v=e4iKfUKBWDk on 20 January 2016

David Bowie Golden Years

 

That’s all folks. Bye for now.

Though please read below if you are an addict for punishment as well as more critical information about using blood-borne human stem cells for treatment of various cancers.  (A late addendum!)

BUGS001

Addendum

[“In addition to their distinctive cytochemical staining characteristics (Giemsa staining), blood cells can be distinguished on a gross level by their average size and granularity as measured by flow cytometry. With a flow cytometer, the optical effects of passing a single cell through a laser light beam can be measured in terms of light scattered by the cell in two directions – parallel to the beam (“forward scattering” or FSC) and perpendicular to the beam (“side scattering” or SSC). Greater FSC correlates with larger cell size while greater SSC correlates with more granularity in the cytoplasm and nucleus of a cell. A two-dimensional plot of FSC versus SSC for human blood cells, reveals that different cell types exhibit distinct average ranges of size and granularity. Thus, flow cytometry can be used to analyze and even physically isolate different blood cell populations. With a modified flow cytometer designed to detect fluorescent light stimulated by the laser beam, i.e., a fluorescence-activated cell sorter (FACS), even finer distinctions between different cell populations can be made if they have been treated with fluorescently tagged monoclonal antibodies directed against specific cell surface molecules, generically referred to as cluster of differentiation (CD) antigens.”]

Accessed at https://mcdb-webarchive.mcdb.ucsb.edu/sears/immunology/cells-organs/blood-cell-morphology.htm on 20 January 2016.

The various WBCs are not only recognised through this automated ‘differentiating’ process, but they can also be harvested by setting ‘gate’ windows around particular regions on the screen visualisation after a first run, then repeating the procedure with the ‘harvest’ button activated.  This differentation procedure mimicks the ‘old-fashioned’ WBC diff-count (differentiation count of at least a hundred cells and preferably more) on a stained blood film or smear, though using staining characteristics and morphology (colour of ‘granules’ particulaly, overall cell size, shape of nuclei and size and density of granules).   The absolute count of each WBC type is determined simply by mutiplying the Total WBC by the percentage of cell types present in each category – easy as pie, eh?

Finally, it is also possible using CD markers to distinguish lymphocyte sub-populations including all of those previously mentioned, the T cell variations, B cells and more recently a population of lymphocyte-like cells (size and morphology) called bone marrow-derived but now blood-borne stem cells. The identification and harvesting of these cells is now almost a routine procedure and has revolutionised treatment of many haematological diseases such as leukaemias and lymphomas as well as other cancers. Sometimes patients are exposed to lethal doses of radiation and then donor-harvested stem cells are given back to the recipient patient. This is a more complicated procedure than donor bone marrow transplants following total ablation of recipient marrow once again, but it carries a much lower risk of donor-versus-graft disease, where the donor bone marrow cells and their subsequent progeny, mature blood WBCs, can recognise and subsequently attempt to destroy recipient cells and tissues that are recognised as ‘foreign’. Blood-harvested stem cell transplants are costlier, certainly short term, but treatment with immuno-suppressant drugs for prolonged periods of illness is far from cheap either!  This is yet another topic for my New NHS, but not as we know it!

 

 

34. Clever Colin’s Combo Chemo Cocktail – Coming up!

Chemo Cocktail Montage

Accessed at https://www.youtube.com/watch?v=vzCl1gJVWyQ on 18 January 2016

On Friday (15 January 2016) Elaine and I visited Ninewells hospital, Dundee to do the usual stuff as part of my Pre-Chemo assessment. I donated an armful of blood for tests; had my blood pressure, heart rate and temperature taken; provided my personal, oral account of the highs (not many of them!) – and the lows (but plenty of them!) of the last three weeks as well as handing over my daily diary. In addition to the foregoing all my carefully crafted, oral and volunteered minor complaints (severe skin itching, typical Oxaliplatin-cold interaction side effects: runny nose, eyes and mouth; tingling and numbness in fingers and toes as well as feeling the shivers, occasional constipation and an overwhelming irritability and need to walk around the house in short, staccato steps – to no good purpose), were dismissed as not significant by my angel nurse – so much for that bit of attempted “flattery gets you everywhere” nonsense- it doesn’t! I was assured I’d be contacted if my blood tests showed anything that needed to be dealt with promptly.

Ninewells Hospital

Ninewells Hospital

Accessed at http://www.nhstayside.scot.nhs.uk/GoingToHospital/OurPremisesA-Z/NinewellsHospital/index.htm on 18 January 2016

I pointed out that I had secured a special meeting with Dr P on Monday, 18 January (today), and I agreed to return to the ward following the meeting if there was to be any ‘change of the plan’. As it happens, there wasn’t, so I didn’t! However, Dr P did notice that, whilst my haemoglobin level had taken another step closer, albeit a small one (now 102.4 g/l compared) to ‘normal’ (150-170 g/l for us men), I did have a low neutrophil (a white blood cell that fights infection) count, and that I should have this checked to see whether there had been any further recovery over the weekend, before arriving for my Combo Chemo Cocktail early tomorrow morning. I’m not allowed to proceed to the Combo Chemo cocktail unless my neutrophil count reaches a ‘magic, safe’ number. So, a quick but impromptu full blood count was proscribed and different angel nurse arrived from nowhere with an armful of phlebotomy tools, swabs, towels and of course blood containers! Damn! Yet another armful of blood goes to the NHS. I’m not sure who is more indebted to whom here! I strongly suspect it is still me, but I have to try every angle to build up my current (or currency?) account with which I can do my bargaining, wouldn’t you? I had an approximately one-hour-long chat (again) with Dr P, this time straight to the chase, “how could I get a PET-CT scan if this might help more with my prognosis?”.

Once again Dr P did a brilliant job at explaining his reasoning for believing that a CT scan would be sufficient at this stage. He felt strongly that I should continue with further rounds of chemotherapy (between 6-8 cycles in total) unless the CT scan revealed a different course of action, such as increasing the dose of the current chemo or a switch to a different drug if my side-effects worsened. He also reiterated his strong view that surgery would not be an option for me, even if a PET-CT scan revealed dormancy of the cancer since it was still likely that some or even the last cancer cell, if remaining, could still re-kick-start the metastatic cancer growth. This is a real fear about surgical intervention for patients such as me, as he has seen the consequences (poor or even completely disrupted healing) of contamination of surgical sites (eg the joined faces of a surgically-reduced stomach) with such ‘feeder’ peritoneal cancer cells. Furthermore, we already have strong evidence (my first, though only CT scan, to date) of spread of my cancer to my abdominal cavity organs – at least pancreas, adrenal gland and a few lymph nodes- as well as possible, additional omental ‘seedlings’ of my peritoneal organs. Dr P believes that this could have occurred via peritoneal cancer cells. We can’t know otherwise, I guess.

The only minor flaw in this argument, however, is that we have no way of ‘knowing’ rather than ‘intimating’ such cells are present. Peritoneal samples were not taken nor examined for the presence of poorly differentiated adeno-carcinoma cells with characteristics of close proximity to my primary gastric cancer. It is possible, again in my view, even if less likely, that all my secondary cancer deposits could have been blood or lymph fluid borne, carried via the vascular or lymphatic vessels, respectively. Notwithstanding this latter point (which I couldn’t raise in the meeting since I only thought of it when we were driving back home over the Tay Bridge!), and despite all of my slight objections or queries, I have realized better now the merits of Dr P’s arguments and his stance – he fundamentally thinks it is in my best interests, and I am appreciative of his concern for my overall and long-term well-being.

Well folks, that’s it. I have to be back again in Ward 32 at 9:30 am tomorrow for my next cycle of intra-venous Chemo (Epirubicin followed by my dastardly Oxaliplatin!), assuming those little neutrophils have returned in adequate quantities to permit it safely. Now, I think you have deserved a bit of music for your bother of checking my blog (and the cupboard was bare – for three days) and for putting up with some of this medicine and biomedical science stuff. So here goes:

Paul Weller’s live acoustic performance, “Days of Speed”, 2001. Do try either Track 2, “The Loved” or Track 16, “Wild Wood”; just amazing, though you could equally put your i-pod, i-phone, i-pad (or similar android facility) on shuffle and you’d turn up something brilliant, a new version or acoustic rendition of one of his key songs.

Paul Weller Montage

 

That’s all folks.  Bye for now.

BUGS001

 

 

33. Harry Potter and the deathly silence

Harry Potter Deathly Hollows

I’ll briefly repeat my 6 point (bullet) plan for the NHS to preface my focus for today’s section on 5. Research.

  1. Education – underpinned by philosophy
  2. Screening – underpinned by data
  3. Testing – from birth to death
  4. Preventative treatment – promotion of healthy life styles
  5. Research –on preventative medical conditions
  6. Evaluation – led by self-scrutiny

Research on preventative medical conditions

It is a not well kept secret that most medical or biomedical research is aimed at finding treatments or (hopefully) cures for one condition or another, for example, heart disease, cancer or more specifically, Diabetes Type 1. The system is underpinned by vested interest, and clamour for any major change will no doubt be met with “deathly silence” or covert hostility. The current approach to research is admirable and one to which I, myself have contributed.

No, I won’t re-iterate my fondness for Joan Armatrading (Me, myself, I – remember?) with musical or visual illustrations. Now bear with me folks, this blog entry is a serious piece of writing, so there won’t be any visual, musical, film, comedy or poetic interludes, and you are going to have to be grown-ups and read through to the end to find the couple of musical “Easter-eggs” I have buried herein. But I promise you, there’s “light at the end of the tunnel”, “gold at the end of the rainbow”, and a “couple of new artists” to discover, but only if you continue reading from here and preferably, make a comment in the ‘reply here’ box at the end of the whole blog!

…so, to continue with the serious stuff.

My PhD thesis was entitled, “The anaemia of chronic renal disease”. Also, I worked with many clinicians and research students to discover more about, for example:

  • interactions between platelets and prosthetic materials used in venous grafting;
  • binding of platelets to defective connective tissue in Ehlers-Danlos syndrome;
  • levels of platelet Adenosine Tri-Phosphate (ATP), and Adenosine Di-Phosphate (ADP), an intra-cellular biochemical as well as an extra-cellular aggregator of platelets (causes platelets to clump or clot together to prevent blood loss normally), in unexplained minor bleeding disorders; and
  • effects of human immunodeficiency virus (HIV) on blood coagulation factor interactions.

With hindsight, I now see that although these and the many thousands of medical discoveries that lead to better treatment of patients’ suffering are admirable; and ironically, contribute to the very success of improved health and social care in an expanded global population, through substantially reduced infectious disease in some parts of the world, and increasing longevity in both western and developing societies. However, this will not be a sustainable strategy for the future.

The aim of research is to translate laboratory or pilot studies to serious clinical trials and eventually to practice. This is the challenge, as this translation process does not always materialise, but can’t be avoided as part of an overall experiment. Similarly, research designed basically as a “treatment of disease” approach is not likely to translate easily to a “proactive, prevention of disease” approach, designed to reduce incidence and prevalence of illness and disease. Accordingly, I suspect, a new overall strategy will be required for the New NHS despite many proactive, preventative efforts and projects already being pursued.

For example, intense efforts are being made to develop better blood-taking and drug-giving devices for new-born babies and for insulin-dependent diabetics (Type 1). The so-called Velcro-type patch comprising hundreds of micro-needles on a small Elastoplast-sized backing pad which when applied can be used to take heel-prickblood samples in neonates without pain and much less tissue damage. The hope is also to be able to administer drugs or biological therapies for example in diabetics, such as recombinant human Insulin (rhu-Insulin) through the same device which can be similarly used to withdraw blood, at least for blood glucose-level testing. After treatment the patch can be removed much like a current Elastoplast with minimal inconvenience. This would be a major improvement over the current methodology for daily multiple testing and treatment of Type 1 diabetics.

Early death diseases

There’s a raft of relatively rare but ‘killer’ diseases that are predominantly genetic, requiring both parents to have contributed a recessive gene to generate a homozygous (both copies of genes are similar) condition or phenotype (both recessive genes are needed for the expression of the disease state). The disease state may be immediately apparent after birth of the affected child or the symptoms may be delayed and for some diseases early death may ensue. These conditions include Multiple Sclerosis, Huntingdon’s Chorea. Much research and funding is already aimed at discovering preventative measures but much more is required. ‘Minority’ diseases would be given a definitive slice of the research pie in my new NHS.

Diabetes

The cause of Diabetes type 1 is still not fully understood but the cause of the massive increase in Diabetes Type 2 can be largely attributed to life-style choices, in this case over-eating and the development of over-weight/obesity. There’s still a small proportion of type 2 diabetics where the cause may be known or even not known, but they are not in this new life-style category. The impact, particularly of this in childhood and young adults as well as older people (those previously and mainly affected), is that the treatment bill and cost to patient health is not only attributable to diabetes itself but also all of the usual suspects, side-effects, obesity, heart disease including heart attack and stroke, and thrombosis leading to poor circulation of especially the extremities (hands and feet) and potentially resulting in amputations. The cost to all health care bills is enormous and growing worldwide. Preventative research would surely pay huge dividends as a long term investment?

Genetically-linked disease

As genetic profiling becomes a ‘norm’ in the future NHS it will be possible to determine whether there are links between phenotypes or even ‘carriers of particular genes‘ and the incidence of major diseases such as heart disease, cancer, lung disease as well as rarer diseases. This would open further potential anticipatory interventions as medicine became more confident in its approach to proactive medicine based upon research findings such as these – better predictors of future, potential patients.

Researching Disease and ‘the money’

One of the barriers to adopting a proactive, preventative approach is that it ‘costs too much‘. In the new NHS we would need to reverse this mind-set. A key question will be, “is it not more expensive to continue with old approaches?” This may well be the case, especially longer term. Often however, the answer is not known. So, research to answer these questions will be required more and more as NHS funding becomes ever more limited as spending per capita rises and overall budgets stagnate or are cut. This can be summarised as “retrospective analysis of treatment costs for diseases, particularly late-onset, though not only” and cost of early intervention.

Evidence-based medicine as well as research will require awkward questions to be asked. For example, despite some claims that gastric banding is an effective treatment for overweight and obesity, to me, it sends the wrong message ie treating the patient’s symptoms and not the cause. Plus, my own stereotyping of overweight patients has maybe clouded my view. I say this now since my gastric cancer which largely occluded the whole of my stomach lumen possibly acted like a gastric band. My appetite diminished progressively as the cancer presumably grew until I commenced chemotherapy. But it also continued since and overall I have lost four stones. Whilst not all of this is likely to be due to ‘gastric banding effects of the cancerous lump’, it is undoubtedly a component. So, I now see how and why gastric banding works. Will it be less costly than other interventions either short or long term? Do we know the answers already? If not, this may be research for the future.

Where is the money coming from for research and new approaches to medicine? This may be a major research question itself, but there are a few other questions or approaches that can be addressed.  Can savings be made from not treating preventable ill-health and reduced treatment of age-related diseases?  Who pays and how, when ill patients rather than healthy(ier) populations still predominate? Treatment may have to be front-loaded initially and then gradually scaled back in say, a five to ten-year transition period. Also, maybe there should be more direct links between those gaining most from national profits on curative treatments and drug sales from suppliers and vendors (Pharmaceutical companies, medical device manufacturers and sales companies) and the raising of revenue to be spent on the New NHS?

Finally, maybe further revenue should be raised through levies and taxes on harmful products eg sugar in soft drinks, nicotine in smoking products (cigarettes, cigars, pipes) as well as reduced and non-nicotine products (E-cigarettes) that simulate or prolong coming-off nicotine containing items. The present Government has already proposed such a tax – a 10p premium on sugar-containing soft drinks, particularly those aimed at the child and young adult markets. Governments will simply need to be bold (tell truth to power) when they deal with opposition from vested interest groups. Researching the impact of such levies and taxes might also become a more acceptable or legitimate activity in future, though probably it would fall into my category 2 or 3 (see below) in a new classification scheme for defining research.

 

The Future of Medical Research?

We require more forward-thinking or anticipatory approaches such as these. While we focus on treating current illness, and not on future health as well as current health, the imbalance in ‘treatment-focusedversus ‘health-focused’ research will persist.

Individualised health care utilising complete personalised genotypic data may well be the future; and it is not just me that thinks so. Mark Beggs (quoted below) is already leading an innovative approach to the use of informatics to assist, where appropriate, in the treatment of patients utilising genomic data (gene profiling based on the Human Genome Project).

[Mark Beggs: “AnalytiXagility extends its services to industrialise the ability to link and analyse sequence and other data sources to support precision medicine research and initiatives.

The platform provides capability for national genomics facilities, genomics initiatives in the NHS, stratified medicine research, bioinformatics start-ups and annotation service providers.

These services are made available through the Stratified Medicine Scotland Innovation Centre (SMS-IC). This unique centre brings together experts from academia, industry and the NHS in Scotland to implement a biomedical informatics service to aid clinical and translational research, and enable stratified medicine. As the lead industrial informatics partner, Aridhia is able to offer immediate solutions on a monthly subscription, without the need for investment in infrastructure.”]

Now I am not quite sure what stratified medicine research” (Begg, 2015 – see above) actually is or could entail, but if it is about defining different types or classes of research (such as say, new-proactive; current-substantiate and old-modify) and then prioritising these differently, then I am fully supportive of stratified medicine research. Furthermore, I’d favour the following prioritisation for clinical and scientific research projects:

  1. New-Proactive (focus on genomics and approaches that have long term health benefits or reduce costs long term, though there may even be increased short term costs)
  2. Current-Substantiate (focus on demonstrating effectiveness of newly adopted protocols; further validation of current protocols; and collection of side-effect data on drug or procedural interventions, especially multiple-drug interactions)
  3. Old-Modify (focus on minor improvements or reducing known non-life threatening side effects of treatment, especially for those diseases that are preventable by life-style interventions and may also be classified as age-related diseases or conditions)

If research could be classified in this way (or similar) and that it was prioritised as 1 > 2 > 3, then this would be a positive ‘driver’ for a switch to ‘preventative-type research’. Both Governments and Industry could further incentivise a shift-over by making research or development grant funding available using a similar order of priorities, or by allocations of specific percentages of ‘winning grants’ in line with world-agreed priorities eg 1 (60%) > 2 (30%) > 3 (10%). This would further promote a shift but also keep the ‘old model’ going as older researchers and research projects continue or are gently phased out. In addition, some research and its funding would still be required to monitor, evaluate and ‘tweak’ the previous ‘new’ work as it became the ‘old’ research and practice. This would be necessary even if monitoring and evaluation were embedded in new proposals for research or development grants.

In summary, in the New NHS proactive and speculative research will play an increasingly important role in sub-serving the aim of decreasing the incidence and prevalence of disease. It will also aim to reduce the impact on patients of specific diseases that may have no cure or limited treatment potential. It will also be geared to seeking how to minimise the costs of diagnosis, screening and treatment, particularly of life-style related diseases.

The current trends in research funding will be reversed and research based on data and hard evidence (the numbers) and derived information should and will also be more prominent. Research funding and priorities will lead to the re-alignment of rewards for those undertaking research. The present categories of ‘weighted’ and ‘recognised’ (Citation compendia and ‘top-ranked’ journal articles) will need to be challenged. The use of big data (eg the genotypic library from the human genome project) and informatics will play an increasingly important role not only in new, personalised treatment but also in leading as well as intimating at research and potential research projects.

A methodology for determining the priority of these new categories of research will be needed, though at least two suggestions have been made here. Financing research and development will probably require more money than at present, and several options have been presented and explored. This will not necessarily be ‘new money’ though in the first and early years of transition this may be true. However, as the New NHS matures and (hopefully) fewer patients develop diseases, or, at least, the same number of patients with fewer and less harmful symptoms should release ‘old money’ for newer treatments and new research.

And now, your prize (for reading the article).

As promised, here are your Easter eggs. They’re not exactly buried well, but I trusted you not to just skip to the end of the article after my tip-off earlier since you’d probably think that I would have a nefarious plan to ensure your uptake of my offer of “goodies for reading” wouldn’t be easy. If you are here already and haven’t read the rest of the forgoing text, then perhaps you’ll amuse me and read it anyway?

Those of you who have read all my blog entries may be aware that I have already briefly mentioned Keb’ Mo’, by name only (no music titles or sound bites offered). So, he is my first offering today.

Keb Mo Montage

Keb Mo from a little later than his first album (also Keb Mo, 1994).

Keb Mo Am I Wrong – YouTube

Accessed at https://www.youtube.com/watch?v=qKQWhsLbe9E on 14 January 2016.

Here’s a little background. Elaine and I first encountered Keb Mo (I’ve dropped full spelling from now on!) at Coromandel Blues festival in 2008, on North Island, Coromandel Peninsula, New Zealand. He was billed at about six down the list, on the main stage, on the last night which also featured Buddy Guy (top billing) and K T Tunstall (second up). It is fair to say that Keb, standing alone with an acoustic guitar and just the PA, absolutely ‘blew us away’ as well as all the other acts, in my opinion. We saw Keb play again in Melbourne in 2011, by which time I had purchased about 8 CDs from his back catalogue. There’s lots of goodies, but as a key sampler do have a listen to, “Am I wrong”, a fast moving track from his first and eponymous album. It’s amazing – again, in my opinion – though you may need to like blues music, at least somewhat, to even begin to agree!

My second choice is more straight forward, but only a little. We returned to the UK from Australia in 2012.  Three months later I bought a sampler, triple CD album (“Latest & Greatest ACOUSTIC SONGS”, 2013) for only £5.99 from Tesco.  It was going to be some further four months before we would be unpacking my precious hi-fi and collections of LPs and CDs and I simply couldn’t wait! Now who would have guessed that I would come to fall in love with three tracks, in particular from disc one, and that one of these would become my favourite on the whole album. Even I wouldn’t have believed it, in advance of listening anyway. However, the proof is in the listening: try Pixie Lott’s “Mama Do (uh oh, uh oh)”, Ryan Adam’s “Wonderwall” and Duffy’s “Mercy”. And the winner is… very difficult to pick!

Seriously, who would have thought an American could do a better version of “Wonderwall” than Oasis themselves, but it’s true! However, I give the prize to Pixie Lott for just surprizing me with an acoustic version of a song I know well but kept me wanting this version of “Mama Do” to continue just that little bit longer!

Pixie Lott Montage

Pixie Lott and Mama Do.

Pixie Lott – Mama Do (uh oh, uh oh) – YouTube

https://www.youtube.com/watch?v=RPV8c3Q4D8U

 

BUGS001

 

That’s all for now, folks. I think I have earned my rest which I plan to take tomorrow. See you in a couple of days.

 

 

 

32. Bad news, good news; but what is the truth?

Newspaper rack

British newspapers, accessed at http://www.gettyimages.co.uk/photos/the-guardian-newspaper?sort=mostpopular&excludenudity=true&mediatype=photography&phrase=the%20guardian%20newspaper&family=editorial on 11 January 2016

What is the truth and who can you trust to tell it these days?

  • Your partner?
  • Your solicitor or lawyer?
  • Your MP, SMP or MEP?
  • Your doctor or GP?
  • The BBC news?
  • Aljazeera
  • The daily or Sunday Newspapers

I just don’t know any more, and this poses dilemmas.

Aljazeera News

For those of you that don’t know, Aljazeera is an international news broadcasting channel that “…broadcast to more than 220 million households in more than 100 countries.”

and

“Al Jazeera Media Network has more than 4,000 highly experienced staff from over 70 nationalities, making our newsrooms the most diverse in the world.”

 

I have this ginormous dilemma. When I was first diagnosed with my stomach cancer (posh name: malignant, poorly differentiated, gastric adenocarcinoma) my superb consultant oncologist described it as ‘aggressive’ and that without chemotherapy (surgery was ruled out altogether – see Blogs 2 and 3), I might survive for only between 6 to 8 weeks (and this was 3-4 weeks after the CT scans and gastroscopy were carried out, on which this call was made). My fate was sealed apparently. I would be put on a programme of Palliative care, and that is what has happened. To me this is a much worse prognosis than being put on a programme of Curative care, even if this also only involved chemotherapy, initially. The fact is, I don’t know what a programme of curative care for my condition at my late stage (Stage 4, involving spread to lymph nodes and other structures within my abdomen) would look and feel like. But, I’d like to be proscribed it, for sure!

My dilemma is that after three cycles of the Combo Chemo cocktail of Epirubicin, Oxaliplatin and Xaloda (EOX) I appear to be improving (no or few very small lumps not detectable by palpation, albeit my own self-examination), and a stemming of severe weight loss (I now tip my bathroom scales at just ‘dead-on’ 9 stones). That’s 4 stones less than my weight last Christmas 2015, but at least it is consistent with equivalent stages in the cycle of Chemo, about 10-14 days after injection of E and O! Despite this and despite my direct request to be re-designated as a Curative Care Patient by Dr P this has been refused. That is my dilemma. I don’t see why this is such a problem. So what is my true situation? Personally, I’d prefer to know. I can take it (the truth), I am a big boy (or used to be), and I am one of those people who prefers straight talking and no bullshite! So, what then?

Let’s look at a different context, newspaper journalism, to discover more about the dilemma of discovering the truth. It’s topical so I thought I’d look at how two well-respected newspapers, the right wing supporter, “The Times” and the left wing supporter, “theguardian” both reported yesterday’s (Monday 11 January 2016) news headline of another Labour front bench member, Catherine McKinnell, resigning her cabinet position as Shadow Attorney General. The tone, positioning and degree of responsibility assigned to Jeremy Corbyn are compared with reference to short passages taken from each newspaper’s online article (truncated).

The texts from each newspaper and my commentary are presented as follows:

All text is in Calibri font

Headline – in bold font

News text – normal font

My comments – italicised font (and direct quotes are italicised and bold)

The Times

Headline, “Corbyn hit by new resignation from shadow cabinet”.

Jeremy Corbyn’s frontbench team continued to fracture in the face of his disastrous reshuffle this morning, with the resignation this morning of his shadow attorney general.

The very first sentence (as well as the title of the piece – above) gives this away as an attack on the Labour Leader.

Catherine McKinnell wrote a letter to the Labour leader, announcing her resignation on account of “concerns about the direction and internal conflict” within the party.

This is factual, and pretty much reported in the same way by the Guardian too.

The decision came on the day that Mr Corbyn called for activists to be given a “big say” over Labour’s policy on the renewal of Britain’s nuclear deterrent as he seeks to circumvent sceptical MPs.

Mr Corbyn’s reshuffle has sparked major unrest within the party, after the Shadow Culture secretary…

These two sentences once again have as their focus Mr Corbyn and highlight issues that portray Mr Corbyn negatively (“ …he seeks to circumnavigate sceptical MPs”; and “…reshuffle has sparked major unrest…”).

The rest of the article requires a subscription.

________________________________________________________

theguardian

Headline, “Shadow attorney general Catherine McKinnell resigns”.

The shadow attorney general, Catherine McKinnell, has resigned from Labour’s frontbench, citing “concerns about the direction and internal conflict” within the party.

The opening sentence focuses on what the MP has done and at least one of her reasons for doing it. The latter clause is reported neutrally and was of a similar tone in the Times reporting.

McKinnell was only appointed to the shadow cabinet last September and had not yet made her mark in the job. With three young children, the Newcastle North MP, who was first elected in 2010, said in a letter to Jeremy Corbyn she was having problems balancing her party commitments with family life.

This sentence implies that Catherine McKinnell may not be doing a great job and that other factors such as work-life balance are important to her in reaching a decision to resign. In my view, there’s a slight sexist tone in this reporting.

However, she also made pointed comments raising concerns about what she described as an “increasingly negative path” that the Labour party has adopted, which is likely to be seen as direct criticism of Corbyn and his leadership. She stressed her desire to channel her energies into representing the concerns of her constituents.

In this sentence the Guardian emphasises Catherine McKinnell’s view about what is negative (that she doesn’t like?) and only relates this by inference to Corbyn’s leadership role. And finally, the Guardian re-emphasises positive aspects of McKinnell’s decision to resign – to “…representing concerns of her constituents.”

More text is available in the Guardian article, but I have omitted it as I have tried to restrict the textual analysis to similar numbers of sentences and their location as the lead parts of each reporter’s article for their respective newspapers.

So, what would you conclude? Answers please in the comments section.

In my view, as a passionate labour party politics supporter, I am inclined to think theguardian’s version is nearer the truth (whatever that is). I believe this because I heard Jeremy Corbyn answering questions by Nick Robinson (of whom I am also a fan – normally!) on yesterday’s BBC Radio 4, “Today” programme.

Jeremy Corbyn

Tweet re Jeremy Corbyn

Jeremy Corbyn coming under fire on Twitter after his appearance on Radio 4’s Today programme, accessed at https://twitter.com/bbcnickrobinson on 11 January 2016.

Despite valiant attempts by Nick to ‘fill’ the air time and ask leading or multiple questions and then not actually giving Mr Corbyn the time he promised him to put his case on subjects of his choosing, Mr Corbyn stayed calm, answered the questions succinctly, without fluster or fuss and never once drew attention to Nick’s slightly (at least) naughty style as well as content. One – nil to Jeremy Corbyn.

Do any of the rest of you get the impression of a media conspiracy to discredit Labour generally, and Mr Corbyn’s leadership style in particular, for fear of a genuine awakening of the public, many of which are apathetic, appeased, natural labour-oriented supporters, but who are silent, non-voting members of society? They could wake up of course, and is this the “Establishment” fear?

Finally, is this conclusion the truth? Nope! It is my interpretation of all the data and information I collect, though filtered through my own values and philosophical approach. For example, I deliberately added “Mr” to Corbyn occasionally to soften the sentence and perhaps win you over – at least a little! So who can you believe? This is the nature of a dilemma!

Definitions of “on the horns of a dilemma”:

faced with the choice between two equally unpalatable alternatives;

in an awkward situation

Synonyms

between the devil and the deep blue sea;

between a rock and a hard place (informal); and

between Scylla and Charybdis

Collins dictionary

So what should I do when I next meet Dr P? Answers please – in the comments section!

See you again soon.

 

 

 

31. What’s in a name?

mason coat of arms

Mason family crest accessed from https://www.houseofnames.com/mason-family-crest on 10 January 2016)

Well, just about everything, that’s all! I have been looking into my own surname, Mason, recently (I’ll get to Ancestry.co.uk sometime soon too), and found out all sorts of good stuff. You should look into your own. I bought a little book, “Mason: The Origins of the Masons and Their Place in History”, Iain Gray, Lang Syne Publishers Ltd, 2012, in one of those typical gift shops you find in Scottish towns and villages such as Pitlochry, and in only 32 pages it gave me sufficient information and confidence to share my new enthusiasm with you all.

Like other surnames, Mason arrived as Macon or Masson (French spellings) with the early invader, Rollo, in around 900 as well as with the later invasion by William the Conqueror and his cronies who arrived on these shores in 1066. These Normans were originally descendants of The Vikings (Norsemen) from Norse territories via their first site of rape and pillage, Normandy (the shores of Norse – men – land), on the coast of France. My little book also gives these spelling variants: Machin, Machon, Massen, Massons in addition to the above mentioned, Macon and Masson; as well as Clacher, used in the Highlands and Islands (Gaelic). So, if you have one of the aforementioned surnames all I have written and will write applies to you too, and you will be entitled to pick one of several tartans with which to have a full 8 metre kilt constructed, as I intend to do.

Mason Tartan Montage

A few of the many Mason tartans.

As a member of the North Eastern fraternity by origin, and hence sometimes referred to as a, “wannabe Scot” I have no problem wanting to wear a kilt – as an Englishman. Anyway, who knows, I may even be derived from a Scottish Lineage such as those of Richard Le Mason (1271 from Aberdeen); William Maceoun (1320 from Berwick) or Thomas Mason (1490 from Couper Angus). Now, my dad had a brother (one of another 11 brothers and 1 sister, to two fathers!) called Tom and my son is called Richard – perhaps I’m on to something here, after all.

Following the early, inherited Norman habit of giving surnames based upon geographical locations (eg Moray, Galloway, Renfrew), occupations were strong contributors to the spread of surname use, initially amongst aristocracy and later more and more of us commoners. So, in addition to Mason others such as Cooks, Porters and Constables (take note Irene and Alan!) grew in popularity. Mac (and Mc) means “son of”, so like the Robertson (~MacRobert in Scotland) in England and Wales, gave rise to the distinctive Scottish flavoured surname category. There are many more classes but I haven’t time to list them all here.

My fascination with my surname, perhaps not surprisingly stems from my interest in the “Masons” and “Freemasons”, both having strong connections with the building and architectural businesses that grew around the time of the Norman Invasion with the building of castles, forts, fortresses and grand homes for chivalrous Knights and their families. The Masons were workers and formed closed cliques with their own internally recognisable system of crafty handshakes and passwords to protect their growing guilds. They often lived in lodgings and their guild, the Craft Masonry, protected their interests early in their history, but its membership was extended to non-workers, including the aristocracy ie Freemasons.

Masons Montage

Masonic symbols of The Grand Lodge of Scotland in Edinburgh (Accessed at http://www.grandlodgescotland.com/ on 10 January 2016)

The Scottish Masonry (including Freemasons) established the three major ‘Craft’ degrees or levels within the Masons’ framework: “Entered Apprentice; Fellow Craft and Master Mason. These three degrees or grades together with many higher levels make up the total hierarchy, some of which none of us will get to know about, unless you become one of them, a very tricky manoeuvre to pull off, I understand.

Rosslyn Chapel Montage

External and Internal images of Rosslyn Chapel Nr Edinburgh accessed at https://en.wikipedia.org/wiki/Rosslyn_Chapel. on 10 January 2016.

Now here is the intrigue that has me very interested to find out more. The Sinclairs (St Clairs) were nominated as the head of the Grand Lodge of Scottish Masons (1736) having also ancestry stemming way back, and forwards to 1446 when the now-named Rosslyn Chapel, standing just outside Edinburgh, was founded, and three years later when William Sinclair was created Lord Sinclair (1449). This incomplete chapel comprising only the East Transept and Choir of the originally planned church cross is thought to have links with the Knights Templar who may have travelled to Scotland to escape the inquisitions taking place following a Papal Bull in 1307 outlawing their existence; and (maybe) links about secrets relating to the Holy Grail – Wow!!

Knight templar2

A Knight Templar in full battle-cry accessed at https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwih95qBzKDKAhUJVRQKHfhKDAsQjRwIBw&url=http%3A%2F%2Fgreyfalcon.us%2FThe%2520Knights%2520Templar.htm&psig=AFQjCNGivd2znrwBP5oY8IL0LO9dDEyzqQ&ust=1452561662608100  on 10 January 2016.

Finally, and the crowning glory or capstone (sorry, I couldn’t resist this building link!) is that the Sinclairs and Masons themselves are blood or near relations or kinfolk (whatever that means), according to Iain Gray (2012). So, there we have it, I might be a Viking descendent or close friend who knows someone, who knew someone, who knew someone way back that may be party to the secret of the Holy Grail; and I may be entitled to wear Sinclair as well as Mason (or Masonic) tartan kilts. So there, put that lot in your pipe and smoke it!

Sinclair Tartan Montage

Just two of the many Sinclair Tartans (Red modern and Hunting Ancient) with which to make a kilt at about £60 per metre! Accessed at www.scotlandshop.com on 10 January 2016.

 

That’s all for today, but I’ll be back soon.

30. Menus and statistics

Pub luch menu

Today I thought I might be able to give science and Medicine a rest – after yesterday’s marathon on preventative treatment. My topic today is just as important – Menus and what flows from them, inevitably data and statistics. So first, why bother? Well actually, menus and the food we eat (or can’t eat) is pretty important to us cancer patients. When you are told you are going on a 4-6 months course of chemotherapy you attend briefings for all sorts of things. One of these is given by your own assigned dietician. Mine is called S and she is marvellous, very commonly exhorting me to drink my Ensure high calorie diet drinks as often as possible, especially immediately after I have had my Chemo day’s worth of intravenous medication, the E and O (Epirubicin and Oxaliplatin) of my EOX combo cocktail. Here’s what a bottle of Ensure looks like:

Ensure Vanilla drink
Vanilla-flovoured high calorie Ensure ‘milky’ drink.

This one is vanilla flavoured and ‘milky’ to the taste buds (what’s left of them after being poisoned for about a fortnight after taking EOX). Doesn’t it look a harmless, inviting little thing? Well it’s not. Two days after you start consuming these things you become overwhelmed – they start to taste foul and sickly and the last thing you want to do is consume at least 1000-1500 calories-worth (about 4 -5 bottles). What do I do? You mean apart from skive and lie? Well now, I think I have found the answer, for me anyway. I pretend my ‘creamy’ ones are milk and then warm them up and pour the vanilla (Ensure) ‘milk’ over my Ready Brek, sprinkled randomly with Weetabix (my double blind controlled trial remember – c’mon, keep up!). Mix, et voila!, instant porridge with chemotherapeutic properties (kidding really!). But at least I get a shot of Ensure with least damage to appetite.

What else do I do? My dietician recommended I try pineapple which contains an ingredient that revives flagging taste buds. Mine flag from morning to night, let me tell you. If I’m eating pasta (in a tasty sauce, like bolognaise), with a plastic fork (to cut down on cold steel of an ordinary fork-induced cold, tingling sensational aftershocks from the side effect of Oxaliplatin), then if I ate the fork rather than a piece of pasta I wouldn’t be able to tell the difference! However, both the pineapple and plastic cutlery tips work – especially during the first 10 days of seriously bad after effects of Combo Chemo.

Effects on your partner are just as devastating. How would you feel after cooking a wonderful chicken gourmet meal in sauce with golden crispy, hand-crafted chips and beautiful freshly compiled salad and plonked it down in front of loved-one, to be then told, “I’m not keen on that smell; I’m not hungry now; could you take about two thirds of that off my plate”? You’d be pretty p****d-off, right? A small conflagration the size of the second world war might ensue, and a truce will be a long time in the offing? Am I right, am I right? Well who’s to blame – no-one, see! It’s that damned cancer again, and this time, it’s treatment with Chemo that is causing the grief. Trouble is, you can’t take it outside and give it what it’s been asking for. Nope, you both grin and bear it, and hope the other two thirds of that meal are not where the threat of being was – in the pooch’s belly (if you have one) or the back of fire (if you have one – we nearly do – a multi-fuel wood burner instead). But it does the job of being a threat alright! The rest of my menu? See below for stuff that works for me!

Wait 10 days – and all will be better with the world. Meantime, don’t weigh yourself, you will lose weight, it’s inevitable but your aim is to minimise the rate of loss. I like to think I’ll be at my last Pre-chemo body weight by about day 14 – gaining a fair bit from days 10 – 14. Weighing yourself is scary – another tip I learnt from my dietician, S. So, don’t do it – just eat what you can (and then some) whenever you can – even taking aboard another Ensure drink – this time a ‘juicy one’.

ensure stawberry drink
Strawberry -flavoured Ensure high calorie diet drink

These are marginally better than the ‘milky’ ones, in my opinion. I try them neat (Yuk!); diluted like a cordial – better; and after 10 days are up and I can start on ‘cold’ stuff again – so, I might even try a ‘frozen lolly’ variant – neat tricks eh?

I take most of my calories as soup – home made, canned, pureed meal even as I move to solids. But I really just long for the last ten days of the Chemo cycle when I can get back to ‘normal’ food as soon as possible. The one shining light I have to look forward to during this phase is that I am encouraged to eat as much chocolate as I like. Well, I do like, and I have just consumed the best treat of the last 3 months – a Cadbury’s Crème egg – courtesy of an Elaine treat on her return from her Saturday morning ‘Jazz’ exercise class. Damn -her, she’s so good and conscientious!

I think I’ll skip the statistics now – for today anyway. All this talk of food has made me feel like an early lunch! But, I’ll whet your appetites for numbers for tomorrow:

My reminder of a couple of days ago has certainly done wonders for visits to the Cancer Blog site. Yesterday (8 January) brought 21 visitors (from the UK, New Zealand, Vietnam, Australia, USA, Mexico and Spain) and 90 viewings of different blogs (an average of 4.6 per visitor). This is the second highest ever! Must be Ruthie Foster’s music, eh?

Well that’s all folks but here’s another female music artist I like a lot, Shawn Colvin. Try her early albums first and then work forwards. I’d recommend the 1992 CD “Fat City”, and the tracks 1, “Polaroids”, 3, “Tenderness On The Block, and 8, “Set The Prairie On Fire” as exemplars.

Shawn Colvin Fat City Album
Shawn Colvin, “Fat City”, 1992.

Back soon folks!

BUGS001

 

 

 

 

 

 

29. Harry Potter and the half blood population!

Harry Potter Half Blood Prince

 

I’ll briefly repeat my 6 point (bullet) plan for the NHS to preface my focus for today’s section on 4. Preventative treatment.

  1. Education – underpinned by philosophy
  2. Screening – underpinned by data
  3. Testing – from birth to death
  4. Preventative treatment – promotion of healthy life styles
  5. Research –on preventative medical conditions
  6. Evaluation – led by self-scrutiny

 

4.  Preventative treatment – promotion of healthy life styles

We are now moving into the phase of considering solutions to the problems posed by the current inadequately designed NHS system. I want to explore some of these solutions in some detail whilst eliciting a longer list that I and you together are able to compile for further consideration.

Scandal Revealed

Did you know that between 1 and 10% of the population may not have the father they think they do?  This includes many whose mother is aware of the facts but also some who are equally in the dark! How do we know this? Well, in the heat of the scare of the threat of Acquired Immunodeficiency Syndrome (AIDS) quite a few facts that probably shouldn’t did emerge, including some blood grouping data (legitimately undertaken for obvious reasons) but which revealed that some haemophiliacs and other ‘high risk’ groups tested for Human Immunodeficiency Virus (HIV) and AIDS had ‘impossible blood group types’, based upon parental blood group matching. I will not insult you by explaining why this is possible, but look to nature’s driving forces for a clue!

So what, you say? I say this is a big deal. Without accurate genetic data on individuals it is very easy to make errors of judgement when making decisions about treatments of people with illnesses. I think this strengthens my case for global genetic typing of individuals at birth and providing this information as accessibly as possible (to relevant parties (eg Medical professionals) but keeping it well away from others (eg Health and actuarial insurance companies).

I say these things because I believe we need desperately to move to a system of preventative medicine coupled to promotion of healthy life styles, and mass screening, where relevant. Let’s look at a couple of examples but before we do it’s time for a tune!

I have noticed I have been very amiss in representing the female side of even my own record collection so I’d like to put the record (pardon the pun!) straight by sharing my enthusiasm for three female artists from the last six decades of rock and popular music. First, Joni Mitchell. I particularly like her Jazz era but I’ll start instead with one of her 60s hits (“Chelsea Morning”, Track 2, Side one from the album, “Clouds”, 1969).  Marvellous song and brings to mind a trip to London only a year later I took to protest about cuts in government spending on higher education. Whatever happened to politicised students and student unions that did things?

Joni Mitchell Montage

My second choice is Joan Armatrading from the 80s onwards who inspired a generation including Tracy Chapman (sadly not one of my three) – but is one of three black women who I admire greatly. The third is Ruthie Foster whom most of you will not know but has become my favourite female artist of all time (not an easy decision) for her range of eclectic music tastes, her vocal range and the range of her resilience to be almost unknown in her country (USA) and yet admired by a select bunch of us, who think she should be better recognised. I have seen her play live in Melbourne and in Glasgow – brilliant.

Returning to Joan Armatrading, what track would you choose – again not easy? I am going for “Me, Myself, I”, from her eponymous LP of 1980.  This song has particular poignancy right now, as whilst I am totally committed to team work, there comes a point, like now for me and this damned cancer, where all you have to rely on is yourself.  I think the triple assertion of the title of Joan Armatrading’s song underpins  my current views precisely. So, despite all the wonderful assistance and well wishes from all of you I am, unfortunately, going to have to rely on me, myself  and I to get over the final hurdle.

Joan Armatrading Montage

And so, to Ruthie Foster – only one track represents the lot – blues, jazz rock, guitar solos, pathos and her own song writing: “Lost In the City”, from her compilation CD, “Stages”, 2004). And if her range isn’t wide enough take a listen to her definitive (in my opinion) Reggae track (“Real Love”) and an amazingly insightful gospel song, “Church” (both on the same album, “Stages”).

Ruthie Foister Montage

 

And so, back to Section 4.

Preventative treatment and promotion of healthy life styles.

As you will note, although I have divided this plan into six sections they are all intimately linked and the integrated plan should be read as a whole.  I’ll provide a summary (with diagram) at the end.  Hence, this section should be read very closely together with sections 2, 3 and 6 as screening and a more open, personal approach to evaluation will provide underpinnings to the basis for adopting a preventative treatment programme.

Early diagnosis for a healthy population – the key.

Let us take one of my own examples (I have or have had plenty to chose from!) to commence. During the course of my stomach illness prior to being diagnosed with stomach cancer I was variously treated for over-acid production and gastric reflux into my oesophagus, gastric ulcer or suspected ulcers, and helicobacter pylori. In the early part of this phase of what now turns out to be gastric cancer, I was never once given a physical examination involving palpation or feeling for lumps. Even if present, they may have been too small to detect and my treatment would have proceeded the same way. However, this simple procedure would have detected much larger lumps and I could have been on my way to an early diagnosis – something the government and NHS say they want to happen – for patient health and to make financial savings.

I was given Omeprazole, a Proton Pump Inhibitor (PPI), but not the one that scares banks (Payment Protection Insurance). This seemed to work (for a short time) and I was quickly taken off it. However, the pain recurred some few weeks later and I was put back on it. At the time I was told that I might have helicobacter pylori and a schedule of treatment would be designed so that this could also be screened for. I was also told that I could also have endoscopy which would be confirmatory. Now, as I have said before I am not saying that mistakes were made, so that is not my point here, but in the end I had to have an endoscopy as well as a CT scan, no doubt at some cost, and this was already in addition to the cost of drugs as well as GP time (three visits) to my surgery. This, in my view, is a classic case where an apparently expensive investment up front (gastroscopy in this case) might have not only been a better medical decision (for me) but also a cheaper one if it had detected my cancer or early lesions in a timely manner – in other words, early detection of disease. This is the key.

Early detection is good for all concerned – most importantly the patient, but secondly doctors and GPs (their success rates are better), the NHS (it is cheaper in the long term) and governments – it saves money and the service is both more effective and efficient (normally nearly impossible to achieve) in the long run. As little as a month later I visited the surgery again (my own actual GP this time) overwhelmed with pain. Dr M reviewed my case and treatment and then gave me a physical examination and immediately detected a large lump in my abdomen. He pointed for me to feel it (which I did) and he said that we have to consider this may be a tumour and ordered a CT scan and gastroscopy immediately. These took 2-3 weeks to be scheduled but at least I was now on my way – with the right diagnosis, but too late in my opinion, and after other costly treatments.

Please see Appendix I for supportive government information regarding proactive approaches to healthcare.

Education, education education

My second example focuses on education.  I have already mentioned the many patients that accumulate in a very attractive outdoor garden at the main entrance to Ninewells hospital smoking in a very clearly demarcated area designated as ‘non-smoking’.  These same people are often visited and supported by friends and relatives that also smoke and who both with their loved-one  or family member, the “patient”, may already be an amputee.  Now, I have not checked and there may be other reasons for the amputation but it is common that smoking is associated with heart and circulatory disease which my lead to blood clotting, particularly in the leg veins, and even result in amputation if the leg cannot recover from treatment with clot-busting drugs.

Is this not a case for more education for family members as well as patients to warn of the dangers of continuing with bad or even life-threatening behaviours and habits particularly when good options for reducing  the offending behaviour are available (eg reducing smoke/nicoteen dependence through patches or nicorette gum; using e-cigarettes; stop being a poor role model for family members, especially young impressionable minds of off-spring).  None of this is easy and maybe other measures are required such as a ‘one-off warnings’ that continued bad habits might (would definitely?) limit further treatment and access to both GP and hospital medical services, and social services.  This may sound drastic or draconian but what else will our increasingly ‘pushed’ NHS do anyway? 

As demand not only rises but places unfair decisions at the door of overworked medical, nursing and other carer staff then not all demands will be met, not only short term but also long term.   Prioritisation and limiting access to ‘deserving’ patients may become the norm.  Making decisions about such cases will increase tensions on medical services, particulaly consultants, who will have to deal with an increasing ethical workload as well as a medical one.  This has implications for the medical curriculum as all doctors, including established GPs and hospital staff as well as those in training (students, house officers, senior house officers, registrars, senior registrars) will need to be better equipped to be able to take decisions that save lives and others that may cost them.

My third example draws on the link of this programme with the sixth step:

Evaluation – led by self scrutiny”.

In higher education we have been wrestling with learning and teaching evaluation for more than two decades – at institutional level with Enhancement-Led Institutional Review (ELIR) and more locally at Departmental review and course and module reviews. The most difficult topic remains at a personal level through teaching reviews. These might include 360 degree appraisal, peer review of teaching, self review of teaching and even the preparation of teaching profiles and portfolios for ‘probation’, ‘continuation’ and ‘promotion’ and even accreditation (eg the Higher Education Academy HEA membership and fellowship schemes). There is still no requirement for a teacher in higher education (HE) to have a teaching qualification (or experience) before taking their first class!

I believe the sequence described lies at the heart of the difficulty in getting all evaluation right. Perhaps if we focused more on self-evaluation with a strong emphasis on openness, honesty and critical friends to corroborate or verify (or deny) these self diagnoses then the flow back up the sequence to ELIR or institutional level review would be much easier and testable. I think the latter is still true in Medicine although the concept of the reflective practitioner and critical friends whether pairs (eg Mentors and line managers) or groups (eg Multi-disciplinary Teams, MDTs) is much more established. Perhaps it still isn’t working as well as it should.

There is a lot of past as well as current evidence that this is the case. The example of Harold Shipman springs to mind. Also, there is the disturbing fictional series, “Bodies”, featuring a Consultant surgeon and a keen, honest junior doctor working alongside him. His attempts to whistle-blow on his superior, the surgeon, were thwarted by the power differential of the boss-report relationship and by the fear of other staff, well aware of the situation, to do anything about the errant consultant or even support their junior colleague. The abuse from above by the consultant was astonishing. Surely, it can’t be like this in real life, can it?

The culture must change. Honest, blunt communication sometimes is what is needed. This must be a responsibility of patients and medical and social care staff alike if the system is to work. Hierarchies are inherently non-permissive for such exchanges but this must be tackled and changed in the New NHS. Staff need to be able to self-diagnose their own mistakes, listen to feedback from others (patients as well as colleagues) and then act upon it. Rewards for staff for their openness and honesty need to be geared towards this approach rather than only rewarding good work or excellence. The latter must still happen but it needs re-balancing.  My own consultant, thus far, has demonstrated these qualities aplenty, though I do hope still to persuade him that I should be considered to be a “curative care” rather than a “palliative care” patient. Also, I do wonder what discussions, if any, have taken place at my own GP surgery amongst all the doctors who dealt with my case.

Appendix I

In the last three days I have just become aware of the government’s own review of the NHS and its intention to provide a more proactive, health and well-being oriented service. These are the key issues and the date and agenda for the first conference arising from the review.

[NHS Five Year Plan: Responding to the Prevention Challenge -22nd March 2016, Royal National Hotel London
http://www.openforumevents.co.uk/
http://www.openforumevents.co.uk/event/nhs-five-year-plan-responding-to-the-prevention-challenge/?utm_source=P1.0+NHS+5YP+Digital+O%2Fc+4+21.12&utm_medium=email&utm_campaign=P1.0+NHS+5YP+PREVENTION+W%2FC+21.12
One year on since the NHS Five Year Forward View was published, the roadmap for change is taking traction with new initiatives and projects helping to secure the future of the nation’s healthcare system. The NHS Five Year Plan: Responding to the Prevention Challenge conference will explore how to make the NHS sustainable by incentivising and supporting healthier lifestyles. A key element at the heart of the 5YFV is prevention of long term conditions and promotion of good health and wellbeing. Our agenda aims to support the NHS and wider health economy, at a local and national level, to build a more proactive society, prioritising health and wellbeing and reducing the impact of lifestyle related health problems.
The future of the NHS, improving the quality and access to health services and supporting a healthier population all depend on a radical upgrade in prevention and public health strategies. NHS England recognises that more needs to be done to respond to the prevention challenge. The NHS Prevention Programme Board, which was established in January 2015, has made a strong start in getting serious about prevention. Evidence shows that by investing in early interventions greater costs can be reduced further down the care pathway, however, this approach requires joined-up care and treatment, often across a range of service providers, that is centred around a patient’s needs. Following the Five Year Forward View how will new models of care drive better outcomes for patients and for the health system?
Join us for the opportunity to learn about the key activities and priorities for responding to the prevention and public health agenda, providing strategic direction and oversight to stimulate national action on the wider determinants of health. The NHS Five Year Plan: Responding to the Prevention Challenge will give you the opportunity to build contacts and benefit from knowledge sharing and networking to respond to the prevention challenge.]
Programme
09:30 Keynote Address
Simon Stevens, Chief Executive, NHS England (invited)
‘Getting Serious about Prevention’
NHS England recognises that more needs to be done to respond to the prevention challenge. The NHS Prevention Programme Board, which was established in January 2015, has made a strong start in getting serious about prevention. Evidence shows that by investing in early interventions greater costs can be reduced further down the care pathway, however, this approach requires joined-up care and treatment, often across a range of service providers, that is centred around a patient’s needs.
09:50 Professor Kate Ardern, Director of Public Health, Wigan Council (invited)
‘Prevention Policy in Practice’
A key element at the heart of the 5YFV is prevention of long term conditions and promotion of good health and wellbeing. The key for stakeholders, at a local and national level, is to build a more proactive society, prioritising health and wellbeing and reducing the impact of lifestyle related health problems.
10:10 Sharing Best Practice
Dr Diane Reeves, Chief Accountable Officer, Birmingham South Central Clinical Commissioning Group (CCG) (confirmed)
‘Diabetes, an Early Priority’
More people in Birmingham are set to avoid developing diabetes as a local clinical commissioning group has been chosen to pilot a national diabetes prevention scheme. The NHS Diabetes Prevention Programme was an early priority for the Prevention Board. Type 2 diabetes is one the biggest public health challenges of our time, costing the NHS £8.8bn a year. However, the World Health Organisation (WHO) estimates that 80% of Type 2 diabetes cases are preventable.
10:30 Main Sponsor
10:50 Question and Answer Session
11:00 Coffee in the Networking Area
11:45 Case Study
12:05 Dr Debbie Smith, Lecturer in Health Psychology, University of Manchester (confirmed)
‘Behaviour and Lifestyle Change’
This presentation will explore the benefits that a behavioural change could have in terms of improve outcomes and reduce costs in the short-medium term. Supporting healthier lifestyles could help to reduce risk factors through a focus on healthy eating, physical activity and positive mental health.
12:25 Sharing Best Practice
Phil Veasey, Public Health and Community Engagement Associate, C3 Collaborating for Health (confirmed)
‘The Realities and Practicalities in Exercise for Health’
A key element at the heart of the 5YFV is prevention of long term conditions and promotion of good health and wellbeing. Our agenda aims to support the NHS and wider health economy, at a local and national level, to build a more proactive society, prioritising health and wellbeing and reducing the impact of lifestyle related health problems.
12:45 Case Study
13:05 Question and Answer Session
13:15 Lunch in the Networking Area
14:15 Chair’s Afternoon Address
14:20 Case Study
14:40 Pinki Sahota, Chair, Association for the Study of Obesity (invited)
‘Bringing Obesity Up the National Agenda’
Action on obesity can have short-term and well as long-term benefits, underlining the importance of bringing obesity up the national agenda. The NHS Prevention Board will continue to play an active role in the wider prevention debate, providing strategic direction and oversight to stimulate national action on obesity.
15:00 Danny Mortimer, Chief Executive of NHS Employers (invited)
‘NHS Workforce – Role Models for Healthy Lifestyles’
Improving the health of the workforce of the NHS is another key priority with NHS England pledging £5 million for a programme of work designed to develop and support new workplace incentives to promote employee health and to cut sickness-related absence. Prevention is cheaper than cure and supporting people to manage their own health and healthcare can both improve outcomes and reduce costs.
15:20 Question and Answer Session
15:30 Panel Discussion
‘Collaboration to Promote Healthier Communities’
The 5YFV argues that large scale system change can only be achieved in collaboration with other key players. Delivery of a successful prevention strategy will require concerted action from individuals, local government and other public, private and third sector bodies alongside the health service. How can such integrated working be achieved?
Michele Moran, Chief Executive, Manchester Mental Health Social Care Trust (invited)
Councillor Richard Leese, Leader Manchester City Council (invited)
Alistair Smyth, Head of Policy, National Housing Federation (confirmed)
Dr Diane Reeves, Chief Accountable Officer, Birmingham South Central Clinical Commissioning Group (CCG) (confirmed)
Professor Kate Ardern,Director of Public Health, Wigan Council (invited)
16:30 Chair’s Closing Remarks and Event Close

 

 

 

28. Ockham’s Razor – or putting it as simply as necessary and no more!

William_of_Ockham

(William of Ockham (1287-1347)) Accessed from https://en.wikipedia.org/wiki/William_of_Ockham#/media/File:William_of_Ockham.png on 3 January 2016).

So what is going on?

Perhaps I can start by reviewing my last Pre chemo meeting at Ninewells Hospital. This was taken by Dr L one of Dr P’s registrars.   She was helpful but could only answer one out of my nine questions, but promised to refer the rest to Dr P. I met with Dr P on Chemo day (7 December 2105).

I first asked about the possibility of abdominal lavage for cancers that had spread from the original site in the stomach to more distant tissues such as lymph nodes. Dr P reassured me that this issue had been reviewed on multiple occasions and whilst strong advocates occasionally emerged following some success, on balance, results were no better than via intravenous chemotherapy. One –nil.

Dr P agreed to look into the use of the new drug treatment for Malignant Melanoma using Almycin. One – all.

Dr P agreed to undertake CT scans to determine my progress by the beginning of my fourth round of Chemo. Two – one.

I mentioned that my iron tablets had been counter-indicated with two of my other medicines but he reassured me the risks were minor. Three – one.

One of my fellow brothers in arms, N had mentioned his own research into the merits of consuming high calorie diets. Dr P dismissed these concerns as it is more important that the patient be fit and has as much energy as possible for fighting the cancer. Five- two.

I then mentioned the possibility that when I had had my episode with the curry that I may have dislodged part of the tumour as food passed through the narrowed gastric canal. He didn’t dismiss this as fanciful since he’d had another patient that had a similar disease who thought she might have coughed up some of her cancer following a sneeze. She had the foresight to bring along a piece to the meeting and Dr P had the openness to have the tissue sample processed and then examined by an histo-pathologist. It turns out the patient was correct! Six – two.

Then came my killer question. Could it be that my progress was sufficient for me to be re-designated to a programme of curative rather than palliative care? Dr P was clear – NO! I’m not sure I understood this but decided to ‘park’ this issue for a while. Seven – two!

So why is there reluctance to recognise my progress as a positive outcome and to give me more encouragement? Dr P suggested that the progress could be temporary and that it might be more disappointing to discover this especially if this is confirmed by Scan data. And so, on balance, he favoured a conservative view. I still don’t buy this but leave it. However, I am determined to pursue the PET-CT scan route to uncover further information that might make my own case more persuasively.

So can I find an answer from a consideration of Ockham’s Razor.

(Accessed from Wikipedia at https://en.wikipedia.org/wiki/Occam’s_razor on 3 January 2016)

[Occam’s razor (also written as Ockham’s razor and in Latin lex parsimoniae, which means ‘law of parsimony’) is a problem-solving principle attributed to William of Ockham (c. 1287–1347), who was an English Franciscan friar and scholastic philosopher and theologian.]

The principle can be interpreted as

Among competing hypotheses, the one with the fewest assumptions should be selected.

[The application of the principle can be used to shift the burden of proof in a discussion. However, Alan Baker, who suggests this in the online Stanford Encyclopedia of Philosophy, is careful to point out that his suggestion should not be taken generally, but only as it applies in a particular context, that is: philosophers who argue in opposition to metaphysical theories that involve an allegedly “superfluous ontological apparatus.”

Baker then notes that principles, including Occam’s razor, are often expressed in a way that is unclear regarding which facet of “simplicity”—parsimony or elegance—the principle refers to, and that in a hypothetical formulation the facets of simplicity may work in different directions: a simpler description may refer to a more complex hypothesis, and a more complex description may refer to a simpler hypothesis.]

In other words, sometimes simple things are said in a complicated fashion (like much of my blogging) and others say more elegantly what appears to be a complicated idea in very simple, understandable language (how I’d like to write my blog!).

Would a shift to a curative regime mean that I would have to have further scans and that DR P was trying to protect me from my own enthusiasm? So what do other Scans help reveal about cancer?

What tests are used to detect stomach cancer? A range of measures are used. These include physical examination (GP) plus other general health checks, Endoscopy (Gastroscopy) and CT scan.  A full account of this is presented in Appendix 1.  Of particular interest is the section on further tests for gastric cancer involving various scan types such as CT scan, PET scan, PET-CT scan and MRI scan.

 

Summary

It is clear that Scans don’t do the same thing.  A particular scan type, say PET-CT scan, may reveal useful and specific information about my cancer.   MRI scans may reveal soft tissue better than CT scans alone.  So, for example, PET-CT scanning may reveal how well the chemotherapy treatment is working and it may also show the difference between scar tissue and actively growing cancer.

These and other aspects of what PET-CT scanning can do may be important in determining whether I might be considered for further curative treatment such as surgery.  So, should this be used at my first opportunity (after cycle 4 of EOX) rather than CT scanning alone?

 

Appendix 1

(Accessed from http://www.cancerresearchuk.org/ on 3 January 2016)

[Endoscopy
This is the main test to diagnose stomach cancer. An endoscope is a long, thin, flexible tube with a light and camera inside. During the test you usually have a sedative to make you drowsy and less aware of what is going on. Once you are drowsy and relaxed, the doctor or nurse endoscopist will pass the endoscope tube down your throat into your stomach. This allows them to look at the inside of the foodpipe (oesophagus), stomach and the first part of the small bowel (the duodenum). They will take tissue samples (biopsies) of any abnormal looking areas.
There is detailed information about having an endoscopy in our cancer tests section. Sometimes the endoscopy tube has an ultrasound probe at the end. It takes an ultrasound scan of the stomach and surrounding area. This is called an endoscopic ultrasound.
You can have this test as an outpatient. But you should take someone with you to take you home. You won’t be able to eat or drink for about 8 hours before the test so that your stomach and duodenum are empty.
Once the test is over you will need to rest for a while. Because of the sedative, you may not remember anything about the test once it is over.]
A Further test is the PET-CT scan.
A PET-CT scan uses a CT scan combined with a PET scan. A PET scan shows up areas of active cancer cells using small amounts of radioactive glucose. It can sometimes help to show up areas of cancer in the upper part of the stomach. We have detailed information about PET-CT scans.
A PET scan uses a very small amount of radioactive drug to show how body tissues are working. PET-CT scanners tend to be in the major cancer hospitals. So you may have to travel to another hospital if you need to have one. Not everybody who has cancer will need one. Other types of tests and scans may be more suitable.

PET CT Scan 2

PET CT Scan

PET Scans
[How a PET-CT scan works
A PET-CT scan uses X-rays to take pictures of the structures of your body. At the same time, a mildly radioactive drug shows up areas of your body where the cells are more active than normal. The scanner combines both of these types of information. This allows your doctor to see any changes in the activity of cells and know exactly where the changes are happening.
What doctors use PET-CT for
PET-CT scans are used for many types of cancer and are generally thought to be more accurate in diagnosing cancer than PET scans alone. PET-CT scans can help to
  • Diagnose cancer
  • Stage a cancer
  • Make decisions about whether you can have surgery to remove your cancer
  • Make decisions about which is the best treatment for your cancer
  • Show how well the treatment is working
  • Find the place in the body where you cancer first started to grow (primary cancer)
  • Check whether your cancer has come back
  • Show the difference between scar tissue and active cancer tissue]
 These are key decision making reasons for using PET-CT scans and I think I need such information? Note to self: ask Dr P about PET scans?

(Accessed from http://www.cancerresearchuk.org/ on 3 January 2016).

[After you have had treatment for cancer, a scan may show that there are still some signs of the cancer left. But this may not be active cancer. It could be scar tissue left over from cancer killed off by your treatment. A PET-CT scan can sometimes show whether this tissue is active cancer or not.
What having a PET-CT scan involves
The scanning department will give you instructions on how to prepare for your scan. These are normally written in your appointment letter. Generally, you should not have anything to eat for about 6 hours beforehand. You can usually only drink water during this time. You may be told not to do any strenuous exercise for 24 hours before the scan. Unless you are told otherwise, you should carry on taking any medicines prescribed for you by your doctor. If you are diabetic, you should contact the department a couple of days before your appointment. You may need to adapt your diet and sugar control routine a little.
When you arrive, check in with the receptionist so the radiographers know you are there. Then you usually take a seat in the waiting room until someone calls you for your scan. You can take a friend or relative, but they will usually not be allowed to go into the scanning room with you. The radiographer may ask you to change into a hospital gown. You will need to take off all your jewellery and any other metallic objects. They may want you to take a dose of diazepam (Valium) to relax the muscles around your neck and shoulders. This can give clearer pictures on the scan.
You will have a small tube (cannula) put into one of the veins in the back of your hand or arm. Then you have the radioactive drug (tracer) as an injection through the tube. You need to rest for about an hour afterwards. This allows the drug to spread through your body and into your tissues. Before your scan begins, you will go to the toilet to empty your bladder.
In the scanning room, you lie on your back on the narrow bed. The radiographer will help you to get comfortable and make sure you are in the right position. The bed gently moves through the scanner. The scan takes between 30 to 60 minutes, depending on which parts of your body are scanned. The scan is not particularly noisy but the computers and air conditioning make a constant background noise. You need to stay as still as you can during the scan. You can talk to the scan operator through an intercom if you need to.
Some people feel a bit claustrophobic (‘closed in’) when they are having a scan. If you think you are likely to feel this way, tell the radiographers before the day of your appointment.
After the scan
Once the scan is over you will be able to go home straight away. You can eat and drink what you like and go back to normal activities. Although the amount of radiation from the radioactive drug is very small, it is best not to have long periods of close contact with pregnant women, babies and young children for the rest of the day.
If you have had diazepam (Valium) you must not drive for the rest of the day, as it makes you drowsy. You will need someone to take you home from the hospital.
If you are travelling abroad within a few days of your scan, it may be a good idea to take your appointment letter with you to show that you have had a scan. Most airports have sensitive radiation monitors which may pick up the trace of radiation following your test.
Possible risks of a PET-CT scan
During a PET-CT scan you are exposed to radiation from the X-rays and the radioactive drug. The radiation in the radioactive tracer is very small, and goes away (decays) very quickly. It does not make you feel unwell. Drinking plenty after the scan helps flush the drug out of your system. The radiation from the CT part of the scan is also kept to the minimum necessary. The risk of the radiation causing any problems in the future is very small. Doctors only do these scans if they are necessary. They make sure the benefit of having the scan outweighs any possible risks.
You should not usually have a PET-CT scan if you are pregnant, as there is a risk that the radiation could harm the baby. If your doctors think it is essential for you to have the scan, they will tell the staff in the scanning department and the dose of radiation will normally be reduced. You should not bring babies, young children or anyone who is pregnant to the scanning department.
If you are breast feeding, let the department know a few days before your appointment. They will let you know if you need to stop breast feeding for a length of time after having the radioactive drug. You may need to store enough expressed milk for at least one feed.
The results
It can take time for test results to come through. Usually, a specialist in radiology or nuclear medicine examines the scan and has a report typed up. The scanning department sends the report to your specialist, who gives you the results.
Understandably, waiting for results can make you anxious. It usually takes up to a couple of weeks. If your doctor needs the results urgently, they make a note of this on the scan request form and the results are ready sooner. Remember to ask how long you should expect to wait for the results when the doctor first asks you to go for the test. If it is not an emergency, and you have not heard a couple of weeks after your scan, ring your doctor’s secretary or specialist nurse to check if the results are back.]

(Accessed from http://www.cancerresearchuk.org/ on 3 January 2106).

 

MRI Scan

[This scan uses magnetism to build up a picture of the inside of the body. Your doctor may suggest an MRI because it sometimes shows up soft tissue more clearly than a CT scan. There is more about having an MRI scan in the about cancer tests section.]