Wednesday, October 20, 2010

Rhythms of life

I was supposed to go to the Australasian Sleep Association conference this week. Actually, I was planning to attend a single day on non-respiratory sleep disorders, and then come home.

So I gave myself two days to get to Christchurch and attend the meeting and get back again.

However, at the end of a pressured and busy day on Monday I decided to pull out, and stay home.
What a great decision! Two days of no consulting in Hamilton, where the sky is blue and the temperature in the low 20s. And where there are no earthquakes!

I’m taking today as a PD day, and spending some time with the new sleep medicine multimedia text. I’ve just been looking at some stuff on chronobiology – that is, day and night rhythms.

These rhythms seem to be built into every living thing. The section of the textbook begins with an evaluation of the historical recognition of day night cycles. They start with Alexander the Great, who observed and recorded daily leaf and flower movements around about 400 years BC, and then skipped well into the enlightenment period, a span of over 2000 years, to 1729. In that year it was demonstrated by a chap called Jean Jacques d’Ortous de Mairan that leafs opened in a circadian (day/night) rhythm that was independent of the environment of the leaf. Even in a dark closet the plants leaves closed up at night time, opening in the morning in anticipation of sunlight! (This video from youtube demonstrates the behaviour of beans - exposed to sunlight, with thanks to mrlutzvulturepeak).

Daily changes in the body temperature of people were demonstrated in 1866 by William Ogle. Charles Darwin suggested in 1880 that periodicity of leaf movements was a feature of all plants. In the 20th century various insects and animals, and people, have been demonstrated to have circadian rhythms which are independent of external stimuli. In the case of people, if we are not exposed to the modifying impact of sunlight we demonstrate a circadian rhythm which runs over about 25 hours. That is, if a person lives in a cave (as a chap called Michel Siffre did, for example, for 2 months in 1962 – an ice cavern no less) then our biological rhythm gets out of sync with the outside world to the tune of about one hour every day.

Here’s the thing – I quite like reading history. And I read a lot of the Bible. In particular at the moment I’m memorizing the first chapter of the book of Genesis for something that I want to do with the kids at our church in a couple of weeks.

So if we want to think about when humans first recognized day-night rhythms that impacted on plant life then think we should think about this, for example:

“Then God said, let there be lights in the expanse of the heavens, to separate the day from the night. And let them be for signs and for seasons, and for days and years, and let them be lights in the expanse of the heavens to give light upon the earth. And it was so. And God made the two great lights – the greater light to rule the day and the lesser light to rule the night – and the stars. ……And God saw that it was good. And there was evening, and there was morning, the fourth day.”

No one knows for sure when the book of Genesis came to be written. It was probably written around the 5th century BC. The stories contained within it were probably well established in oral tradition by then Even if you don’t believe that these stories constitute sacred scripture, at the very least they are very old, and culturally very important, stories.

One of the striking things for those of us interested in day and night rhythms is the constant refrain within these very-old stories, which follows after every creative exertion of God. “There was evening, and there was morning, the first (second, third…..) day.”

The pervasiveness of chronobiological, and in this case particularly day/night or circadian rhythms, in animal and plant life, even when those animals or plants are born and raised without the influence of external factors (like the sun, and variable temperature), is startling, and not satisfactorily explained by science. It seems to me that this is just the way everything is made.


Results world spirometry day

In Hamilton last Thursday we tested 83 people. Sixty percent of our participants were female. Our catchment area was predominately Hamilton with 24% coming from outlying areas even as far as South Australia.
The majority of our participants were aged 55 years and over with 27% falling in the 55 -64 age bracket, 29% between the 65 – 74 age bracket and 30% >75 years.
Six percent of participants were current smokers, 46% ex-smokers and 48% reported they had never smoked.
Thirty-one percent reported they coughed more than the average person and 29% reported they coughed up phlegm or mucus.
Shortness of breath after walking on a flat surface for 100 meters or more was reported by 25%. Twenty seven percent had had a lung infection for an extended period of time in the past and 23% currently suffer from a lung problem. Thirty-five percent of participants knew what a lung function test entailed and 20% of our participants had had a lung function test in the past.
Overall 73% of results fell into the normal range.


Monday, October 18, 2010

Laws on leaness

I had been meaning to write a blog on Obesity demographics for a few weeks now and was prompted to digress slightly today when I noticed an article in the paper about a junk food tax. This debate has raged for a while with advocates suggesting the government has been derelict in not introducing any legislative reforms to address the nations expanding waistlines and that a tax might decrease consumption of junk food. Tax revenue would be directed to make fruit and veg cheaper, which has risen 7.8% this year compared to junk food price rise of approximately 1.5%. Those who sit on the other side of the fence claim such laws are big brother like, probably wont work (where is the evidence is the catch cry) and there should be more energy spent (excuse the pun) getting people more active and improving their diet. 

From what I know of health promotion programs I think the later has been done in a myriad of ways yet the obesity epidemic is getting worse not better. At what point does legislation need to be introduced to save people from themselves?

We have seen the success of such legislative reforms in relation to tobacco control and road safety so is it not plausible this would work for obesity?

As we to and fro about what are the best interventions one thing is unequivocal, we are getting fatter. Obesity has now over taken tobacco as the biggest preventable risk factor to our health.

Latest estimates show obesity in Australia is estimated to cause:
  • 23.8% of Type 2 diabetes (n=242033)
  • 21.3% of CVD (n=644843)
  • 24.5% of osteoarthritis (n=422274)
  • 20.5% of colorectal, breast, uterine and kidney cancer (n=30127)
Source: Access Economics report for Diabetes Australia: The growing cost of
obesity in 2008: three years on

Total direct cost: $8.283 billion
Lost well being: $49.9 billion

It can be argued that food choice is a personal one but when obesity is having such a devastating impact on the nations health something more needs to be done about it.


Sunday, October 17, 2010

World Spirometry Day 14th October 2010

Hamilton residents chose to make every breath count, at a mass lung screening event, part of a global public testing day to mark World Spirometry Day.  
Lions club volunteers
We enjoyed a hugely successful day on Thursday and judging by the early figures coming in a record-breaking number of spirometry tests were performed across Europe with 20,000 recorded in the 80 sites who have submitted data to date.
Lisa, Jessica and Vanessa setting up

The day was entertaining in the extreme, our first volunteer whilst she was giving a maximal effort shot her false teeth out onto the floor where she quickly retrieved them and continued on and this gentleman pictured below said he would have the test, provided he could keep his hat on and we had one woman who thought she was about to undergo an eye test! We shared the space in the Hub with the Thursday cake stall and the 2 gentleman running the stall provided us with hours of entertainment.
Patient having a test
The event, which was just one of 600 public lung tests being held across the globe, attracted a total number of 83 event participants and aimed to introduce more people to spirometric lung testing – the fastest and most accurate way to measure lung health and screen for potentially fatal diseases. 
Making every breath count
Spirometric lung function tests gives people invaluable early information about potentially fatal, but largely preventable, diseases such as asthma, lung cancer, and chronic obstructive pulmonary disease – an umbrella term for chronic bronchitis and emphysema, in which the airways to the lungs become narrowed.
Jessica and Irene at the information desk
 Having a spirometry test performed to screen for lung disease is recommended for those over 40 or current or former smokers. In a recent study, smokers with abnormalities on their lung function tests were at a higher risk of developing lung cancer.
In the 5 minutes it took to complete one lung health test, 150 people died of lung disease. Early screening and prevention is the only way individuals can begin to reverse this worrying statistic.
Thursday’s spirometry testing highlighted just how critical awareness, proper testing and early action are in helping people make every breath count.
Once I have crunched the data I will be able to report on our findings.


Thursday, October 14, 2010

Teaching, asking and assessing pneumonia severity.

I remember a senior colleague complaining once, when I was working in London, about how difficult it can be to teach junior doctors and medical students. His complaint was that they often ask questions which don't make sense.  For all of us as we learn, a fair amount of knowledge needs to be acquired prior to the point at which we begin to ask informed and sensible questions.  Until then our questions are often uninformed, or 'silly' – and for the super-smart professor, having to spend time addressing nonsense questions was laborious.

But it is so important that doctors in training – and indeed all people learning – are given permission to ask those ‘stupid questions’. I was never very good at that, and to the extent that I was not good at asking the dumb questions my learning was impeded.

 Which is a long-winded preamble to the fact that I have to take some student doctors for a tute tomorrow. We’re going to be talking about respiratory infections. Some of the discussion is going to be about community acquired pneumonia – so I’ve been looking over some of the pneumonia severity scales. These are tools that can be used by doctors (often junior) at the coal face – ie in emergency departments – to help evaluate whether hospital admission will be required.

I don’t use them very much, because I’m not often seeing the patient at the point of diagnosis of a community acquired pneumonia. But, in the interests of not looking stupid when I get asked a good question tomorrow about these tools I’ve been refreshing my mind.

 The two Australian indices most used, and detailed in our “Antibiotic guidelines” are the CORB and SMART-COP indices. The following summary of CORB – which is much simpler to use but a little less precise – was lifted from antibiotic guidelines:

CORB uses the following patient parameters, based on the most abnormal results obtained during the initial 24 hours of inpatient stay:
 C = acute confusion
 O = oxygen saturation 90% or less
 R = respiratory rate 30 breaths or more per minute
 B = systolic blood pressure less than 90 mm Hg or diastolic blood pressure 60 mm Hg or less

Interpretation of CORB score:
 'Severe CAP' = the presence of at least two of these features.

In the Australian study cohort, the accuracy of CORB for predicting need for IRVS using presence of at least two features was:
 sensitivity = 81%
 specificity = 68%
 positive predictive value (PPV) = 18%
 negative predictive value (NPV) = 98%
 area under the receiver operating characteristic (ROC) curve = 0.74.

A copy of the 'SMART-COP' index can be found by following this link.

 Now, I don’t intend to suggest to these student doctors that they memorise SMART –COP (although they should be able to memorise CORB). Perhaps the best thing about these indices is that they draw our attention again to important clinical parameters – to the sorts of things that we should all be paying attention to when we assess patients with pneumonia.

All of the guidelines go to some lengths to remind us that we cannot rely on the severity indices. We need to exercise clinical judgement when deciding which patients should be admitted to hospital. And there are particular ‘red flags’, any one of which necessitates inpatient care. To quote the antibiotic guidelines:

The presence of any one of the following key features indicates a high likelihood of the patient having severe  disease and these patients require inpatient care:

 respiratory rate greater than 30 breaths/min
 systolic blood pressure less than 90 mm Hg
 oxygen saturation less than 92%
 acute onset confusion.

 arterial (or venous) pH less than 7.35
 partial pressure of oxygen (PaO2) less than 60 mm Hg
 multilobar involvement on chest X-ray.

Monday, October 11, 2010

Smoking Chop – Chop?

I decided to Google the term chop –chop to get things started for my blog, and discovered it has multiple meanings depending on what you are looking for. Quite appropriately there were many references to food services often involving noodles and quick delivery; a hairdresser; a knife business; and I discovered Chop –Chop is even the name of a new reality series which sees two chefs do battle in the kitchen. You may not be aware that Chop- Chop is also Killing Joke’s second single from their third studio album, Revelations. As for the site that said “Uncle Chop – chop”, well, I decided not to go there……

I also discovered that “chop – chop” is a pidgin Cantonese phrase for “hurry up”. This is more in line with what I thought the phrase meant but for those who smoke tobacco it has another meaning. Chop – chop commonly refers to illegally grown or produced tobacco which is sold by weight on the black market.

Interestingly, it has been suggested that the Australian term came about back in the 1990’s from those who worked within the tobacco industry and observed the impact of illegal tobacco trade in Australia. It refers to the production process of illegal tobacco where the curd leaves are roughly cut up into fine strips. It is mostly grown outside of Australia with the main black market trade coming from Indonesia, (and other countries such as China, Philippines, Vietnam, and Brazil) where poor licensing and taxation regulations exist.

A recent report from Price Waterhouse Coopers (commissioned by the tobacco industry) states that illegal tobacco accounts for 12.8% of total tobacco consumed in Australia.

The World Health Organization predicts that illegal tobacco consumption will be MORE than legal tobacco worldwide by 2020.

While it is difficult to know exactly how many Australians smoke chop – chop, a 2002 study by Bittoun in her clinic found 43% of her patients smoked it, 83% said they did so because it was cheaper, and 58% thought it was better for them.

And there is part of the problem. It is cheaper to purchase a plastic bag of chop-chop than manufactured branded cigarettes; estimated to be even half the price of equivalent cigarettes. With the recent cost increases of cigarettes in Australia you can imagine illegal tobacco trading is on the up.

Chop – chop is mistakenly thought of as more “natural” and but certainly is not better for you to smoke than cigarettes. It avoids the regulatory bodies, and avoids excise and taxation levies. The home grown and amateur curing (drying) means no two batches are likely to be the same and the quality of the tobacco varies widely.

Bittouns report for the department of Health and Aging in December 2004 found contaminants such as cabbage leaves, grass clippings, hay, twigs and pulp from raw cotton which are used to bulk up the weight for sale. Some chop – chop was sold wet (again to increase bulk weight) requiring purchasers to dry out their tobacco in the sun or microwave. Water is also thought to be a byproduct of the leaves deterioration process.

The report states a raw adult tobacco plant contains bacteria, fungal spores (mould), pollen, dead insects and residue from pesticides and insecticides. Depending on how the tobacco is processed and stored, the addition of water and heat can provide the ideal environment for these microorganisms to flourish. Aspergillus and Penicilium are the most documented fungi found on raw unprocessed tobacco products and leaves.

Fungi release enzymes as part of their digestive process and are called mycotoxins. Some of these mycotoxins are toxic to humans if they are inhaled, ingested or exposed to the skin. Indeed studies document the negative impact on farmer’s respiratory health when exposed to environmental moulds and grains over time.

We know that fungi and the associated mycotoxins can lead to toxic responses in the liver, kidney, and skin – potentially being responsible for a range of health issues such as nausea, vomiting, dermatitis, eczema, hemorrhages, and immunosuppression.

Aspergillosis is a term used to describe lung disease caused by a type of fungus called aspergillus. People who are immunocompromised have asthma or other chronic lung disease can have allergic responses or colonise this fungus in the lung. Invasive Pulmonary Aspergillosis is a serious infection with pneumonia and can be fatal. Aspergillus is usually found growing on dead leaves and compost or decaying vegetation but has also been found on marijuana, and raw chop-chop samples in Australia.

Extrinsic Allergic Alveolitis (EAA) is used to describe a group of lung diseases which occur after repeated exposure to dusts of animal and vegetable origin and includes mouldy tobacco exposure. Extrinsic - means originating from outside the body, allergic – caused by the allergic reaction of the body to a particular substance or condition, alveolitis – when the tiny air sacs in the lungs become inflamed. Tobacco Workers Lung is a type of EAA from inhalation of mouldy tobacco. In this case the allergy is triggered from a series of complicated reactions from the body’s own natural defense mechanisms. In an acute episode, patients present with symptoms such as cough, fever, chills, headache, malaise and myalgia within hours of exposure. Chronic and ongoing exposure can lead to breathlessness, wheezing, weight loss, digital clubbing, right heart failure and pulmonary fibrosis, and permanent lung damage.

The Bittoun report highlights the fact that many Australian asthmatics are smokers, and many people with COPD also are unable to quit. In such cases, respiratory function and lung clearance is already compromised. The potential side effects to smoking chop-chop are many. So yes, chop-chop may be cheap – but what is the real cost?


Sunday, October 10, 2010

World Spirometry Day

More than 600 events are taking place worldwide on the 14th of October to measure residents’ lung health, employing a fast, accurate 5-minute test to mark World Spirometry Day
Together our efforts will help educate people about lung health and improve both
the diagnosis of and monitoring of respiratory diseases

The main objectives of the 2010 Year of the Lung campaign are to:
1. Increase awareness for lung health and to initiate action in communities worldwide, and advocate for policy action to combat lung disease
2. Reinforce the need to provide increased resources for basic and clinical research to improve patient care and quality of life
3. Convey the message that most respiratory diseases are treatable, but that prevention is highly cost effective
4. Spread the message that clean indoor and outdoor air is a fundamental human right and should be recognised as such

Seven per cent of all deaths worldwide each year are caused by preventable lung diseases. Millions more people face a long and painful old age due to conditions that are treatable if caught early through proper tests, like spirometry.
The first ever World Spirometry Day aims to encourage more people to get their lungs tested for an early indication of diseases such as asthma, lung cancer, and chronic obstructive pulmonary disease – an umbrella term for chronic bronchitis and emphysema, in which the airways to the lungs become narrowed

Manse Medical is hosting this free event at The Hub in Hamilton, Victoria.  Members of the public are encouraged to take a free test to help diagnose various lung conditions.  Staff at the event will give participants free spirometry tests measuring their lung capacity, and if the results raise concern, participants will be sent a letter to take to their doctor.

In the 5 minutes it takes to complete a spirometry test, 150 people will have died from a preventable lung disease.  Spirometry is the most accurate measure of lung health – giving patients valuable knowledge about the permanent damage they may be inflicting on their lungs

With lung diseases set to become the third biggest global killer in the next decade, we hope Thursday’s free spirometry tests will breathe new life into Hamilton residents and resolve to monitor and manage their lung health.
By choosing to ignore your lung health, smokers and those at risk of lung disease drastically increase their chances of a debilitating later life.  On World Spirometry Day, we want to show the public how they can easily regain control of their lung health by taking a few minutes out of their daily routine for a simple and painless spirometry test

Spirometry – the gold standard in lung testing
In the same way that blood pressure measurements provide a simple yet effective screening method for cardiovascular disease, spirometry tests can help to unmask the early symptoms of a variety of lung diseases before any more obvious signs appear and can be invaluable in raising early warning signs for potentially fatal problems

Having a spirometry test performed to screen for lung disease is recommended for those over 40 or current or former smokers. In a recent study, smokers with abnormalities on their lung function tests were at a higher risk of developing lung cancer

For information about World Spirometry Day events taking place in your area or across Europe, please visit:


Sunday, October 3, 2010

An afternoon in the Manse

12.30pm: Meeting with practices nurses, Lisa and Irene. Discuss upcoming community education session on Obstructive Sleep Apnoea, that will be held at the Manse rooms on Wednesday October 27th 7pm-8pm. Confirm that both Lisa and Irene will attend the nurses forum at the 3rd annual Lung Cancer Conference.

1.30pm: Two nurses from Homecare in Mount Gambier had travelled over to meet us. Irene spent sometime going through our procedures for patients using cpap, then we took them on a tour of the Hamilton Sleep Disorders Centre.

2.00pm: Set Irene up for an in laboratory sleep study to show staff from Mount Gambier what signals we see when patient is in the lab. Great of the girls to come over to see what we do and to let us know what they do.

2.30pm: Head back to Manse, attend to emails.

3.30pm: Organise Somte PSG for patient having a home sleep study. Spend too long searching for micropore and gauze. Irene locates gauze for me in about 30 seconds!

4.00pm: Educate patient on the use of the Somte PSG. They have a demonstration on how to attach the equipment once they are home and sent home with a comprehensive list of instructions. About half an hour prior to bed they will attach the equipment and return it in the morning.

4.30pm: Stuart from Carefusion (supplier of our lung function equipment) arrives to meet with Vanessa. He updates logic tree. I briefly chat with them about a training session we plan to have for medical professionals on the use of cardiopulmonary exercise testing. Carefusion will kindly sponsor this training. We are planning this for late November.