Contagion

Yesterday I boarded a plane to Hong Kong along with my lovely family. A long journey to say the least - 11 hours (not helped by an hour delay at Heathrow!) Scouring through the BA inflight entertainment, I have to say, only one movie really appealed to me - Contagion.

Without spoiling the plot (although to be honest, the film was so bad I strongly advise you don't see it), Contagion concerns a deadly pandemic of the fictional disease Meningoencephalitis Virus One (MEV-1). MEV-1 is a retrovirus that infects both the lungs and the brain,  causing severe cough, fever and headache, before culminating in seizure, brain haemorrhage and death. By the end of the film, 26 million people in the world die and it seems everywhere there is chaos and suffering. For those of you keen to see what I'm talking about, the trailer can be found here. Now, as I said, the film was beyond dreadful - horrific, I could have probably have done a better acting job (that's saying something!) However, the film first captured my attention because it concerns the outbreak of a deadly, global pandemic. This is an issue that really fascinates me.

The world has experienced its fair share of epidemics and pandemics. We've had the Black Death, Spanish Flu, Smallpox, Malaria and more recently SARS, MRSA, Bird Flu, Swine Flu and of course, HIV and AIDS. The topic of end-of-the-world situations has always fascinated me for some reason, and simulating such an event through a sudden outbreak of disease is something I take an even greater interest in. The aim of this particular blog entry is to assess (albeit with very limited knowledge) what we can expect to see pandemic-wise in the future.

Bird Flu, or H5N1, sent the world into shock in 2004, killing around 60% of the people it infected, which was only 565 people with 331 known deaths. There was great danger especially in China and Asia. However, despite the initial large shock, H5N1 died down because not that many actually caught the disease. A 60% mortality rate is high, but what stopped H5N1 from becoming a Contagion-esque pandemic was the virus' inability to effectively spread between humans. This all changed, however, when in September last year, scientists in America introduced 5 gene mutations to the H5N1 virus genome. These mutations enabled the virus to spread a lot more effectively between ferrets in a lab, yet the virus was still just as deadly. If H5N1 were to mutate in this way, the world would definitely have a serious problem on its hand. There is even a big dispute Stateside at the moment regarding as to whether it would be safe to publish a scientific report on these findings - bioterrorists could easily access the information and use it to their advantage. David Nabarro, UN coordinator for avian and human influenza, predicted Bird Flu could kill up to 150 million people around the globe. That, folks, would be a big problem indeed.

MRSA stands for Methicillin-Resistant Staphylococcus Aureus; it is a selection of strains from the bacterium species Staphylococcus Aureus. A decent proportion of us find S.Aureus on our skin and in our nasal passages - it is generally harmless. However, once it gets under our skin (through open wounds for example), S.Aureus can be a real pain. It can cause conditions from pimples, impetigo (skin condition) and boils to life-threatening conditions such as pneumonia, meningitis, septicaemia and toxic shock syndrome. My late grandmother suffered from MRSA - it was particularly unpleasant. MRSA and more 'normal' strands of S.Aureus do not tend to differ in how aggressive they each are, they differ in how they can be treated. Simply put, MRSA are strands of S.Aureus that have survived antibiotic treatment (somebody forgot to finish their course..) and through a few natural genetic mutations. They have evolved (natural selection etc.) to become resistant to that particular antibiotic. Over time, hospitals have resorted to using a range of antibiotics to treat MRSA, and over time MRSA had indeed become resistant to this variety of antibiotics too. Thus MRSA appears, theoretically, to be unstoppable over time - it will always win. Maybe so, maybe not. Maybe other bacteria will become antibiotic-resistant too? Multidrug-Resistant Tuberculosis and then Extensively Drug-Resistant Tuberculosis have already been identified. What's next? We'll have to wait and see.

My final scenario revolves around a disease like Smallpox. Smallpox was the first ever disease to be eradicated from the world in 1977 through a lengthy, but effective, vaccination campaign. Smallpox was both extremely deadly (mortality rate of 62%) and could easily spread - in the 20th century alone, it was estimated there were between 300 and 500 million deaths worldwide. Two phials of Smallpox were kept safely stored in US and Russian laboratories, however there are (and always will be) conspiracy theories that the phials were removed for whatever reason (robbery, experiments etc.) and thus there is a definite chance that Smallpox could once again invade the planet. The incubation period (time elapsed between primary infection and appearance of symptoms) is 12 to 24 days. This long period of time would allow infected individuals to spread the virus all over the world (particularly through the recent boom in aviation travel) before any symptoms were detected. Besides, we eradicated Smallpox years ago - how many people are actively looking for symptoms and incidences? Since the virus was completely eliminated back in 1977, no one was vaccinated for it afterwards, as there was no need - people born within the last 35 years would be very vulnerable to it. Governments do stockpile vaccines but they would have to act extraordinarily quickly to prevent significant fatalities. This could very well become a Contagion-esque situation, although fortunately we do know how to treat Smallpox. There's no doubt in my mind, however, that Smallpox would absolutely storm the planet if let loose.

Am I scaremongering? Any other pandemics you reckon could erupt? Let me know!
AJ

Fabrice Muamba

I'm sure that if you didn't see this game in progress, that you will at least definitely have heard about this story on the news. During a football match between Bolton and Spurs on saturday, Bolton's Muamba suddenly collapsed after about 40 minutes of play. He had not been contacted in any way, nor was he moving particularly vigorously - he simply fell to the ground. Obviously, play was stopped and both players and officials were very quick and keen to whistle on the hospital staff. Six medical staff rushed over to try and stabilise the 23-year old, before he was rushed to the London Chest Hospital. A video of the incident can be viewed here.

It is always very concerning when a very fit and healthy 23-year old suffers from such a catastrophic and sudden heart attack. In 2003, Cameroonian footballer Marc-Vivien Foé suffered a very sudden heart attack, similar to Muamba. He was not contacted, he was not even near other players, however he died right there on the pitch. Similarly in 2004, Hungarian footballer Miklós Fehér suffered a sudden heart attack on the pitch, from which he died within a few hours. Fehér was issued a yellow card, to which he bent forward to sigh upon the penalty, before falling backwards and collapsing. Both incidences can be viewed here.

What these two footballers have in common (and I suspect Muamba too) is that both died from cardiac arrest, caused by hypertrophic cardiomyopathy. 


The U.S. National Library Of Medicine defines hypertrophic cardiomyopathy as:

"Hypertrophic cardiomyopathy (HCM) is a condition in which the heart muscle becomes thick. The thickening makes it harder for blood to leave the heart, forcing the heart to work harder to pump blood...Hypertrophic cardiomyopathy is often asymmetrical, meaning one part of the heart is thicker than the other parts. The condition is usually passed down through families (inherited). It is believed to be a result of several problems (defects) with the genes that control heart muscle growth. Younger people are likely to have a more severe form of hypertrophic cardiomyopathy. However, the condition is seen in people of all ages."

The most severe symptom of hypertrophic cardiomyopathy is sudden heart failure, seen in young athletes. This condition is so dangerous as it often has no obvious symptoms and would be undetectable unless it is found through a (very thorough) medical examination.


Obviously this is a terrifying condition. We are all, especially at a young age, encouraged to eat well and exercise frequently to keep our health up. Well these three individuals all did that - their careers depended upon their fitness. It is scary to think that despite their best efforts, they can be ambushed by hypertrophic cardiomyopathy in such a way that two of the three died soon after cardiac arrest (luckily Muamba appears to have been stabilised now). Especially through watching the videos, it is like the hand of God has come down and attacked them with one fell and fatal swoop. It is a truly tragic condition and it is a very distressing situation seeing a player collapse as such, and seeing the horrified and distraught reactions of his teammates and the crowd. Traumatic to say the least. All we can hope for is, I guess, better and more frequent screening for hypertrophic cardiomyopathy.


Let's hope Muamba holds up and makes a swift return!
AJ

Professor Anthony Warrens

Today, at school, we were all fortunate to receive a visit and a talk from none other than Professor Anthony Warrens. For those of you who do not know who this illustrated man is, he is the Dean of Medicine at Barts Medical School. Professor Warrens holds many a degree, and is a member of the Royal College of Physicians. This is only a brief outline of his career, for a more detailed (yet also undoubtedly brief) summary of his career, please click here.

The main focus of Professor Warrens' talk today was on the concept of transplantation, in particular renal transplantation. He showed us much evidence and urged us to support his view that we should, if we agreed with organ donation, sign up to become an organ donor as soon as we could. Professor Warrens showed us that living with renal failure is very tough, and living with kidney dialysis isn't particular pleasant or easy either - it's hard to maintain a 'normal' life whilst on dialysis. Warrens continued by stating that whilst patients needing a kidney transplant could technically survive on dialysis, this sort of treatment isn't available for other organ failures: a brain transplant, for example. In short, we were urged to consider how important transplants are. An issue that is frequently in the news, and one that was illustrated to us today on a graph, is the number of transplant operations undertaken against the demand for transplants. It was staggering - sometimes the demand for transplants were up to five times the supply. This is a shame, for 70% of the UK agree with organ donation, yet only 25% or so of citizens are a registered organ donor.

An underlying question to the talk that we all thought was, "how can we increase the number of organ donors?" This, it appears, is a significant challenge. Professor Warrens explained to us that when he has been supervising patients who were, unfortunately, very close to inevitable death. It was very difficult to convince the patient or his/her family to let the patient's organs be used after death, even if they might be pro-donation. This is understandable - death is a very grave and stressful period in the patient's and family's lives - they do not want to conceive the idea of death in their mind, nor do they want to focus on what to do after death.

Speaking to his patients who did receive transplants, it is worth knowing that the patients were eternally grateful. They realised that the transplant had effectively given them a second chance at life, improving not only their potential lifespan, but also significantly improving their quality of life. This cannot be understated - I am completely for transplants, it is a wonderful thing. However, unfortunately, the UK stance is that in order to become an organ donor, one must sign up to be so. I whole heartedly disagree with this. Coming back to the fact that 70% of people are pro-donation, but only 25% sign up, I believe the UK should shift from an opt-in procedure, to an opt-out method. It would benefit the lives of patients, their family, the government. And no less, it would make Professor Antony Warrens (and myself) very happy and satisfied indeed.

Let me know what you think!
AJ

Work Experience - RASS

I would like to write today on the subject of work experience, and more specifically my experience of it. One of the placements I have is working as a volunteer at a nursing home called The Royal Alfred Seafarers Society, for 2 hours every sunday. The home is almost exclusively for those who served in the Royal Navy, or in the Merchant Navy; and specialises in treating dementia - an extremely prevalent and saddening condition in the elderly.

Unfortunately, there is very little an unpaid, untrained volunteer can do, as most of the jobs are delegated to the experienced nurses. However, I do have a few roles. I like to think of myself as the home's welcome party - whenever there is a new resident I am asked to greet them, welcome them in and have a chat with them about their life, their career, their family and just about anything really. I also chat, in a similar fashion, with other incumbent residents every week. In addition to this, the RASS has spectacular gardens and scenery and whenever the weather's nice, I ask around if any of the residents would like a walk around the garden. I say walk - unfortunately the majority of residents are too weak to use their legs and so my job is to push them in their wheelchairs. It is an enjoyable bonding experience nonetheless, and it really is encouraging to see their positive reactions to the great outdoors.

As I mentioned earlier, the home specialises in treating dementia. What is dementia? In a nutshell, it is a condition caused by diseases such as Alzheimer's, characterised primarily and most notably by memory loss, but also other symptoms such as personality changes and impaired reasoning. It is a particularly saddening condition because sometimes the memory loss is so severe. Once, I was tasked with asking a resident to sign some Christmas cards for his family. He seemed fine at first, able to write the first couple of letters of 'love from'. Then dementia set in: he suddenly dropped his pen. I picked it up and handed it back to him, but after a few rough strokes it wasn't long before he admitted he had forgotten how to write, and that he had no idea what he writing about. Completely new to dementia at the time, I couldn't quite believe it. I bewilderedly filled out the last few letters of 'love from' and handed the pen back to him, to see if he could sign his name. And then it was the next bit that was most tragic - this particular resident had forgotten his own name. I was shocked. I won't conceal it, I had never given much thought to dementia. I held the rather naïve and insensitive view that dementia was only a minor condition - HIV is imploding Sub-Saharan Africa everyday, that was a big deal. But dementia? Dementia never directly killed anyone. How wrong I was. 

Dementia steals identities. A once proud, successful, vibrant life now effectively ended, replaced by pure nothingness. An empty body, you could say - the lights are on, but nobody's home, and nobody will ever come home. This leads me onto my experiences today. I was asked to welcome a new resident, who we shall call Mr. X. I was informed Mr. X was a former Head of Intelligence in the Royal Navy, in which he served for around 60 years. He seemed like a very friendly, engaging person, and spoke with that air of intelligence that makes the conversation flow just that little bit better. The trouble came when I asked him what his job as HoI entailed. He had to think long and hard about it, and his answer of "the odd job here and there" seemed like a rather empty, unsatisfying response to me. Unfortunately Mr. X had dementia. Fortunately, it wasn't severe. But again I saw the horrifying effects of dementia. One of the country's greatest heroes: fighting during WW2, progressing to HoI, serving for 60 years. A life to be celebrated by all, and with many lavish stories to tell. Now all that was left was a few scraps of memory here and there. A general outline - he remembered that he was HoI, but no detail - he couldn't remember what his job was like. Dementia is one of life's greatest tragedies. Such a prominent man reduced to almost nothing. A grave shame indeed.

In my experience, the vast majority of new residents tend to like the RASS. It is an outstanding, clean and well designed home, with exceptional facilities and a loving, dedicated staff. However there is the odd anomaly every now and again. The biggest reason for this is that they simply don't want to be there, for whatever reason. This story was no different. Today I was told to avoid another resident. She was new too. I do not know why Mrs. Y was admitted here, but it was clear she disagreed with whoever or whatever placed her here. Over the past week she had been barking to the nurses from her wheelchair, "Nurse nurse! Get the police, police! I've been kidnapped! Urgent!". Obviously, no nurses felt obliged to call the police, but this is another prime example of the tragedy caused by mental illness and dementia. Mrs. Y was also known to ask to have her wheelchair placed next to her husband's in the lounge area. Her husband? Try the resident who forgot his own name. Were they married? No, he had been at the home for several years, she had been here for one week - they did not know each other, and the extent of the dementia would, unfortunately, mean they would be unlikely to start their 'marriage.' From a certain, disturbing perspective, one might find this story somewhat comical. However, in reality, it is far from it. It is a harrowing story of how dementia can ravage a person so greatly that such events could ever happen.

We do not know great deals about dementia and Alzheimer's. But I know these patients can't be saved now. A panacea may cure them of their memory loss but ultimately their memories have been lost forever in the warps of time and space, never to be discovered again. Such a shame.

Signing off on that rather sombre note,

AJ

Medical Ethics - Euthanasia

"Dr. X is a medical SHO (Senior House Officer) working in the stroke team. An 89 year old lady is admitted following a large stroke which has left her bedbound, incontinent, paralysed down one side and unable to speak. After a few days on Dr. X's ward she develops a chest infection which requires antibiotics. Her daughter tells Dr. X that her mother was always fit and active and it would have been her "worst nightmare" to live like this. She suggests that if her mother could speak, she would refuse the antibiotics."

Does Dr. X administer the antibiotics?

Firstly, it would be worth to clarify the situation. If Dr. X withholds the antibiotics on the daughter's request, allowing the mother to die, then this would be voluntary passive euthanasia. By this I mean that Dr. X would not be actively killing the mother (by injecting a large quantity of morphine, for example), but would simply be permitting her death by removing life-saving treatment. There is a very fine line between active and passive euthanasia, the former of which is illegal, the latter legal. The difference between active and passive euthanasia essentially relies on two key questions that must be asked:

1. Is Dr. X acting or omitting?

2. Is Dr. X intending death or foreseeing it?

Thus we can conclude that in this situation, Dr. X would commit passive euthanasia as he is omitting treatment, and foreseeing death. Death is somewhat intended, although in the realms of law and ethics, death here is passively intended and is thus considered to be foreseen instead. Please note that this is also voluntary passive euthanasia. This is because the mother's daughter has a clear duty of care for her mother - she is close family - as we assume her mother is incapable of making medical decisions due to her condition, therefore this is respecting the patient's autonomy and the daughter's decisions regarding her mother should be carried out as long as they are permissible and legal (i.e. not active euthanasia), regardless of whether Dr. X agrees with withdrawing the antibiotics. The daughter believes it is in her mother's best interests to die, and Dr. X should act accordingly. For Dr. X to go against her daughter's decision would be to commit, in legal terms, battery.

Some may argue against Dr. X allowing this passive euthanasia. The most common opposition comes from the absolute moral principle that killing is wrong in any situation. These opponents may accept there are some very difficult situations and sometimes killing may seem like the right thing to do, but they will always stick to that single, absolute principle that killing is wrong. However, I firmly believe we need to be more relative and flexible with situations like this. A reason these opponents might view killing as a harmful wrong is because of the harm of dying. For most people, dying now would be a great harm compared to living onwards. Thus if there is no harm caused in dying, then killing shouldn't be considered wrong. In the case of voluntary euthanasia, dying would be a benefit in the patient's eyes, not a harm, therefore I hold the position that the voluntary euthanasia would not be morally wrong. To quote Professor Hope:

"Those who argue that mercy killing is wrong in principle forget the conceptual link between the wrong of killing and the harm of dying…It is perverse to seek a sense of moral purity when this is gained at the expensive of the suffering of others."

I do indeed agree that having a first priority of seeking "moral purity" is essentially foolish. In my opinion, Dr. X must allow the withholding of antibiotics.

This is a tricky medical situation, but certainly a more common one.

This is just what I made of the situation,

Let me know what you think!

AJ

Cabozantinib

This may be a little late, but this article came to my attention in the 03/03/12 edition of New Scientist (pg 14, 15). It concerns the results of an experimental anti-cancer drug named Cabozantinib, or "Cabo" for short as the publication dubs it:

"Three months into a trial of an experimental anti-cancer drug, scans that should have revealed bones riddled with cancer were coming up almost clean…It [Cabo] blocks a particular receptor on cancer cells called c-MET, which would otherwise help them spread to new tissue…The trial also suggests that as an unexpected bonus, Cabo blocks a tumour's blood supply, which helps it destroy tumours as well as contain them."

It's clear that Cabo seems to be getting rave reviews from scientists, who appear to be heralding Cabo as a potential super-drug. Will Cabo live up to its potential? I guess we'll have to wait and see. But for now, the future looks bright for treating cancer, at least in my opinion.

Let me know what you think! Drop a comment,
AJ

First Post!

Hello all, this is my first ever post so I thought I'd use it to briefly elaborate on my blog! Medical school applications are so unique relative to other subjects as an applicant must pour in much more to really stand out from the crowd and prove that they are the real deal. We have to extensively read around the area of medicine, arrange a bucketload of work experience placements, achieve outstanding academic grades and that's all before the interview - which must be the most nerve-racking period of time in our young lives. Even then an offer isn't guaranteed, and even if one does arrive, I can bet it's not going to be a walk in the park!

As mentioned in the "About" section, I plan to use this blog to share my knowledges and experiences: I will post regular updates relating to my work experience, my medical reading and generally anything that captures my interest! As well as this, I aim to regularly review medical and scientific news, and to analyse ethically-difficult situations. I hope you enjoy reading this blog as much as I enjoy writing it.

Tell your friends!
AJ