Would you take seal oil?

In a recent Diabetes Management Journal that ended up my desk. “Could seal oil reverse diabetic neuropathy?

This article refers to a study done in Toronto, Canada on just 40 type I diabetic patients whose peripheral nerves have been damaged by their illness. This was an open label-study, proof of concept study. So not randomised nor blinded. The authors used corneal confocal microscopy to look at the changes in the corneal nerve fibre length as a surrogate for more peripheral nerve damage, thus avoiding the need for a nerve biopsy.

The study has been taken up by a number of web and print medical news journals,

I wonder if the editors of these news journal, or indeed the authors of the research paper considered the ethical dilemma of harvesting oil from species protected in many countries around the world, including Australia.
The oil used in this study was sourced from Auum who according to their website are at the forefront of omega-3 supplements. Further, it claims to be “dedicated to developing and manufacturing superior nutritional products to support the health of all.” That is of course unless you happen to be a Canadian seal.

seal-hunt
The Harp Seal (Pagophilus groenlandicus) appears on the IUCN Red List as an creature (some would say resource) of “least concern”. Canada’s seal hunt remains mighty controversial even within Canada. National Geographic asks why Canada still allows a seal hunt. And there is more emotive posts about Canada’s seal hunt, for example The Dodo website. Obviously there are proponents of seal hunting, and you can buy seal products, such as Canadian Sealers Association. Another proponent of seal oils suggests that the cute cuddly white coated variety are no longer hunted. It is okay to harvest these older seals as they are able to swim on their own and have left or been abandoned by their mothers. So that makes it okay if they are “abandoned”. Kerthunk…..

A problems with seal oil is the potential for contamination. One product blurb for seal oil appears to suggest that their product is safe as it is bio-filtered fish oil. As seals are much higher in the food chain than fish, “seals use their digestive system to filter out the many natural impurities found in fish.” Conversely biological dogma suggests the further up the food chain you travel, the more likely you end up with more contaminants, such as mercury, PCBs etc, not less. Dr Ho, who can sell you seal oil overcomes this problem through a process molecular distillation. His process removes all the impurities, such as mercury, metals and PCB’s from the oil and makes it a purer product that is safer for human consumption.

Interestingly, I found on DPAGold another Canadian seal oil distributor’s website this paper written by researchers at RMIT, Melbourne and supported by Meat and Livestock Australia. The authors suggested that taking 10 seal oil capsules a day “may be more efficient than fish oil at promoting healthy plasma lipid profiles and lowering thrombotic risk”.  Thankfully, Meat and Livestock Australia will have to keep their hands (or clubs and harpoons) off Australian seals through federal legislation.

Personally, if I need more omega-3 in my diet I would be using the Australian Heart Foundation list of natural dietary sources and thankfully omits seals, which are protected in Australian waters.

Harp-seal-+-pup1
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Emergency at 30,000 feet.

Three hours into an intercontinental flight, the dark blue waters of the Pacific ocean pass below. A cloudless azure sky offers contrast. The remains of another airline lunch has been collected. Postprandial heads began nodding. A few fellow passengers have already succumbed to slumber assisted by duty free spirits.

 “Can a medical practitioner please make themselves known to a member of the cabin crew, please”

A few people steal quick looks around. Maybe hoping someone else may volunteer, maybe just curious.

Finally, a hand reaches for the call button, a red light came on with a ding. Dave stands, sweeping the remains of crumbs from lunch from his shirt front. He adjusts his glasses and steps into the aisle. A flight attendant strides up with a serious professional look on her face. “Come this way please” and he follows her to the rear of the aircraft. There, a young lad lays curled up looking like he was in some distress. A plaintiff cry intermittently escapes his lips. Next to him a woman, obviously his mother, is worriedly mopping his brow, saying “shhh”. The Father similarly worried, is in the next seat to the the pair.

“Are you a doctor?” the Purser inquires “Do you have some identification?” she continues, demanding polite but firm.

Taken a little aback Dave mutters “Yes, just a minute” he fumbles his wallet from his jeans. Chuckling as he looks through his wallet for some form of identity, “Maybe I should have worn my stethoscope around my neck?” Finally he pulled out his RACGP ID card and offered it. “Hmmm, okay that will do”, the Purser accepted. “Can you help with this young man. He has pain”.

Dave takes the empty seat next to the lad and asks a few questions of the lad’s parents. He lays a confident palm onto the lad’s belly, skilfully feeling, discerning the pain and its possible causes. He nods, knowingly distilling the information. He stands to talk to the Purser, “Where’s the nearest place we land to get the lad to a hospital?” In the blue emptiness of the Pacific there was no where closer than from whence they came. Dave rubs the quickly developing stubble on his chin. He knows there is but one thing he can do.

He turns back to the parents to explain what he must do. Colour drains from the Mother’s face, the Father just nods, silently shocked. Dave looks into the offered medical kit then turns to the Purser, whispering a few requests. The pair heads to the first class galley.

Dave returns, having marshaled his resources and equipment from what he could find. He gives the lad a large tot of first-class OP rum, splashing more onto his own hands and the remainder onto the now naked groin of this stoic young lad. He directed the two burliest cabin crew to hold onto the lad’s arms. To the parents he whispered “its going to be okay, just breath”.

The father solemnly nods to Dave then looks into his son’s eyes, which are now tightly shut unaware of what is about to happen.

Dave pulls on the latex gloves, flicking the cuffs. There is a hush only broken by the noise of the jet engines outside. Armed with sharpest steak knife Dave could find, still warm from its dunk in boiling water, he skilfully cuts into the lad’s tense scrotum. Linen serviettes soak up the blood. He picks up a pair of nail scissors and eye brow tweezers and continues his artful surgery.

The lad gives a rum tainted groan and gratefully lapses into unconsciousness. A young lady in seat 25E quietly vomits into a sick bag. Her partner grimaces and crosses his legs.

Adroitly, Dave untwists the dusky organ on its stalk. A flush of fresh blood fills the testicle. Those watching burst into spontaneous applause.

Finally Dave uses the Purser’s stapler to close the wound and wraps the scrotum in a clean silken scarf.

The young lad’s Father gives a weak smile knowing his son’s future progeny has been saved. Dave wipes his hands on a fresh first class serviette.

The Purser directs Dave to his first class upgrade, hands over a card for lifetime membership of the airlines Gold club and cracks a bottle of Moet. “Well done Doc, I’d fly with you any day”

Behind, the final smart phone camera video light flicker off awaiting an active wifi link.

The pilot announces that the planned emergency diversion to Kiribati is no required to the grateful passengers.

– A work of fiction


 

And if you thought this impossible and not too sqeamish…

Slow Medicine

I recently began working in a new Mackay medical practice started by Dr Nicole Higgins called Health on Central.  And when I say new I mean new. Last time I visited the building it was to buy some screws as it had previously been a hardware shop. Sadly, competition from the mega hardware supermarkets down the road meant the the business became unsustainable and it closed down. Turning a gutted hardware store into a multioffice medical clinic was an adventure I’m sure she will tell you.

The clinic still has an industrial look about it, big windows bring in natural light, a living plant wall, a bench from an old train station and dining table in the middle of the waiting room.

Because the clinic is new, I get to spend 30 minutes with patients and this really has opened my eyes to a different way of practicing medicine. I felt I had time to listen to patients story. Studies have shown that a patient is interrupted at between 12 and 23 seconds after starting their story. Obviously this interruption may mean vital information may be lost and it can make the consultation longer. The silence of the doctor is a neglected tool in building rapport. They are many papers which focus on improving doctor -patient communication. Dr David Dugdale wrote Time and the Patient–Physician Relationship in 1999 which is a good starting point for those seeking to improve the efficiency of time spent in consultation. Dr Simon Morgan, who tried to teach me General Practice up in the NT, wrote this a paper on consultation skill tips for new GP registrars.

Dr Nicole recently exclaimed “Slow Medicine” in a GPDU post, and I thought that sounds like a really good idea. I have a slow cooker at home and I can use it to make wonderfully richly flavoured food. As I discovered Slow Medicine is not a new concept. Dr Alberto Dolaro an Italian cardiologist, wrote about in 2002. It is said he was inspired by the rising Slow Food movement, a reaction to Macdonalds in the culinary heart of Italy. His paper’s abstract describes his ideas,

In clinical practice, hyperactivity is often unnecessary. Adopting a strategy of “slow medicine” may be more rewarding in many situations. Such an approach would allow health professionals and particularly doctors and nurses, to have a sufficiently long time to evaluate the personal, familial and social problems of patients extensively, to reduce anxiety whilst waiting for non urgent diagnostic and therapeutic procedures, to evaluate new methods and technologies carefully, to prevent premature dismissals from hospital and finally to offer an adequate emotional support to the terminal patients and their families.

This goes beyond the drive to improve efficiency in the consultation. The movement focusing less on the time but more on the relationship between doctor and patient, the connections made and our shared humanity. The Slow Medicine has been aligned with the Choosing Wisely movement which aims to educate both doctors and patients that quality of healthcare can be achieved by eliminating unnecessary and sometimes harmful tests, treatments, and procedures. Yes less tests can be better for you.

If you are interested in reading more opinions and thoughts on Slow Medicine here are a few links.

Direct to the source but you will have to rely on google translator if you don’t speak Italian. Slow Medicine Society.

I love the snail logo and their Manifesto which is available in English.

Sobria, Rispettossa, Giusta

Measured, Respectful, Equitable

And if you speak Portuguese have a look at the Brazilian version of Slow Medicine.

If Slow Is Good For Food, Why Not Medicine?

I’m so glad I don’t work in an eight minute medicine world!

For the Very Old, a Dose of ‘Slow Medicine’

I think it is not just important for older patients, I think all ages will benefit.

This paper discussed the pressures those who practice Slow medicine may face.

Dr Michael Finklestein is a strong proponent for slow medicine you can read his thought on his website and his Huffingtonpost articles.

As he says

“In our fast-paced world, we often look for quick-fix solutions to our health challenges, not realizing that these “solutions” in fact may contribute to our problems. Most health challenges are the result of an imbalance in our bodies and lives, and most quick-fix solutions actually exacerbate these imbalances. If, instead, we take a Slow Medicine approach – identifying the root cause of our health challenges, then creating a thoughtful, step-by-step, and long-term response to it – we effectively bring ourselves back into balance.”

If you are interested in benefiting from Slow Medicine, the next time you book an appointment with your doctor, ask how long you get for a standard appointment, and if you think you deserve more than 8, 12 or 15 minutes, ask for a double or even a triple slot, it may make for a less time-stressed appointment.

And, finally I’m sorry if I am running late one day, someone maybe needing my slow care!

Doc, those new tablets just aren’t working so good….

Conversation overheard by the consulting room fly

“Hi Mr Brown, what have you done today?”

“Oh not much Doc, those new tablets you gave me for my back aren’t working as good as my last lot”

Hmmm, checking the prescription record and seeing no change in the medication.

“I haven’t changed your tables for a while, what happening?”

“Those new green tablets for my back pain, well they don’t work as good as the white ones. Hang on I’ve got those tablets in my pocket.”

Living in a world where there is supposedly generic equivalence I wondered if Mr Brown was inadvertently taking the wrong tablet. After all the TGA website suggests,

“A generic prescription medicine works in the same way as the existing medicine. What matters is the active ingredient, which is the same in the generic brands and the existing brand.”

Mr Brown handed over a packet of tablets which contained exactly the same medication as the one prescribed. Except that the brand I prescribed was indeed white and these were green.

Can the colour of tablet really affect how a patient may perceive its effectiveness?

Well yes it would seem!

Delving in to the BMJ from 1970, a trial in 48 patients with anxiety found that changing the colour of oxazepam tablets from red to yellow to green affected the response to the medication. Anxiety symptoms responded better to green and depressive symptoms responded better to yellow. Adverse effects were found not to be colour related. Unfortunate for the authors, despite the trend statistical significance was not achieved.

The colour of a placebo tablet has been found to influence patient’s perception of effect. an earlier study from 1962, revealed that the “maximum” placebo effect was obtained when the patients were given a placebo of the preferred color and the least effect obtained with the non-preferred color.

A more recent Dutch study found  perceived action of coloured drugs showed that red, yellow, and orange are associated with a stimulant effect, while blue and green are related to a tranquillising effect. It has been found that red stimulants work better than blue.   707cbd96c92af08d2c6bcec1af06c708

There has also been found a difference in efficacy between tablet and capsule of the same medication and shape and size of tablets.

Strange creatures aren’t we.

“Well Mr Brown, what i think you need to do it have a chat with your pharmacist and make sure you stick to the brand which you think works better.”

A What rush?

<<Rant Alert>>

Thanks TGA

It would seem the TGA would now like Australian doctors speak more like our cousins across the Pacific Ocean in America, that is. There is a updated list of the politically correct names we should all now be using for a select group of drugs. https://www.tga.gov.au/updating-medicine-ingredient-names-list-affected-ingredients. I know these are really the International Nonproprietary Names but it seems that most of the names are being changes to what Americans call their drugs rather than what generations of Australian doctors have called them.

 

adrenaline 6adrenaline 9adrenaline 3 adreanline 3

Adrenaline shall now be called epinephrine. the sight of a white pointer rushing at you on a small yellow kayak, the feeling as you catch a 100 foot wave or jump from a perfectly good plane  or a solid mountain top, or as you touch 300kph in top gear will now forevermore be an EPINEPHRINE RUSH. Doesn’t really sound the same does it?

Noradrenaline, the alpha receptor specialist, likewise shall be known as norepinephine. Must venlafaxine now be called a serotonin, “norepinephrenergic” reuptake inhibitor? Maybe the Americans were getting confused with North American Aerospace Defense Command when someone called for a box of Norad?

Amethocaine my old friend, a sight for a sore eye, now is tetracaine but it may be better if you have four eyes.

Apparently amphoterin gains a “B”. Not sure what happened to amphotericin A. Maybe the “B” is for better.

All the phenobarbitones are now phenobarbitals but that just doesn’t sound right, too aggressive, these drugs are supposed to be more sedate. Amylobarbital, barbital, secbarbital, nembutal (well that one seems to have snuck in for a while), thiopental…

There are few changes that just seem stupid. Where am I to put methylrosanilinium chloride? Oh, if you told me it was crystal violet then maybe I’d  have a better idea.

I will not be moving the “u” and writing an “o” in frusemide. Just to make that clear. It’s like calling my best mate “Buroce”, sorry Bruce I’m not making fun of you it just won’t happen.

Maybe I can drop the “e” from eformetrol, it might make it sound less rude.

Lignocaine remains lignocaine in my mind and you can put that lidocaine and epinephrine right back and give me what I asked for sister!

There are bunch of other changes which just confuse me like dosulepin instead of dothiepin.

There is a list of minor changes too. Such as we are now supposed to drop the “y” in amoxycillin an change it to a “i”. Also pericyazine become periciazine. Surely there are enough vowels in there already, give the consonants a go please. And of course, son’t forget about the “ph” in cephalexin, cephamandole, cephazolin, cephalothin…..  I see even Wikipedia still call this group cephalosporins. Okay a couple with the “f” have already settled into our local formulary …. ceftriaxone, ceftazidime, and cefotetan….

Its not just antibiotics that loose the ph its also Phytic acid becomes fytic acid. I guess it goes the way of telephone, physiotherapy, phallus, physics and farmaceuticals. Dammed its happened already. Mooo

We loose the “o” in oestrogen and all its cousins like oestradiol and oestriol. It is a word rooted in the latin word oestrus.  Bit like orthopaedic, paediatric and gynaecology…..

Tioguanine, etacrynic acid, beclometasone  and indometacin all seem to be missing a “h” Do the INN committee members have something about touching the tongue to their toot?

Its wong I tell you all wong. See you need that extra consonant otherwise you’ll be making fun of all sorts of people.

Give me Paraffin – soft white any day over soft white paraffin.

Enough….read the list. As I read through the list I wonder how many TGA committee meetings in Canberra it took to devise this list. Or was someone bored one Friday afternoon. No new drugs to approve, hey let’s change some names?

Yep Thanks TGA for surrendering to all things America, sorry INN.

At least we bought a French submarine…. Hopefully they will be launched with a nice bottle of Australian Champagne oops sparkling white, preferably from the Clare or Barossa valley.

Oh by the way, we are still apparently permitted to call paracetamol, well paracetamol. So shove that non-INN acetaminophen suppository up your bum America.

<<Rant Over>>

How do I choose a new drug?

I wonder whether I choose a new drug in the same way I picked my new car_DSC9496-001.

The car buying process involved a lots of research, a bit of procrastination and then some negotiation.

Reading several months of Wheels, Top Gear & Car & Driver

Like reading the MJA/BMJ/NEJM

Reading Carsguide & Caradvice websites

The 6 Minute and Australian Doctor equivalent

Watched Youtube reviews and forums like VW Watercooled Australia to get the gossip on reliability and after sales service

Not sure if there is any medical equivalent, maybe GPDU

Then I did talk with a salesperson

The Drug Rep

And went for test drive

No real equivalent experience here. It isn’t really appropriate to ask for a sample of Targin to see how it helps my chronic pain, or shoot up Saxenda for a month to see if I loose weight.


So should I use drug reps as my primary source of information about new drugs?

Should I even see drug reps?

There is certainly support out there if I do go down this path. There are doctors out there who already say no to drug representatives.  http://www.nofreelunch.org/ and http://noadvertisingplease.org/

Dr Brett Montgomery has written on the subject here  https://theconversation.com/why-i-dont-see-drug-reps-a-gps-take-on-big-pharma-spruiking-32435

Dr Ben Goldacre has blogged on his BadScience website and written on the influence of pharmaceutical companies on drug utilisation.  After eventually making it through Bad Pharma I felt a little pessimistic about the whole process. It’s a bit like House of God, essential junior doctor reading.

A list of problems include

  • Missing clinical data which the rep probably doesn’t know about either
  • Positive paper publication bias
  • Ghost writers instead of academics
  • No decent independent head to head studies, so what if me2 is better than placebo is it better than the first drug?
  • Kick backs to medical journals
  • Half blind public agencies
  • Statistical manipulations and sub- subgroups analysis
  • Glossed over serious adverse effects. “The risk of thyroid cancer with Saxenda is over rated!” or “No that only happens in beagles”
  • Glossy brochures and advertising in journals.
  • Pushy drug reps and their inducements – which do seem limited to lunch rather than international flights these days.
  • Leaving behind drug samples as starter packs
  • Subsidising patients support groups and turning them into pharmaceutical lobby groups
  • Product familiarisation campaigns
  • Breaking news on popular media dressed up as “news” stories
  • Chatting in the ear of the clinic nurses, who also look after the sample cupboard. I wonder if any rep has suggested that the oppositions product be pushed to the back or even in the bin?
  • Paying specialists to “educate” GPs
  • Creating a “disease” to sell a product, eg fibanserin for a woman’s poor libido

As a health professional am I impervious to drug rep propaganda. I think the evidence suggests NO.

A few hints include the average sales force expenditure for pharmaceutical companies is $875 million annually and that is just in the USA. Being Australian, I am of course more skeptical and cynical but even so it has been estimated that in 2012 $30 million was spent by pharmaceutical companies trying to persuade doctors to use their product. I think it safe to assume no one would spend that kind of money if there wasn’t some return.

I think I can say that drug are not evil and may be a source of information but they need to handled with care.

Where are you putting that Mars Bar?

mars2

I saw a recent suggestion that rectal administration of a chocolate bar could be used to reverse hypoglycaemia in a patient who was unable to take anything orally.

This led to a range of comments from colleagues mostly of surprise. There were the suggestions that maybe a Poly Woffle has a better likeness to a stool. I helpfully hinted that the wrapper needs to be removed first.

Use of rectal chocolate bars seemed a little strange but not directly counter intuitively. As a pharmacist, I had the joy of preparing suppositories albeit for my undergraduate manufacturing examination, where a pass required a homogeneous and perfectly contoured little bullet. Suppositories have a long history of medicinal uses, although in the Australian context they are not always a popular choice.

But a chocolate bar!

Mars bars contain Milk Chocolate 40%,  Nougat 33% and Caramel 27%. Specific ingredients are Sugar, Glucose Syrup (Sources include Wheat), Milk Solids, Vegetable Fat, Cocoa Butter, Cocoa Mass, Barley Malt Extract, Cocoa Powder, Emulsifier (Soy Lecithin), Salt , Egg White, Natural Flavour (Vanilla Extract). A 36 gram bar gives you 20.8 grams of sugar and 6.2 grams of fat, and reassuringly 0.5g of fibre. There is some glucose in it and that is what we need to reverse hypoglycaemia. Sucrose will do the same but it first needs to broken down to glucose and fructose by the enzyme, sucrase. Sucrase, unfortunately lives in the brush border of the small bowel not the rectum. This kind of makes sense given that the food goes into the mouth and waste comes out of the rectum and from an evolutionary perspective it is best to absorb the good stuff higher up in the bowel after it has passed the taste bud test.

The upper part of the rectum drains into the superior mesenteric vein which drains into the liver via the portal vein. The middle and inferior rectal veins in contrast drain the lower part of the rectum and venous blood is returned to the systemic circulation via the inferior vena cava and thus avoids hepatic first pass metabolism by the liver. So use of some drugs as a suppository has an advantage, although potentially toxicity is increased as liver metabolism is bypassed.

Drugs aside, is their any evidence for benefit from per rectum glucose?

Long, Geiger and Kenny published in Metabolism in 1967 a small study following radiolabelled glucose infused per rectum compared to intravenously. They showed that if you killed of gut flora with neomycin, then the expired radiolabelled CO2 following rectal administration was diminished greatly. They suggested rectally absorption of glucose was minimal and the CO2 expired was due to the effect of gut flora.

In 1984, Aman and Wranne published a small study using six diabetic children as in their words “volunteers” in Acta Paediat Scand. The title kind of gives away their findings “Treatment of Hypoglycemia in Diabetes: Failure of Absorption of Glucose through Rectal Mucosa” The authors gave their “volunteered” children aged 5 yo 10 years old, their normal insulin dose, half a serve of breakfast then exercised them to ensure hypoglyaemia. They were sent to bed and given a dose of 30% glucose solution via a rectal tube. One of the children’s glucose was 1.4mmmol/L and they were so worried that child got intravenous glucose leaving just five subjects. Two more were given milk, leaving just three subjects. One child who got 100ml of the solution up the bum, managed after an hour to get a blood sugar rise from 1.8 to 2.4 mmol/L and I suspect still symptomatic. Anal leakage was also an a problem. Aman and Wranne quite reasonably suggested that “For the unconscious hypoglycemic child, glucose intravenously or glucagon by injection is still necessary.”

A letter published in 1985 in Diabetes care by Attval, Lager and Smith used healthy volunteers, thankfully a little older and better able to consent to having tubes pushed up their bums. In this case a dose of glucose 1g/kg was dissolved in water and inserted. The mean maximal increase in serum glucose was 19%, compared to 64% per oral. The time to that increase rectally was 30 to 40 minutes after administration. Oral peak was at 20 minutes.

For historical purposes only Tallerman published a study On the rectal absorption of glucose in Quarterly Journal of Medicine in 1920. He noted the change was slow. Interestingly this was done  prior to Banting and Best introducing insulin into clinical medicine in 1922.

Interestingly, glucagon which I would normal inject in severe hypoglycaemia, has been studied by Parker etal in a suppository form and it works quite well. Unfortunately, and possibly thankfully for me and my patients, it is only available in Australia in an injectable form.

Is there an alternative for an unconscious hypoglycaemic patient?

Yes, you can given parenteral glucagon if available. And you can place glucose into the mouth. A New Zealand study by Harris et al published in the Lancet in 2013 in neonates showed that a 40% glucose gel was effective as reversing hypoglyacemia.  The gel was massaged into the buccal cavity and the babe encouraged to feed. The use of the gel was more effective than feeding alone. Now this doesn’t exactly transfer to the unconscious adult. There is the issue of teeth to contend with. But there is evidence that there are glucose transporters within the the oral cavity.

So in conclusion, and without any obvious evidence, I think hypoglycaemic bottoms are safe from chocolate bars and squirting glucose into the mouth seems a more reasonable approach if intravenous access is not readily available. Honey which contains up to 35% glucose would be a useful substitute. Except in neonates of course, because of the risk of botulism.