The Dreaded Headache

“…there have been discoveries of skulls dating back to Neolithic times (between 10,200 BC and 2000 BC) drilled into and partially removed in what is thought to have been an early attempt at treatment”

I was speaking to a friend recently who claimed that he had never had a headache. On further enquiry, it appeared he simply had no concept of what one might feel like, even the dreaded hangover headache.  Now I don’t have any statistics on this, but I suspect that this situation is very rare. Let’s face it, most of us get headaches and, unfortunately, there are lots of things that can lead to one.

Throughout history people have suffered and there have been discoveries of skulls dating back to Neolithic times (between 10,200 BC and 2000 BC) drilled into and partially removed in what is thought to have been an early attempt at treatment. Drastic though that may seem, some have shown signs of bone growth around these holes, suggesting the patients survived this process. Altogether more civilised were the ancient Greeks and Romans who tried either peppermint tea or rubbing raw potato into their heads.

Overwhelmingly the most common cause is the tension headache and most of us will have experienced one of these. They occur due to muscular tension that can develop from the shoulders and neck or from around the muscles of the forehead if, for instance, one’s posture in front of the computer is not optimised. They can also develop through stress or if the eyes have been straining to read a screen for too long. It’s always worth popping to your optician to get your eyes tested if you feel you are straining a lot, especially if you’re getting headaches.

Although tension headache is most common, it is perhaps over-diagnosed at the expense of another common cause of headache – the migraine. Thought to have a global prevalence of 14.7%, it is estimated that the UK population loses 25 million work or school days from the condition each year. That equates to roughly £2.25 billion loss to the economy and produces a £150 million cost to the NHS through prescriptions and GP appointments.

Migraines are typically one sided (although not always), hence the derivation of their name from the Greek word ‘hemikrania’ meaning ‘half the skull’. Despite their impact and prevalence, the process behind what causes them is still unknown. Rather than relating to blood vessels in the brain constricting and then dilating as once thought, it is now suspected to be more related to particular neurological systems. There is ongoing research into various facets of this, including particular gene associations (there is a definite hereditary element to migraines), specific brain regions activated in the earliest stages and the roles of various neuropeptides. It’s all pretty complex stuff.

One third of migraines will start with an aura (a visual phenomenon a little like the image below although it can differ from person to person) and may progress to a throbbing ache, typically lasting for between 4 to 72 hours. Women are more prone than men, and tend to suffer more often during or just before their periods.

Just one way you might visualize an aura

If you have a migraine, it is best treated as early as possible with paracetamol or ibuprofen. If these don’t work, regular sufferers may benefit from trying one of the triptan medications available on prescription. Once established however, a migraine can be debilitating and so lying down in a dark room and resting is often the best course of action.

It’s worth considering that there can be certain triggers. Coffee, chocolate, sugar-free food sweetened with aspartame or sucralose and any foods containing tyramine such as citrus fruits, bananas, processed meats, onions and nuts are all potential offending items.

What of other causes of headaches? I mentioned hangovers earlier and these must be up there alongside tension and migraine headaches in terms of prevalence. Essentially, when we drink lots of alcohol, our bodies dehydrate and this reduces our circulating volume of blood. This causes a shrinkage of the brain that then pulls upon the membranes holding it in place, thus causing an ‘ache’. Like the migraine however, the full process is not wholly understood and there is a theory that suggests a significant contributing factor may be the build-up in the brain, in place of glucose, of a chemical known as acetaldehyde (which is a breakdown product of alcohol).  Either way, the best way to avoid it is obviously to limit alcohol intake and, if you are going to drink a lot, ensure you drink plenty of water before bed and in between alcoholic drinks.

There are several more severe and mercifully less common headaches worth mentioning.

Trigeminal neuralgia (the trigeminal nerve is a major nerve that supplies various areas of the head and neck; neuralgia is ‘nerve pain’) is characterised by short episodes of sharp, intense, electric shock pain in the eyes, nose, scalp, forehead, jaw or even lips. Even the slightest touch can trigger it, including a light breeze, and it can be life-changing for sufferers of severe forms.

Similarly, cluster headaches can be so severe that they are sometimes referred to as the suicide headache. The pain from these is often described as a penetrating and excruciating pain around the eye and can last anything from 15 to 180 minutes. Some have labelled it the worst pain a human can experience. If you are suffering from these, the chances are you won’t need prompting to come and see a doctor.

If you suddenly experience a sudden severe (often described as thunderclap) headache, one that you might describe as the worst headache you have ever had (assuming you have never had a cluster headache!) or as if you have been hit on the back of the head, it might be a sign of a different cause – a subarachnoid haemorrhage (subarachnoid means below the outer layer of the brain, haemorrhage = bleed). This can be accompanied by sensitivity to light and neck stiffness, much like those suffering from meningitis. This needs a trip to A&E to get tested.

More subtly, but still serious, is a headache that manifests in tenderness over your scalp. If you have pain when you press over your temples (typically, in contrast, rubbing here with a tension headache helps) then it may represent an inflammation of the blood vessels in the scalp known as temporal or giant cell arteritis. This is a rheumatological condition and may require blood tests and maybe even biopsy of the offending areas. It can also cause blurred vision so if you think this is happening (typically you will be a woman around your 70th year) then it is worth coming to see us.

Finally, if you are waking up every morning with a headache over the course of several weeks, this is probably something you should also get checked out. It could well be tension, a stiff neck or blocked sinuses but this pattern can sometimes point towards pressure within the brain itself caused by a tumour. No harm in coming to get it checked by us.

Far from wanting to worry you, the chances are that, if you have a headache, it is caused by tension or a migraine. So my advice is similar to what it would be for many other health conditions. Maintain a healthy and balanced diet, with plenty of exercise, and ensure you drink enough water through the day. Get your eyes checked regularly and make sure you consider your posture both at work and at home on the sofa. Manage stress (as much as that is possible!) and if you are worried that the headache has any worrying features, feel free to come and see your GP. As for hangover headaches though, I’m afraid you’re on your own. “

Exercise

“Fit and fat is better than being unfit and thin.”

Forget pills, staying active is the best medication.
After-all, when it comes to being healthy, there is almost nothing else that comes near it in terms of its effectiveness.

There is a quote from a health promotion consultant called Dr Nick Cavill that seems to pop up more and more regularly these days – ‘If exercise were a pill, it would be one of the most cost effective drugs ever invented.’ When you look at the statistics, it is difficult to disagree.

There is strong evidence to suggest that exercise reduces the risk of the following conditions by the following percentages…

Coronary artery disease and stroke – 35%
Type 2 Diabetes – 50%
Colon cancer – 50%
Breast cancer – 20%
Osteoarthritis – 83%
Depression – 30%
Dementia – 30%
Hip fractures – 68%
Falls in older adults – 30%

These are not insignificant numbers as I’m sure you will appreciate. Exercise really is good stuff and also helps with self esteem, sleep quality and energy levels.
The government’s aim is for everyone to be doing around 150 minutes of moderate aerobic exercise each week. Moderate exercise is something that essentially causes you to breath faster, increase your heart rate and feel warmer – a good way to gauge it is if you are breathing too heavily to sing the words to a song. Examples might be going for a brisk walk or hike or playing a game of volley ball. Only half of us in the UK are reaching that target. It doesn’t take too much of an imagination to consider the effect it would have of all of us matching this target on the mortality rates for all of the conditions above.

It goes deeper than this though. We are a species that evolved as hunter gatherers, constantly on the move, but in world with televisions and remote controls, motorised vehicles, and robots that do your hoovering for you, it comes as no surprise that we are suffering from the effects of a sedentary lifestyle. As such, even if we are reaching our exercise targets, if we spend the rest of the time sitting or lying down (and the average person in the UK sits for 7 hours a day, 10 hours if you’re over 65 years old) then those benefits are lost or at least have less impact on the risk of adverse health conditions.

It is therefore key for us to move about every now and again even if we’re not exercising. The recommendation is that every half an hour, we should get up and move about for 2-3 minutes. Practically I know sometimes it may seem difficult but actually when you think about it, is it really? Sometimes only the smallest things need adjusting to achieve this, whether it be an agreement with your boss to get up and walk around the office once in a while or maybe even (as horrifying as this sounds) keeping the remote in the shed at the bottom of the garden. Essentially we’ve all got a bit lazy and our bodies are experiencing the consequences.

For those thinking, ‘well my knee hurts too much for me to do any exercise’, or ‘the local volley ball court is too far away,’ I’m afraid that’s no excuse. Remember, moderate aerobic exercise is anything that gets you breathing and increases your heart rate, so if your knee hurts, do some swimming or even some armchair aerobics, likewise if you can’t get to your local sports centre easily, go for a brisk walk down the road or around the garden for 30 minutes every day. There is a mode of exercise for almost everyone.

Why does exercise and activity help you may ask? Recently, research has revealed quite in depth benefits that we were previously unaware of. Much of this has to do with the anti-inflammatory effects of activity. At the cellular level, our bodies are in constant turnover. Each cell in our body has something called a mitochondria which is essentially a mini power plant. It is here that we produce energy to be used in various processes throughout the body. Each mitochondria will build up a charge and if we are not using energy, they stay charged. The longer they do, bits of charge will gradually escape in the form of ‘free radicals’. These free radicals are bad news and contribute to cell and mitochondrial damage, aiding the ageing process and generally making us less healthy. It is thought that this process causes microscopic inflammation throughout the body.

Activity and exercise helps by utilising this energy and preventing release of free radicals but also produces anti-inflammatory substances from muscle that help to mediate the inflammation at a cellular level. That is not to mention its effect in increasing insulin sensitivity of cells, reducing risk of conditions like diabetes, along with strengthening heart muscle to reduce average heart rates and contributing to lower blood pressure and cholesterol.

There is a lot of focus these days on weight loss when it comes to exercise. This is quite a damaging concept and is reinforced by many commercial diet plans and courses. Although it is important to maintain a good weight and avoid obesity, weight loss is not the be all and end all. There are two types of fat. Subcutaneous fat (sub – beneath; cutaneous – skin) is the stuff that pads out our waist lines and is the most visible. However, arguably far more important is the fat that surrounds our organs like the liver and the heart. This is called visceral fat (viscera meant ‘internal’ in latin) and build-up of this visceral fat has significant implications for our general health. Even if our exercise seems to be doing nothing to our subcutaneous fat, it will be having far greater effects on our visceral fat and this is very important. Therefore we mustn’t measure the success of our exercise or indeed any form of activity with weight loss. Fit and fat is better than being unfit and thin.

The Eye

“…fingerprints have approximately 40 individual features but the average iris has 256.”

What do the following celebrities all have in common? Christopher Walken, Dan Akroyd, Simon Pegg and Jane Seymour. It takes only a quick glance at the title of this article to ascertain that it must be something to do with their eyes. Well done though if you said that they all have ‘Heterochromia’, which means that each of their eyes are different colours. Regardless of whether or not one’s eyes have this rather exotic trait, these clever and intricately complex little organs tend to be a focal point and, at an individual level, one of our most vivid and emotive defining features.

They are thought to have evolved initially in single celled organisms that held light sensitive proteins. Over many millions of years, the process of ‘seeing’ became a reality through a mind-boggling transition into the eyes that we see today. Across the animal kingdom, there are many different types of eye and, as is the outcome of all evolution, the creatures they serve benefit in different ways depending on the environments in which they live.

Geckos can see colour 350 times better than us, bees have 5 eyes, most spiders have 8 and worms merely have a collective of light sensitive receptor cells. Not all eyes are structurally the same. For example, some vertebrates, including cats, have an extra layer of tissue behind the retina (the layer of cells that collects and processes light) called the tapetum lucidum. This reflects any light that has got through first time round and reflects it back into the retina again, giving rise to excellent night vision – very handy for catching unsuspecting mice. It also results in the eye-shine we see when some type of mammal is lurking in the bushes and served as inspiration for the ‘cats’eyes’ we see on our roads.

We humans must make do without these handy features and we are limited to just the two eyes. This is better than one though, as it gives us a perception of depth. To enable us to see, we must collect the light from around us and process it. Light bounces off everything (almost) and if we look towards something the light from this will hit our eyes. This light travels first through the cornea and second through the pupils (the holes made by the retractable fibres that make up the iris (the part that gives our eyes their colour). Here it hits the lens, a rounded clear organ that alters in size as we focus differently. This allows it to redirect light from different distances onto the back of the eye where the retina sits, so that it doesn’t produce a blurry picture. At the retina, the light is converted by different types of cells into nerve signals and the information is then taken via the optic nerve to the brain where it is further compiled into what we understand as ‘sight’. Interestingingly, because of the way in which the light is focused on the retina, the unprocessed image is upside down and back to front, so the brain must flip these back the right way round.

As doctors, the eyes are a useful thing to check when examining a patient because they can tell us a lot about a person’s health. Shining lights into the eyes causes the pupils to constrict and faults here can point to certain neurological conditions as can double vision and loss of visual fields. Looking at the back of the eye, we can sometimes tell if there is raised pressure in the fluid surrounding the brain, and at the front, there are characteristic appearances in or around the eyes of people who might have thyroid problems or high cholesterol. In babies, it is important to check for something called the red reflex, the normal red-orange colour of the eye when light is shone. Asymmetry here or a white reflection can sometimes point to something called retinoblastoma which is a type of cancer.

The most common eye examination one might receive is the visual acuity check. Using the Snellen charts, reading the letters on rows of ever decreasing size, we challenge ourselves to get to the very bottom level. The phrase ‘20/20 vision’ is often talked about, which essentially means we can see something at 20 metres that the average person would see at 20 metres. Outside the USA, we use 6 metres as a scale and if you wanted really exceptional vision, you would aim for something more along the lines of 6/7 (in other words you could see something from 7 metres that the average person would only be able to read at 6 metres).

If our vision isn’t quite up to scratch, we might need a correction and this is where glasses and contact lenses come in. Depending on which survey you read, between 69% and 77% of people in the UK wear glasses or contact lenses – so many that it is isn’t surprising that they have become somewhat of a fashion accessory!

More seriously, there are currently approximately 2 million people in the UK living with a level of sight loss that has a significant impact on their daily life. There are around 350,000 people registered as blind or partially sighted alone.

There are a plethora of conditions that can cause such sight loss.

  • In the UK, age-related macular degeneration is a major cause (a deterioration of the macula, a part of the retina, due either to the formation of deposits on the retina or to fluid build-up underneath the macula).
  • Diabetes is a big cause of sight impairment as well – it causes progressive damage to the blood vessels at the back of the eye and is known as diabetic retinopathy.
  • Glaucoma is a build-up of pressure in the fluid within the eye. Your optician will check your pressures by puffing air at the eye using a machine. As long as it is well controlled and monitored it can be treated with certain medicated drops.
  • Cataracts are a gradual clouding of the lens. When vision is too severely affected, surgery is an option to correct this.
  • Retinal detachment is an emergency and characteristically involves a sudden curtain of vision loss falling over one eye. It may be preceded by flashing lights and a sudden increase of floaters and needs an immediate trip to eye casualty.

Incidentally, floaters are small bits of debris that float in the eye and move around with a slight lag as the direction of gaze changes – these are common, and, except as mentioned above, are not normally something to worry about, though they can be very annoying. Unfortunately they are essentially untreatable.

As GPs, we often see a handful of more common and less serious conditions that could have been dealt with first by a pharmacist or managed at home. Red and gunky eyes most often represent conjunctivitis, while red swollen eyelids (blepharitis) or a cyst or stye over the lid can be treated with hot compresses, and a watering eye can be your body compensating for a dry eye, so try some lubricating drops. Most eye conditions do not need antibiotic treatment.

If your eye is painful however or if you are not quite sure, this must be reviewed, especially if it is red as well. There will be a local eye casualty (if you’re in the UK) that patients can call if they are unable to get to their GP. This may be where your GP refers you if they feel it needs more in-depth specialist review.

The following recommendations can help to keep your eyes healthy:

  • Don’t smoke – Unsurprisingly this causes all sorts of problems including macular degeneration and cataracts.
  • Make sure you wear sunglasses – it protects against harmful UV rays and makes you look awesome.
  • Get regular optician checks – apparently around 10% of the adult UK population have never had an eye check. Problems are not always immediately evident and so it’s best to get checked every two years at the very least, more frequently if you’re over 40.
  • Eat the right things – generally anything with lots of omega 3 fatty acids and vitamin A (also known as retinol which helps with night vision!) Examples would be oily fish, kale, spinach, peppers, oranges, broccoli and eggs.

So overall, eyes are pretty marvellous things and, more than that, they are deeply personal. One only has to look at the rising use of retinal scanning to realise just how individual they are -fingerprints have approximately 40 individual features but the average iris has 256. We only have two of them, so we must take the best care of them possible.

The Ear

“The list of famous musicians who suffer from tinnitus is quite something: Bono, Pete Townsend, Chris Martin, Neil Young, Will. I. Am…”

“Music is like a dream. One that I cannot hear.”

The loss of hearing that Ludwig Van Beethoven suffered towards the end of his life was cruel and his words illustrate just how much we rely upon our hearing to enjoy the world around us.

Our ears, unsurprisingly, are integral to the process of ‘hearing’. This sense is one of which those who were born deaf simply have no concept; this set of channels, bones and nerve cells is able to convert vibrations from all around us into an almost indescribable entity in our heads.

To be fair, the really remarkable stuff all happens in the brain.  What we hear as ‘sound’ is merely the brain’s interpretation of what is happening in the physical world, much like what we see. But let’s not forget the ears’ role in all of this. A sound is essentially vibration of air particles that travel in waves at high speed. If I drop a saucepan on the floor, it will create ripples in the air that spread out in all directions. This wave of sound reaches the ear and is collected by the first section, the outer ear, where it is channelled inwards towards the ear drum.

As the air hits the ear drum, the ripples are conducted into three tiny ossicles (the smallest bones in the body) called the Malleus, Incus and Stapes (colloquially known as the hammer, anvil and stirrup). These are pretty special because they gradually reduce the amplitude of the vibrations, in effect scaling down the sound so it can be processed in ever smaller regions. The last of these bones is attached to another smaller drum that then transfers the vibrations into fluid which is contained in a tiny organ called the cochlea. The walls of the cochlea are covered in tiny hair-like nerve cells which, when excited by the vibrations, convert them into nerve impulses which then travel via the vestibulocochlear nerve to the brain where the magic happens.

This way of hearing sound is not the same throughout the animal kingdom. It is thought that the bones of our mammal ears were once incorporated into the jaws of a common ancestor of us and modern day reptiles. Indeed some reptiles, including snakes, use their jaws to ‘hear’ sounds, while others, such as insects, use antennae to detect vibrations in the air rather than ears.

Such a delicate system is of course vulnerable to the louder sounds. Anything above around 85 decibels (for example busy traffic, a motorbike or listening to music on full volume via headphones) will damage your hearing and the longer the exposure the worse it gets. Damage mainly comes from destruction of the tiny neural hairs in the cochlea which are irreplaceable.

It is therefore important to take precautions to reduce such exposure (for example, by ensuring that you use noise cancelling headphones rather than turning your music up just to cancel outside sounds and not listening at more than 60% volume). Ear protectors in noisy work environments are important. A sure sign that you are damaging your hearing is the ringing sound that tends to be experienced after a loud concert. If you’re lucky, this will fade after a few hours but repeated exposure can cause tinnitus. This is a really unpleasant and often intrusive condition in which a sufferer will experience that ringing in the ears all of the time when there is no obvious source.

The list of famous musicians who suffer from tinnitus is quite something: Bono, Pete Townsend, Chris Martin, Neil Young, Will. I. Am. Unfortunately, there is no known cure for this although, depending on how intrusive it is, there are measures you can take to introduce distractions and psychological techniques that help combat the depression which is often strongly associated with this complaint. If you develop a one-sided tinnitus, it may be a good idea to get this checked out with your GP, as sometimes there can be other underlying causes.

Probably the most common ailment we see in General Practice when it comes to ears is infection. Any part of the body exposed to the outside world is vulnerable and the ear is no exception. Happily, the vast majority of earaches are caused by viruses that can track up from the tube at the back of the mouth (Eustachian tube) that helps equalize the pressure between the inner and outer ears. (If this gets blocked, you lose that ability and so the difference in pressure can become very uncomfortable, particularly if you travel on an aeroplane). Most ear infections will be cleared up by the body’s own immune system after about 3-5 days and so otherwise healthy adults shouldn’t need to see a GP (even if you’re about to go on holiday) until after this. Your best first port of call is your pharmacist. If, however, there is a lot of discharge coming from the ear or you are feeling feverish and shivery, it is worthwhile getting us to check on things.  Note also that children with ear infections should be seen more promptly.

Critically, and contrary to what seems to be an ongoing fashion, you do not need to clean your ears. The wax in your ears is there for a reason. It is a mixture of oil, sweat and dead skin cells which, as unpleasant as that sounds, help to collect the very things that might cause infection. The wax brings these out as the skin of the ear canal gradually grows outwards, a bit like a natural conveyor belt. Just occasionally, wax can build up to excessive levels causing a conductive hearing loss and it is at this point that we might be able to help out with some syringing or micro suction. You should not, however, be putting anything like cotton buds in your ears. All this does is push wax further in and irritate the skin of the canal, predisposing it to infection.  Nothing smaller than your elbow is the rule!

The ear has one final trick up its sleeve. There is a separate part of each cochlea which forms a series of canals called the semi-circular canals. It is here that the body derives its sense of balance. These canals are filled with fluid that moves in one direction en masse as we ourselves move. This stimulates hair cells on the walls that send signals to the brain indicating we are on the move. If all is working well, it combines in the brain with visual information from our eyes to give us a sense of position.

If however there is a bit of loose material in the semi-circular canals that brushes against the hair cells independently of the direction of movement, this sends a lot of confusing signals that don’t match up with what we see. This can give rise to something called Benign Positional Paroxysmal Vertigo (BPPV) which causes a nasty dizziness, often described as a sensation that the room is spinning or a feeling akin to being on a swaying boat. It causes nausea and vomiting and tends to be triggered by turning the head. Fortunately, this is something that does eventually fade on its own but not before a period of fairly uncomfortable and enforced inactivity. Medications to help with the nausea are available and the only other ‘cure’ is something called the Epley’s manoeuvre which can be attempted by some GPs if symptoms are not abating naturally.

So, overall, the ear is a complex and valuable part of our lives. If you do have a feeling your hearing isn’t what it once was, don’t be afraid to get it checked.  Hearing loss is unfortunately something that occurs frequently as we get older. There are hearing aids available now that can make a really big difference, not to mention their crucial role in placating the neighbours who have to put up with the TV volume set to maximum!

The Brain

While we know more than we ever have, there is still a lot to learn meaning that, in an ironic sense, the brain is still something we can’t fully get our head around.

Someone once said that if the human brain were so simple that we could understand it then we would be so simple that we couldn’t. I would have to agree. The brain is our vastly complicated seat of consciousness and individuality, controlling most functions of the body, some of which we are aware of and some of which are on a more subconscious level.

If one were to zoom in to see it under a microscope, one would find literally billions of nerve cells, or neurons, forming a continuous interconnected network signalling to each other using electrical pulses and chemical transfers. There are around 86 billion of these neurons in the adult brain, meaning that if you were to pick an area of the brain the size of a small grain of sand you might find as many as 100,000 neurons in just that one area. What’s more, each one connects to around 1,000 others via connections known as synapses.

As we zoom out again, we see that the brain has a wrinkled surface that, if stretched out flat, would cover the area of four A4 sheets of paper. It is cushioned and bathed by a viscous layer of cerebrospinal fluid that, as the name suggests, runs all the way down around the spine as well.  Weighing in at around 2% of our body weight, our brains manage around 98% of human function, which is a pretty good return. It follows therefore that it needs a fairly good power supply and, indeed, it has an important network of blood vessels that supply it with oxygenated blood and nutrients – it uses around 20% of the body’s energy supplies.

With such a complex make-up and such a plethora of responsibilities, it is no wonder that it is regarded with such intense interest and yet is still relatively poorly understood compared with other organs of the body. As with much scientific endeavour, much progress has been made in its understanding over the last century.

Take the frontal lobe for example. As part of the quest to understand the brain in more detail, scientists identify areas in accordance with their perceived function. The frontal lobe is thought to be involved in executive function such as judgement, decision-making, planning and control of behaviour – functions that became clear following an accident involving a railway worker named Phineas Gage in which, rather unfortunately, he received a metal pole through his forehead. Though he survived this ordeal, the once calm and understated worker famously showed a marked change in personality towards aggression and surliness.

Had the pole gone through his occipital lobe, he might have had trouble with his vision and, if it had pierced the temporal lobe, he would potentially have had trouble processing sound, using his memory and producing speech.

The point is that certain areas of the brain are involved in particular tasks. This can become apparent when someone has a stroke. Most strokes happen when blood supply to an area of brain tissue is interrupted.  The result can be, for example, loss of motor function in one side of the body. If there is a problem in one half of the brain, then the problem (when talking about motor function – i.e. moving an arm) manifests in the other side of the body. This is because nerve fibres from each side of the brain cross over at a certain point before descending the spine to the rest of the body.

We know that the brain performs so many functions. It allows us to move, to smell, to hear and to sense temperature. It also enables us to think. While this complexity is admirable, when it goes wrong the consequences can often be very distressing. Infection, head injury and cardiovascular disease all affect the brain’s health, as well as conditions such as Parkinson’s disease which affects the production of dopamine, (normally used to regulate our movement) and resulting in involuntary shaking, slow movement and stiff muscles.

Most significant of all, as our population grows older, dementia is becoming the largest cause of mortality in the UK and all over the developed world. Research is ongoing and we still have a long way to go both in understanding the processes involved and in treating the effects. It should be mentioned that dementia is not a single disease, rather a term to describe the symptoms that occur when there is a decline in brain function.

Alzheimer’s is the biggest cause of dementia. Though not fully understood, it is believed to be related firstly to the build-up of amyloid plaques and secondly to neurofibrillary tangles made up of proteins called TAU proteins. As more of these build up, the ability of the neurons in the brain to transmit information gradually diminishes. Research is currently focusing on the processes involved in the development of these two features. Just as importantly, the search is on for biomarkers (markers that we can sample in the blood or spinal fluid) that might give us an idea of whether someone might be developing a dementing condition, giving greater opportunity to take early steps to manage the condition and also to research disease progression over longer periods of time. Although it can be difficult to face, and often slow to present, if you have any concerns about memory, it is important to see your GP as there is often support available and it may also be the result of more benign and treatable conditions (for example low vitamin B12 levels or underlying infection).

When concentrating on the more physical effects of the brain, it is sometimes easy to overlook the deeper thought processes that are involved in our mental health. Much of our individuality comes through the environment in which we grow up. In the same way that we form new connections and synapses in our brains through repetition as we learn an instrument or practise our times-tables for example, it is thought that personality traits develop to some extent in the same way. For untold reasons, however, our minds can be fragile and depression and anxiety can be extremely damaging. Often there are so many different factors, both social and physical, that make such emotional issues difficult not only to treat but also to recognise. Chemical imbalance plays its part, for example in relation to levels of serotonin in the brain, and in such cases there can be a role for medication. More recently, there has been a push for increased awareness of mental health conditions in an attempt to remove any stigma attached to something that can cause a lot of problems if left unaddressed.

How do we look after our brains? Staying happy is a good start and there is plenty of support available for people for whom this is not the case. Keeping your mind busy helps to maintain your ‘neural plasticity’ – it ensures you are creating new synapses by learning new things. Maintaining healthy social networks is equally as important.

Regular exercise is vital for brain health as it increases the blood supply to the neurons, reduces blood pressure, helps blood sugar balance, improves cholesterol and reduces mental stress.

Getting enough sleep each night is important (8 hours being the aim).

Your diet can also give you benefits. Anything rich in omega 3 such as oily fish is useful and a ‘Mediterranean-style’ diet is a good start. Blueberries are rich in anti-oxidants, thought potentially to reduce inflammation involved in plaque formation in the brain, and dark leafy greens, such as kale and spinach, will give you good sources of vitamins C and E and folates – all thought potentially to reduce the risk of Alzheimer’s.

There is some evidence to suggest that certain people may benefit from medications like statins and aspirin but it’s always a good idea to come in to discuss any medication with your GP or pharmacist. And don’t forget not to smoke or drink too much alcohol.

While we know more than we ever have, there is still a lot to learn meaning that, in an ironic sense, the brain is still something we can’t fully get our head around.

 

Medicine: A work in progress

Our job is to sift through all of the research that is carried out (and there is a lot) and utilise the research that makes sense.

As I sat down to write this article, my initial aim was to try and pinpoint the biggest advances in medicine over the past year. In doing so, I rather suspect I made a rod for my own back. It turns out that pin-pointing specific advances that aren’t incredibly specialised and frankly mundane for the uninitiated is quite difficult. Headlines from certain sections of the media pronouncing grand new breakthroughs every other day would have you believe that vast strides are frequently made overnight. Talk of “miracle cures” and such is all too common and, while regular grand discoveries may not in reality be as frequent as they were perhaps a century ago, this is not to say that dramatic advances are not being made. Rather the process behind these advances is simply more gradual and far more intricate.

This led me to reflect upon one of the most interesting aspects of medicine and hopefully by the end of this article I will have conveyed the numerous ways in which medicine and the way in which we practise it remain a work in progress.

Throughout the last century people felt justifiably reassured by the steady advance of medical know-how. The twentieth century saw some incredible breakthroughs in the organisation of medical care, the understanding of disease and the implementation of effective treatments. (Antibiotics, public health, surgery, pharmaceuticals… the list is almost endless.) A lot of this will have been based on a new approach – evidence-based, which I will come to later.

Even now, however, even after all these advances, it is important to acknowledge that we don’t know everything and must constantly strive to improve and develop existing treatments as well as being on the lookout for new ones. Part of this will involve adapting to changes in demand which may vary to one decade to another. Thankfully, as you read this, that is exactly what many people are working on in order to stay up to date and push the boundaries in order to make treatments more effective. Not only is medical research important, it is – for better or for worse – big business. As such, a phenomenal amount of money is invested in research every year. In the UK alone, the Industrial Strategy Challenge Fund has set aside £146m of government money over the next four years for life sciences. Add to that the countless charities working on medical research along with the pharmaceutical companies and one can see how much activity there is in this field.

It is inevitable therefore that we see headlines almost daily about rumoured miracle treatments for this and that and warnings about things to avoid that at first glance seem perfectly innocuous (eg burnt toast – cancer).

Our job is to sift through all of the research that is carried out (and there is a lot) and utilise the research that makes sense. Often this is done via panels that do that work for us and produce guidelines, though it must be said there is frequent disagreement amongst professionals about even these. Needless to say, there is considerable variation in the quality of research and some of it must be taken with a pinch of salt.

If we consider the development of a new drug, for example, one of the most important aspects is naturally whether or not it is effective. In order to answer this question, studies must be carried out to trial it on ideally as many people as possible in order to iron out any statistical inconsistencies. The longer the trial goes on the better, for the same reason. Add to that the complicated task of removing as much bias as possible from those carrying out the study and one will find that, of the thousands of studies carried out each year, very few have enough statistical power to draw totally reliable conclusions.

Unfortunately, even the most unfounded conclusions end up as headlines. Here’s an example. “Tattoos could give you cancer, new research suggests”. This was based on a study in which 4 out of 6 donors had ink particles in their lymph nodes after post mortem. There was no information about whether the donors had cancer or not. And yet, for many, that headline is enough. For this reason, we all have a responsibility to be wary about what we take from the news no matter where it is published. It is so easy to fall foul to misinformation, even health ministers are not immune.

It is important to add that some studies, although they do not come up with firm conclusions, add to the body of research out there. If people didn’t at least try to generate evidence, progress would be much slower. For example, last summer a UK study hit the headlines following its claim that the age-old notion of finishing a course of antibiotics may be outdated. It suggested that doing this actually contributed to antibiotic resistance. Quite rightly the study did not sway official advice – to finish the course of antibiotics even if you begin to feel better before they run out – because the way the study was carried out left too much scope for bias from the organisers. It did however raise the question and will no doubt encourage further, more powerful, studies in the future that will give us a better idea of what we should be doing.

So this is what I mean by an evidence-based approach, as mentioned earlier. This approach has become the cornerstone of modern medicine and for good reason. So, while it may not have given us a list of show-stopping breakthroughs of late, it has given us a valuable and active research community that is perpetually in motion and coming up with improvements and suggestions, however large or small, all of the time.

To finish, I must stress that development of medicine is not just about medications and treatments. It is vital that we are able to utilise these treatments in the best and most effective way possible. Technological advances are becoming more prominent (artificial pancreases for type 1 diabetics and drones delivering medical supplies for example) but, with the current levels of demand and the well documented pecuniary squeeze in mind, for me the biggest advance in 2017 has been the provision of locally available care. As hospitals come under more strain, a big drive to treat more people in the community is afoot through minor injury units, intermediate care and rapid assessment units. Having services like this makes a huge difference and I feel I must highlight how much of a positive these additions have been. The more people are aware of the services available, the easier it is for the health services to spread the load. After all, if the strain on our health services becomes too difficult to sustain even at the most basic level, it may be even more difficult to make the clinical breakthroughs of the future a reality. 

The Problem with Antibiotics

Our honeymoon period with antibiotics and their undeniable benefits ended long ago, but since their inception we have created a deep seated culture of dependence.

Many thanks for your responses to my article last time around – keep those suggestions for topics coming. Shortly after I had finished the article about the common cold, I developed a cold of my own, so I have decided to postpone indefinitely my planned article on smallpox.

Our topic this week is antibiotics – a subject which is garnering more and more attention in the media. Since 2015, there has even been an annual ‘world antibiotic awareness week’ which, appropriately, was last week.

Why the fuss? Well I am sure most people by now have heard all sorts of stories in the news about antibiotic resistance and the emergence of ominously entitled ‘superbugs’. This is all for good reason as I will expand upon.

To begin with, let’s focus on antibiotics and what they actually are. Prior to their discovery and development in the early half of the twentieth century, we had no really effective ways of treating bacterial infections. Historically, all manner of approaches were used, from the rather dramatic process of blood-letting (thought to stabilise the balance of the perceived four humours: blood, phlegm, yellow bile and black bile), to the use of things like willow bark by the ancient Greeks for curing fevers and pains. (Willow bark actually contains salicin, which is chemically related to modern day aspirin).

Things all changed when the Scottish botanist Alexander Fleming returned to his laboratory in 1928 after a family holiday and noticed that mould had grown in his petri dishes of staphylococci bacteria. The mould in question (penicillium) had killed off the surrounding areas of the bacteria prompting Fleming’s famous response – ‘That’s funny’.

The rest, as they say, is history and since then many different families of antibiotics have been developed to fight off bacterial infections that had once been, at best, troublesome and, at worst, fatal. As we approach a century of antibiotic use, we can look back upon a vast improvement in our ability to treat infections such as pneumonia, syphilis, tuberculosis, meningitis and many more. This has no doubt had a vast social and economic impact. However, now we come to the problem.

Antibiotic resistance is a process that has been developing from the very beginning. In broad terms, let us consider a group of bacteria exposed to an antibiotic. In any reproducing population, there will always be random mutations that occur in the genes of certain individual bacterial cells. Sometimes these mutations happen to protect the bacteria from the effects of an antibiotic. Bacteria without that protection die, leaving the resistant bacteria free to multiply without competition. Over time, these populations spread from person to person, meaning that, when the same antibiotic is used repeatedly, it becomes less and less effective in controlling these bacteria. That’s it in a nutshell.

We are now at a stage in which no new class of antibiotic has been found since 1987 and there are thought to be around 12,000 deaths each year in the UK as a result of bacteria resistant to antibacterial treatment. If this trend continues without further action, the World Health Organisation (WHO) state that the global mortality from such infections could be as much as 10 million people a year by 2050. Advancements and achievements in modern medicine such as chemotherapy, organ transplants and routine operations like caesarean sections and hip replacements – all of which rely heavily on the availability of effective antibiotics – are now potentially at risk.

Development of resistance is and always was a natural and unavoidable process but our use of them has unequivocally made things worse than they could have been. In 2015, it is thought that around 25% of antibiotics were taken unnecessarily in the UK. When you factor in un-regulated use of antibiotics in farming and the availability of antibiotics over the counter in some countries, one begins to see how much of a global issue this is.

On a personal note, I have certainly seen strikingly inappropriate use of strong antibiotics prescribed in other countries for even the most trivial of ailments. There is most definitely a responsibility amongst us as healthcare professionals to monitor what we are prescribing. Having said that, there have been surveys suggesting that up to 90% of GPs have experienced pressure from patients to prescribe antibiotics even when this was not appropriate and would serve no purpose. While this obviously differs from area to area (and to be fair you’re a pretty good bunch), we all share a certain responsibility in tackling this issue.

I don’t want to sound too gloomy, and thankfully there has been some international recognition of the issue. The WHO endorsed a global action plan in 2015 (though lamentably it will certainly now have to make do without the help of Robert Mugabe) and since then 193 countries have given further political endorsements via the UN to install tighter regulation and encourage further research into new antibiotic classes.

As often is the case with such gradual phenomena, the effects of such crises are not always immediately apparent. However, in this case, the signs have been there for a long time and Fleming himself warned about the potential for resistance. Now those signs are becoming ever more obvious and we must face up to the inconvenient truth. We stand to lose a lot if we refuse to do so.

Hygiene both in the community and in hospitals is vital to prevent the spread of bacteria. Responsible and restrained prescribing from doctors both here and all over the world is also required. Research into new antimicrobial agents is ongoing but slow, and techniques to bolster our existing agents is important for our short term management of the more serious infections. Crucially, educating people as to why it is often inappropriate to prescribe an antibiotic is just as important – after all we’re all in this together.

Our honeymoon period with antibiotics and their undeniable benefits ended long ago, but since their inception we have created a deep seated culture of dependence. This will be difficult to withdraw from, especially considering the advances we have built around it. Over the coming years, we must now consider whether or not an even more dramatic shift in our utilisation of such medicines is required before nature takes the matter out of our hands.