Statins

What are statins and what are they used for? 

Statins are a class of drug used to lower the amount of cholesterol in the blood. In today’s World, the word cholesterol has negative connotations and thoughts of cardiovascular disease immediately spring to mind. As a result of all this bad press it can be easily missed that cholesterol is an essential material in our bodies. It is an integral part of our cell membranes, increasing rigidity and influencing the properties of this boundary. HDL is normally referred to as good cholesterol as it is this that will take cholesterol plague lining the arteries and deposit it in the liver. LDL and VLDL on the other hand create this plague so it is the formation of these that statins aim to interfere with.     

Cholesterol taken in to our bodies from a diet actually makes up quite a small proportion of the cholesterol circulating in our bodies, the majority is created in our liver. Statins reduce the production of LDL’s by competitively inhibiting HMG – CoA reductase. This is the first enzyme in a long chain of chemical reactions that lead to the creation of cholesterol. This decrease in the concentration of cholesterol in the liver promotes the uptake of LDL’s already in the blood so the mechanism is doubly effective. This production of cholesterol occurs mostly at night which explains why statins are taken before going to sleep.            

Side effects? 

Despite their wide use statins can actually have numerous quite severe consequences. The main two are muscle damage and raised liver enzymes. Their benefits also rely on patients understanding the workings of statins. Many assume that these drugs are a miracle cure to their cholesterol problems and continue with their previous diet if not increasing their intake of fatty foods. This negates the workings of the statins. These people are then still increasing their risk of heart disease yet believe the matter is being taken care of. 

COPD

During one of my work experience placements I was lucky enough to sit in on a practical exam for medical students. In one section of this mock test the students had to in effect discharge a patient who had been diagnosed with COPD, explaining their treatment and answering any questions the pretend patient may have had. That then was the source for the topic of this particular entry.

So what is COPD? 

Well, COPD stands for Chronic Obstructive Pulmonary Disease and is an umbrella term for a variety of different illnesses. Normally the illnesses will be a combination of bronchitis and emphysema to different degrees of severity. For the most part it is people over the age of 40 that develop COPD and in the UK recent research has suggested that as many as 3.2 million people may be sufferers, many of whom are undiagnosed. COPD is constantly linked with smoking due to the adverse affects smoking has on your lungs. It is currently the 6^th largest cause of death, killing 60,000 people a year. Scarily though it is one of the few illnesses to have rapidly increased in occurrence in recent years so by 2020 it could be the 3^rd largest cause of death.   

Emphysema:- This is a progressive disease causing the tissues in the lungs to be damaged gradually over time. Alveoli lose their elasticity causing them to narrow. This alters the shape of the lungs reducing their effectiveness and causing shortness of breath.

Bronchitis:- This is the chronic inflammation of the bronchi and is normally diagnosed by a persistent cough that brings up phlegm. 

Symptoms: 

As the constituent parts of COPD are progressive the symptoms can vary massively. As such in less serious cases symptoms such as coughing and shortness of breath can be present in addition to tightness in the chest and wheezing.  As the disease worsens however anxiety can result from breathlessness and especially in winter the risk of lung infections are great. Many of these infections (or exacerbations) can lead to people being hospitalised with a death rate then of 10 %.  

 

Treatments: 

 Unlike other lung problems like asthma COPD is not reversible so treatment is primarily to slow the progression of the disease. A simple treatment is exercise. This is done in an attempt to keep the heart strong and the lungs active, in tandem with this physiotherapy can be used in much the same way that it is used for patients with CF: to remove mucus. 

To help widen the airways nebulised or drugs in tablet form can be used. Of the many drugs used, steroids are normally the most effective. Proactive treatment is very important so at the first sign of an infection antibiotics must be given to try and reduce the damage. It’s also very important that all sufferers are vaccinated against the flu and against the most common cause of pneumonia, the pneumococcus bacteria.  

Alex Butcher 

Sources of information:

http://www.bbc.co.uk/health/physical_health/conditions/copd1.shtml 

http://en.wikipedia.org/wiki/Chronic_bronchitis 

http://www.lunguk.org/you-and-your-lungs/conditions-and-diseases/copd

CF

What is Cystic Fibrosis? 

Cystic Fibrosis (as most people would have learnt about at GCSE) is an inherited disease. It affects over 9,000 people in the UK with 5 babies every week being born with the disease. In order to inherit it you must receive two faulty genes, 1 from each of your parents, as such carriers of the disease have a 1 in 4 chance of having a baby who suffers from Cystic Fibrosis. It’s caused by a mutation on the long arm of chromosome number 7 in the gene for the protein cystic fibrosis transmembrane conductance regulator. This impairs the cells’ ability to manage chloride.    

What are the symptoms?

While there are many possible effects (most of which are detailed in the diagram below) the disease mainly affects the lungs and the ducts of the pancreas. As chloride cannot be managed effectively secretions throughout the body become thickened. In the pancreas tubes are blocked so digestive enzymes cannot reach the small intestine, as a result food is not broken down and sufferers appear malnourished. This can also cause diabetes in some people as insulin too is produced in the pancreas. The thickening also affects the mucus that lines the lungs. Over time it fills tubes, hardens and blocks them reducing lung capacity, it is this that makes the disease so fatal. One very odd symptom of CF is that when kissed the skin of a sufferer will taste unnaturally salty due to the inability to manage chloride.   

How is the disease dealt with?    

Medication:   

For the lungs and airways the medication is based around trying to increase lung capacity by breaking down mucus and making breathing easier by opening up airways. To this end bronchodilator drugs are used (commonly used for sufferers of asthma) to relax the muscles that surround the airways. Steroids are also taken to reduce the swelling of airways, while antibiotics are used to deal with infections and DNase (an enzyme) to break down the mucus.   

For the digestive system pancreatic enzymes should be taken with the first bite of every meal to aid in digestion along with nutritional supplements. Those who also suffer from diabetes as a result of CF would also take insulin.   

Physiotherapy: 

What is also commonly used a series of percussions on the chest in an attempt to loosen the mucus sitting on the person’s chest.      

Transplant: 

In the most serious of cases where both longs fail a lung transplant may be necessary. While there is a relatively high success rate (70%) for the operation itself, after 1 or 2 years the new lungs fail too. 

How has treatment progressed? 

In recent decades the life expectancy for sufferers has greatly increased. People today now have a life expectancy of around 40 with newly born babies having a slightly higher prediction. This is mostly due to the speed and extent to which the treatments are now administered.   

For more information on the disease visit: 


http://en.wikipedia.org/wiki/Cystic_fibrosis  
http://www.cftrust.org.uk/aboutcf/whatiscf/  


To see videos of real life stories:  


http://www.nhs.uk/Conditions/cystic-fibrosis/Pages/Introduction.aspx

Alex Butcher 

Know the score

In medicine, different scores are used in different situations to assess the condition of a patient. These scores are a useful way of summarising a patient and can therefore be used to decide the next step in that patients care. I’m going to concentrate on two of these scores.  The first we would all have been scored against at least twice in our lives while the second is something I hope none of us never have been and never will be scored against.

The Apgar score: 

This was a score developed in 1952 by an Anaesthesiologist called Virginia (surprise surprise) Apgar, one of the few female consultant Anaesthesiologists of her time. What makes her endeavours to promote this score so amazing is that she never had any link to obstetrics throughout her career yet made a system which would save the lives of thousands of babies. 

            So what is it? It is a score from 0-10 which every new baby is given normally one minute after birth followed by five minutes after birth. There are five criteria used in this score, each one given a weight of 0,1 or 2 points. The different criteria and how the score is decided is shown below:     

A baby with a score of 7 or above is generally healthy, while 4 and below there is cause for concern. There are many factors which can affect the initial apgar score but generally it is worsened if the baby was born by caesarean section or by a complicated delivery. What made this score so revolutionary was that people noticed that if proper care was applied to babies that had a low apgar score after one minute, their condition could vastly improve when the second score was given. Previously however blue and limp babies would be assumed to be still born and left to die.

GCS:  

            You’ve probably heard this abbreviation shouted across ER’s in your favourite episode of Casualty so prepared to be enlightened as to what these three letters signify. Glasgow Coma Scale……. Ok maybe it doesn’t sound that exciting but it has proved to be very very useful. This scale is a measurement of the conscious state of all trauma and acute medical patients. This particular scale is from 3 to 14 (or in the revised version 15) and similar to the apgar score is used to determine what the immediate next stage in the patients care should be. It was first created in 1974 by Graham Teasdale and Bryan J. Jennett who were professors at (yehp you guessed it) the University of Glasgow.  

            The scale is made up of 3 independent tests each concentrating on an individual section, the score from each section is then added together to determine the final score. Below again is a summary of how the score is decided.    

From this the severity of the brain injury can be estimated:

• Severe, with GCS <9
• Moderate, GCS 9-12
• Minor, GCS >12

For more information on the apgar score:

http://kidshealth.org/parent/pregnancy_center/q_a/apgar.html  

For more information on the GCS visit: 

http://www.patient.co.uk/doctor/Glasgow-Coma-Scale-(GCS).htm 

Alex Butcher 

Is it really possible to cough up a tumour?!

The simple answer, apparently, is yes. Prompted by a recent article in the metro I’ve done a little bit more research into an idea which truly seems impossible. In the article, it was described how a woman through two coughing fits coughed up a large tumour which had been accumulating in her trachea. At first the woman thought nothing of it, believing the small object from her first cough was just some viscous phlegm. However after her second round of coughing and the appearance of a much larger piece of flesh she went to her GP where the substance was sent to be tested. When it emerged that the malignant tumour this woman had inadvertently coughed was what it was she was scanned in an attempt to see if the cancer had spread. Miraculously, it hadn’t. The woman was perfectly healthy. These cases are incredibly rare with around only 30 known cases but even the one instance proves it is possible.    

Though there are few cases where a whole, previously undiagnosed tumour is coughed up there is something similar which is far more common. Through my research it seems that for patients undergoing radiation for lung cancer, coughing up parts of their tumours is surprisingly common. While it definitely does not happen in every case, many people find that they will produce small fleshy lumps after undergoing their treatment. I could not find any studies on this subject but what I could find was a blog forum with a doctor discussing instances such as these.

For the blog visit:  

http://onctalk.com/bbPress/topic.php?id=221  

For the original article in the metro visit:

http://www.metro.co.uk/news/887005-mother-saves-herself-from-cancer-after-coughing-up-inoperable-tumour

Alex Butcher 

Don’t worry it’s only your heart failing……..oh……..

            Recently many people close to me have been having cardiac problems and with increasing obesity and life expectancy in this country heart problems are becoming ever more common. Around 900,000 people have in the UK have heart failure with 68,000 new cases every year, primarily found in people above the age of 70. What heart failure definitely is not is your heart just stopping, (that would be a problem…) rather the weakening of a part or certain parts of your heart so that it becomes incapable of pumping the volume of blood around your body that is needed to for everything to function correctly.

There are different types of heart failure:

1. Systolic heart failure is when the ventricles of the heart do not contract properly with every beat. Severity of symptoms depends on how much the ventricles are affected. The left, right or both ventricles can be affected.
2. Diastolic heart failure is when the chambers of the heart do not fill correctly in between beats when the heart is at rest. This can be due to the ventricle walls becoming stiff and incapable of stretching far enough to accomodate a sufficient volume of blood. This can again be found on both sides of the heart.
3. Unfortunately there is a third option and this is that you can have both types at the same time!   

Heart failure rarely presents itself on its own, more often it comes accompanied with many other conditions which might include high blood pressure, certain arrhythmias and faulty heart valves.  

What are the symptoms?

            The symptoms normally depend on the side of the heart that is affected. For the left side these tend to be respiratory problems (mostly shortness of breath) made worse when lying down or doing exercise.

            If you have right sided heart failure swollen legs and ankles are commonly seen along with nausea, dizziness and loss of appetite.

How is it diagnosed?

            Heart failure is quite difficult to diagnose as the symptoms presented can be related to many many other conditions, however if it is suspected a echocardiogram is normally done (ultrasound of the heart) and from this a confident diagnosis can be made. In addition to this a blood test to test for natriuretic peptide can be done as this is sometime raised in patients with heart failure.

What can you do to protect yourself from heart failure?

            There’s nothing very specific that can be done but the usual suspects of drinking, smoking and lack of exercise all increase the risk of heart failure.

For more information on the drugs used to treat heart failure visit:

http://www.patient.co.uk/health/Heart-Failure.htm  

Other source of information:

http://www.nhs.uk/Conditions/Heart-failure/Pages/Introduction.aspx     


Alex Butcher 

What makes a good doctor?

This old age interview question is one that every aspiring doctor must consider when they are deciding if medicine is for them. I remember my impression of doctors when I was younger as being smartly dressed gods in white coats rushing around hospitals saving lives. This impression soon faded to the reality we see on work experience of very hard working people, often under a pile of paper work doing their utmost to improve the lives of their patients. By thinking about this reality and what you need to be a doctor you can discover if you think you have what it takes. As a first entry I thought it might be a good thing to write about, as the likelihood is many of us will have to answer this on the most important/stressful day of our lives so far (interview day!). Normally the interviewer will ask for the 3 most crucial qualities a doctor must possess, so it’s these qualities that I’m going to focus on.  

One of the most obvious but something that cannot be overlooked is how a doctor must be caring. Everything a doctor does must be an attempt to make their patients’ lives better, as the (now) cliché interview answer goes ‘I want to help people’. While saying this is metaphorically shooting yourself in the foot in an interview the problem is to be a doctor you must want to help people. If you are not a caring person maybe medicine isn’t the best career path for you…..   

Another important quality that is needed by everyone throughout their medical career is dedication. The day you decide to become a doctor you are saying you must get through one of, it not the most competitive university applications there is, pass one of the longest and most strenuous degrees there is and commit yourself to a lifetime of hard work (as we’ve all seen in our work experience). To do all this requires a huge amount of dedication and I think maybe it is this quality that makes all medics such amazing people.

Perhaps the most important thing a doctor must be is diligent. Diligence is defined as ‘The earnest and persistent application to an undertaking’ and without this work ethic you cannot be dedicated and you cannot be as caring as you need to be - why diligence is so crucial. Atul Gawande in his book ‘Better’ writes ‘The seemingly easiest and most sensible rule for a doctor to follow is: always fight.’, and is this not what diligence is? Persisting to fight and do the best for your patients.    

So those are what I believe are the 3 most important qualities a doctor needs, the only question is, do you have what it takes?  

Alex Butcher