Category: Humour

44. Bad news, Worse news, Worst news!

Well, I am not the only one who can get ill. This is the bad news.   We were due to spend a week in Yorkshire this week but Elaine has been struck down by the actually, really serious “dreaded lurgy” (Lurgy– an ​illness or ​disease, ​especially one that is not ​serious:He’s got the ​dreaded lurgy.” Definition of lurgy from the Cambridge Advanced Learner’s Dictionary & Thesaurus © Cambridge University Press).

The Goon Show - Lurgi

Accessed at https://www.youtube.com/watch?v=WPHpYRgD4fU on 17 February 2016

The term originates from an episode of the 1950s radio comedy “The Goon Show” in which an epidemic of “The Dreaded Lurgi” was said to be about to sweep across Britain. It turned out that the lurgi was in fact a fictitious disease created by brass instrument makers who had claimed that no brass band player had ever died of the lurgi (thereby increasing sales hugely). “The Goon Show” was an anarchic and surreal radio comedy series that starred Peter Sellers, Spike Milligan and Harry Secombe. It was written by Spike Milligan and Eric Sykes. by mammon_the_source August 03, 2009

In this case Elaine’s condition has been completely debilitating, and though we set off on our sojourn on Sunday, following her birthday on Saturday and travelled to Ellen’s flat in Glasgow we finally acceded to illness winning, and came home to Ceres on Tuesday afternoon. We had planned our “Thelma and Louise – style” road trip that was to take us via Glasgow to Newcastle, Malham, Bradford, Bingley, Burley-in-Warfedale and Ilkley, and home again, seeing as many relatives and friends as we could during the whirlwind visit. Sadly, it will be postponed, perhaps until a similar time in my next cycle of Chemo. That damned Cancer – is always a factor in any forward planning. This is the worse news!

I am just coming through the first week blues period (for me anyway) and having had my couple of steroid-supported good days on days 1 and 2 after the Combo Chemo Cocktail I succumbed to the now-third time repeated pattern of nausea and loss of appetite characteristically appearing sometime on days 4-7. Day seven, yesterday, was not good.

Apart from me having to do the driving as Elaine was not even well enough to share it, I then felt lousy all afternoon and was eventually struck down by own version of the dreaded lurgy – diarrhoea! This isn’t the worst news! I could barely leave the vicinity of our downstairs loo for more than 3 minutes, or dice with death and risk brown trousers syndrome, if I did. Fortunately, this episode lasted only 4 hours! I recovered sufficiently by 9:00pm to be able to have my second bowl of porridge for the day.

Accessed at http://www.theguardian.com/tv-and-radio/2016/feb/09/happy-valley-recap-series-2-episode-1-scars-sheep-rustlers-and-a-serial-killer and http://www.theguardian.com/tv-and-radio/2016/feb/16/happy-valley-recap-season-2-episode-2-blood-shiraz-all-over-rug  on 17 February 2016

Happy Valley 2

Happy Valley 1This was also just in time to watch the third episode of “Happy Valley” – a murder mystery/detective featuring Sarah Lancashire (second series) and fortunately for us, set in Yorkshire, specifically the Halifax/Bradford area. The language is perfect. “I’ll tek owt for nowt”. By the way, living in Yorkshire then Scotland sometimes makes me wonder whether my subconscious has more say than I do about my approach to money (and not wanting to spend it – unless on LPs, CDs and posh Hi-Fi to play them on). So, you’ve no doubt heard about the definition of a Scotsman, “someone with short arms and long pockets”; and a Yorkshireman, “A Scotsman with the generosity squeezed out of him!”. Apologies to those who would have preferred gender neutrality!

Speaking of music, hi-fi and guitars (I know we weren’t, actually, but I need only the slightest invitation!), I bought the most recent issue (403) of “Guitarist” monthly magazine which featured a forthcoming sale of some of Gary Moore’s enormous collection of vintage as well as contemporary guitars including, possibly, the restored Gibson Les Paul of Peter Green, his earlier mentor and good friend.

Accessed at http://www.musicradar.com/guitarist and http://www.musicradar.com/news/guitars/video-gary-moores-key-guitars-examined-633188  on 17 February 2016

Gary Moore Guitarist 1

Now only Peter himself can make the transcendent tones of songs such as, “I Loved Another Woman”, (Peter Green’s Fleetwood Mac) or “Love that Burns” (Mr Wonderful), sound any better than Gary’s versions, on for example, “Blues for Greeny”.

Peter Green Fleetwood Mac Mr Wonderful

Peter Green (Playing) and the first two albums, Peter Green’s Fleetwood Mac (Dustbin and dog album) and Mr Wonderful (semi-naked photo of Mick Fleetwood). Accessed at https://en.wikipedia.org/wiki/Fleetwood_Mac_%281968_album%29  and https://en.wikipedia.org/wiki/Mr.Wonderful_%28Fleetwood_Mac_album%29 on 17 February 2016.

The article, celebrating the fifth anniversary of his death, is fabulous, drawing on Gary’s own guitar technician’s recollections and his own (newly discovered interview) stories about his early career with Thin Lizzy and Peter Green’s influence upon him. For example, did you know that he would have on stage a series of guitars ready to select for particular tracks, and for each guitar there would be a back-up and a further back-up to the back-up, just in case!

So, many of these guitars have never been played on tour or on a recording. Consequently, they are not as valuable as those that have or vintage guitars such as Peter Green’s original or the 1959 Gibson Les Paul used on “Still Got the Blues”. The guitar sound is ultimately only as good as the weakest link in the chain so Gary’s awesome sound was also due to his Marshall JTM45 amp – 1989 and a Marshall Guv’nor pedal.

Accessed at http://www.gary-moore.com/1990’s.html  on 17 February 2016.

Gary Moore Montage

In summary the auction sale – some on line – so that ‘Joe Public” like me may even become an owner, perhaps of the less expensive, small stuff, anyway. No worries, I say! Though I suspect I can’t even afford the tiny stuff let alone the small stuff. This is the worst news!

Guitars like the “Peter Green refurb” will probably not be on sale at all in the first round.

Now back to my “Primary”, my latest NHS reforms paper. I have probably said this elsewhere, but I am beginning to lose track of what was blogged where, so bear with me.

Open Forum New NHS

My paper, or at least the abstract, has been accepted for the conference on the Future of the NHS 5 Year Plan. My abstract and personal details were added to the web site for the conference a couple of days ago. Here is the abstract link:

The New National Health Service (NHS) – but not as we know it!

Open Forum New NHS 2

Now this really is bad news as I must complete all editing on the paper as soon as possible. I promise then you will get your 6th part of the Harry Potter series – truly! On another positive note, I completed my fist blog job for the “Jobs.ac.uk” web site. You can read this blog at: https://blogs.jobs.ac.uk/working-abroad-in-higher-education/2016/02/12/1-recruited-antipodeans/

That’s all folks. Bye for now.

BUGS001

 

 

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42. Man in a Van with a Scan!

Mobile Scan Van Montage

Accessed at https://www.google.co.uk/search?q=mobile+CT+scan+trailer+images&biw   on 10 February 2016

So, why am I returning to this theme again?

Well, actually I’m not, though it does provide one example where there’s a problem (with at least) though usually with only two (good or great) solutions, thus presenting decision-makers with the “horns of a dilemma”, “Hobson’s choice”, “between a rock and a hard place” etc. The dilemma here is should the NHS take an immediate cost saving – hiring from a private provider for mobile CT Scans – like the one I had carried out fairly recently, or build more facilities on their own premises? Hiring is cheaper right now so they do it – no surprise there – when government cuts are so deep and apparently never-ending.

But what about a bit of creative thinking? Why doesn’t the NHS (or even more entrepreneurial: why not an individual hospital or maybe a few hospitals) buy their own fleet of Mobile Scan Vans and then ‘rent’ them to whichever hospital or wider UK region requires them? The money may change hands but it would at least remain in the overall budget handed out to the NHS. Surely someone thought about doing this before individual hospitals started doing their own thing? Surely, or am I missing something? If I am not missing something, then maybe someone (with power and position) could at least kick off a fresh debate? Speaking of kick offs, let’s have a quick digression. So here is a new example to kick off proceedings!

Commencing on Saturday afternoon it was the start of the UK-initiated, RBS 6 Nations Rugby Championship. This annual tournament pitches each of 6 National teams against one another in a biannual alternating cycle of home and away fixtures against the same team. So each team plays 5 matches, and one year say, England will play Scotland at Murrayfield (‘away’ in other words) and next year will play them at Twickenham (at ‘home’ this time). Also, any of the teams will either have three home games and two the following year, or vice versa.

RBS 6 Nations Rugby 1

RBS 6 nations kicks off! Accessed at http://www.rbs6nations.com/en/home.php on 10 February 2016.

The tournament comprises national teams from England, Scotland, Wales, Ireland, France and the most recent European addition, Italy. The latter played damned well against, and should have beaten, France, deservedly, playing in Paris too. Once again a team was ‘robbed’ by poor refereeing decisions, ie not going to the TMO when clearly this was necessary! Further, cos it pleases me, England won and retained the Calcutta Cup (a tournament within a tournament) and both Wales and Ireland made sure they couldn’t win the other two tournaments within a tournament, the “Tri-Nations Cup”, (One UK team beating all the other three) and the “Grand Slam(One team beating all the other 5 teams).

The other kick-off happened on Sunday night/Monday (early) morning – the USA’s own version of Rugby, the 50th American Football Superbowl, though now they have pretty decent Rugby team too. This particular play-off was between the Denver Broncos and the relatively new team (brand new, to me anyway), the Carolina Panthers. I haven’t watched American Football for quite some time. In fact, John Elway, the present-day coach (or Director, General Manager or some-such) was actually playing starting quarterback for Denver Broncos some 20-odd years ago when I used to watch regularly – a new Tele-channel treat (Channel 4)! Doesn’t time fly?

Superbowl American Football 1

50th Superbowl played between Denver Broncos and Carolina Panthers. Accessed at http://www.nfl.com/videos/carolina-panthers/0ap2000000093202/Broncos-vs-Panthers-highlights on 10 February 2016.

Denver won by the way, 24 to 10, with apologies to those of you who still haven’t watched the match either on “Catch-up” or your own recording (I still absent-mindedly call this ‘taping’ a programme!). I guess, once again, this displays my age, though since I “lay it all out there” for you all in the blog anyway, this may have already taken care of that query for anyone who was curious, I suspect.

Now I must return to the primary blog entry. I rather like this cancer metaphor, so from now on ‘digressions’ will be known as secondaries (1, 2 and so on…). My intravenous Combo Chemo Cocktail day went to plan and so there’s nothing to report on the technicalities side of it. However, my visit to Ward 32 this morning prompted me to reflect on my previous visits, and that brought home the dilemma of wanting to get the best treatment (for oneself) and yet having to challenge what you are being offered in your current regime, especially when you think something that might be better is available, though you are clearly thinking and ultimately, if voiced, speaking as a non-expert. What to do, eh?

For example, today is “Chemo-day” for me, and for every other patient on my sub-wing of the ward. I can only receive treatment if my granulocytic neutrophil ‘count’ reaches a minimum threshold level, otherwise it is deemed, “too risky”. It is too risky because low levels of granulocytic neutrophils are associated with being too susceptible to potential life-threatening infections. (See my entries for Blogs 34 and 35). This happened to me a couple of ‘cycles’ ago when my granulocytic neutrophils were ‘low’. Fortunately for me my assessment day was a Friday and I had the weekend for further recovery of my “neutrophil count”. I was lucky they did recover sufficiently and I received my Combo Chemo Cocktail, on the scheduled day, on time and according to plan.

34 35 Montage

If my neutrophil count had not recovered in time what options are available? Well, the usual one offered is to postpone treatment, await neutrophil count recovery and then recommence, as soon as the neutrophils swarm back into the circulatory system and reach the magic ‘threshold value’. But what if this doesn’t happen (quickly, at least, or even before the next cycle is due?). I don’t know yet because it hasn’t happened to me. I did ask about blood or even granulocyte neutrophil transfusions, but was informed that this is not a preferred treatment since it is likely to turn off or at least reduce one’s own progenitor cell proliferation, differentiation and maturation response leading to neutrophil release into the blood stream.

So, curious biomedical scientist that I am, with some inside knowledge of my own about stem cell kinetics and haematopoietic growth factors (HGFs), I have dug around in the current online literature for some ‘answers’ or at least possible routes for a patient caught in this position.

First, there is the issue of what might be available at all, coupled to who qualifies to receive it? Then there is the issue of how much any such treatment might cost and what cost-benefit analyses are brought into the equation about who gets what? Then there might also be the issue of treatment versus severity and time course of side effects. There is also the dilemma of willingness to treat versus allowing a patient ‘s body to recover naturally. So let’s examine some of these potential dilemmas.

Let’s get the first issue out of the way quickly. A treatment for low neutrophil counts already exists and has been used in exactly the circumstances described above. I know, I have met and discussed this with another patient on our ward who knows someone, who knows someone, if you get my drift for concern about maintaining anonymity? I believe this information is true. The second part of the issue is more problematic as the case for receiving the treatment, in this case, Granulocyte Colony Stimulating Factor (G-CSF), had to be argued very strongly, though the argument clearly succeeded eventually!

So the first dilemma is should allowing neutrophil production to take place naturally take precedence over giving an exogenous source of G-CSF? This haematopoietic growth factor (HGF) is one of a family of glycoproteins that plays a major role in the proliferation, differentiation, and survival of primitive hematopoietic stem and progenitor or precursor cells, as well as release of and functional activation of some mature cells. G-CSF and other HGFs bind to specific receptors on the surface of their target cells to mediate their action. G-CSF acts upon bone marrow differentiated, unipotent precursors – differentiated from more immature or precursor multipotent and totipotent stem cells. These, predominantly, neutrophilic precursors interact with this growth factor that stimulates both proliferation and differentiation of the target precursor cells and ultimately increases the release of young, new neutrophilic granulocytes into the circulation.

Donald Metcalf. Blood. 2008 January 15;111(2):485-491.  Accessed PubMed Commons.

“Three types of action of hematopoietic cytokines. (A) Lineage restricted. (B) Action on multiple lineages; broken line shows actions only at high concentrations. (C) Sequential actions; SCF acts on stem and early erythroid progenitors, while EPO acts on more mature precursors. The notion of sequential actions was later found to be incorrect.”

HGF actions on stem cells progenitors

Hematopoietic cytokines such as G-CSF are not simply mandatory proliferative stimuli but also act on cell survival, differentiation commitment, maturation induction, and the functional stimulation of mature cells.

G-CSF montage

The importance of a hematopoietic cytokine such as G-CSF can be validated in several ways. (A) By injecting G-CSF to elevate neutrophil levels and (B) by deleting the gene, a procedure resulting in low neutrophil levels and poor neutrophil responses to challenge infections.

At least these newly released neutrophils are ‘natural’, though the “extra production” and early ‘release’ mediated by G-CSF might be barely construed as not absolutely normal, at best in my book. There would be a timescale issue, as treatment could not commence (even if G-CSF was on hand) until at least the normal starting date, with Chemo treatment then being delayed also by at least several days. I’m not sure of the protocol now used, though granulocyte life span is actually quite short, about 7-days, and so neutrophil output stimulated by G-CSF should kick in fairly soon though sometimes a sharp fall precedes the increase, normally apparent within 24 hours, peaking in a couple of days later.

Of course, if this is a known issue for a patient, say low neutrophil levels have been recorded on at least two occasions, then the treatment with G-CSF could be anticipated and commenced either before or at least on the Chemo assessment day/date, thus shortening the time required (hopefully) to raise neutrophil levels to at least the threshold value, but hopefully beyond it. Nevertheless, there may be other considerations that treatment teams take into account such as toxicity of G-CSF, though it is low but this should be discussed with the patient. The one exception to using G-CSF routinely with cancer chemotherapy to prevent neutropaenia and fever might be in the case of some lymphomas where stimulation of tumour growth may occur.

The above example highlights the more general dilemma of seeking a treatment not recommended by one’s medical team and risking upsetting them by ‘pushing’ either for it or for a “second opinion” and the “mental anxiety” that one believes might follow from such mild (or should be) confrontation with the team. It is one thing for Consultants to welcome second opinions when they initiate these because they themselves are not sure, or their immediate multi-disciplinary team (MDT) recommends it, as part of their assigned role.

It is completely different, in my view, when a patient seeks to change the MDT’s view or recommended course of action, as now an amateur rather than a professional is initiating a suggested change in direction. Power always lies with the decision makers and traditionally these are the givers rather than receivers of information, advice and medical treatments, as in these illustrations.

So, a decision to take up one’s own case is not to be taken lightly. The thought may always be there that you don’t want to upset anyone, least of all your carers or consultant, on whom you constantly depend. Everyone is human and despite guidance (the GMC document for example) and acceptance of the principles of decisions ultimately lying with the patient, we patients always have nagging doubts about whether we will continue to be treated the same as before we “made a fuss”, became a ‘difficult’ patient etc. We are also human and hear too many stories similar to the one of returned food at a restaurant coming back complete with additional, well stirred-in spittle, courtesy of an offended chef – just reacting in an unprofessional but understandable way, unfortunately.

One more illustrative dilemma will suffice to reinforce the earlier general point. How expensive is G-CSF treatment and what are the cost-benefit analyses that determine whether it is used. “Three cytokines, erythropoietin, granulocyte colony-stimulating factor, and granulocyte-macrophage colony-stimulating factor, have now been in routine clinical use to stimulate cell production and in total have been used in the management of many millions of patients.” Metcalf, D. (2008). “Haematopoietic Cytokines”. Blood. 2008 15;111(2):485-91.

Clearly the medical argument has already been won. There would seem to be no argument except cost in a budget-limited NHS hospital. I have been assured on several occasions, albeit on other issues, that cost is not the limiting and determining factor, and in spite of my offering to find funds if it was. It is unclear how to proceed when faced with these conflicting statements, so often the issue is simply dropped by the patient who inevitably feels not as informed as their medical team (undoubtedly true). And yet the patient may feel rightly that they have only one life, and their continued treatment according to the agreed regime might be their last chance – for life!

So there we have it, whilst I fully believe in challenging authority (and living with the consequences) when your actual life really does depend on the good will of your authority figures then you inevitably think twice, as “dying, not living, with the consequences” might be the outcome!

That’s all folks. Bye for now.

BUGS001

41. From Bad to Good, to Great News!

Great News Montage

Got to get your priorities sorted out – music CDs (though LPs would have been preferable!) are always great news – but what is mine in this blog?

Accessed at https://www.google.co.uk/search?q=good+news+images  on 7 February 2016.

Well, how would you feel if you tried to confirm the time of your next appointment with the person who has information regarding your date with destiny, and then discover that it isn’t in his diary? None too enthralled, I suspect. Me either! But this is what happened to me and my proposed appointment with Dr P to discuss my latest CT scan results. So, this was bad news on last Thursday morning.

Come Thursday afternoon I received a call from Dr P’s secretary to confirm that he would see me after-all, sometime on Friday afternoon during the time I was attending Ward 32, Ninewells Hospital for my pre-Chemo assessment, which naturally included donating yet another armful of my Chateau Sang! So, here is the good news! Though, this did raise my anxiety levels a little earlier than would have been the case if my appointment for Monday had not been cancelled. Every silver lining is surrounded by a dark cloud! Every silk purse is still a sow’s ear. So, what next?

Come 1:30pm on Friday afternoon, I was mid-way through my Pre-Chemo assessment meeting with my nurse for the day, A. Suddenly, (after much ‘paging’ earlier) Dr P appeared in the main consulting room where I was awaiting the “needle and cannula” from yet another of the Dracula-figures, I conjure in my mind when I am about to be phlebotomised! Dr P appeared very buoyant and could barely wait to get the formal “hello, how are youbusiness” quickly out of the way, and then, on to more pressing matters. “I wanted to see you face to face, because it is not often I am able to give my patients good news!”, he said.

My results were good news, too. Dr P said I was probably in the top few percent of patients, in his experience, of the way my stomach cancer had responded to the Combo Chemo Cocktail. The primary site, my stomach cancer, had responded well and had shrunk considerably. I asked, “roughly what percentage”, to which he replied, “I was afraid you’d ask that!”. He couldn’t be precise about the actual amount, but said that he was confident the reduction in size of my stomach cancer was substantial, maybe more than 50-60% reduction overall.

Afterwards, I wondered whether the method of Stereology, creating three dimensional image data from two dimensional image data, as applied in Biomedical science, including representing some structures within a larger superstructure (for example the number of mitochondria or volume-percentage of say, the nucleus, or total mitochondrial volume, of a cell), could be used, with suitable software, to provide quick, accurate and reliable information from CT scan images? Note to self to research this and report to Dr P.

He showed Elaine and I the CT scan images on a small computer screen of both before (first scan about three months ago) and after Combo Chemo treatment (a couple of weeks ago). Everything was just a mass of “grey stuff” as far as Elaine was concerned (CT scans don’t come in coloured-flavours unfortunately). I fared a little better and just about could see the “shades of grey” (memories of earlier, Blog 7) he was trying to point out that represented my stomach lumen, stomach wall, anterior and posterior segments; as well as external-to-stomach structures such as lymph nodes, and so on…

Shades of Gray

The reason it was difficult to discernwhat was what, so-to-speak”) regarding the extent of “shrinkage of the cancer” was that the stomach cancer lump was actually not an isolated lump at all, rather, it comprised a massive thickening of almost the entire stomach wall. Coincidentally, this is probably also what made earlier surgery an unlikely option, I guess, unless I had been prepared to forego having a stomach at all, ever; including after the hoped-for recovery and my survival.

Anyway, he said that whilst all that was good news, the more exciting thing was, (wait there’s more…) I have great news”. He moved the computer images posteriorly (towards the duodenal rather than the oesophageal end of my stomach) and pointed out, by comparison of pre-post Combo Chemo images, the almost complete elimination (at CT Scan resolution anyway) of the various abdominal cancer deposits, including lymph nodes and ‘seedlings‘. So, was I going to have a glass (or more) of alcohol-containing fluid later that night – you bet!

So that’s (not quite) all (my news) folks, but the rest is short, honest! One outcome of writing these last 40 or so blogs is that my career might be taking a turn for the better – if I want it. I responded to an “anybody interested? ” employment call from http://www.Jobs.ac.uk. for potential ‘bloggers’. I applied, sending them a link to my web site and Cancer Blog. And guess what, I am now an employee of the company I use to check out for potential employment!? I’ll let you know when I have posted my first blog on either, “Higher Education” or “Higher Education in Australia”. At least I have experienced both – just for most of my working life!

And on another note, as you know, (5 Blogs-worth so far, ie the Harry Potter… series), I am writing a paper in response to a UK Government review of the NHS, to shift to a more preventative approach to treatment and a proactive approach to promote health. I am hoping to attend the first conference on the dissemination of a Plan developed after a year-long consultation that ended in December 2015. The programme for the conference was already published but I contacted the organisers anyway to ask whether I could participate in any capacity, but with an intent to promote my “patient’s perspective”, and as an informed biomedical scientist and higher education specialist educator and trainer. They are reviewing my abstract now! I hope to attend the conference on 22 March 2016 in London regardless of the outcome of their decision about publishing my paper.

So, there you go: lots of silver linings in dark clouds just now – though, I am trying not to get too carried away. I’ll still be having at least another two cycles of Chemo, commencing next Tuesday. My consultant’s only concern is the same as mine – the nerve damage caused by the Oxaliplatin. Anyway, he checked the extent of damage with a sharp needle (a non-technical test, rough and ready, but probably effective!) and will monitor again each time a new cycle of Chemo is due. I’ll be doing my own self-checks from now on too.

That’s (definitely) all folks. Bye for now!

BUGS001

40. Blogging – how it can turn your life around?

I like carrots – a lot, as it happens. But lest you think I have turned into an actual Rabbit (Buggsy – below) let me update my blog with a recent photograph.

Colin Beard Montage

Note: I am not even a shade of orange from over-consumption of carotene (an ingredient found in carrots but other stuff too that is responsible for the characteristic colour); au contraire, I look and feel like I need a good dose of UV light, please. Like Buggsy, however, you may have noticed I have a little more fur than a few weeks ago!

As I have to tick a box, concerning ongoing degrees of alopecia, in my daily ‘cancer’ diary I thought I should let you know that I am heading towards ‘baldy or Trichomeless’ not just atop my crown, but also under my arms, on my chest, and very disturbingly, around my pubes though not my bum! I still have hairy legs, feet and toes (no relation to Head, Hands and Feet – the ‘70s band already commented on in Blog 8). So, some trichome-bearing sites (see also Blog 15) seem impervious to chemo attack.

So, why am I telling you this? Well, the beard is an attempt to check up on whether overall ‘hair-loss’ is due to the damned stuff just falling out whilst some new stuff continues to replenish losses, though inadequately. Or, does the Chemo cause both hair-loss through drop out and inhibition of new growth (my head hair has barely moved in nearly three months). Well, as you can see from the photo, I do appear to have hair-growth, a beard, albeit even more gray colour than previously and of a “fine-downier” consistency than in past attempts to grow a beard, pre-chemo. The current beard appears to be standard male-pattern: commencing from the top of ears and via sideburns to cheeks; to upper lip and lower chin; as well as the neck – though I did shave the lower part of it a few days back – sorry!

I wonder if anyone has done research on Combo Chemo Cocktail modulated-body-hair loss? I’d be happy to join such a clinical trial. I can already document the pattern caused by my EOX mixture! So, if a budding new researcher is looking for a PhD topic; halt, look no further, I have one here already on a plate. And, there’s probably drug company sponsorship just waiting on your knock on their door. And further, there’s no shortage of patients. I can guarantee a whole bunch of them from my Chemo ward – well, at least my pal, N, fellow brother-in-arms and an EOX recipient in the past.

I received an email from one of our friends, J, (and blog reader) earlier today. She forwarded a link to an online article in the digital version of theguardian. How can my search engines have missed this?

theguardian Montage

However, this is less my point than the more crucial issue that I might not have (ever?) been made aware of this ‘cancer cure’ and vital research carried out at the Royal Marsden Hospital, but for my blog and my friend, J, reading it!

Will this new blog-linked information turn my life around? In all honesty I don’t and actually can’t know. However, the story is impressive, and although the patient highlighted had malignant melanoma, (Stage 4 with spread to lymph nodes and other places – just like me), other named cancers had been treated successfully too. Stomach cancer wasn’t one of the named ones – so, not like me! So, am I back to square one, like with the Proton Beam Therapy? Who knows, perhaps Dr P, when I see him!

You might want to read the whole article, but below I have extracted the major points, as I see them, and linked them with some of my own comments. Read on…

Accessed at https://www.theguardian.com/science/2016/feb/04/revolutionary-drug-immune-system-advanced-cancer?CMP=Share_AndroidApp_Gmail on 4 February 2016.

The closest thing yet to a cure for terminal cancer?

Sarah Boseley, Health editor of theguardian.

The following are extracts of theguardian article, together with some of my own text – to link slightly disparate arguments following my selection decisions. My text is italicised bold.

[“Immunotherapy has given Sandra Sayce an extra 10 years of life, and now new combinations of the treatment may offer hope to many more patients. Nobody, including Sayce, is prepared to say that her advanced skin cancer has been beaten. Yet the last treatment she had for stage 4 melanoma, which normally kills within months, was nearly 10 years ago.”

“She was then given immunotherapy, which teaches the body’s defensive immune system to identify cancer cells and attack them from within, in the same way it would fight off a cold. After the treatment, the cancer disappeared. “It took me a couple of years to believe it was true,” she said at her home in Ruislip, west London. “You never quite lose that concern at the back of your mind, but there is no active disease and I have been stable for so long,” she added.”

She was given a drug called ipilimumab. It was a novel approach, designed, she was told, to reprogramme her immune system. She had just four treatments – one a month from September to December. “I had a head-to-toe rash, which itched,” she said. “But I knew quite quickly that it was doing something.” The lesions in her leg, which had become lumpy, started to flatten. The lesions in her liver and spleen disappeared. She has had no further treatment and there is no sign of cancer.

Cancer can evolve to be able to survive the toxic drugs thrown at it, just as bacteria become resistant to antibiotics, said Larkin. “The critical difference with immunotherapy is that you are actually reprogramming the immune system, if you like. The idea is, if the tumour does change and evolve, the immune system can also change and evolve with the tumour. I can’t exactly prove that but I fundamentally think that’s the critical difference.”

He persuaded a leading US pharmaceutical company to open an arm of a trial using ipi – as everybody now calls it – and a newer immunotherapy drug, pembrolizumab, at the Marsden as well as the world-famous US hospitals. He succeeded in enrolling more people on to the trial than any other centre. Alone, the drugs can have great results with several types of cancer – kidney, bladder, head and neck as well as melanoma – but in only 20-25% of patients. The hope was that a combination might help more.”]

Since then, much better outcomes have been achieved with combination therapy.

Prof Martin Gore, medical director at the Royal Marsden Hospital, who is also a melanoma and kidney cancer specialist, argues strongly that medical oncologists and GPs need to stay aware of recent findings and be proactive in getting their patients involved in trials for new treatments such as these. He comments on a response from a presumably sceptical doctor in theguardian article:

[“People say it is all right for the academics but we can’t do that. We’re too busy,” he said. Prof Gore went on to say, “I’d quite like to see that being challenged a bit, saying, ‘come on. I do it – why don’t you do it?’ If you are a doctor, by definition you should be interested in research. Our colleagues at the GMC [the General Medical Council, which regulates doctors] expect us to keep up to date.

“It is not that people don’t want to do it. It is that people are too busy. Many people’s jobs are incredibly crowded with clinical work. In some places, the oncologists are very embattled with the number of patients. That goes for general practice in spades. I think we need to look at that a bit to know how we can change the way we work so we have breathing space. I think we have a way to go in terms of challenging the system to allow people to do it or even expect people to do it.”]

READ ON…

I do hope you have either read the above or arrived here deliberately.  Either way, good, because you just have to read the last two paragraphs of this blog entry, for the whole thing to make (much) sense.

So, maybe there’s a chance, even a tiny, tiny, tiny one would be good! Then again, if we believe we are dealing with my tiny world of quantum mechanics (Blog 38 ), ipi and/or the newer pembrolizumab, preferably used in combination therapy, may work AND may not work on gastric cancers; but until someone looks to see if my cancer has gone after I have been treated, then we will not be able to predict an outcome to the question, “Could I be treated with the new immunotherapy agents for my cancer?”. So, voila, I have a fool-proof method of getting the treatment I want (and without confrontation) if I work on the following:

So, perhaps we’ll give it a go then. Eh?

Well, say no more; nudge, nudge; say no more

Wink, wink; nudge, nudge; know what I mean?

 (Nudge, Nudge – a British expression used to make someone realise an ulterior motive to your conversation.  Accessed at http://www.urbandictionary.com/define.php?term=wink+wink+nudge+nudge  on 4 February 2016.)

 

Wink Wink Nudge Nudge

The expression was popularised in the 1960s in the infamous, “Nudge, Nudge” sketch (laden with sexual innuendo) from the third Monty Python’s Flying Circus episode.  Accessed at https://en.wikipedia.org/wiki/Nudge_Nudge on 4 February 2016.

And Eric Idle’s selection from “Personal best”, Accessed at http://www.montypython.com/tvshow_Monty%20Python’s%20Personal%20Best%20%282006%29/19 on 4 February 2016.

That’s all folks. Bye for now.

BUGS001

 

38. Reviewing my Gastric cancer – a case for Proton beam radiation therapy?

Proton Beam Therapy CGI action

Simulation of Proton Beam Therapy specifically targeting a tumour located deep in the brain.  Accessed at http://www.proton-therapy.org/howit.htm on Wednesday, 2 February, 2016.

Next Monday morning I will sit down with Dr P to discuss the results of my CT scan carried out last Tuesday – an anxiety-invoking two week wait! What will he say? For the big picture, there’ll be a decision about whether to carry on the same treatment (EOX combo) for 6 cycles (4.5 months) or for 8 cycles (6 months).   There’s pros and cons of course, but some days I just so, so want to be free of consuming medications of one sort or another, such as “shite-tasting” pills, solutions, suspensions, revolting creamy stuff and even the marginally better but still sickly fruity stuff, that the 6 cycle option really appeals!

The alternate is to carry on to 8 courses (6 months) to “kill the buggar some more”, and then I have to bite the bullet over the current side effects. But, there’s more…! I would also have to hope that permanent damage to key areas of my body doesn’t occur. I’m thinking particularly of nerve damage to my finger-tips which do take a ‘pounding’ because of the cold-response that is induced by Oxaliplatin in my EOX Combo Chemo.

The upside of the 6 cycle option is that I’d be free of the afore-mentioned as well as other side effects a little sooner. The downside, however, is that remnants of tumour may still remain or even have developed at new sites (though not visible by CT scan) that could trigger a re-appearance of my cancer at its original site or at any new as well as old metastatic locations. Sneaky sods – these cancer cells, eh?

The only upside of the 8 cycle option is that it kills more cancer (I have already been informed that a complete eradication down to the very last tumour cell cannot be guaranteed and hence I bear my label of receiving palliative care only). When Dr P starts mentioning surgery or radiotherapy then there might be a glimmer of hope for a switch to a curative-care regime though that, it would seem, is a long way off. But hey, who knows?

So, it’s complicated! I’ve just got to have in my blog at least one Steve Martin movie – in a starring role! This is certainly not his best, but the title is just right for my “coincidental link!”.

Its Complicated 1

Accessed at http://www.imdb.com/title/tt1230414/ on 2 February 2016.

Even if I was given a free choice – minus Dr P’s own advice– what would I do? What further questions should I ask this time? I’m still trying to sort this out. But of course, I am interested in any form of treatment that may give me a chance of being re-classified as a curative-care patient! As mentioned above radiotherapy could be an option if my only cancerous site could be narrowed to a single or at least easily noted location (only for certain would do).

And then suddenly, bang – there’s a BBC news item (Monday, 1 February) reporting on a recently highlighted study, published in the Lancet (Public Release: 29-Jan-2016), Yock, T. et. al., (2016). The Lancet Oncology: “Proton beam therapy offers potential to treat childhood brain cancer with fewer severe side effects than conventional radiotherapy”.

Accessed at http://www.eurekalert.org/pub_releases/2016-01/tl-tlo012816.php on 2 February 2016.

The new study involved 59 patients, aged 3 to 21, who were enrolled between 2003 and 2009, and revealed that the childhood brain cancer medulloblastoma treated via a procedure known as Proton Beam Therapy, “appears to be as safe as conventional radiotherapy with similar survival rates (83% at 3 years; 80% at 5 years)”; and additionally, compared to conventional radiotherapy, “proton radiotherapy may not be as toxic to the rest of a child’s body (hearing loss:12% at 3 years-15% at 5 years) as well as having, “no cardiac, pulmonary, or gastrointestinal toxic effects, which are common in patients treated with photon radiotherapy”. This looks interesting!

Protons can be generated and focused into beams in a controlled way using large particle accelerators. Uhm… particle accelerators.  Might I digress for a moment, or ten? CERN in Switzerland has the biggest and most powerful particle accelerator in the world – though everyone seems to own it!

CERN Supercollider Montage

CERN’s powerful particle supercollider. Accessed at http://home.cern/topics/large-hadron-collider on 2 February 2016.

This one, known as The Large Hadron Collider (LHC) comprises a 27 kilometer ring of superconducting magnets that focus and accelerate beams of particles towards one another at speeds close to that of light.  This machine though is used for things other than Proton Beam Therapy; notably, crashing sub-atomic particles into one another and creating even smaller ones! Now people in particle physics think this is great and even get Nobel prizes for their work, or share it with others who have also had a great idea or conducted an ‘elegant’ experiment. For example, Professor Peter Higgs at Edinburgh University predicted the existence of the now, so-called Higgs Boson. Its existence was only confirmed in 2012 and he got his share (with François Englert) of the Nobel prize for Physics in 2013.

Prof Peter Higgs

Professor Peter Higgs. Accessed at https://en.wikipedia.org/wiki/Higgs_boson on 2 February 2016.

I’m not sure how great this is and if you bear with me I’ll share with you the rather different view I take. If I take my hammer and smash a large rock, I get a cluster of small rocks. If I then take one from said cluster of (smaller) rocks and smash it again with even more malice this time, lo and behold, I generate a further cluster of even smaller rocks. I think I’ll call one of these, the smallest piece as it happens, Mason’s Mason (pronounced Mayzon!).  I have so-named it because it behaves similarly to a photon which is able to appear in two places at once; and is also a particle and yet behaves like a wave at the same time.  This ‘duality‘ is a phenomenon explained by Schrodinger’s cat analogy.

Schrodingers Cat

Schrodinger’s thought experiment Accessed at https://en.wikipedia.org/wiki/Schr%C3%B6dinger’s_cat on 2 February 2016.

Schrodinger devised a “thought experiment” in which a cat is locked in a sealed box that contains a radioactive substance that may decay (or not). If it does this is detected and further triggers release of hydrogen cyanide which kills the cat. The “not knowing what has happened yet state” was (jokingly?) referred to by Schrodinger as the “superposition state” where the cat can be both alive and dead – until an external observer looks inside the sealed box (Schrodinger, 1935). It is then either alive or dead. And this analogy helps you understand the quantum mechanics that underpin behaviour of very small particles (but definitely not cat-sized ones) such as atoms and photons, apparently!

Anyway, the Mason obeys the same rules and thus at any one time it may be here, or it may be there, depending upon where you look for it – simple and elegant, eh? People have received Nobel prizes for less, don’t you know? And let me tell you, I predicted its existence in 1956 when I was only 4 years old, and had just learnt about hammers and how much damage they do to one and half-year-old baby sisters! Now is this rocket science? If so, I’d like my (share of) Nobel prize for “common, or is that uncommon, sense”, please!

Now to digress back to my pre-digression:

As I was saying, protons can be generated and focused into beams in a controlled way using large particle accelerators. Proton beam therapy damages cancer cells in the same way as radiotherapy. Unlike X-ray beams, however, proton beams stop once they hit their target (a tumour growth normally), rather than carrying on through the body. Thus, the proton beam more specifically targets the cancer whilst sparing more of a patient’s own nearby normal tissue. And, it is the latter that reduces side effects.

Protons are positively-charged particles found together with Neutrons in the nucleus of every atom. The movement of proton beams (like other ionising radiation sources) through ‘solids’ is governed by what is known as the Bragg peak effect, after William Henry Bragg (1903). He defined the properties of various ionising radiation sources with reference to their energy loss (Vertical axis) as they traverse matter which slows down their movement (Horizontal axis). Energy sources such as α particles, other ion rays and protons all have characteristic patterns (Fig 1).

BraggPeak Curve

Fig 1 Bragg curves for Photons (eg X-rays); and protons. Accessed at https://en.wikipedia.org/wiki/Bragg_peak on 2 February 2016.

What distinguishes the proton curve is the ‘peak’ of energy reached just prior to its final abrupt decay – that is also marked by an annihilation ‘explosion’, with luck and a trained operator focusing this at the 3D location of the tumour, say in the spinal cord. In contrast, X-rays continue, albeit with slower exponential decay, beyond the site of a targeted-tumour and further into normal tissue which will continue to be exposed to damaging radiation, that also affected normal tissue precisely located ahead of the tumour (double bad news there, for the radiotherapy camp!).

Proton Beam Therapy is not a new form of treatment but it is news-worthy, mainly because the UK lags behind some other countries in not having even one machine of its own capable of generating a high energy proton beam that can be used to treat patients across a sample of the total spectrum of 2000 or so cancers, and not just eye cancers (see below).

“Currently (2013) the UK has one proton beam therapy facility, at Clatterbridge Cancer Centre. But it’s a ‘low-energy’ machine, only suitable for treating people with rare eye cancers.”

Nevertheless, the UK government has recognised this glaring gap in its cancer care provision, and in 2013 it commissioned two state-of-the-art high-energy proton beam facilities to be built in the UK by 2018. These are to be located at the Christie Hospital in Manchester, and at UCL Hospital in London – at a total cost of £250 million. In addition, there are plans to build a research-focused proton beam centre in a new institute at Oxford University – a major investment being supported by the Government and Cancer Research UK, among others.

Proton Beam Therapy UCL Facility

The proposed PBT facility at University College London (UCL).

Currently, cancer patients (mostly children) that require Proton Beam Therapy must be referred by the NHS to facilities in either the USA or Switzerland. From 2018, the first cancer patients treated at the new NHS facilities will be those for whom current evidence already recommends proton beam therapy:

  • children with several specific types of cancer
  • some adults with rare cancers, particularly where tumours have developed near the brain, base of the skull or spine.

It was in 2014 that a previous news headline propelled Proton Beam Therapy into public consciousness when a small boy, Ashya King, was snatched from a Southampton hospital by his parents, Brett and Naghmeh King, against medical advice, in order to take him to a Proton Beam Therapy treatment centre in Prague, in the Czech Republic.

His parents believed their son was not being offered the best treatment available for his condition and consequently took matters into their own hands. With hindsight, it is easy to criticise the heavy-handed approach by the hospital authorities who first tried to prevent the ‘family abduction’ and subsequently notified the police who then issued arrest warrants and ultimately withheld the parents (in Spain) from their son whist he underwent treatment in a foreign hospital in a foreign land – a scary prospect for anyone, but a small boy, come on? In defence of the local NHS hospital, it later agreed to fund this treatment, which ultimately was also successful – cancer-free for 9 months.

Should I get carried away with new possibilities such as Proton Beam Therapy for my cancer? Sadly, after reviewing even a small sample of the online literature, the answer is probably no! Leaving aside whether there is sufficient research evidence generated from properly conducted (randomised, controlled, blind etc – you get it, right?) clinical trials to claim superiority over radiotherapy, more importantly, it seems, is the type and location of the cancers best suited to Proton beam therapy. Gastric cancer (probably, especially for adults) isn’t one of these – at present.

Following completion of my 6 or 8 cycles of my current chemotherapy regime I should know whether my own primary tumour site has been declared ‘clear’ of active cancer, leaving only residual active metastatic deposits. As previously described, these are in in part of my pancreas, a few lymph nodes and one adrenal gland. If only one of these sites is active at this time (he says optimistically!), then who knows, perhaps “targeted therapies” such as Proton Beam Therapy, Cyberknife and Immunotherapy using modified viruses such as herpes and measles, will present new opportunities – even for me?

Whilst there are some benefits of Proton Beam Therapy over conventional approaches it may be premature to think that this is the ‘answer’ to cancer cure. Even leading experts remain cautious?  What follows is a range of statements made by one of the UK’s leading clinical radiotherapists and Proton Beam Therapy specialist, Dr Adrian Crellin.

“Since it delivers a lower dose of radiation to surrounding tissues, proton beam therapy’s main advantage is in reducing side-effects, rather than improving survival or cure,” he says. This helps patients whose tumours are near sensitive organs (e.g. the brain or spinal cord) by reducing damage caused to healthy tissue– especially in children, as their organs are still developing.

There are also suggestions that it can reduce the (small) risk of developing a second cancer later in life. And, for some rare cancers in adults, the reduced damage to surrounding tissue means proton beam therapy can be given at a higher dose. This, Crellin says, might be more effective at destroying cancer cells, although clear-cut evidence of survival benefit is limited. “But it’s critical to stress that for most patients right now, there’s no strong evidence that proton beam radiotherapy is ‘better’ at curing cancer, or improving a patient’s chances of survival, than conventional x-ray radiotherapy.”, says Crellin. That’s why it’s so important that more research is done on proton beam therapy (2013).

Maybe the recently published study in the Lancet Oncology at least provides further evidence that such investigations are happening and are beginning to bear fruit.  Accessed at http://scienceblog.cancerresearchuk.org/2015/07/16/proton-beam-therapy-where-are-we-now/ on 2 February 2016.

On the other hand, bloggers such as me (ie cancer patients, some with not a lot of time left) argue strongly that Proton Beam Therapy, if it was a lot cheaper (it costs about £40,000 to treat one patient!), would actually replace X-ray radiotherapy, and there would be no debate. I am not sufficiently qualified to comment, but if the recent Lancet Oncology paper is predictive of future clinical trial outcomes, then the bloggers have it, in my opinion, since Proton beam therapy is no worse on mortality data and similar or better overall on morbidity data. It boils down to money, as it always does in health matters – compare just about any aspect of the health or illness of poor people with that of wealthy folk and guess what you will find?

That’s all folks! Bye for now.

BUGS001

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]

 

 

 

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.