Monthly Archives: September 2015

Brace yourself, genetic testing might give you more than you bargained for

Sep 30

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Brace yourself, genetic testing might give you more than you bargained for

July 1, 2015 6.10am AEST

BRCA1 and BRCA2 gene mutations prompted Angelina Jolie to have a preventative double mastectomy and surgery to remove both ovaries. Sebastian Kahnert/AAP

Authors

  1. Lab Head, Metastasis Research Group, Lowy Cancer Rearch Centre at UNSW Australia

  2. Program Authority and Senior Lecturer, Pharmaceutical Medicine at UNSW Australia

Disclosure statement

The authors do not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article. They also have no relevant affiliations.

Partners

UNSW Australia provides funding as a member of The Conversation AU.

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Drink red wine to prevent cancer. But don’t drink too much! Get some exercise. But don’t overdo it. Give up, it’s all genetic anyway – think of Angelina Jolie!

We are constantly bombarded with conflicting information about our risk of developing cancer. It is difficult to know who to believe, let alone how to respond.

What if you could take a simple test that would reveal your individual risk of developing not only a range of cancers, but hundreds of other diseases? Imagine if it could also tell you which drugs would be most effective for you, if you did develop cancer or other diseases.

The rapidly reducing cost of DNA sequencing has made this one-time fantastical idea an emerging reality. Only 10 years ago it cost about US$10 million to sequence a human genome, so there was little prospect that individuals would, or could, seek out their own unique genetic maps to find out more about their ancestry or their inherited health risks.

Recent advances in genetics mean genetic sequencing is more affordable (US$1,000 to US$3,000) and already guiding treatment across a range of illnesses from cancer to degenerative brain diseases.

New unregulated direct-to-consumer businesses are emerging, making it possible for anyone to order their individual genetic profile by posting off a saliva sample taken at home. But do you really know what you are signing up for?

The age of personalised medicine

Personalised medicine means using a patient’s genome to both predict their likelihood of developing certain diseases, and to guide which treatments are most likely to be effective in a particular individual. It’s also called customised medicine, precision medicine, individualised medicine, bespoke medicine and targeted medicine.

Our genes hold our hereditary information. Every cell in the human body is made up of about 20,000 genes that are passed down from parents to child. Genes contain information that instructs the growth, development and function of the human body. Some genes control simple characteristics such as hair colour and height, others influence complex characteristics such as intelligence. Some genes control how other genes work, telling them when to switch on and off.

Some genes control simple characteristics such as hair colour and height, others influence more complex characteristics like intelligence. from http://www.shutterstock.com

We all have alterations, or mutations, in our DNA. Mutations can be passed down from parents to children, or can occur spontaneously, especially as we age. Some are harmless and may determine, for example, whether our ear wax is wet or dry.

However, a mutation in an important gene that prevents it from working properly, or a gene that is missing altogether, can have serious consequences. Early genetic testing focused on debilitating inherited diseases, such as cystic fibrosis and Huntington’s disease, that are caused by mutations in single genes. Tests looked only for a known mutation in a specific gene to confirm or rule out the associated condition.

As testing has become more sophisticated, we have been able to extend this approach to more complex conditions such as cancer. Mutations in two genes called BRCA1 and BRCA2 are associated with an increased risk of developing breast and ovarian cancer, and can be inherited within families.

BRCA1 and BRCA2 normally help clean up mistakes in our DNA that our cells can make when they divide, a process called DNA repair. When either of these genes is altered or mutated, this protective function is disabled, leading to uncontrolled replication of cells with mistakes. This can lead to cancer.

The good news is that we can test for these mutations, and patients can then use the results of this test to assess their risk of developing cancer, and make informed choices. This is the same hereditary genetic mutation that prompted Angelina Jolie to have a preventative double mastectomy two years ago, and preventative surgery to remove her ovaries this year.

The other good news is that in recent years scientists have discovered that patients with mutations in BRCA1 and BRCA2 are exquisitely sensitive to some forms of chemotherapy and a second type of drug called a PARP inhibitor. The same mutation that generates the mistakes in these cells can actually make them more responsive to this drug. Decisions about treatment can then be “personalised” to the individual.

What does the future hold?

Currently, health systems in Australia and overseas do not offer patients the option of sequencing their entire genome as a means of identifying and managing future health risks. Today genetic testing is only available in Australia for specific genes, is tightly regulated and is used only when symptoms are apparent, or a genetic risk is likely, such as a close relative developing a particular cancer or condition.

In five to 10 years’ time, however, we may be facing very different choices, including the option to look for future diseases before they actually occur.

As many cancers do not appear until middle age or later, a young healthy person might discover they have various elevated risks among the many anomalies a DNA test could throw up. Such results might not be provided by a medical professional, but by a commercial operator, and without genetic counselling to explain what they mean to the individual and their family.

Insurance companies could use genetic profiles to deny higher-risk individuals various types of insurance, or increase their premiums. from http://www.shutterstock.com

What might the implication be of a high-risk result? Should an individual’s relatives be informed, as their risk may also be high, or do they have a right not to know? And what about minors: will parents have the right, or even an obligation, to test babies and children for potential genetic risks, even if medical science offers no prevention or treatment options?

Are we psychologically equipped for these kinds of dilemmas and scientifically literate enough to interpret our own results?

There are currently many reasons to be cautious. First, there are potentially millions of genetic alterations. Most are still not understood. Personalised medicine cannot currently give anyone a comprehensive picture of individual risk simply because far too much remains unknown.

Second, personalised medicine can only indicate elevated risks, it cannot determine whether or not a patient will actually go on to develop a certain type of cancer. Environment and lifestyle also play a big role in our health.

Insurance companies, however, deal entirely in risk. That means genetic profiles could be used to deny higher-risk individuals various types of insurance, or increase their insurance premiums.

Third, health outcomes for some individuals may be based on the financial viability of developing drugs. Many drugs and therapies are currently used for large numbers of patients, making them financially viable for pharmaceutical companies to develop. Genetically targeted cancer drugs, suitable for much smaller groups of patients, may be extremely expensive or might not be brought onto the market at all if society is not willing or cannot afford to pay for them.

Fourth, we may be at risk of eroding our quality of life by creating a new state of “worried wellness”, waiting for disease to strike.

Finally, we may not be sufficiently savvy consumers. New commercial operators are coming onto the global market offering a range of largely unregulated services. Currently, you don’t get much more than details of your ancestry for a US$99 DNA test. But more specialised businesses are emerging that offer, for example, to “identify potential health risks that are present now or may develop in the future”.

Is this just hype, and offering unsubstantiated hope to consumers, or does this represent the first stage of patient empowerment over their own health and lifestyle choices? It will be fascinating to watch this new age of personalised medicine develop in the coming years.

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Tea lowers Blood Pressure

Sep 28

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I am an inveterate tea lover, and always have been. There is a chapter in my book devoted to the benefits of tea, and more research confirms this. Remember however, it must be black tea to reap the benefits.

Effects of tea intake on blood pressure: A meta-analysis of 21 randomized controlled trials

JACC – Journal of the American College of Cardiology, 10/22/2014 Gang L, et al.

The authors undertook a meta–analysis of randomized controlled trials to determine changes in systolic and diastolic BP due to the intake black and green tea. The meta–analysis showed that long–term (≥12 weeks) ingestion of a tea (green and black tea) resulted in a significant reduction in systolic and diastolic BP.

Methods

  • MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched from 1966 until January 2014 for studies in parallel group or crossover design in which BP was assessed before and after receiving black or green tea for at least 1 week.
  • The weighted mean difference was calculated for net changes in BP by using fixed–effects or random–effects models.
  • Previously defined subgroup analyses were performed to explore the influence of study characteristics.

Results

  • 21 eligible randomized controlled trials with 1323 subjects were enrolled.
  • After the tea intake, the pooled mean systolic and diastolic BP were –1.8 mmHg (95% confidence interval [CI], –2.4– –1.1 mmHg) and –1.4mmHg (95% CI, –2.2– –0.6 mm Hg) lower, respectively, compared with the tea–free controls.
  • Subgroup analyses showed that the BP–lowering effect was apparent in the subjects who consumed a tea over a median of 12 weeks (systolic/diastolic BP, –2.6/–2.1 mmHg, both P <0.001).
  • Stratified by type of tea, green tea significantly reduced systolic and diastolic BP of –2.1 (95% CI, –2.9– –1.2) and –1.7 (95% CI, –2.9– –0.5) mm Hg, and black tea significantly reduced systolic and diastolic BP of –1.4 (95% CI, –2.4– –0.4) and –1.1 (95% CI, –1.9– –0.2) mm Hg, respectively.
  • The benefits of tea intake were not influenced by ethnicity, treatment dose of tea catechins, individual health status, or caffeine intake.

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Nature’s lubricant makes your body a well-oiled machine

Sep 27

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You may not have heard of the protein lubricin, but it’s what keeps your body moving. And now it’s being used to treat disease and produce new therapeutics.

We wouldn’t get very far without lubricin keeping our joints moving. tableatny/Flickr, CC BY

The old adage goes that the human body is a machine. And in many ways that isn’t far from the truth. Like any machine, the human body is made up of many individual parts moving together in a highly coordinated fashion. Parts slide by other parts with every blink and step. And to keep everything running smoothly and undamaged, the machine needs to be well oiled.

Chances are, you have not given much thought to your body’s lubrication. And in many ways, this is testament to just how effective it is at protecting against damage and wear. One reason that the sliding surfaces of the body are so resilient is because of a little known protein called lubricin which is nature’s most effective “grease”.

Lubricin was discovered coating the surfaces of joint cartilage, and is perhaps the body’s most effective boundary lubricant. The lubricin molecule consists of two adhesive “feet” flanking either end of a long flexible and non-adhesive “string”. It is this dichotomy that is the secret to its effectiveness.

These adhesive feet attach themselves to virtually any surface, forming a loop in the central non-adhesive string. As more and more lubricin attaches to a surface, it self-assembles to form a dense, carpet-like layer of lubricating loops. This layer is known as a “polymer brush”, and it cushions surfaces where they contact, reducing friction as they slide.

Proteins ain’t proteins

Much of what we know about how lubricin protects joints came from the study of a rare but debilitating genetic disease, camptodactyly-arthropathy-coxa vara-pericarditis syndrome. If you find that to be a mouthful, you can call it CACP.

People afflicted with CACP syndrome suffer a mutation in the lubricin gene that leads to a loss of its lubricating ability. Although at birth the joints of CACP syndrome sufferers show no signs of abnormality and are otherwise healthy, the absence of lubricin’s protection quickly leads to joint disfigurement, pain and eventual loss of mobility. Symptoms first appear in children as young as 18 months.

CACP symptoms are similar to those of arthritis sufferers – in fact, CACP syndrome is often misdiagnosed as early onset rheumatoid arthritis – and this led researchers to investigate the possible link between lubricin and arthritis pathology.

It’s now known that arthritic joints contain considerably less lubricin than healthy ones. However, recent discoveries have also found that the concentration of lubricin in joints drop considerably following an injury and remains abnormally low for as much as a year post trauma. This drop in lubricin levels may shed light on the strong causal link between osteoarthritis development and a history of joint injury.

We now believe that these reduced lubricin levels in arthritic and injured joints contributes to both the onset and degenerative nature of osteoarthritis disease, against which there are few effective treatment options. Fortunately, recent animal studies indicate supplementing injured joints with injections of lubricin can be an effective treatment for preventing osteoarthritis development. It does this by reducing wear and tear to cartilage and the death of cartilage cells, which is a major osteoarthritis risk factor, during the critical healing period.

Sight for sore eyes

Although long associated with joints, we are now finding lubricin in some unexpected places, such as the eye. It appears that lubricin is a lubricating component of tears and provides the similar protection to cornea surfaces as it does to joints.

Lubricin also plays a role in keeping our eyes from drying up. LMAP/Flickr, CC BY
Click to enlarge
June 25, 2015 6.14am AEST

Nature’s lubricant makes your body a well-oiled machine

The company Lubris Biopharma is currently conducting clinical trials on a new lubricin treatment for dry eye syndrome.

This syndrome affects millions of people worldwide and is a particularly difficult problem to treat. This is because the eye’s natural cleaning process tends to quickly rinse traditional lubricating molecules into the tear ducts. As a result, eye drops need to be administered frequently, often hourly.

Since lubricin adheres so strongly to surfaces, it is very difficult for the eye to remove it from the cornea surface, allowing a single drop to provide a full day’s worth of relief.

Lube job

In addition to medical therapies, lubricin’s self-assembling and non-stick properties are promising to usher in significant advances in microfluidic based lab-on-a-chip technologies, which are being developed to diagnose diseases such as cancer, AIDS and Ebola.

The unwanted adhesion of antibodies and other biomarkers to the surfaces of these devices is a major source of “noise” and a persistent obstacle to maximising the diagnostic sensitivity. Recent research shows that lubricin anti-adhesive coatings rival the current best technologies, and it can be applied to any substrate material without costly and difficult surface pretreatments or grafting chemistries.

Lubricin coatings thus offer better performance and greater functionality without significant increases in manufacturing costs. As researchers continue to assimilate the body’s slick lessons in lubrication, the possibilities and applications of lubricin will surely grow ever wider.

We might not often think about our body’s lubrication system or lubricin. But a deeper understanding of this remarkable protein is helping us treat diseases and produce new therapeutics to help keep us working as a well oiled machine.

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Effect of oral magnesium supplementation on physical performance in healthy elderly women

Sep 24

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Magnesium(Mg) tablets are one of the supplements I have been on for many years. There are many benefits from Mg, with very few negatives. This is one of the research articles showing why we should take Mg.

Effect of oral magnesium supplementation on physical performance in healthy elderly women involved in a weekly exercise program: A randomized controlled trial

American Journal of Clinical Nutrition, 07/17/2014 Veronese N, et al.

The aim of this study was to investigate whether 12 wk of oral magnesium supplementation can improve physical performance in healthy elderly women. Daily magnesium oxide supplementation for 12 wk seems to improve physical performance in healthy elderly women. These findings suggest a role for magnesium supplementation in preventing or delaying the age–related decline in physical performance.

Methods

  • In a parallel–group, randomized controlled trial, 139 healthy women (mean ± SD age: 71.5 ± 5.2 y) attending a mild fitness program were randomly allocated to a treatment group (300 mg Mg/d; n = 62) or a control group (no placebo or intervention; n = 77) by using a computer–generated randomization sequence, and researchers were blinded to their grouping.
  • After assessment at baseline and again after 12 wk, the primary outcome was a change in the Short Physical Performance Battery (SPPB); secondary outcomes were changes in peak torque isometric and isokinetic strength of the lower limbs and handgrip strength.

Results

  • A total of 124 participants allocated to the treatment (n = 53) or control (n = 71) group were considered in the final analysis.
  • At baseline, the SPPB scores did not differ between the 2 groups.
  • After 12 wk, the treated group had a significantly better total SPPB score (Δ = 0.41 ± 0.24 points; P = 0.03), chair stand times (Δ = –1.31 ± 0.33 s; P < 0.0001), and 4–m walking speeds (Δ = 0.14 ± 0.03 m/s; P = 0.006) than did the control group.
  • These findings were more evident in participants with a magnesium dietary intake lower than the Recommended Dietary Allowance.
  • No significant differences emerged for the secondary outcomes investigated, and no serious adverse effects were reported.

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Progesterone protects against Breast Cancer.

Sep 23

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This is an interesting scientific article showing something we have known for a long time- progesterone protects against breast cancer. Note – it has to be the natural progesterone and not the progestogens (synthetic) in most HRT.  Women make large amounts of progesterone during pregnancy, which is why it is very rare for pregnant women to develop breast cancer. Progesterone is in most of my Bioidentical prescriptions.
Nature. 2015 Jul 8. doi: 10.1038/nature14583. [Epub ahead of print]

Progesterone receptor modulates ERα action in breast cancer.

Mohammed H1, Russell IA1, Stark R1, Rueda OM1, Hickey TE2, Tarulli GA2, Serandour AA1, Birrell SN2, Bruna A1, Saadi A1, Menon S1, Hadfield J1, Pugh M1, Raj GV3, Brown GD1, D’Santos C1, Robinson JL1, Silva G4, Launchbury R1, Perou CM4, Stingl J1, Caldas C5, Tilley WD2, Carroll JS1.

Author information

Abstract

Progesterone receptor (PR) expression is used as a biomarker of oestrogen receptor-α (ERα) function and breast cancer prognosis. Here we show that PR is not merely an ERα-induced gene target, but is also an ERα-associated protein that modulates its behaviour. In the presence of agonist ligands, PR associates with ERα to direct ERα chromatin binding events within breast cancer cells, resulting in a unique gene expression programme that is associated with good clinical outcome. Progesterone inhibited oestrogen-mediated growth of ERα+ cell line xenografts and primary ERα+ breast tumour explants, and had increased anti-proliferative effects when coupled with an ERα antagonist. Copy number loss of PGR, the gene coding for PR, is a common feature in ERα+ breast cancers, explaining lower PR levels in a subset of cases. Our findings indicate that PR functions as a molecular rheostat to control ERα chromatin binding and transcriptional activity, which has important implications for prognosis and therapeutic interventions.

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How to take care of your vulva.

Sep 22

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By Celia Shatzman May 7, 2015

How to take care of your vulva

When it comes to your lady parts, you probably don’t know as much as you think you do. “Many women don’t even know what the vulva is,” says Libby Edwards, MD, chief of dermatology at Carolinas Medical Center in Charlotte, North Carolina. “They call everything down there the vagina, but the vagina is the internal organ and the vulva includes the vaginal lips, clitoris, and the opening to the vagina.”

As a vulvar dermatologist (yes, that’s a thing) Edwards specializes in caring for women with chronic vulvar symptoms like itching, pain, rawness, painful sex, and chronic discharge. (For more on the specialty or to find one in your area, visit the National Vulvodynia Association at nva.org.)

Why see one? The vulva tends to be an area that a general dermatologist will bypass during routine skin checkups, says Cynthia Rasmussen, MD, FACOG, director of vulvovaginal services at Harvard Vanguard Medical Associates in the Boston area. But you don’t have to schedule an appointment with a specialist to get their top tips on caring for your skin down there—they’ve shared their knowledge, below.

You clean too well.
The vulva naturally secretes thick oils that protect its delicate skin from the secretions and friction it’s exposed to on a daily basis, Rasmussen says. Scrub off those oils with harsh cleansers (think body washes or douches with dyes, fragrance, or surfactants), and your vulva will be more prone to irritation, she says. Worse, you’ll remove the good bacteria that help maintain a healthy pH and make room for odor- and infection-causing bacteria to move in. So keep it simple and clean your vulva with warm water, by hand, then leave it be.

You use feminine hygiene products.
Products claiming to clean, deodorize, and groom the area are best left at the drugstore, Rasmussen says. The fragrances, dyes, chemicals, preservatives, and anti-itch anesthetics they contain aren’t necessary, and can cause allergic reactions. “Vulvar skin is extra sensitive because it’s thinner than skin on other parts of the body,” she explains. “Also, the vulva and vagina are hormone responsive tissues, and sensitivity goes up after menopause and may increase during parts of the menstrual cycle.” All you really need? You guessed it—water, Edwards says.

You haven’t discovered Vaseline.
Irritated vulva? Moisturize it, Edwards suggests. Just like other spots on your body, your vulva can get dry, even if you haven’t gone through menopause yet. But don’t reach for a regular body lotion, which are typically packed with drying alcohol and irritation-causing fragrances. Try a tiny dot of basic petroleum jelly, like Vaseline ($2, drugstore.com), which is free of fragrance, alcohol, and preservatives.

You don’t know how to deal with post-menopausal dryness.
Nearly every woman deals with some degree of vaginal dryness when she hits menopause. “Post-menopausal skin in the area is thinner, dryer, and more vulnerable to irritation,” Rasmussen explains. It can make sex hurt, predispose you to urinary tract infections, and cause urethral and bladder irritation. Luckily, vaginal moisturizers, available at drugstores, can help: “They help retain moisture, but are designed not to irritate the delicate mucous membrane of the vagina,” Rasmussen says. Still, it’s smart to look for an option with a simple ingredient list and dab just a small amount on your inner thigh to make sure it doesn’t cause burning or irritation before attempting full coverage.

You use fancy lubes.
Lube is a great option for women experiencing dryness, whether you choose water-based, silicone, or oil-based formulas, says Rasmussen. (Oil- and silicone-based lubes stay slippery indefinitely but can stain sheets and clothing, while water-based lubes wash off easily but can dry out and become sticky.) No matter which you prefer, avoid anything with dyes, perfume, fragrance, flavor, or ingredients that claim to give a tingling or warming sensation, all of which can be irritating. Yes certified organic personal lubricants ($7, yesyesyes.org) come in both water- and oil-based versions made entirely of ingredients you can pronounce, like aloe, sweet almond oil, cocoa butter, and beeswax.

You’re using the wrong birth control.
Many women are allergic to latex or spermicides.

Many women are allergic to latex and spermicide, both of which are ingredients in most condoms. If you feel a burning sensation after using one, don’t brush it off. “Latex condoms can cause hives or rashes in women who are allergic to the material,” cautions Edwards. (If you suspect you’re allergic, try non-latex condoms made of polyurethane or polyisoprene.) But that’s not the only form of birth control that should be on your radar. “Some hormonal contraceptives, especially progesterone contraceptives such as Depo-Provera shots, can thin and dry the vagina, making sexual activity uncomfortable,” she adds. If you have sensitive skin or notice an increase in dryness, talk to your doctor about alternative birth control options.

You wear pretty lingerie.
“The way thongs rub your skin can cause tissue irritation,” says Rasmussen. “In general, you’re best off with full-coverage unbleached 100% cotton underwear.” Those with sensitive skin can have reactions to dyes and synthetic fabrics, and the elastic can aggravate women with rubber allergies. But you don’t have to stop wearing pretty little things in the name of health: all of Knock Out’s lacy, colorful underwear have a 100% cotton, dye-free liner (from $19, knockout.com).

You shave (or wax, or use depilatories).
Waxing incorrectly could burn the vulva.

“Most of us store our razor in the shower, a warm, moist environment where bacteria can multiply,” says Rasmussen. “That’s a recipe for infection the next time you nick yourself.” But you don’t have to entirely nix your razor: Just use a natural shaving lotion like Pacific Shaving Company All Natural Shaving Cream ($8, pacificshaving.com), which contains none of the irritating chemicals and fragrances found in traditional foams, and use a brand new blade each time you shave (try buying disposables). Alternative hair removal methods can get you into trouble, too: “The harsh hair-dissolving chemicals in depilatories are very irritating to the sensitive vulvar skin,” Rasmussen explains. Waxing, if done incorrectly, can also be risky because it’s possible to burn the skin. Your safest bets: laser hair removal or trimming hair with small scissors. (Read these 13 things you need to know before your next bikini wax.)

Your laundry smells amazing.
“When someone comes to me with distressed skin, I immediately ask them what they wash their clothes in,” says Rasmussen. That’s because laundry detergent with dyes and perfumes can irritate delicate vulvar skin. Choose detergents that don’t contain dyes and perfumes, and skip fabric softeners and dryer sheets, which are loaded with irritating chemicals. Look for detergents labeled “Free and Clear”, which means they don’t contain dyes or perfumes. One to try: Gentle Extra-Softening Pureturgent Liquid Detergent ($10, worldmarket.com), an unscented, biodegradable formula with aloe vera.

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We’re overdosing on medicine – it’s time to embrace life’s uncertainty

Sep 21

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This is my 700th posting (blog) I enjoy what I do and intend to do many more. I try to cover a wide range of medical issues, with a bias to hormonal problems mainly. I keep to reputable sources of information, from credible institutions (academics, universities, medical publications) wherever possible. Keep reading.

We’re overdosing on medicine – it’s time to embrace life’s uncertainty

August 3, 2015 6.09am AEST

Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little. Kathea Pinto/Flickr, CC BY-SA

Author

  1. Senior Research Fellow at Bond University

Disclosure statement

Ray Moynihan is helping organise the Preventing Overdiagnosis conferences. He wrote this article in close collaboration with Dr Iona Heath.

Bond University is not a member of The Conversation and does not financially support the project. Find out more

The Conversation is funded by CSIRO, Melbourne, Monash, RMIT, UTS, UWA, ACU, ANU, ASB, Baker IDI, Canberra, CDU, CQU, Curtin, Deakin, ECU, Flinders, Griffith, the Harry Perkins Institute, JCU, La Trobe, Massey, Murdoch, Newcastle, UQ, QUT, SAHMRI, Swinburne, Sydney, UNDA, UNE, UniSA, UNSW, USC, USQ, UTAS, UWS, VU and Wollongong.

The more we learn about the problem of too much medicine and what’s driving it, the harder it seems to imagine effective solutions. Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation.

But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.

We’re all ill now

A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing. In the United States, it’s estimated that more than US$200 billion a year is squandered on unnecessary tests and treatments. In the United Kingdom, senior medical groups are calling on doctors to reduce all the wasteful things they do. And in Australia, the Choosing Wisely campaign recently kicked off with lists of unnecessary and harmful health care.

Not only are we overusing pills and procedures, we’re creating even more problems with “overdiagnosis” by labelling more and more healthy people with diseases that will never harm them.

Screening programs targeting the healthy can detect potentially deadly cancers and extend lives. But they can also find many early abnormalities that are then treated as cancers, even though they would never have caused anyone any symptoms if left undetected.

The common ups and downs of our sex lives are often re-labelled as medical dysfunctions. Older people who are simply at risk of future illness – those with high cholesterol, for instance, or reduced kidney function, or low bone mineral density – are portrayed as if they were diseased.

The doctors expanding disease definitions and lowering the thresholds at which diagnoses are made are often being paid directly by the companies that stand to benefit from turning millions more people into patients.

It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death. Javier ie/Flickr, CC BY-NC-ND

What’s driving all this excess is a toxic combination of good intentions, wishful thinking and vested interests – fuelled by sophisticated diagnostic technology that often offers the illusion of more certainty about the causes of our suffering. It’s as if we’re seeking technical fixes for the fundamental reality of human existence – uncertainty, ageing and death.

Fundamental shifts in thinking

Indeed, intolerance of uncertainty has been suggested as among the most important drivers of medical excess. Doctors order ever more tests to try, often in vain, to be sure about what they’re seeing – to be more certain. But disease and the benefits and harms of treating it are inevitably fraught with uncertainty because we’re trying to apply knowledge derived from populations to unique individuals.

More broadly, uncertainty is the basis of all scientific creativity, intellectual freedom and political resistance. We should nurture uncertainty, treasure it and teach its value, rather than be afraid of it.

No matter how much the marketers of medicines try to make us feel broken by the mere passing of time, ageing is not a disease. Disease definitions that equate “normal” with being young are fundamentally flawed and require urgent review.

The doctors who defined osteoporosis, for instance, arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as “diseased”. Similarly, those who defined “chronic kidney disease” have classified the normal changes in kidney function that happen as many of us age as somehow abnormal. Brace yourself for the impending arrival of pre-dementia, the latest attempt to medicalise the ageing process.

In all cases, the people who wrote these definitions included those with ties to pharmaceutical companies – reinforcing the need for much greater independence between doctors and the industries that benefit from expanding medical empires.

Rays of hope

Everyone must die and everyone, patients and doctors alike, is more or less fearful of dying. So, it’s perhaps not surprising that we so often turn to biotechnical approaches rather than paying real attention to the care of the dying – a core purpose of medicine.

The doctors who defined osteoporosis arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as ‘diseased’. sandeepachetan.com travel photography/Flickr, CC BY-NC-ND

What we tend to forget is that medicine cannot save lives – it can only postpone death. Yet we persuade ourselves it might somehow keep extending our lives, and we come to view almost every death as a failure of medicine.

Doctors persist with treatments for the dying well after these have become obviously futile, often with the support of patients or their families. Deep, difficult and necessary conversations about death and dying are only possible in a context of trust, which becomes increasingly difficult as health-care systems are ever more fragmented.

But, there are many positive signs of change within medicine. The Choosing Wisely campaign mentioned above is a partnership between doctors and wider civil society. And it’s now an international movement to wind back excess medicine.

A new approach called shared decision making is promoting much more honest conversations between doctors and the people they care for, embracing uncertainty about benefits and harms, rather than peddling false hopes. Another new approach among GPs called quaternary prevention is urging doctors to protect people from unnecessary medical labels and unwarranted tests and treatments.

Perhaps all these new movements will re-establish doctor-patient trust, helping us reduce fear and embrace uncertainty, and end the pretence that medicine can cure ageing and even death. Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little.

Former president of the UK Royal College of General Practitioners, Dr Iona Heath, co-authored this article. Dr Heath will deliver a free public lecture on the problem of “Too Much Medicine” at the University of Sydney this Wednesday night, August

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What causes headaches?

Sep 17

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Health Check: what causes headaches?

July 27, 2015 2.10pm AEST

Author

  1. Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist at Barwon Health


Tension-type headaches feel like a dull or heavy, non-pulsating band of pain, usually on both sides of the head. RXAphotos/Flickr, CC BY-ND

More than half (52%) of people will have a tension-type headache at some point in their life, around 18% will get a migraine, and 4% will suffer from chronic daily headaches. These are the most common headache-related diagnoses. Although there are some variations globally, the figures seem remarkably consistent across populations.

Secondary headaches can be initiated by triggering factors such as medication overuse, medication side effects, neck pain, sinus disease or dental problems. These account for small percentages individually compared to the primary headaches, but may be more treatable if the predisposing problem can be sorted out.

Tension-type headache

Tension-type headaches (TTH) feel like a dull or heavy, non-pulsating band of pain, usually on both sides of the head. The name comes from an erroneous belief that overly tight muscles are the main reason for the headache.

TTH usually occurs in episodes, with each lasting from several hours up to a few days at a time. There is not usually much associated nausea, light sensitivity or sound sensitivity.

Chronic TTH is a less common form and is diagnosed when you have experienced at least 180 days with a headache per year. It is generally not aggravated by routine physical activity; it’s just there all the time.

Genetic tendencies explain some of the risk for developing TTH, with your own risk increased threefold if you have an immediate family member with the condition.

Infrequent episodic TTH does not appear to be strongly associated with psychological stress, despite this common belief. Chronic TTH has a stronger association with higher psychological distress, but it is unclear whether this is a cause or effect of having long-term disabling headaches.

Strangely for such a common and problematic condition, there is still little agreement about exactly how the pain is produced in TTH.

The most attractive hypothesis to me is that it represents a “virtual” pain whereby multiple low-grade inputs (likely including inputs that are “almost-painful”, or below the threshold for conscious pain) add up to produce sensitisation of the trigeminal nerve nuclei (the nerve shown in orange below).

stihii/Shutterstock
Click to enlarge

This turmoil registers as pain referred to the distribution of the head, usually the forehead, temple and back of the head locations. Examination of these areas doesn’t show any abnormalities because in TTH, there is no one driving mechanism of the headache.

Treatment remains almost trivially simple, despite years of research. It’s almost true to say that the proverbial “cup of tea, a Bex and a good lie down” sums it up. Aspirin, paracetamol or ibuprofen plus rest and possibly some cold packs seem to be the most reliable treatment. There is conflicting or negative evidence for almost every other, fancier therapy.

Migraine

Migraine alone is the sixth most disabling condition globally.

Migraines are usually one-sided, associated with nausea and light sensitivity (photophobia) and may also be preceded by idiosyncratic sensory experiences called an “aura”. Aura phenomena can include moods or emotions, such as deja vu, visual symptoms (flashing lights or jagged lines are common) or problems with speech.

Migraine is a clinical diagnosis; there is no objective test that can verify it with our current technology. But compared to the frustration of researching and treating tension-type headaches, migraine has been steadily giving up its secrets over the past decade.

Migraine physiology is extremely complex. The headaches seem to arise because of dysfunctional regulation of the tone of some of the blood vessels inside the skull.

Migraine sufferers – Migraineurs – may have genetic vulnerability to migraines because of overly responsive calcium channels in their nerve membranes or other mutations which result in them having overactive signalling pathways in the brain.

Environmental or internal triggers can provoke these nerves to over-react, resulting in the activation of a reflex pathway. This dysregulation of normal structures causes the headache, nausea, photophobia and phonophobia (sound sensitivity) typical of an attack.

Migraines are often associated with light sensitivity. Rishi Bandopadhay/Flickr, CC BY-NC

The period of headache in a migraine attack corresponds with a rise in the blood levels in the head of a peptide called calcitonin gene-related peptide (CGRP). CGRP is one of the most common pain-inducing signal molecules in the body. When the CGRP falls, the headache goes away. Where the extra CGRP comes from is not clear but it probably is released from the overactive networks of cells in the brainstem.

The most effective group of drugs for migraine are the triptans. So effective and specific are these drugs that the diagnosis of migraine needs to be reconsidered if they don’t abort the headache attacks most of the time.

Triptans work by activating certain subtypes of serotonin receptors in the brain. Taking a triptan early in a migraine attack seems to directly lower the CGRP release and oppose its effects on blood vessels thereby stopping the attack. Triptans are not however useful to prevent frequent attacks of migraine.

Migraine prophylaxis is achieved by several drugs of different classes, with radically differing mechanisms of action. Some are anticonvulsants, which clearly work by suppressing the nerve overactivity typical of migraineurs. Others, such as the beta-blockers (propranolol) and calcium-channel blockers (verapamil) target the nerve endings on the blood vessels. Others which are known to be effective, such as botulinum toxin (Botox) and amitriptyline (Endep) work by means which are yet to be fully understood.

Severe migraineurs suffer years of disability and as a public service I would like to suggest that if you know someone who has severe migraines (you almost certainly do) please read this excellent list of what not to say to them when trying to be sympathetic or helpful.

Chronic daily headache

Imagine that you never had a day without headache. You can remember vaguely the time when you didn’t feel that pounding in the temples, squeezing in the back of the head or piercing pain above the eyes but it seems like another life. Such is the lot of sufferers of chronic daily headache (CDH).

Some headaches begin as as frequent but clearly episodic tension-type headache, or migraine, but then “transform” into what seems to be basically a continuous headache for at least some part of every day.

There are a number of rare headache types which may cause chronic daily headache and diagnosis of the these can lead to specific treatments which work well. This is the role of a neurologist or pain specialist with a special interest in headache.

If you have more than just the occasional headache, it pays to get a proper diagnosis. Jared Earle/Flickr, CC BY-NC-ND

Possibly the most common reason why tension-type headache or migraine can transform is medication overuse, especially short-acting opioids such as codeine. The best solution to this problem is to avoid long-term regular use of codeine for headaches, though the evidence would suggest we may never achieve this goal except by making codeine prescription-only.

Frequent use of triptans is also believed to sensitise the trigeminovascular networks in the brainstem, thereby lowering the bar for triggering of migraine attacks. If the threshold for an attack becomes too low, they may never quite switch off, and one attack will run into the next one.

If you have more than just the occasional headache, it pays to get a proper diagnosis, as the reasons for your headache can be many and varied. Some have specific treatments for them, and others such as TTH seem quite difficult to find a specific treatment for. There are new classes of drug treatment under development, for migraine in particular, so it looks hopeful that future generations may not have to labour under the burden of poorly treated headaches.

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Vaginal oestrogen for overactive bladder in post-menopausal women.

Sep 16

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Br J Nurs. 2015 Jun 11;24(11):582-5. doi: 10.12968/bjon.2015.24.11.582.

Vaginal oestrogen for overactive bladder in post-menopausal women.

Ostle Z1.

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Abstract

This article asks the question ‘Should nurses recommend vaginal oestrogen for overactive bladder in post-menopausal women?’ The article will review the evidence for use of vaginal oestrogen and consider the potential side-effects and risks. The main finding is that vaginal oestrogen is effective for treatment of overactive bladder in post-menopausal women with vaginal atrophy. However, vaginal atrophy is undertreated. This article identifies some of the barriers that may prevent diagnosis and treatment, and suggests changes in practice. Nurses should take the initiative and ask post-menopausal women about symptoms. Nurses should be trained to examine women, diagnose vaginal atrophy and discuss treatment.

KEYWORDS:

Continence; Overactive urinary bladder; Postmenopause; Urge urinary incontinence; Vagina

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My new Address.

Sep 13

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I will be at my new address from tomorrow. It is 201-205 Morayfield Road, not far from the old clinic. When coming from Brisbane or elsewhere south, take the Buchanan road exit, which will take you around the shopping centre onto Morayfield road where the Morayfield 7 Day Medical Centre will be just left of the Intersection. If approaching from south on Morayfield Rd, you will find yourself on the wrong side of the median strip and will have trouble doing an about turn. Check this website for complete directions:

http://www.ipn.com.au/gp/qld-morayfield-morayfield-7-day-medical-centre/

The Phone no. remains the same.

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