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.

 

 

 

 

 

 

The Deep

This was written by one of the scientific advisers on the TV series Blue Planet. Alex Rogers is an esteemed marine biologist and, although he’s not the best writer out there, this is an engaging and interesting book. If I’m honest, some of the descriptive passages of the underwater reefs in extreme detail did get a little bit tedious, but when he starts talking about the environmental aspects, he really hits home. This is an important book and towards the end, he gets into the real nitty gritty. 

The impact we are having on the oceans is shocking, something only surpassed with our complicit lack of action. The conclusion is sensible and important and gives the reader a list of things they can do to help change things. Ultimately only time will tell if this is enough. 

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 16th 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.

Dry January: Probably a good idea

‘Billionaire Vodka’ is filtered through ice and then some Nordic birch charcoal before being passed through sand made from crushed diamonds and gems.

I saw a programme on television a while back (I think Chris Packham was involved) in which there was a gentleman who, seemingly unprovoked, would quite regularly lose co-ordination, become disorientated and somewhat ‘lary’. Despite his protestations, his wife began to suspect that he was sneaking off to the pub at every available opportunity without telling her. Understandably this placed rather a strain on their relationship until finally it transpired that he was innocent after all. It turns out he was suffering from something called Auto-brewery Syndrome.

This thankfully rare condition is thought to occur when there is an overgrowth of yeasts in the intestines that produce a natural fermenting process in the gut, resulting in high alcohol levels that make the sufferer quite literally drunk without having consumed any alcohol.

Fermentation (the science of which is known as zymology for the purposes of pub quiz trivia) is key to producing alcohol and there is evidence to show that we, as a species, have been using it to make alcoholic drinks for thousands of years, as far back as 7000 BC. In the middle ages we were brewing beer as an everyday drink, often protecting against various water-borne diseases. It was also quite handy for sailors to take along with them on long voyages. Essentially, alcohol – specifically in alcoholic drinks ethyl alcohol or ethanol – is produced when yeasts and bacteria break down natural sugars found in fruits and grains in the absence of oxygen. Lactic acid that causes cramp in muscles during exercise is formed through a similar process.

Of course, as much as we like it, drinking the stuff does not always result in the best of outcomes. Some research has estimated that, at any one time, up to 0.7% of the world’s population (equivalent to around 50 million people) are drunk. Unfortunately in the UK in 2016 7,327 people died from alcohol specific causes and around 40% of all violent crime involves alcohol in some way. It accounts for more than a million hospital admissions each year.

As you can imagine, this creates rather a strain on the health service as well as on a person’s general health. When we drink alcohol, it creates a numbing effect on the brain, resulting from inhibition of certain neurotransmitters. Most likely it is this sensation that has us coming back for more each time. While in the moment it could be described as pleasant, it has some far more negative effects.

Your body reacts to ethanol as a toxin and this causes a reduction in insulin effectiveness in the long term if we drink a lot. Conversely, in the hours after drinking lots of ethanol, there will be an upturn in insulin production, lowering our blood sugar and causing tiredness and fatigue. As it is broken down, it produces acetaldehyde, which is heavily implicated in hangovers. It is also something which has been implicated in ethanol’s role in causing cancer, in this case by damaging DNA.

There are seven proven types of cancer (probably more yet to be proved) in which alcohol has a causative role: bowel, breast (possibly due to increased oestrogen levels), laryngeal, pharyngeal, mouth, oesophageal and liver. The liver becomes more and more damaged with persistent alcohol use and the scarring produced from this (cirrhosis) can cause irreparable and unpleasant consequences which may ultimately be fatal.

If that is not enough, excessive alcohol will drive up blood pressure and predispose a drinker to diabetes, all of which increase the risks of heart attacks and strokes. Alcoholic drinks account for around 11% of the UK population’s sugar intake further compounding this risk. It will inevitably cause weight gain and likely some tooth decay along the way.

Sleep can be greatly affected by alcohol. While many people drink as an aid to sleep, although that initial numbing effect may help them drift off, the sleep achieved will be restless and inefficient. Time spent in REM (rapid eye movement) sleep will be increased, resulting in less time spent in deep and restful slumber. This only causes fatigue and makes things worse rather than better. 

What then, is a ‘safe’ level of alcohol? The chief medical officer’s official recommendation is that we do not exceed 14 units of alcohol each week (one unit is 10ml of alcohol). This is a reduction from the old recommendations and represents roughly 6 pints of beer, or 6 glasses of average strength wine.
Often people underestimate how many units there are in their drinks – it is more than you might think!

If you do drink 14 units a week, spreading them out is the way to go rather than all at one time. If you are drinking any more than this, you are really not doing your health any favours, not to mention your bank account. Incidentally, the most expensive vodka in the world will set you back a cool 3.7 million dollars. ‘Billionaire Vodka’ is filtered through ice and then some Nordic birch charcoal before being passed through sand made from crushed diamonds and gems. Served in a diamond encrusted crystal bottle, it is some fairly serious stuff. While not all alcohol is priced that high, it does highlight the glamour that often surrounds it. Therein lies much of its danger.

Dependence on alcohol can creep up on you and, if unchecked, can quite literally kill you. It is thought that only 6% of alcohol dependant people will access treatment every year, so if you are unsure it is worth coming to see your GP or accessing any of the online resources listed at the bottom of this article.

You may have heard every now and again about the benefits of alcohol. In the past, before the advent of anaesthesia, surgeons would ply their patients with alcohol before procedures and physicians would recommend a ‘hot toddy’ to stave off a cold. In fact, while giving an initial boost (due to the effects of alcohol on the mind) a dash of whisky in your hot drink probably only serves to slow down the natural process of fighting off the infection.

Certainly there have been studies reported in the papers about regular red wine being good for your heart. The truth is, certainly in my mind, that there is simply not enough evidence to back this up. While some studies have shown benefits, the context in which they have been carried out is far from conclusive. Things like red wine do contain ingredients known as flavonoids, thought to be rich in anti-oxidants which, among other things prevent clotting disorders. However, current evidence only points towards an overall benefit in a very small amount of alcohol (5 units a week) for women over 55 years old. Before you all go rushing down to the pub, remember that is a mere 5 units a week!

So I would recommend that the next time you feel a spot of cenosillicaphobia coming on – a pathological fear of an empty glass – consider filling it with something other than alcohol instead. I’m not saying we should stop drinking altogether but moderation is the overwhelming key. And if there are any generous billionaires out there, I would much prefer a nice house or three rather than a bottle of vodka. Thanks. 

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. “