Medical Articles

Health in the UK – an updated reflection

I was speaking to an elderly patient last week, well into their 90s, who was frail, unwell and needed some attention. Throughout the conversation, they could not stop apologising for, in their words ‘wasting my time’ as they knew how busy we all were. The conversation left me quite emotional if I’m honest, not least because that very same day I lost count of the number of appointment requests we received from, for example, people who had woken up with a bit of a raspy throat, or who had been congested and coughing from a cold or chest infection for the last week. The contrast in perspective of what the role of the health service should be could not have been sharper.

The average number of times an adult saw their GP in 2015 was seven times a year. Twenty years prior to that it was Three times a year. Much of the increase is related to an increase in chronic disease with which GPs must contend. But it also seems that the threshold with which patients seek help from their doctors, even in the face of headlines about how overwhelmed the NHS is, has lowered. The average adult will get two or three colds a year (the number is higher for children at eight or even more) and at no time is that something a GP needs to see. Yet GP surgeries are inundated with people suffering from sinus infections, colds and chest infections, the vast majority of which are caused by viruses and which will get better eventually on their own. Crucially there is nothing a GP can do to treat these infections. Antibiotics do not work against viruses. The natural course of these infections tends to be an initial sore throat and/or fever followed by congestion, coughing and fatigue. Often people will say the cough has gone to their chest. It seems to be a common misconception that this is the time to go and see a GP whereas it simply means the virus is either a bronchitis, effecting an area a bit lower down in the respiratory tract or even that the congestion is beginning to loosen and the virus us on the road to recovery. Granted the viruses are bad at the moment. Having endured a bit of down time during the social distancing prompted by covid, our bodies are a little less resilient to them and so they are more severe and last a bit longer. Three weeks is not uncommon. That still makes no difference ultimately in how we manage them.

Flu is also causing problems for much the same reason. Flu is also a virus and the vast majority of cases require rest, fluids and will get better on their own. Severe flu can be more serious and so if you are breathless at rest, really drowsy or unable to get enough fluid on board to stay hydrated, then contact your GP. Otherwise, no it’s not nice, no you probably won’t get out of bed for a few days, yes you’ll have a high fever, yes you’ll feel achy and tired but you don’t need to automatically contact your GP and you certainly don’t need antibiotics.

If you are at all worried, your first step should be to look at the NHS website. If you are not sure having looked at that, your next port of call is the pharmacy. Only after that should you consider contacting the GP surgery.

Part of the demand issue at the moment has been the Strep A outbreak which has understandably caused some concern, particularly for parents of school age children. Of course if you are concerned that this may be effecting your child, of course contact your GP but please do apply some common sense. There are lots of viruses that cause similar symptoms but if they develop the characteristic rash and red tongue should you call the GP.

GPs are commonly faced with demands for antibiotics from patients and surveys have shown that a majority have felt pressured into prescribing them even when they know they will do no good. Clearly it is inappropriate for patients to come in with such demands, but we as clinicians must take some of the blame. The truth is, in a busy hectic day (and they really are non-stop), sometimes the easy thing for a GP to do is to give someone an antibiotic. All that does is increase the number of people that come in for antibiotics the following year whilst adding to the already huge problem of antibiotic resistance – a calamity hiding in plain sight.

There are many things that need addressing in the NHS at the moment. Nurse to patient ratios on hospital wards have been unsafe for a long time. In the UK there are 2.8 doctors to every 1,000 patients compared with 3.7 per 1,000 in comparable EU nations. The population is ageing and the increase in prevalence of chronic issues such as diabetes, obesity, alcohol and substance abuse, heart disease and mental health mean that as people age, they do so with a high level of morbidity. In other words, people are less healthy. This necessitates a lot more GP and nursing time as they care for ever more complex patients as they spill over from hospitals and secondary care. One study showed that around 40% of all GP appointments are accounted for by just 10% of patients. This has doubled in the last 20 years.

Most of these people really do require that care but there is a proportion of patients that access health services entirely inappropriately and put extra strain on the system as a result.

As healthcare professionals we want to help people. But when it isn’t possible and moreover, when it starts to impact upon other people who are far more in need or our help – the person who is unwell with cancer, the person who’s been having symptoms preluding a heart attack, the person who is suicidal, the elderly in need of support and care – that is when it becomes more than a little frustrating from our side of things. When people start taking liberties with a health system that is on its knees, the system falls apart. Those who shout loudest are not always the ones who need help.

With that I wanted to end with a couple of suggestions. I won’t get involved in the political aspects. But there are two things that I think would make a huge difference to the pressures the service faces.

At the moment, much of the focus is on more funding, more staff, more hospitals and greater infrastructure. While that is all important, it is only necessary because demand has gone up. If the demand was impossible to reduce any further then absolutely, focus everything on increasing supply. But of course demand is no way near that lower threshold.

In the short term, reducing unnecessary utilization of the health service is something that could have a fairly immediate effect. Looking forwards, it is a case of empowering people to keep themselves healthier so that, even though the population is older, it is healthier and so requires less intensive input. It may seem simple and maybe even a little vague, but I have heard no better suggestion in the face of the ageing population.

As such, the following suggestions are the two key things I think we need to fight for in the face of the NHS crisis which deepens every year.

1 – Health and medicine as part of the school curriculum – while people need to know when it is not appropriate to access health care, it is at least as important for people to know when they should. There are lots of people out there who ignore health issues and do not get help when they need it. Education around health will also have invaluable longer-term benefits for a healthier and happier population.

2 – More aggressive action on the availability of food containing high levels of sugar and salt. Diabetes and heart disease along with obesity are chronic issues which are only getting worse. Shops lined with junk food are a feature only of the last few decades. Another example of the luxuries that we now take for granted but which have long been creating repercussions which affect us all, whether it be directly or indirectly.

As we see yet another ‘winter crisis’, rather than wait for the next shake-up or the next cash injection from the powers that be, the best way to heal the NHS – perhaps the only way – is if we take some ownership of the problem ourselves rather than relying on someone else to heal it for us.

Previously on Covid-19

As we approach June, I thought it might be a useful exercise to recap on the last few months. After all, there’s quite a lot that has happened and it’s been a bit of a blur thus far! Who knows what the next few months will hold but these are the key events from a Coronavirus point of view since it all began.

31 Dec 2019 – The Wuhan Municipal Health Commission reports a cluster of pneumonia cases in the Wuhan province of China.

8 Jan 2020 – Chinese scientists announce that they have found a new strain of coronavirus.

12 Jan – The genetic sequence of the new coronavirus known to be causing these new cases is released publicly by China. The virus is known as SARS-CoV-2.

13 Jan – the first official case outside of China is identified in Thailand.

30 Jan – There are now 98 confirmed cases in 18 other countries and the WHO declares a Public Health Emergency of International concern.

31st Jan – The first 2 cases are confirmed in the UK.

11 Feb – The disease caused by the virus is named as Covid-19 by the WHO.

5 March – The first confirmed UK death related to Covid-19 is reported.

11 March – Due to being “deeply concerned by both the alarming levels of spread and severity and by the alarming levels of infection” the WHO announce a pandemic. The 2011 film ‘Contagion’ begins trending on various streaming platforms.

12 March – The UK moves from the “contain” approach to what is referred to as the “delay” phase. This means that people with symptoms are no longer tested unless requiring admission to hospital.

16 March – The WHO advises “test, test, test”.

20 March – Schools, nurseries, restaurants and pubs all ordered to close.

21 March – The government shielding scheme started. This has caused some confusion, both then and now. Letters were initially sent by NHS England to those with features suggesting they were ultra vulnerable should they contract Covid-19; even more so than the vulnerable groups normally granted free flu jabs annually. These included those with organ transplants, undergoing active chemotherapy or with any immunosuppressive condition. Some letters were sent to people who did not need to be on the list while others who did need to be on the list were not initially identified as the data used to draw up the lists was from a national database. Subsequently, lists have been revised at a more local level. The letters advised shielded patients not to leave their houses at all if possible and offered information about local support agencies.

23 March – The government announces lockdown measures with advice that people stay at home, only leaving for one form of exercise a day, for work if absolutely necessary, to shop for essential items and to fulfil any medical and care needs.

2 April – Suspected Covid-19 hospital admissions peak in the UK at more than 3,400 in a single day.

3 April – Worldwide cases of Covid-19 pass 1 million.

5 April – It is announced that Boris Johnson has been admitted to hospital with Covid-19.

6 April – The Primeminister is moved to ICU.

10 April – The UK daily hospital death rate reaches its peak at 980 for cases involving Covid-19.

12 April – Mr Johnson is discharged from hospital.

20 April – The government furlough scheme officially comes into effect.

23 April – Testing begins on the vaccine developed at Oxford University which uses an inactivated adenovirus with an additional “spike” protein found on SARS-CoV-2 in the hope that the body will develop an immune response to this protein, thereby potentially providing some immunity to SARS-CoV-2 itself. (Due to the more recent drop off in cases, there have been some reports that the trial may struggle to get results because a sufficient number of participants will need to be exposed to the virus for it to be reasonably certain that the vaccine works.)

29 April – Official figures show UK deaths pass 26,000 as care homes deaths related to Covid-19 are included for the first time.

5 May – Doctors in France report that, having retested a swab taken on 27th December 2019 on a patient at a hospital near Paris (who had no recent travel history), Covid-19 had been identified. This has raised questions over how long the virus has really been in circulation.

13 May – It is announced that lockdown measures are to be eased somewhat. Members of the public are still to observe previous measures but are now able to take unlimited exercise, restart open air sports and meet one person from another household in the open as long as social distancing measures are observed.

14 May – Data are published that show A&E attendances for April were 0.9 million, down 57% on April 2019. While clearly a very large number of A&E attendances are unnecessary, this raised concerns over how many serious medical conditions may have gone untreated or undiagnosed as a result of people’s reluctance to attend.

20 May – The official figures show that there have been 250,908 confirmed positive Covid-19 cases in the UK to date and 36,042 deaths. Bear in mind the drawbacks of such statistics without a robust and extensive testing system in place.

22 May – Testing is finally rolled out again for those with symptoms and, theoretically, anyone above the age of 5 and with symptoms (which now include loss of taste or smell) can access either home testing kits or testing at one of the regional sites via the NHS website. (Not via your GP).
These tests are swabs and detect the presence of viral RNA on the mucosa and in the saliva and can tell whether there is current infection or not.
In order to detect whether one has had the virus at some point in the past and therefore probably has a level of immunity (although this is not yet proven), an antibody test is needed. There has been much talk of these, first mentioned by the government in March as being imminent. However, as yet, no antibody tests are available. Two tests (developed by Abbott and Roche) were validated by Public Health England on the 14th May and will apparently be used from next week to test NHS and care workers. These tests are available privately from various centres but people should be cautious about the results. For a start, it could take up to 28 days after the infection before the test can properly confirm if a person has had the virus. Secondly, as mentioned above, there is currently no telling how much immunity one gets from having had Covid-19 so, until this is better understood, the benefit of antibody testing is largely for community statistical purposes.

So there you have it. The story so far. The next few weeks will no doubt contribute to our ever expanding knowledge about the virus. It might be useful to mention at this point an app developed by Kings in London called ‘COVID Symptom Study’ that I would encourage everyone to download and fill in if you haven’t already.

The more we know, the better we can understand how best to open things up and prevent a slide back into a second peak. Data, for all their faults, are key. Testing is integral to this.

Thoughts on our Healthcare

“It is forecast that by 2030, the global consumption of antibiotics will rise by more than 30% (200% if it continues at current growth levels). By 2050, the annual death rate will have risen from 700,000 to 10 million with no action.”

It is a humbling situation when one realises how fragile we are in the face of nature and how little we really know in the battle to protect ourselves.

My generation have the unique honour of having grown up at a zenith of medical know-how. As a child, I often reassured myself that, if I or anyone I knew ever became unwell, everything would be fine. I always comforted myself that, should it be needed, there would be the medical expertise somewhere to cure anything. I was confident that the medical care and consensus behind every treatment was solid and complete; its efficiency spotless. Now I realise that this was simply a form of therapeutic self-delusion.

The truth is that, although our capabilities far exceed the wildest dreams of Hippocrates and Aristotle, we are far from perfect. What we don’t know far outweighs what we do. Treatments remain speculative, their quality reliant upon where we fall at any one time on the curves of demand and supply. Despite officious regulation, treatment remains highly subjective according to who treats you (bearing in mind this may be an exhausted doctor or nurse running on empty), and could still be based on faulty or unreliable evidence. We can’t guarantee a cure for your cancer and we can’t always tell for sure why you’re feeling so tired and achy, so sometimes we have to guess a bit.

Our exaggerated opinion of our own ability as a species extends beyond just medicine of course. While that can be catastrophic in other fields, it does at least provide some benefit in a healthcare setting. Confidence in physicians can be a therapy in itself. Despite what I have said, this trust is important and well placed. Though not perfect, we are better than nothing! And yet, when something like the Covid-19 pandemic hits – something so undeniably out of our control – it highlights those cracks that we’ve otherwise consciously chosen to ignore.

What has struck me most about the Covid-19 pandemic is our reaction to it. While in some places it has highlighted tremendous courageous and community spirit, in others it has merely brought out human attributes that are the polar opposites of the aforementioned. For me, it has emphasised the prospect (and quite possibly the need) for fundamental change in how we utilise the medical expertise and the knowledge we have accumulated.

The meaning of ‘our NHS’ has become a bit warped in recent times. When someone has been treated with kindness and care, it is the NHS that gets the thanks. In reality, it is the people that work for the NHS who should be thanked as well as the organisation as a whole; a distinction that I feel too often gets overlooked. Obviously this is semantics and very often that is what people will mean when they praise the NHS. But in merging the two, a powerful message is being lost.

The people that work in healthcare, whether it be within or without an NHS, deserve all the praise they are getting. Likewise, the idea of a National Health Service that provides universal, comprehensive and free healthcare should also be praised. The problem is, at its inception in 1948, the idea of comprehensive healthcare is very different from what it is now.

In 1948, paracetamol was yet to become readily available, open heart surgery was 4 years old, statins had not yet been invented and antibiotics were in their infancy. Fast forward to the present day and we are seeing around 200 heart transplants a year in the UK, an entire pharmacy of medications available to us at our beck and call, lifesaving emergency services 24/7 and access to state of the art intensive monitoring equipment. Around half of the UK population takes at least one regular prescription medication. If your hips or knees go, you are entitled to have metal replacements inserted for no extra charge. If you have a rash, you can have it seen to or if you want your ingrowing toenail sorted, you can have it clipped or lopped off. If your ears are blocked, someone will clear that for you too.

With our population increasing and growing older, it is little wonder that the whole thing is beginning to creak. The outcome…? You have to wait a long time for your hip replacement, you might be denied the chance to have your bunions sorted out because it is a low funding priority. Your GP is running late by 20 minutes or even a bit longer. That may seem a bit insensitive or flippant (or both) but believe me, I’m not happy about it, certainly if it means people are waiting for treatments in agony. While some have a rational grip on such situations, others will not. Those are the ones that abuse the staff who are only trying their best in impossible circumstances.

Demand has far outstripped supply already. At current levels of funding, the promise of delivering a comprehensive service is no longer accurate. But that is only if we all agree on what counts as comprehensive.

We have been rather spoilt with the NHS, rather like a child who is given one sweet and then pleads for several more, never content with what they are given. The level at which our baselines have shifted (there is an actual concept know as shifting baselines syndrome that one could probably apply to much that is wrong with the world) is significant. Consider 100 years ago, antibiotics were non-existent, surgery was more dangerous than beneficial and not long before that there wasn’t even the luxury of an anaesthetic. Just read the 1810 diary account of Fanny Burney, the English novelist, who developed Breast cancer and underwent a mastectomy without anaesthetic to see what I mean.

Antibiotics and our use of them serve as a perfect microcosm to demonstrate my point. For all they have given us, they have also contributed to levels of antibiotic resistant infections that kill 700,000 people a year globally. Don’t get me wrong, antibiotics are great; a lifesaver in fact. Prior to their widespread utilisation, a cut or scratch could become infected to life threatening degrees and as such they have arguably become the single most important tool in our therapeutic arsenal (vaccination is arguably more important). And yet they have suffered a severe case of mission creep. They lend a hand in all sorts of unexpected ways. Caesarean-sections and routine hip replacements would be rather more hit and miss in terms of survival without them. Not content with saving lives, in fact they have become somewhat of a luxury, whether it be to shorten a cough or a bout of diarrhoea or to fatten up our animals so their meat is better.

In the UK, at least 20% of antibiotics prescribed in primary care are inappropriate (I would probably argue that figure is higher depending on your definition of inappropriate). At any one time, a third of patients in hospital are on an antibiotic.

Resistant organisms transfer at will from one person to another, or to food and animals. As they do, we edge ever closer to a circumstance in which we are unable to treat them at all. There are already strains of TB and gonorrhoea that cannot be treated even by the antibiotics reserved as last resort.

The WHO cites antibiotic resistance as the biggest threat from global pandemic. Considering what is going on at the moment that should prick some ears. Just as there are warnings about antibiotics, so there were for coronavirus. A pandemic such as the one we find ourselves in isn’t exactly a surprise and yet to a large extent, we have all been caught napping. I liken it to sitting on a beach with a bag of popcorn, admiring the spectacle of a tsunami rolling in. Suffice to say, a tsunami of antibiotic resistance is far less palatable than the comparative swell of coronavirus we are seeing now.

It may therefore be time for some realism and some hard choices. This includes both those at the very highest levels but also, I’m afraid, for us all. Who knows in what shape we’ll emerge from the current saga.

In an ideal world, the government would pledge a suitable amount of money for the NHS to cater perfectly for everything from the largest and most severe of our medical needs down to the smallest and most trivial. Failing that, management of the entire system must get realistic and we must allow it to do so. No one wants to see a privatised NHS, (including the government if what they say is to be believed). Clarity of mission alongside acknowledgement of the problems– not spin – is what we need. Without this, whispers and rumours of privatisation will continue. If measures are to be painful, in my opinion telling people that is far better than trying to sneak it under their noses. Better still, a cross party approach in order to depoliticise proceedings is preferable so election success no longer rides on it. What we don’t want to see are more layers of management. Time and time again, we experience instructions from those at the top, far removed from the realities and often the progress we make is in spite of these targets instead of because of them. In any situation, the more layers you add, the more complex it becomes and the easier it is to trip over yourself. A bit like the game Tetris – a certain amount of blocks at the right speed will build something solid but as soon as the rate and number of bricks increases, it all runs away from you.

Just as importantly, perhaps even more so, is our individual role in all of this. As we clap our health workers every Thursday evening while in lockdown, perhaps take a moment to consider what we ask of them under normal circumstances. A large proportion of GP consultations are unnecessary and could be dealt with either by a pharmacist, or by the patient themselves. The NHS website has the information available if people were only to access it.

Between February and March, there has been a 22% fall in A&E attendances, many of would have been unnecessary anyway and would have taken up valuable resources and time. General practice and outpatient secondary care has also seen a sharp drop in demand for routine enquiries. Many issues will have gone away on their own, or have been dealt with using online advice. Still more infections will have settled without antibiotics. We must harness this new way of using the health service.

This current situation may therefore serve as a not so gentle reminder of what are reasonable expectations in terms of our healthcare. That said, between early and late March, there has been a fall of 150 patients per day presenting with symptoms of heart attack. Now, it is unlikely that the Covid-19 pandemic has somehow cured heart disease altogether and though many people with chest pain turn out to be fine, there will be some within that cohort of 150 who have had real heart attacks; heart attacks that are currently going untreated.

Lack of presentation for this sort of thing, or indeed other worrying symptoms of things like cancer (loss of weight and appetite or a change in bowel habit to name just three), means the health impact of this pandemic will not be just related to Covid-19. For anyone with worrying symptoms like this, you absolutely must not ignore them just because of the outbreak.

We need to use the NHS sensibly. Not too much, but not too little. We have swung from one extreme to the other in the last few months. Once we emerge from this, we must all consider how best to use it going forwards, and focus on the bigger issues at hand, no doubt at a time of great change. Self-care is a big part of that, not just in how we deal with an acute medical situation but also in how we look after ourselves in general. Smoking alcohol, diet and exercise are the key areas that cost nothing to improve.

As a nation, our perspective in terms of the scope of our healthcare has run away from us. Some expect miracles – you don’t need to go to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash. Meanwhile, the threshold for others is far too high and there is a proportion of people that will hold off in coming to a doctor when they actually need to be seen.

As doctors we want to ensure that everyone who needs to be seen, and who we can help, presents to us appropriately. At the same time, we would request that others, who might reasonably be able to manage their own minor issues, do so. It is a fine balance and even writing this makes me uneasy that some may stay away for fear of overusing the service. The level of disparity in comprehension of how best to use the NHS is, in my experience, remarkable.

Nevertheless, I think we all could perhaps do with shifting our baselines back a hundred years or so. As doctors, we need to look at how we are using our resources and considering whether far more significant changes are necessary. Antibiotics use is just one example. Fundamental change at the top is needed to streamline the provision of healthcare and cut out the obfuscating bureaucracy. Difficult lines must be drawn. Leaders must consider taking more than half a glance at the deeper issues facing us – after-all from our current position, an antimicrobial resistant pandemic suddenly doesn’t sound as far-fetched as it did a few months ago. If that change is severe then so be it. Sometimes you have to go backwards to go forwards. In that case, we all have a responsibility to understand it and adapt, though politicians must realise that we cannot be expected to do that if left in the dark.

Urgent care must remain a priority for the service as a whole, but how we look after an ageing population effectively is just as vital. Prevention of health problems is key. One of the best ways to help therefore is to look after yourselves properly (we can only do so much in that respect) but also to seek help when appropriate in order to avert bigger health issues down the line. Staying away isn’t always the answer (particularly at the moment) although granted, there is a fine balance. That balance has always been upset one way or another and we all need to contribute in order to redress it. Now might be the time to set it straight.

How to Use the NHS

Some now expect miracles – there is no benefit and therefore no point in going to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash (these are real examples).

It may be a bit of an understatement to mention that a lot has changed recently. No more so than for those working in the health service and, while many are unwell with Covid-19 and while those that need it most struggle to get the PPE they need, the everyday aspects of their jobs have somewhat fallen by the wayside. Figures for February and March show a 22% fall in A&E attendances. General practice and outpatient secondary care have also seen a drop in demand for routine enquiries.

While this has freed up resources for the issue at hand, some may notice that many of the issues for which they might normally have sought help and advice have gone away on their own. Others have been able to find the answer to their questions online. The sore throat that you had might have cleared up on its own without antibiotics. That painful ankle might have cleared up with measures you followed from the NHS website.

This unusual set of circumstances has highlighted an area that perhaps we can all learn from as we emerge from this crisis (though there is a long way to go yet). As a nation, we have become somewhat spoilt by the free healthcare we can expect; our perspectives have shifted over time as more becomes possible. Some now expect miracles – there is no benefit and therefore no point in going to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash (these are real examples).

In 1948, at the inception of the NHS, paracetamol was yet to become readily available, open heart surgery was 4 years old, statins had not yet been invented and antibiotics were in their infancy. Fast forward to the present day and we are seeing around 200 heart transplants a year in the UK, an entire pharmacy of medications available to us at our beck and call, lifesaving emergency services 24/7 and access to state of the art intensive monitoring equipment. Around half of the UK population takes at least one regular prescription medication. If your hips or knees go, you are entitled to have metal replacements inserted for no extra charge. If you have a rash, you can have it seen to or if you want your ingrowing toenail sorted, you can have it clipped or lopped off. If your ears are blocked, someone will clear that for you too.

With our population increasing and growing older, it is little wonder that the whole thing is beginning to creak. The outcome…? You have to wait a long time for your hip replacement, you might be denied the chance to have your bunions sorted out because it is a low funding priority. Your GP is running late by 20 minutes or even a bit longer. That may seem a bit insensitive or flippant (or both) but, believe me, I’m not happy about it, certainly not if it means people are waiting in agony for treatments. While most people have a rational grip on such situations, a few do not. Those are the ones that sometimes abuse staff who are only trying their best in impossible circumstances.

This current situation may therefore serve as a not so gentle reminder of what are reasonable expectations in terms of our healthcare. That said, between early and late March, there has been a fall of 150 patients per day presenting with symptoms of heart attack. Now, it is unlikely that the Covid-19 pandemic has somehow cured heart disease altogether and, though many people with chest pain turn out to be fine, there will be some within that cohort of 150 who have had real heart attacks; heart attacks that are currently going untreated.

There have been some cases of people cancelling urgent cancer referrals due to concerns over the virus. While one can understand the anxiety surrounding this, these referrals are there for a reason. Do not delay them.

We need to use the NHS sensibly. Not too much, but not too little. We have swung from one extreme to the other in the last few weeks. Once we emerge from this, we must all consider how best to use it going forwards, and focus on the bigger issues at hand, no doubt at a time of great change. Self-care is an enormous part of that, not just in how we deal with an acute medical situation but also in how we look after ourselves in general. Smoking, alcohol, diet and exercise are the key areas that cost nothing to improve.

As doctors we want to ensure that everyone who needs to be seen, and whom we can help, presents to us appropriately. At the same time, we would request that others, who might reasonably be able to manage their own minor issues, do so. It is a fine balance and even writing this makes me uneasy that some may stay away for fear of overusing the service. The level of disparity in people’s views of how best to use the NHS is, in my experience, remarkable.

In summary then, urgent care must remain a priority for the service as a whole, but how we look after an ageing population effectively is also vital. Prevention of health problems is key. We should look after ourselves properly as far as is practicable but also seek help when appropriate in order to avert bigger health issues down the line. Staying away isn’t always the answer (particularly at the moment) but there is a balance to be achieved. Now might be a good time to redress that balance.

Covid-19

There are elderly people who are vulnerable and rely on certain supplies alongside others with genuine medical conditions or who are in pain who need things like paracetamol to control pain. It does no good at all if it’s stored up in Steve Jobsworth’s bomb shelter.

When I googled how many films Hollywood actor Kevin Bacon has been in, the answer “at least 61” popped up. The figure is as high as it is vague, and is the basis of the parlour game “six degrees of Kevin Bacon”. For those that don’t know, the game involves challenging yourself to find the shortest path between a chosen actor and Kevin Bacon based on who they have acted alongside. It is built on the idea that, in this day and age, two people on Earth are six or fewer acquaintance links apart – the concept of “six degrees of separation”.

The world is interconnected to a degree never previously seen, allowing local crazes to spread quickly across the globe. The South Korean pop song Gangnam Style reached 3 billion views on Youtube in 2017 – just one example amongst others that include the ice bucket challenge, Furbies and David Beckham hairstyles.

That’s all well and good when what spreads is (arguably) something positive. When it comes to disease, our global closeness becomes more of an issue. By now, the novel coronavirus first isolated in the city of Wuhan in China has become international news and, as of last week, a full blown pandemic. Pandemic originates from the Greek words “Pan” meaning “all” and “Demos” meaning “people”. According to the World Health Organisation, a pandemic occurs when there is a worldwide spread of a new disease.

At the time of writing, there are 596 official cases reported in the UK.

Globally, that figure is currently at 132,500, the majority of which are still from China. In all, around 10 deaths so far have been reported in the UK and 5,000 deaths globally. Although there is a lot of emerging information still being analysed amidst a lot of conjecture and misinformation, this outbreak is turning out to be quite a shock to us all. One positive to emerge amongst the chaos is the high level of international communication and co-operation means that something like this has far less impact than it might have done in the past. There are obvious exceptions here (Trump) but nothing’s perfect.

Historically, true pandemics were far more devastating. The most recent example, the Spanish flu of 1918 is estimated to have killed around 100 million people and is thought to have infected around 27% of the world’s population. Perhaps the most famous of them all is the bubonic plague or “Black Death”. The most widely known outbreak of this decimated the populations of Europe throughout the 14^th Century, killing around 75 million people. The culprit, a bacteria known as Yersinia pestis, is still around today and between 2010 and 2015, accounted for 3,248 cases of plague worldwide. Nowadays, it can be treated with antibiotics, but in the 14^th Century, people still believed in such things as the four humours, conceived in part by the Roman physician Galen, who also apparently coined the term ‘plague’. In the belief that the plague was a punishment from God, some practised self-flagellation to repent for their sins. It didn’t do much good.

A similar outbreak, known as the plague of Justinian, broke out across the Byzantine Empire in AD 541 and it is thought that this was also due to a form of Yersinia pestis. This affected between 13 and 26% of the world’s population at the time. Both forms of plague were so transmissible and virulent in large part because of the fleas on the back of rats that were transported along the Silk Road and across the oceans on ships.

The association with animals is quite a common feature in disease outbreaks and epidemics. There are many viruses for example, carried by animals that do not infect humans. However, all it takes is a genetic mutation in this virus to enable it to cross the species barrier. The resulting pathogen is one to which populations have no innate immunity, hence the tendency for them to spread more rapidly. That is what is thought to have happened in the case of this novel coronavirus. Coronaviruses are widespread in our population already, many of which are responsible for a simple cold. However, various forms can cause more severe illnesses – for example the Severe Acute Respiratory Syndrome (SARS) from 2003. This was a coronavirus. The current outbreak was thought to have originated from a seafood market in Wuhan and the transfer from animal to human is known as zoonotic. SARS was thought to have been caught from civet cats and the coronavirus that caused the MERS (Middle Eastern Respiratory Syndrome) in 2012 originated from dromedary camels. It should be easy to guess where the H1N1 influenza virus that caused the swine flu outbreak in 2009 came from.

With so many different names, things can get a bit confusing. The WHO takes responsibility for naming the disease itself (now christened as COVID-19) but the International Committee on Taxonomy of Viruses is responsible for naming the virus based on its genetic makeup. They have labelled it as SARS – CoV – 2. In an attempt to prevent unnecessary fear in the regions that suffered most from the SARS outbreak in 2003, and perhaps taking a leaf out of Prince’s notebook, the WHO are referring to it as “the virus responsible for COVID-19”.

In the modern age, notwithstanding the risk to human life, there is potential for huge economic impact during outbreaks such as this through restriction of human movement so vital to industries such as tourism and shipping. This aspect is beginning to emerge in levels the current infrastructure has never experienced before and how it affects us all is perhaps an even bigger uncertainty than the virus itself. Some estimates of a 25% reduction in the global tourism industry have even been suggested. With markets and livelihoods at risk, tremendous efforts to look for solutions are underway. Much of this builds on successful work carried out in the past.

Smallpox is the flagship example of the success of vaccination. Caused by the variola virus, smallpox was responsible for around 300-500 million deaths throughout the 20^th Century but was officially eradicated through vaccination in 1979. Only one other disease has been wiped out in the same way, though it is less well known. Rinderpest was a virus that affected cattle and buffalo and, again through vaccination, was declared formally eradicated in 2011. Interestingly it is thought that the modern measles virus may have branched off from the rinderpest virus (making it zoonotic) around the 11^th Century.

The Ebola virus that affected West Africa between 2012 and 2016 did not reach pandemic proportions although it caused 11,310 deaths in the affected regions. (Ebola was also zoonotic, coming from apes, bats and deer). Following the development of a vaccine, the outbreak was halted. This was largely due to the rapid co-operation between drug regulators, pharmaceutical firms, and charities across the world who, along with the WHO, collaborated more closely than they normally would have done.

The Coalition for Epidemic Preparedness Innovation (CEPI) was set up following the Ebola outbreak and aims to forearm experts all around the world against future outbreaks of disease. As a result, techniques and templates for faster vaccination development have been outlined and experts are using new technology in gene sequencing more and more. The genetic sequence of SARs-CoV-2 was published by Chinese scientists in January and work is underway already to find a vaccine.

Seasonal flu jabs are an important part of our disease prevention techniques already. In the USA between 2017 and 2018 around 60,000 people died from influenza and so this is no time to become complacent considering that early mortality rates (and one must be cautious considering there may be mild cases that are not making their way into the stats) seem to indicate a higher percentage for Covid-19. Neither though is it time for panic as around 81% of COVID-19 is mild and self-limiting. It may be difficult not to do just that in light of the unprecedented measures the government are now advising.

The latest update is that, if you are in the UK, one should self-isolate if one has a new cough and fever. I will admit, some of the projected figures look alarming and it may be that this goes on for some time, eventually inducting this current coronavirus into the seasonal epidemics in the coming years alongside flu. Had this happened in 1918, who knows how bad it would have been? Then again, we didn’t have the force (destructive or not depending on how you look at it) that is social media back then. It would seem this is becoming more of a social experiment of how well we can all pull together and co-operate as much as anything else. Hopefully we don’t embarrass ourselves.

Common sense is our biggest ally here. If you think you might have it, take the necessary precautions but don’t panic. Don’t call your GP if you just have the sniffles (most likely a normal cold anyway) but do contact help if you are struggling with your breathing or concerned that you are deteriorating. Look at the NHS and government websites for the latest guidance, not Twitter or Facebook. Don’t panic buy. There are elderly people who are vulnerable and rely on certain supplies alongside others with genuine medical conditions or who are in pain who need things like paracetamol to control pain. It does no good at all if it’s stored up in Steve Jobsworth’s bomb shelter.

As far as I know, there is no current advice on what to do if you come into contact with Kevin Bacon.

Dieting: The right way

“The heaviest man ever recorded weighed in at around 635kg (99 stone) – about the weight of an American Bison.”

As January draws to a close, so too will many new year’s resolutions be wavering. In fact, around 80% of peoples’ resolutions will have failed by the second week of February. One of the most common ones will be to go on a diet and to join the gym. January accounts for around 12% of gym applications but most will have completely stopped after about 24 weeks. Even worse, around 87% of diets will have already failed by the 12^th.

While I think the use of new year’s resolutions to kick start such health drives is a positive thing, there is so much information around, particularly online and largely unregulated, that may render those well intentioned efforts fruitless, quite literally.

Dieting is nothing new. At the beginning of the 20^th Century, people turned to eating tapeworms to help them with weight loss – that is until they started getting intestinal cysts, meningitis and seizures. For some reason, during the 1930s and again in the 1970s, it became popular to eat half a grapefruit with every meal in the hope that the scales would become more complimentary. In the 1800s, apple-cider vinegar was added to water (apparently popularized by Lord Byron) and in the 1960s, a ‘drinking man’s diet’ emerged which consisted of eating lots of meat and washing it all down with alcohol, even at breakfast.

The purpose of all of these, you will notice, will have been to lose weight. I suspect now, if you asked most people why they go on a diet or go to the gym, it will be ‘to lose weight’ or ‘to look better’. We have an ideal body shape these days which is endlessly highlighted through online and social media. There is a huge pressure for us to look right.

Arguably, this has been with us for a long time. One only has to look at the statues from ancient Greece and Michelangelo’s famous statue of David in Florence to see the template for the ideal build and shape of a human that has persevered ever since.

Not reaching that ideal puts huge pressure on our mental health. The trouble is, achieving it is getting harder and harder with the choices and options available to us, both in the modern diet and our increasingly sedentary lifestyles.

In the UK, 29% of adults are classed as obese, as are 20% of year 6 children. It is thought that around 10,660 admissions to hospital each year are directly attributable to obesity. Thus the importance of controlling weight and fitness is not just about looking right.

All too often, people choose to make their lifestyle changes after something has happened – if they are lucky enough to do so – at which point the aims change from honing their body image to things like reducing blood pressure, preventing or controlling diabetes, treating depression, and lowering the risk of heart attacks and strokes. Ultimately, all of this is achievable, but not through the short term fad diets that are so popular in the consumer market of today.

Let’s look for a moment at the physiology of our body and its energy supply. We need energy to live, that much is obvious. That means every cell of the body, in order to function, needs a supply of energy. This comes from our diets which can broadly be split into three categories: fats, carbohydrates and proteins. The majority of our energy comes from fat and carbohydrates. Fat is too large to be absorbed into the blood stream on its own, so when we eat it, it is broken down in the gut to form fatty acids and glycerol so it can be absorbed.

Fat is mainly stored in the liver and in the subcutaneous (skin) tissue. It can also accumulate around internal organs (visceral fat). When we are not eating and need energy, we draw on these stores to power our bodies, a process kick started by a drop in insulin levels. This will also bring into play the sugars stored around our body, again largely in the liver, in the form of glycogen. A drop in insulin will convert this glycogen into glucose and the fat into fatty acids and glycerol once more, which can then race around the body to power things.

As we eat, insulin levels rise. This encourages cells to take up glucose as a source of energy in the short term, but also promotes a reversal of the process above and stimulates the storage of all of the new energy we are ingesting so we can use it later.

Put simply, our weight is governed by the rate at which we store the energy from the foods we eat against the rate at which we use that energy.

Energy is measured in calories and one calorie is the amount of energy required to raise the temperature of water by 1 degree Celsius or 4.184 joules. 1,000 calories is equivalent to 1 kilocalorie and it is kilocalories that we see on the sides of our food packaging.

Hopefully therefore it should be fairly clear that, in order to maximise our health, there is a need for both healthy intake of food and an active, energy burning lifestyle. If not, then our weight will suffer along with a lot of other things. The heaviest man ever recorded weighed in at around 635kg (99 stone) – about the weight of an American Bison. In the UK, the record stands at 444kg (70 stone) – the weight of the average Moose.

Our intake of fats should be around 30% of what we eat. Any more and it can build up in our bodies and cause problems, for example high cholesterol, heart disease and obesity.

In the same way, getting all of our energy from carbohydrates (sugars) is not the answer either, as this can reduce our body’s sensitivity to insulin and cause diabetes. In a cruel twist, excess sugar can also be converted to fat anyway.

We all lament the fact that, in general, the foods that are bad for us are the ones that taste nice. The key, as I suspect you have heard many times over, is balance. This is not repeated for the sake of it but because it is truly important. Many modern diets will hinge on cutting out whole areas of energy – for example the Atkins diet and its dislike for carbohydrates. While this can result in fast initial loss in weight, it falls down in many other areas. If one cuts out an entire food group, one loses the benefits of the foods within that group. If you cut out carbohydrates, you’re cutting out a tremendous source of fibre, vital for gut health and a healthy microbiome. It is also likely you are depriving yourself of the many vitamins and minerals contained within those foods that your body needs. Longer term it falls short and, perhaps most important of all, it is not sustainable.

This brings me to my most important point. If you want to be healthier, reduce your risk of heart disease and diabetes, look better, feel better, lose weight, or whatever your goal, you need to make a permanent and sustainable change to your diet and lifestyle and avoid something that is unrealistic. If you say that you are going to the gym every day but one having not been for the past 5 years, it won’t work. Likewise, if you say you will cut out fat completely from your diet forever, it won’t work.

That’s not to say that making a change won’t be difficult but crucially, if you do it in the right way, it is something your body will eventually assimilate as the norm.

So…

Prepare your food for the week ahead and don’t shop while you’re hungry. If that chocolate bar is in the cupboard, you’ll eat it!
Join a gym, club or class but make your activity levels fun and sustainable so you aren’t put off it.
Watch out for portion size.
Use brown rice, brown bread and brown pasta
Avoid saturated fats and eat more polyunsaturated fats and cooking oils.
Plenty of fruit and vegetables
Set goals and guidelines to stay within
Eat 3 main meals a day and snack only on nuts and seeds (a tricky one but very important)
Drink 6-8 glasses of water a day
Reduce your alcohol intake
Stop smoking!

Good luck!

Just Another Cigarette

When you really think about it, that well-known pastime we call smoking is actually quite bizarre. It is the act of inhaling and exhaling the fumes of burning plant material. For me, thinking about it in that purely literal sense makes it seem as weird as it does when you say the word ‘iron’ over and over again until it loses its meaning and just becomes a sound. (A psychological phenomenon, incidentally, that has been labelled ‘semantic satiation’)

It is even more so when you think of the fact that smoking, specifically tobacco, has been responsible for around 100 million deaths in the last century. Why then have we as a species become so intertwined with this strange habit and, for that matter, such a harmful one?

For a start, we didn’t always know that it was harmful. As far as we know, people have been smoking as far back as 5000BC – we know this from various drawings depicting the act. Tobacco specifically is native to the North and South American continents and was used by natives long before the “new world” was discovered by Europe. It was brought over here in the 16^th Century when it was smoked in pipes and cigars. Some doctors at the time even thought it helped to prevent cancer, though I hasten to add this was not the universal opinion.

In 1880, an American chap named James Bonsack patented a cigarette rolling machine that was quickly picked up this side of the pond and the modern story of the cigarette began. These days, around 15 billion cigarettes are smoked every day.

It wasn’t until the Royal College of Physicians, in 1962, announced that cigarettes caused lung cancer and other diseases that we realised fully the harmful effects of smoking. By then, however, the manufacture and supply of cigarettes was a global industry and its sheer momentum has made it very difficult to combat over the years.

Just how harmful and costly to our health smoking is cannot be underestimated. Tobacco is the single biggest avoidable cause of cancer in the world. Each cigarette contains around 5,300 chemicals according to cancer research and 69 of these are known to cause cancer. Lung cancer is the most prominent but the habit also causes, amongst others, cancer of the larynx, oesophagus, bladder, pancreas, kidney, stomach, cervix and bowel as well as some leukaemias.

If it doesn’t cause any of these, you can expect to suffer from one or more of the following…

Heart disease and strokes
Chronic Obstructive Pulmonary Disease – leaving you with chronic coughs and progressively struggling for breath.
Peripheral vascular disease – cold and blue feet and legs at risk of ulcers and chronic pain
Premature ageing of skin by 10 to 20 years
Weak and brittle bones
Reduced fertility and impotence (smoking while pregnant causes miscarriage, premature birth and stillbirth and increases the chance of cot death)

I could probably go on, but I think you get the picture. Ultimately, up to two thirds of smokers will be killed by their habit.

By far the best way to stop smoking is to avoid starting in the first place. In the past, this has been made more difficult by advertising of tobacco products. Furthermore, the habit tends to be passed down in families. The very idea of smoking has been normalised to a huge extent – it has been glamourised in popular culture and films especially. Even knowing what I know, I have to admit that the cigar makes 60s era Clint Eastwood look far more impressive than he would without. But we’ve all grown up to accept that. This social conditioning is part of the problem and may have something to do with the whole ‘reckless and carefree is cool’ attitude.

The trouble is that reality catches up with the fantasy eventually and between 2016 and 2017 there were 484,700 admissions into hospital due to smoking and in 2016 there were 77,900 deaths.

Once started, the nicotine contained within is the culprit that makes stopping so difficult. It has both stimulating and tranquillising effects on the brain and creates new pathways that stimulate pleasure centres that begin to rely on the presence of nicotine to work. If a smoker stops suddenly, they will begin to experience withdrawal symptoms. These symptoms may include cravings, depression, anxiety, insomnia and lack of concentration. All that means it is far easier just to light up a fresh cigarette and carry on where they left off.

All the while, the carbon monoxide in the smoke binds to our haemoglobin, the protein in our blood that transport oxygen around the body, and reduces its oxygen carrying capacity. It’ll make running for your train let alone that marathon pretty difficult.

Fortunately, tougher laws on advertising now mean that cigarette packets now have to display warnings about the harm smoking causes. This transfers the responsibility of the harm they do from the tobacco companies onto the smokers who pay for them. It is a bizarre situation in which the companies themselves are now trying to make their tobacco products as undesirable as possible, some countries even going so far as to pick Pantone 448 c, the ‘world’s ugliest colour’, to adorn the sides of their packets.

Such is the reliance induced by smoking that people still spend on average around £140 each month on cigarettes, meaning they could save about £1,700 each year – the equivalent of a pretty decent holiday or a large contribution to the deposit on a house for example.

Practically all forms of smoking are harmful. Whether you smoke it from a pipe or a cigar or even chew it, you are at risk. Shisha is also known to cause cancer. This puts the tobacco companies in a predicament and we are entering a new age in which e-cigarettes and vaping are emerging as safer alternatives. While certainly thought to be safer, e-cigarettes are still new enough that longer term trial data are unavailable. Meanwhile, the NHS party line is that they are better than other tobacco products at least.

Of course, the best option is to quit altogether. If you do so before 30, then you may be lucky enough to experience the same length of life as an average non-smoker. You will be able to taste and enjoy food more, your breathing and general fitness will improve, and the appearance of your skin and teeth will improve. After a year your risk of heart disease will halve and after 10 years your risk of lung cancer will also halve. At 15 years, your risk of heart disease will be the same as someone who has never smoked.

Going cold turkey is the least successful method. If you are serious about stopping, you may benefit from following a smoking cessation plan. Nicotine replacement products can be obtained through one of these and sometimes certain medications (Champix or Zyban) may also offer support. Visit www.smokefreelifeoxfordshire.co.uk for more information on all of this. Ultimately you have to really want to give up, otherwise you probably won’t succeed. And it may interest you to know that, in contrast to many of his film characters, 89 year old Clint Eastwood is actually a non-smoker.

Summertime!

With all the hot weather recently, I have decided to focus a little on the impacts that a warm summer might have on our health. (Cue thunderstorms and rain). Many associate summer with some of the finer things in life – trips to the coast, beautiful clear skies, Pimms and a high concentration of bank holidays. For others, it means unbearable heat, vicious sunburn, stifling sleepless nights, sun cream all over your clothes and the long agonising wait for the start of the domestic football season to begin again.

In order to enjoy the positive aspects, I have put together some tips on staying healthy through the change in environment during these warmer months.

Let us start first with how our bodies regulate heat. The word homeostasis is used to describe the way the body maintains balance in various processes, including electrolytes in the blood and blood pressure. Part of this homeostatic balance however is related to thermoregulation. In other words, the body’s constant battle to keep its core temperature stable within quite fine margins – around 37.0 degrees on average. Any higher or lower than ideal and this begins to affect many of the normal processes going on in the body at any one time. For example, diabetics tend to absorb more insulin in warmer weather and so a closer eye on insulin doses is required.

Our main tactic in controlling temperature, at least in losing heat, is through the process of sweating. As we sweat, the water from our tissues takes heat from beneath the skin, and the heat energy is lost as the sweat then evaporates. It stands to reason therefore that, in warmer weather we sweat more and so our requirements for fluid go up. Normally we should be drinking 6 to 8 glasses of water each day (about 1.2 litres) but in warmer weather, we should increase this to allow for the extra fluid loss. It is no surprise that summer is kidney stone season, with twice as many presentations when compared to the winter months. This is in part due to greater rates of dehydration but also, as your skin gets more sun exposure, you produce more vitamin D which in turn increases calcium absorption and promotes the build-up of these stones in the kidneys.

Although not particularly hairy when compared to most mammals, the small hairs that cover our skin also help in the process. If our body decides it needs to lose heat, signals from the hypothalamus in the brain prompt the hairs to flatten across our skin. Conversely, if we need to warm up, the hairs stand on end (hence goosebumps) thus creating a tiny layer of air trapped in amongst them to warm us up a bit.

If we are getting too hot, our heart rate tends to speed up in order to speed the circulation from the core out to the peripheries where the heat can be transferred from the body through our skin.

As you can see, we have some inbuilt mechanisms to prevent ourselves from becoming overheated, but sometimes that is not enough. Heat stroke can be nasty and causes headaches, dizziness, confusion, cramps, and pale clammy skin. If this happens on a warm day, lie down in a cool shaded place, try to cool the skin with water and a fan, and drink lots of water or rehydration solutions (you can get these over the counter at any pharmacy or supermarket and are good to have handy, particularly on holidays in the sun). If this is not improving things within half an hour, or if you are concerned, you must seek urgent medical attention.

To keep cool in general, avoid prolonged exposure in the sun (fairly obvious), wear a hat to provide some shade, make sure you are well hydrated and avoid drinking too much alcohol which can dehydrate you.

At night, warm temperatures can really disrupt sleep, leaving you tired and unrested the next day. If flipping the pillow to the cool side isn’t quite cutting it, you could try the following measures.

Start when you get up… close the blinds and keep windows closed during the day if it is hot outside to prevent heat building up inside.
Avoid a heavy meal, especially with spicy food before bedtime.
Drink cold water, but not ice cold as sometimes this can confuse the body’s normal heat losing measures.
Take a tepid shower before bed.
Use light, cotton bedding
Encourage air flow with a fan
You can even put your bedding in a bag and then in the freezer for a bit so it is extra cool at bedtime.

Summer’s drawbacks are not always directly related to heat though. The other big drawback is hay fever. This is a real menace for many people and ranges from the very mild to the debilitating. The most severe cases require specialist input with immunotherapy. It is not a new problem and even as far back as the 9^th Century, numerous remedies were put forward, some more successful than others. Inhaling tobacco, chloride of ammonia, chlorophorm or using cocaine spray never really caught on.

Classically, hay fever causes sneezing, coughing, runny nose and itchy eyes but it can manifest itself in other ways too. Loss of smell, headaches around the temples and forehead and tiredness can also be signs.

Over the counter remedies are often your best option to treat these, such as anti-histamines and eye drops but you can alleviate some of the symptoms even more by following these steps:

Use vaseline under the nose
Don’t dry your clothes outside (so they don’t pick up all the pollen)
Keep the windows shut and stay indoors when you can on days with a high pollen count
Use wrap around sunglasses
Vacuum and dust regularly
You can even get fit pollen filters for your car air conditioning

Hopefully for the most part, all of the negatives of summer are outweighed by the positives but if you follow the above steps, it will make things even easier on your body. And in some cases, the sun can even improve things. Those with skin conditions like eczema and psoriasis will see an improvement in their symptoms due to the increase UV exposure (UV phototherapy is a recognised treatment for psoriasis). Having said that, for most cases you should protect your skin from the sun as much as possible. Sun cream is essential and, if you neglect it, in later life you will be far more prone to damaged and unhealthy skin, not to mention a far greater risk of skin cancer. You have been warned.

The Pancreas

While the pancreas may not be one of the A-listers or showstoppers of the organ world (if there is such a thing), it is as important as any other cog in the system. For a long time, perhaps owing to its position behind the stomach, its true function was completely unknown. It is curious in appearance, shaped a bit like a leaf and rubbery in texture (apparently). This gave rise to a certain vagueness in its naming – it means ‘all flesh’ in Greek. Until the late nineteenth century, many thought its only function was as a shock absorber in the upper abdomen just below the ribs and the sternum.

The discovery of a sneaky duct that connects it with the first part of the small intestine was the first clue that it might have a deeper role. It was then discovered that the pancreas secretes a rich cocktail of juice and enzymes through this duct and into the intestine in order to help with our digestion. Specifically it helps in breaking down fats (with an enzyme called lipase), starches (with amylase) and proteins (with various different proteases). Basically, anything with ‘ase’ at the end generally means it is an enzyme of some form or other.

This is important because, without the ability to break these dietary components into smaller building blocks, we would not be able to absorb them from the intestines into our bloodstream. In addition, the pancreas produces lots of bicarbonate (an alkali) to neutralise all of the acids secreted in the stomach so that once your food gets into your intestine, it is at optimal pH for absorption.

That role alone is extremely useful you might say, but the pancreas is not finished there. While its function in digestion relates to what is known as the exocrine system (essentially ‘exo’ means outside and the digestive system is classed as ‘outside’ because it begins and ends outside!) the pancreas has a vital endocrine role. Endocrine relates to the travels of hormones throughout the closed circulatory system, i.e. the blood.

In those years where scientists considered the pancreas to be nothing more than a glorified cushion, hormones controlling the body’s sugar levels were thought to be pumped into the circulation from the brain. This idea persisted until a chap called Langerhans identified in 1869 an area of tissues in the pancreas different from the rest. When these areas were (rather cruelly) removed under anaesthetic from dogs, the animals went on to develop features of diabetes.

Through various means subsequent to this, it was proved that these ‘islets of Langerhans’ (useful to know for pub quizzes) secreted hormones, the first of which discovered was named insulin after the Latin term for ‘islands’. We now know that the pancreas also produces a second hormone called glucagon as well. As part of the endocrine system, these hormones are secreted from the pancreas into the bloodstream and it is here that they perform their vital work.

Insulin helps the cells around the body to take up sugar from the blood stream to use as fuel and also helps to store it in the liver. Glucagon performs the opposite role, mobilising energy stores in the liver and fatty tissue for those days when we’ve not had time for lunch or have decided to run a marathon.

In this way, to use a rather crude comparison, the pancreas is a bit like the national grid. When it receives certain signals that more energy than usual might be required, like going for a long run (just as TV coverage of a royal wedding, for example, might cause a surge in electricity uptake, to keep the national grid analogy alive), it prepares by secreting more glucagon to draw from the reserve of energy we keep stored in our livers and fatty tissue. If, on the other hand, we are providing more energy than we need by eating lots of sugar, the body switches to insulin to use up the sugar being eaten and store any spare energy left over.

So evidently the pancreas when it is working well is extremely important. When it is not, diabetes can result. But what else might go wrong?

Sometimes, the pancreas can become inflamed and this is known as pancreatitis. Every medical student will most likely know (or at least have heard of) the pneumonic GET SMASHED. Each letter represents a potential cause for pancreatitis, the two most common being Gallstones and ETOH or Excessive Alcohol. ‘S’ stands for Scorpion venom and, as there are not many scorpions running around Henley, I’ll not dwell on that too much.

Pancreatitis can range from the mild to the severe and can even be life threatening. Symptoms include severe upper abdominal pain going through to the back, nausea and vomiting. You may also sometimes get a fever and also diarrhoea. It often results in a stay in hospital where you can receive pain relief, fluids and oxygen if needed.

The other main condition affecting the pancreas is cancer. Pancreatic cancer is the UK’s 11^th most common cancer and tends to affect those in older age groups more. Around 9,600 people in the UK develop pancreatic cancer each year.

The big issue with pancreatic cancer that gives it a high mortality rate is the difficulty in its detection. This means that it is often picked up only at later stages. Researchers are always looking for effective tests that might be used as a good screening tool, but as yet none has been found. The symptoms are often very vague but include…

-Weight loss

-Dull, boring pain or fullness in the upper abdomen which can go through to the back as well

-Jaundice, often without pain or any other symptoms (this occurs because of the pancreas’s proximity to the bile duct which, if pressed on, causes a back-up of the pigment bilirubin in the blood.)

One in ten cases may have a genetic element so, if a family member has had pancreatic cancer younger members may sometimes be screened.

If you are at all concerned about this, it is of course always worth coming to see your GP for a check.

As always, there is always more to learn. Even now, research is being done into other hormones produced by the pancreas which may perform roles as yet unknown, thereby, in the future, potentially opening up different possibilities for the treatment and understanding of various diseases, including diabetes. For that reason alone, I think the pancreas deserves a little more time in the limelight.

Heart and Soul

“Normally about the size of your fist (unless you’re Donald Trump)”

To say our bodies are complicated is somewhat of an understatement. The number of processes each one carries out every second is staggering. From managing all the thoughts racing through your brain, digesting last night’s dinner, pumping oxygen into the blood from the outside world and contracting a select group of muscles just to stop you from falling over, it is in perpetual activity even if it doesn’t always seem like it. The organs of the body take on all these different roles, each one vital to the workings of all the others.

For now, however, I will focus on one of the most vital of all our organs – the heart. For obvious reasons, it is pretty useful. With every beat, it pumps blood into the arteries taking with it all the vital components of the blood into your tissues and all the other organs of the body as well. Indeed so vital is its role that it is little wonder it has adopted an almost spiritual role. We’re often told to follow our hearts – though this makes little sense in literal terms – and apparently that’s where home is as well. Part of the reason the Aztecs most commonly extracted people’s hearts as a form of sacrifice was their belief that it was the seat of the individual, more so than the brain, a belief shared by classical philosophers such as Aristotle.

In reality, the only bearing it has on our thinking and individuality is in its relationship with the brain – without the heart, the brain would be nothing. Normally about the size of your fist (unless you’re Donald Trump), it is made up mostly of muscle and comprises four chambers. Two of these called the atria and these sit atop the two larger ventricles, which do most of the pumping. The right atrium and ventricle take returning blood from the veins of the body and send it straight out to the lungs to be resupplied with oxygen. From there, the blood returns to the left atrium and then left ventricle, where it is given a final push into the body to do all of its good work. Generally it takes around 20 seconds for blood to circulate round the body before it gets back to the right atrium again.

To prevent back flow, there are several valves and, as these close, they cause the characteristic sound of your heart beating that we can listen to more closely using a stethoscope. Often we can pick up whether there is a bit of turbulence in the system if the valves are not functioning properly – ie a heart murmur.

If all is well, your heart will beat regularly and the signal for this comes from within the heart itself, from a collection of cells in the atria (called the sino-atrial node). Electrical impulses originate from here and spread like a circuit through the heart tissue, making the muscles contract in time with each other. In a lifetime, you can expect your heart to beat around 3 billion times, or 115,000 times a day. When the tissue that conducts these electrical impulses throughout the heart muscle is damaged, this can sometimes result in funny rhythms, or arrhythmias, of which there is a spectrum varying from serious to not so serious. Ultimately, the beating of the heart is governed ‘in house’ and though signals from the brain can stimulate it to speed up and slow down, the rhythm originates from the heart itself which is why, if a heart is removed from the body, it will continue to beat on its own for a little while.

Inevitably with such an important role, when things go wrong, we tend to know about it. In the past, infectious disease tended to be the leading cause of death but, since the middle of the last century, heart disease rose considerably, overtaking infectious disease (certainly in the developed world) as the biggest killer. However, due to plenty of research and advances in healthcare, in the last 15 years death rates from heart disease and stroke have reduced by about 50%. It is still the leading cause of death in males between the ages of 50 -79 years old and, though more common in men, heart disease is something we should all, including women, be thinking about.

Heart disease is a term thrown around a lot but what is it exactly? It falls into a broader category of cardiovascular disease which encompasses things like stroke as well. Essentially the main issue for any cardiovascular disease is the process in which arteries become blocked resulting in loss of blood flow to the areas these arteries supply. When the area that blocked arteries supply is heart muscle, we call this ischaemic heart disease. (Most strokes occur when blood supply is blocked to a part of the brain).

When an artery supplying heart muscle (coronary artery) is partially blocked, the heart needs to work harder as one exerts oneself. If the supply cannot meet the demand, this gives rise to chest pain which resolves when rested. This is angina.

When a coronary artery becomes blocked and blood supply is cut off completely, this results in chest pain not relieved by rest (often accompanied by nausea, shortness of breath, sweating and a feeling of impending doom), and areas of heart muscle can die. This is a heart attack, also known as a myocardial infarction. (myo = muscle, cardia = heart)

Following damage or weakening of the heart muscle (sometimes due to valve problems), the heart sometimes beats less powerfully than before and can result in reduced cardiac output that doesn’t meet the normal demands of the body. This can result in fluid build-up in the legs and reduced exercise tolerance and is known as heart failure.

The process that blocks the arteries is known as atherosclerosis which is essentially a build-up of fatty material that circulates inside your blood vessels. Over time, this atheroma gradually accumulates, like a natural dam in a stream, and restricts the blood flow, often without any symptoms until the last minute. Like many things there is no one cause for this but rather a group of risk factors that are commonly preached about by healthcare professionals but that are worth repeating here.

Smoking (stop it!)

Inadequate physical activity

Poor diet

Obesity

High blood pressure (the higher the blood pressure in the blood vessels, the harder the heart has to pump to push the blood around, inducing extra strain that can damage heart muscle over a period of time, not to mention increasing the chance of blood vessels blocking)

High cholesterol

All of these are things that can be managed and optimised and are extremely important to consider, particularly if you have a family history of heart disease. If you are concerned about any of the above, it is always best to come and have a chat with your GP to talk about the best ways to reduce your risk of heart disease. Having a healthy heart doesn’t need to be more complicated than addressing the above factors and prevention is always better than the cure.