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Archive for January, 2014

Uncertainty, Acceptance and Trans-Atlantic COPD

17 Jan, 14 | by tomfardon

I taught some 4th year medical students last week, in my bronchiectasis. We saw a variety of patients, mostly chronic infection, but some IPF, some difficult asthma, and some lung cancer, such is the way in a small department, such as ours. The students were most interested in the lung cancer patients. We, like many centres, run an accelerated investigation process for our patients, whipping them through the CT scanner, and up to clinic very quickly. One of the students asked if the patients get scared, getting tests before they see us. The other asked what happens to the patients who go through the scanner, and don’t have a tumour: “Do they get a non-urgent appointment instead”?

Everyone gets an urgent appointment if they’re in the ‘urgent, suspected cancer’ stream. The student looked puzzled – but if the scan is normal, why would you see them urgently, she asked, increasingly puzzled.

It led to a discussion about what leads patients, people, all of us to stress and anxiety. I think the worst thing for anyone is uncertainty. You see your GP, they say that you might have cancer, and you spend every waking hour from that point worrying, stressing, panicking, even, about the possibility you might have cancer. The uncertainty is the stressor. The patients come in wanting an answer, a release from the uncertainty – being told there’s nothing wrong is the best release, but being told that the do, indeed, have cancer, leads to a release also. Once you know, you can start to cope. It’s very hard to cope with uncertainty.

Later in the clinic the students asked me about eCigarettes; are they safe? I’m not certain. And that’s the problem – uncertainty again. We simply just don’t know enough about the effects of eCigarettes on the lung, and their standing as a medical instrument, rather than a medicine, means we’re not likely to see any evidence for a while. This case discussion in this Month’s Thoraxreports on a patient with marked deterioration in pulmonary function, cough, sputum production and breathlessness, which abated once the patient stopped vaping. The first of many? Or an idiosyncratic reaction that’s unlikely to be repeated? Certainly I see more and more people vaping around Dundee. It seems to be slowly gaining acceptance.

We’d like everyone to stop smoking, holistically speaking – everyone can exert their free will to smoke or not, of course. How can we stop people smoking? A manager in the department asked me for advice a couple of years ago, as her 14 year old daughter had started smoking. I shared the link to a Flickr photostream of post mortem lung cancer specimens – she showed them to her daughter, who immediately quit, or so she said. So the spectre of lung cancer was sufficient to induce smoking cessation on this occasion, but this study in Thorax shows that, in Denmark at least, being screened for lung cancer doesn’t increase smoking cessation.

Last week COPD made the news in the US, and the UK. The news in the US was the FDA’s decision to approve umeclidinium/vilaterol, and the publication of more safety data for the same combination. Over on this side of ‘the pond’, COPD made the news when Phil Everly succumbed to COPD, but the reporting didn’t focus much on the disease, rather focussing on the music. When Kylie Minogue had breast cancer, the profile of breast cancer increased significantly. Perhaps Phil Everly wasn’t big enough news.

Remember to check out the Thorax Weekly to see the snippets I find through the week, the Thorax Facebook page, and the Thorax Twitter feed.

And next week, more musings.

Eat, Drink, Smoke, Vape, Run.

11 Jan, 14 | by tomfardon

It’s been an interesting week. The floods down South didn’t appear up here, but there was enough wind to blow the Tay half way across the city. And this weekend we’ve had the first proper frost of the year: -2.5 when I started to defrost the car this morning to go and set up parkrun. Brass Monkeys.

The telebox has been inundated by programs about obesity this week, at least this is the week I’ve noticed it most. The new show is Weight Loss Ward, where the massively obese people in and around Sunderland go to lose weight, prep for gastric banding, and ultimately have their ‘life saving operation’. Images of Terry, 300+ kg were followed by his gastric balloon insertion, and subsequent weight loss of 15 stones, leaving him only double his ideal weight. There’s a lot of chat in the show about him being able to get up the stairs, into the bath, and out of the house, but not a lot of discussion about the respiratory efforts of such a degree of morbid obesity. A couple of students recently asked me about the effects of obesity, and the benefits of gastric banding/balloon surgery on respiratory function, and breathlessness – here’s a very nice review of just that from Thorax back in 2000. A colleague has said for many years that patients at our ‘breathlessness query cause’ clinic should simply be redirected to the obesity clinic – a slight over exaggeration , but an analysis of the BMI of the patients in that clinic would make an interesting student project.

The obesity epidemic can be ‘halted or reversed’ say ‘doctors’ in this piece in the Independent this week.The Mail tells us that 58% of the UK population are overweight. Not new news, but not a lot has changed since this paper 11 years ago showed very clearly the cardiovascular risks of obesity.

If ‘sugar is the new tobacco’, ‘weed is the new weed’ and it’s legal in Colorado, and the purveyors of the finest weed are charging a premium, yet the first 10 days of legal sales has already generated 5 million US$ of sales. Prices are inflated by 100 – 150 %, comparing the legal shop price to last year’s ‘underground’ prices, but much of that is Colorado state tax. Legalisation of marijuana can be seen as ‘normalising’ casual drug usage, or perhaps it is just a money generation exercise. A more detailed investigation of the economics of legal marijuana can be found here. For a review of the potential harmful effects of marijuana smoking (written by my boss) look here. If you’re thinking of a ski-ing holiday to Colorado to get a legal high, they’ve sold out.

If sugar is the new tobacco, and over a third of US states are moving to legalised marijuana, what of the humble cigarette? I think smoking is still a bad thing.

One of our registrars gave a nice presentation at our department education meeting this week on the rise of the eCigarette. eCigarettes, not regulated by anyone in particular in the UK, provide the ‘vaper’ with nicotine in an aerosol of propylene glycol, which is essentially antifreeze – though ethylene glycol is the really nasty one in the glycol family. There’s no set amount of nicotine in any brand, or design, and there’s no regulation of whatever else can go into an eCigarette. The sales pitch is that they are for current smokers who wish to continue with the pleasurable parts of smoking, but avoid the harmful aspects. There’s some evidence that they aren’t harmful (despite the antifreeze). They haven’t been advertised as nicotine replacement therapy, or a means to quit, in the UK at least, because that would mean they were a drug, and therefore subject to stringent testing. As one of my colleagues pointed out, coffee contains nicotine in reasonably high quantities, and we don’t get worked up about his Nesspresso machine in his office – I do wonder if there should be *some* limitation on coffee availability… I digress. If vaping is a safe, reliable alternative to smoking, and reduces, even removes, the risks to health associated with smoking, surely there is no argument? We should be telling all our smoking patients to switch to vaping forthwith. Can’t get long term oxygen therapy because you’re still smoking? Switch to vaping, and you can have your concentrator in 5 working days. Love the taste, but don’t want the risk? There’s an eCigarette for you. Tried NRT and Champix, and nothing works? Vaping is the answer. But there is some evidence, such as the seemingly controversial study in 60 Million Consumers, a French Consumer magazine, that reported Les cigarettes electroniques ne sont pas sans danger!. The Daily Mail’s usual journalistic rigour can be seen here.

But perhaps there’s something a little bit more sinister going on. ‘Big tobacco’ has been very quick to scoop up the eCigarette manufacturers, not to immediately close the factories, and essentially put an end to their competition, but to support and promote their use. If big tobacco can keep the nicotine doses low enough, and the price just about affordable, but more than a pack of 20, then what does the nicotine craving, thrifty vaper do?

One of our SpRs told us about a new craze at his son’s school: shisha sticks. Very easily available online, these are eCigarettes without any nicotine, just a fruit flavour in an antifreeze propylene glycol aerosol. They look like an eCigarette, come in a variety of colours, and flavours, and using one looks a lot like smoking, French inhale and all. They cost £3 for 500 inhalations, and the kids are ‘all doing it’. Will they progress to vaping eCigarettes, or smoking tobacco? If there’s a cheaper one..? Looking ridiculous is obviously not a concern of kids in school, so long as they all look the same ridiculous, but “smoking looks cool”.

A quick walk the length of Dundee’s main shopping street this afternoon, on the way to the library (via the video game store), I saw 3 ‘bus stop’ of adverts, and 2 ‘rotating poster’ adverts for differing eCigarettes, on top of 3 stalls in the shopping centres selling the brands at discount to anyone and everyone. At the one in the Wellgate, a woman was helping her early-teenage daughter pick out a shisha stick, whilst at the one in the Overgate, a group of mid-teenage boys were buying their first nicotine-included eCigarette. They didn’t look 18 to me, and no-one bats an eyelid. But they’re safe, as far as we know.

John Britton, in his excellent Thorax editorial, concludes:

In short, these products represent a huge opportun- ity to improve the health prospects of millions of smokers in the UK and world- wide. They will present challenges and problems, but are an opportunity not to be missed.

Back to parkrun.

At time of writing over 56,000 people did a free, timed, 5k run in a park at a parkrun event this morning, either at 9, or 9:30 am. As a comparator 37,500 people did the London Marathon in 2013. This weekend our local parkrun saw a record attendance for 4 runs in a row. 154 Dundonians, out running through the ice and freezing winds, through a park, at 9:30 in the morning, reducing their cardiovascular risk, and enjoying the fresh air. But, running in sub zero temperatures does put one at risk of cold air induced bronchospasm. Scottish Ironman Triathlon Record Holder Graeme Stewart was in just that position today after tough run through the park, and he was not alone. The physiology required to Swim 3.8k, Cycle 120 miles, and then run a marathon, all in eight and a quarter hours, undone by the cold air in Camperdown.

There’s a clear sense of health and wellbeing at all the parkruns I’ve been to, and certainly it is a rarity to see any runner smoking before or after the run, and I presume not during – I wonder how long until people vape after parkrun? I’ll stick to the Mars Bar cheesecake in the Camperdown wildlife centre cafe after my park running.

Remember to check out the feed Thorax Weekly to find things I scoop up from the internets during the week (Eg. Are eCigarettes Safe, YouTube asks)

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5 Things and a Scoop

3 Jan, 14 | by tomfardon

It’s New Year – Happy New Year, by the way – and the internet is full of last year’s greatest, top 10s of everything from 2013, some top 16s, worst 5 things too, not to mention the all important top 40 countdown (Does anyone else miss Top Of The Pops…), and the even more important 20 words I should avoid in this blog. So, rather than recap 12 months of highs in Thorax, or in respiratory medicine, I’ll try to look forward at the 5 things I’d like answered in 2014. In no particular order…

1. What to do for patients with COPD.
This has to be on everyone’s agenda somewhere, doesn’t it? Sammy Suisa gave us the preview in 2013, but it wasn’t until the end of 2013 that he dropped the full bomb – Canadian COPD patients on Symbicort, and more so Seretide, get more pneumonia, and they die. “But the data is retrospective” (although from an enviably large database, but retrospective non the less) “so is it valid”, say my colleagues. “Where’s the prospective data?”. It’s in TORCH, of course. So job done. “But why do ICS/LABA reduce exacerbations, and” (nearly statistically) “significantly reduce all cause mortality?”, my specialist nursing colleagues ask. And at the ERS in Barcelona, data spewed forth on the “Dual Bronchodilator” approach, novel only because no pharma company has up to this point been able to produce a LABA and a LAMA, but known since 2002 to the jobbing chest physician (Spiriva + Serevent was a common enough prescription in the mid and late naughties, certainly in our practice). There’s even some triple therapy data out there, but it has the big ugly shadow of “the steroid data” looming over it. Ultibro (Which is too close to Ultimo if you ask me) is the first to licence, and the first to market, in the UK at least, yet it will not be promoted, due to cut backs in the primary care division of Novartis. We wait for new molecule, or put our hopes into Roflumilast, or perhaps a resurgence of theophylline. In an area of respiratory medicine that has such a huge evidence base, we are still looking out through a fog of misunderstanding. My take on this is that the big studies done up to this point have not stratified out the patients in any meaningful way; there’s been divisions by FEV1 (Shown nicely by ECLIPSE to have little bearing on exacerbation rate, or anything else, really), or by treatment burden, but no consideration of separating out the “drier” emphysema patients from those will a more productive, “wetter” variants in chronic bronchitis, and what of COPD patients with bronchiectasis. I don’t think we need bigger studies, I think we need smarter studies, with real life phenotypes, putting into studies those patients we actually recognise as being patients we see.

2. What to do with macrolides?
Always on the agenda at bronchiectasis meetings, splitting the audience variably, is the use of long term, low dose, macrolides. Bronchiectasis continues to be the slightly ignored, slightly odd cousin of CF; we get the CF ‘cast offs’. Azithromycin works really well in CF, so why not try it in NCFB?”. The problem is when it really doesn’t work so well – DNA’ase works wonders in CF, works dark magic and mischief in NCFB. So we try, and we dabble, and we see successes, and failures, and try to find our way in a research vacuum that many centres in the UK are desperately trying to fill. Back to macrolides. We’ve all seen them work, I’m sure. We can all recall an unfortunate patient, often young, with recurrent infections, to whom, as a punt, we gave long term clari, only to see them at 3 month review, with a na’er a cough, spit or tickle. And yet, the advice on who should receive it, and indeed which moiety, and what the criteria should be for initiating, and stopping, are wooly, and not well adhered to. At a recent meeting of chest physicians in Scotland, there was no consensus at all on how long a trial of macrolide should be given to a patient with NCFB, with opinions ranging from 6 weeks to a year; some physicians wouldn’t give it at all. So we need a trial, a big trial, a well designed and well co-ordinated trial A multi-centre, UK wide trial perhaps? Certainly there’s a need for it in NCFB, but what of the other diseases? There’s been “macrolide creep” in recent years, creep into asthma, COPD, and anything else that produces exacerbations, infective or inflammatory. The COPD trials show some improvements, but the trials didn’t differentiate between phenotypes, which makes it difficult to know if Mrs Miggins with emphysema, or Mr Melchit with chronic bronchitis are going to react in the same “magic” way. So we give them both a trial, but of which? And what dose? And for how long? And if it works, how long do we continue it? If 2014 provides me nothing else but a clear guideline to follow, backed up by some really good evidence, telling me who and what and how much and for how long, I’ll be a happy blogger.

3. What to do in UIP in the Post-Pather World?
Sounds like a great title for a BTS symposium. I am not an ILD enthusiast. We have an ILD lead, and it’s not me. But I do a remote/rural clinic once a week, and see plenty of ILD, mixed up with everything else. Pre-Panther, it was straightforward enough – have a open and honest discussion with the patient about the risks associated with steroids/azathioprine, and the near impossibility of predicting their prognosis, and the patient chooses, and usually chooses to sit it out. But at least they had a choice. Now, Post-Panther, we have no obvious option. We have pirfenidone – and a handy booklet courtesy of Thorax on the indications for it – but it’s expensive. Massively expensive is something I’m used to, after all I have 3 patients on ivacaftor, and 3 on posaconazole, but I feel I standing on firm ground giving these, and it’s small numbers. A quick calculation on the back of a beermat suggests we probably have hundreds of patients who qualify for the pirfenidone treatment. At an ATS many moons ago, Talmadge King stood up in an ILD symposium (I’m not an enthusiast, but I do try to keep up my CPD). He proposed that the only ‘ethically sound’ management plan for a patient with UIP was to enrol them into a study. There was much wailing, and gnashing of teeth, but in the end, no-one had a better plan. I don’t see we’re much further on. So I’ll keep up my current practice, which is to refer to our enthusiast those who meet the pirfenidone criteria, and keep a list of everyone else…

4. Can someone work out what Sarcoid is?
I see a lot of sarcoid, and I’m not sure anyone really knows what it is, do they? My good friend Wikipedia says it’s probably a lingering reaction to an infection. agrees that it’s probably triggered by an infection, in genetically susceptible people, but can’t specify the causative organism. I really like the Royal Brompton’s patient information page on sarcoid; it’s charmingly honest about our lack of understanding of the disease, leaving the patient with “bad luck” as their causative organism. What confuses me, and others I chat to about such matters, is the massive variation in disease severity. Remember at medical school when you were taught that BHL and EN in young people would resolves spontaneously? Remember when revising for MRCP the stats about percentage of patients disease free at 9 years without relapse? I recall the steadily increasing numbers of patients who come up to my clinic on ever rising doses of immunosuppressants, with little in the way of improvement. Patients with complications of steroids that start to outweigh the underlying disorder, and patients who crumble in front of me, as I look on, helpless and slightly embarrassed that we don’t have anything else to offer. It must be more than one disease, right? Surely it’s a spectrum of granulomatous disorders, some of which are exquisitely steroid sensitive, and others that are rampant even in the face of aggressive immunosuppression. Or is it simply that these patients do have an infection. An infection that causes granulomata, that we just simply can’t detect, grow, let alone treat, that immunosuppression is providing jet propelled assistance to, and we’re ‘first doing harm’. Again, I’m not an enthusiast, but I try to keep up – there wasn’t a lot at the ERS about sarcoid, but a quick Google Scholar search (0.05 seconds, if you must know) gives me: CD4 subset dysfunction; pulmonary function tests are more useful than HRCT, or KCO; and early data on exhaled breath condensates in pulmonary sarcoid. The work is going on, but I’d like Santa to let me know what causes Sarcoid in time for Christmas.

5. A Reliable Indicator of Infection…
The Holy Grail? A marker to distinguish between an infective exacerbation, and a non-infective exacerbation of COPD would be very nice, thank you. My next-office-neighbour at work is the professor of infectious diseases, and national lead for antimicrobial stewardship: a way to cut needless antibiotics would be high on his wish list for 2014, I’m sure. I’d like to take it one step further, and ask for something we’re very near to: a practical way to take 16S analysis of sputum/bronchial washings to the clinical environment so we can quantify the microbiological load in the bronchiectatic/CF/COPD lung. We know there’s bugs down there, but are they really the cause of Mrs Miggins’ current admission? IV antibiotics over a 2 week stay in hospital do seem to make our patients feel better, but the physio, hydration and rest they get must have something to do with it, my registrars keep telling me. We’ve started 16S analysis on a research basis, but the information we get from the test needs to reach a clinical audience. I heard a very interesting talk last semester by Prof Colin Palmer, on the GoShare project. the ‘automisation’ of full genome sequencing over the past decade means a sample of blood can be turned into a full genome sequence in a couple of hours, and all for a couple of hundred quid. Understanding the information that’s been handed to you might take a while, but the system delivers information that was beyond our dreams 30 years ago. Back to infective markers, and we’ve had, and continue to use, Pro-Calcitonin, although only in our ICU environment as we’re yet to be convinced. As the theory of the lung being a sterile environment withers on the vine, and we start to understand that infections are a disruption of the balance of microorganisms within the lungs, we need technology like the 16S analysis closer to the bedside. As my neighbour tells me with a face of thunder: “We’re going to run out of antibiotics at the rate you give out Tazocin”

My look forward to 2014 has become more of a review of things I don’t understand, and a wish list for the things I can’t control. But I spared you the Top 10 of Everything.

One final note is to take a look at the Thorax Weekly “Props” to @DundeePublicH (It’s not just about water) for pointing me to, a site that allows me to grab anything I think is interesting over the week, and put it in “one digital place”. I’ll drag some of it over to here on the Blog, and discuss at variable lengths, and wait for the torrent of discussion to appear in the comments section.

My pick of the Scoops from this week? Will Big Lungs Make You a Better Cyclist?.

Stay classy, internet.

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