Should Doctors Strike?

Although it’s a dull story, it is an important ethical issue in the medical world on the basis of whether doctors should ever strike or withdraw their services.

Both Unite, “which represents 100,000 NHS members” (http://www.bbc.co.uk/news/business-16790168) and The British Medical Association (BMA), “the professional medical association and trade
union for doctors and medical students” (www.bma.org.uk) have rejected the new pension reform set out by the government. “Unions point out that, overall, public workers must pay more and work longer” (http://www.bbc.co.uk/news/business-16790168) but the government have said that it is the “final deal on the table, and that it is fair” (http://www.bbc.co.uk/news/business-16790168).

So, what actually is the bare outline of the new pension scheme?
The people in the health service who will be spared from the pension reform are, the "530,000 NHS staff earning between £15,000 and £26,557" and "those less than 10 years away from retirement" (http://www.bbc.co.uk/news/business-16259238).

But those who earn more than £26,557 will be expected to pay more towards their pension; as reported on the BMA website, "currently doctors pay 6.5%, 7.5% or 8.5% depending on what they earn" but "by April 2014 individuals who are currently paying 8.5% will have to pay 14.5%" (http://tinyurl.com/6umt56a). On top of the increase in rates that doctors will have to pay towards their pension, they will also have to "work to the age of 68 to be able to draw a full pension" (http://tinyurl.com/6umt56a), up from 60 on the 'old' pension scheme.

Some surveys were carried out by the BMA which showed that "8 out of 10 association members thought the NHS pension scheme proposals were unacceptable" (http://tinyurl.com/78rsmqm). The new scheme has lead to doctors "saying for the first time in a generation, they would be prepared to take industrial action" (http://tinyurl.com/78rsmqm).

In this story there are a number of talking points;
Firstly, the fact that the amount that a doctor will have to pay towards his pension will rise, as illustrated in the statistics above, which means that they are therefore not getting paid as much from the government at the end of their careers by the government, but are funding a lot more of their pensions themselves.

Secondly, raising the age of retirement means that the average doctor will spend around 44 years in the medical service (assuming they graduated at 24 years of age and then started their foundation years immediately after graduation). That is a staggering length of time to sustain the high demands of time, learning and commitment that is necessary for a doctor.

Thirdly, the ethical issues of strike action by doctors. This is surely the most important talking point that has resulted from the governments new plans on pension reform. Doctors have said that they would be willing to take industrial action against the new reforms. But what could that mean for the patients, and is a dispute over pensions a justifiable reason to withdraw their services from the public domain. This argument was summed upon the BMA website; "the BMA will now draw up detailed plans on taking industrial action, with all attempts being made to minimise any risk of harm to patients" (http://tinyurl.com/78rsmqm). So it shows that they are being cautious in the matter...

It would be great to hear your points of view on this matter by posting a comment underneath or even sparking a good discussion based on what you think should happen or what is best for the community.

James Maskalyk

So there is this guy James Maskalyk. Doctor, writer, humanitarian worker.

Short overview.
"Practices emergency medicine in Toronto, founding editor of the open access journal Open Medicine (http://www.openmedicine.ca/). He has worked for Medecins Sans Frontieres (MSF) (http://www.msf.org.uk/) since 2005 as a writer and doctor. Wrote a memoir, Six Months in Sudan. Also written a blog about his experiences" (http://www.sixmonthsinsudan.com/page/blog/). (Student BMJ 2011;19:d6429). All of those links are worth checking out if you have a few minutes.

I read an interview on him in the BMJ and he seems like such an inspiration to young doctors after his travels to South America and I loved this comment, "I saw how sick people seemed compared with patients in Calgary, Canada where I was training. I knew that medicine could be a tool to working towards understanding and embracing an unfamiliar world." (Student BMJ 2011;19:d6429).

'PathFinder' Brain Surgeon Robot

In reference to last weeks post, Worldwide Flu Pandemic?, the story has developed, with the BBC posting an article on the 20th of January saying "scientists who created a potentially more deadly bird flu strain have temporarily stopped their research amid fears it could be used by terrorists" (http://www.bbc.co.uk/news/world-us-canada-16662346), full story on that URL.

In 2001, news arrived that the "first medical robot designed to operate on the brain has begun clinical trials at Queen's Medical Centre in Nottingham, UK" (http://tinyurl.com/6vcogut). This sounds quite astounding if you think about the level of accuracy and precision that surgeons need to have and; in terms of ethics, surely we couldn't give over the job of neurosurgery to a robot? This video shows neurosurgery that was carried out with an awake patient and underlines the accuracy that a neurosurgeon needs (http://www.youtube.com/watch?v=FD8ckoy9NVU). They are able to do it while the patient is awake because there are no pain receptors in the brain and there can be "anaesthetic administered locally, to the scalp" (http://tinyurl.com/7dbrwec).

The robot that began its trials in 2001, called the "PathFinder, will not be able to do operations that are not already possible, but it could do them much faster and more accurately" (http://tinyurl.com/6vcogut). PathFinder can "align the surgical tools to within 1mm" (http://tinyurl.com/6wrqgnz) which is incredible and is certainly more accurate than conventional surgery, because of the movement of the surgeons hand with the instruments.

The PathFinder is also very safe, otherwise it would not pass the trials or even be used; as this New Scientist article illustrates, "despite the name, surgical robots are not automatic and do not operate in any way like factory assembly-line robots. Rather, they are precision machines controlled remotely by a surgeon" (http://tinyurl.com/6nfeb4b). Another article, http://www.imperial.ac.uk/college.asp?P=7449, shows an experiment that was carried out based on the precision of knee surgery by a robot called 'Acrobot' and also illustrates the precision of these robots.

Another example of a robot used for neurosurgery is the 'NeuroArm'. The team on the NeuroArm Project had to overcome a number of challenges, including "how could a machine be created to be as precise and dexterous as the human hand, without compromising surgical technique?" (http://www.neuroarm.org/project/). This is one of the questions that all of the companies who make robots for surgery must ask themselves. Another video (http://tinyurl.com/7383jft) shows the NeuroArm in action.

Ten years on from when PathFinder was first unveiled I have been unable to find any statistics on the performance of the robot at all or in fact many other articles on the robot. But there are other surgical robots that have been developed (worth looking at) since 2001, such as the NeuroArm (http://www.neuroarm.org/project/) and also the ROBOCAST (http://tinyurl.com/7pk33h9).

Worldwide Flu Pandemic?

Another article from the New Scientist website that I found was looking into this question; "Two labs have made lethal, highly transmissible versions of bird flu virus – do the risks of it escaping outweigh the benefits of the research?" (http://tinyurl.com/7q74mgz). The labs have "brewed up variants of H5N1 that can spread between ferrets merely breathing the same air" (http://tinyurl.com/7q74mgz) which shows that this is an extremely contagious virus that could most certainly cause a pandemic in human beings.

I found out about the H5N1 virus, Avian Influenza, on PubMed Health (The World's Largest Medical Library). Avian Influenza is a "flu infection in birds; the virus that causes the infection in birds can mutate to infect humans, such mutation could start a deadly worldwide epidemic" (http://tinyurl.com/3hcyygv). People have been infected with the virus all across the world and "slightly more than 60% of those who became ill have died" (http://tinyurl.com/3hcyygv). This is a staggering statistic, which was also hinted by D. A. Henderson of the University of Pittsburgh, Pennsylvania who said that the "1918 flu would look like nothing if this really got loose." To give a scale to his words, he is referring to the epidemic "known as 'Spanish Flu' or 'La Grippe' between 1918-1919 which killed between 20 and 40 million people" (http://virus.stanford.edu/uda/).

In 2004 the H5N1 virus "caused poultry disease in eight Asian countries and infected at least 44 people, killing 32, most of these people had close contact with poultry" (http://tinyurl.com/7maqhxz). This shows that there are recent examples of the severity of this flu. New Scientist say that they "don't know for sure that the viruses would behave the same way in people as in ferrets [indicated in the aforementioned experiment], but the assumption has to be that they do" (http://tinyurl.com/7q74mgz). However on another website, http://tinyurl.com/7maqhxz, it is suggested that "the virus does not easily transmit from human to human" due to the binding properties of the H5N1 virus.

I think, based on the theories of the biologists and the conflicting views on how effectively the virus will take hold in humans, that we need to be aware that there is a serious risk associated with laboratories manufacturing and testing this virus and that maybe there should be limited access for those those who are working on the virus, so as to reduce the chances of passing it on. Maybe the scientists should live on a campus where they are isolated from others while they are experimenting on the virus. So in answer to New Scientist's question; "do the risks of it escaping outweigh the benefits of the research?" I would say that yes, it is worth the research so we can learn more about mutations and viruses but there needs to be strict regulations and monitoring in place to deal with the risk of a pandemic.

Indian drug-resistant TB

I picked this story up from the New Scientist website (http://tinyurl.com/6oqv3rf) which was about a "strain of tuberculosis that is resistant to all existing TB drugs" which has been "emerged" in Mumbai, India.
Tuberculosis is an infection caused by bacteria that infects the lungs but can also "spread to other parts of the body". Either, the "immune system deals with it, or it fails to kill or contain it. If it is not treated, an active TB infection can be fatal. It can damage the lungs to such an extent that a person cannot breathe properly" (http://tinyurl.com/78j3mds). There have been "12 confirmed cases of which three are dead" said Zarir Udwadia of the Hinduja National Hospital and Medical Research Centre in Mumbai "(head of the team whose diagnoses of four cases has just been published)", (http://tinyurl.com/78j3mds).

"Several medicines are used to treat TB and the treatment usually lasts six months" (http://tinyurl.com/789jpvy). The issue with the strain of TB that has been uncovered is that it is drug-resistant (as indicated in the title...) and this has caused a big worry to Mumbai as it is such a densley populated city and TB is passed on "through inhaling tiny droplets of saliva from the coughs or sneezes of an infected person" (http://tinyurl.com/78j3mds) which is incredibly easy when there are so many people, ("30,000 per square km", http://tinyurl.com/6lpbyco). The worry is that this will result in an epidemic in Mumbai with an incurable disease affecting the majority of the population of the city. "It's estimated that on average, a tuberculosis patient infects 10 to 20 contacts in a year" (http://tinyurl.com/6oqv3rf).

The only way to prevent this strain from continuing to be spread is by "quarantining them in hospitals with isolation facilities till they become non-infectious – which is not practical or possible" (http://tinyurl.com/6oqv3rf) and will become even harder to enforce as there becomes more people affected.

The World Health Organisation (WHO) will be organising a meeting to "decide what steps to take next" (http://tinyurl.com/6oqv3rf). New Scientist also mentions two other cases, one in Italy (2007) and another in Iran (2009) where there were cases of people with "totally drug-resistant (TDR) tuberculosis" and say that the "Indian report is the first since then" (http://tinyurl.com/6oqv3rf).

PIP Breast Implants

I didn't really know a lot about the recent breast implant story but I decided to find out about it...this is what I came up with.

Recently there has been a lot of coverage in the news about PIP (Poly Implant Prothese) breast implants due to "a health scare, after French authorities found a rupture rate of 5% and recommended implants were removed" (http://www.bbc.co.uk/news/health-16395244). Poly Implant Prothese was a French firm that "were banned in 2010, after their implants were found to contain industrial grade silicone gel, rather than medical grade" (http://www.bbc.co.uk/news/health-16395244). This supposedly led to a higher risk of the implants rupturing.

Andrew Lansley, the Health Secretary for England, launched a review, at the beginning of the week, due to the conflicting evidence for the rupture rates of the PIP implants. Some sources claimed that there was only a "1% (rupture rate) - in line with other implants" (statistics from the Medicines and Healthcare products Regulatory Agency (MHRA) (http://www.bbc.co.uk/news/health-16395244). Fergus Walsh, the medical correspondent for the BBC, has written an article at http://www.bbc.co.uk/news/health-16401016 about warnings of the statistics that have been produced and how some of it can be misleading due to the way that the data has been set out and collected.

In essence, this story is about the peoples reaction to the story. "40,000 British women have been fitted with the implants" (http://www.bbc.co.uk/news/health-16395244). Essentially, the data that Andrew Lansley is trying to get is the data that these women want to know; how many British women have had ruptured implants?

The options aren't very good at the moment for the women who have had the PIP implants. "Private clinics are refusing to replace the implants free of charge" (http://tinyurl.com/7w9o556). Looking at Attwood Solicitors website I found that those with the PIP implants can put a claim in for compensation but it's  not guaranteed. They also directed me to other websites for 'patient advice'.

I looked at three of the five websites that they advised the patients to look at;
- Harley Medical Group quoted The Chief Medical Officer (Dame Sally Davies), she said, "there is not enough evidence to recommend routine explantation (removal) of these breast implants". HMG have decided to find out which of their patients were given PIP implants and deal with those people, but have decided not to give free removals. (http://tinyurl.com/6prsrpq).
-Surgicare Medical Group have said that they have not been recommended to remove these implants and say they have been monitoring their rupture rates over several years and have not found any data that is a cause for concern. (http://tinyurl.com/6p7c9x9).
-Transform Cosmetic Surgery Group commented saying that they do not have sufficient data of ruptures in the PIP implants to remove them free of charge for their patients. (http://www.transforminglives.co.uk/latest-news.html).

Andrew Lansley said today that "private clinics that fitted implants have a "moral duty" to remove them" and that "the NHS would pay to remove, but not replace, implants if a private clinic refused" the issue with this is for the taxpayer who will then have to foot the bill; but he then said that "if the NHS was forced to remove an implant "the government would pursue private clinics to seek recovery of our costs" (http://www.bbc.co.uk/news/uk-16523464).

Assisted Suicide

As most people know Dignitas is the Swiss suicide clinic founded in 1998. I decided to go on the internet and find out some news stories about it after the news that "there is a strong case for allowing assisted suicide for people who are terminally ill in England and Wales" (http://www.bbc.co.uk/news/health-16410118). The case, made by The Commission on Assisted Dying, was that "it was possible to allow assisted dying within a strict set of rules to ensure it was not abused" (http://www.bbc.co.uk/news/health-16410118), the whole story is on the BBC News link.
Digging around on the internet I found an article on MailOnline on the 20th October 2011 about nurses not being able to tell patients about Dignitas or even offer it up as a suggestion even if asked about it by patients. They were even told they could go to prison for talking to patients about assisted dying, (whole story at http://tinyurl.com/7z6op7d).

Another story, run by The Telegraph on the 8th January 2012, gives information about a "clampdown" on the clinic because of the increasing number of British people who are travelling to Switzerland to die. Legalisation that could be put in place aims to make the patients have a longer counselling service to make sure that they want to die, (whole story at http://tinyurl.com/ldqh75).

The final story, a famous one, about a 23 year old rugby player who took his life at Dignitas. He was one of the youngest British man to take his life at Dignitas and was the first time it was really noticed by the British public, (whole story http://www.guardian.co.uk/uk/2008/oct/18/11).

These stories really bring the ethical issues to light, that people do really want to end their lives for one reason or another, as they don't see that it's worth living for anymore. The issue for doctors is that it is their duty to keep these patients alive, and giving them an option of suicide doesn't follow with their duty.

Disaccharides and Monosaccharides

Another one for AS Biology, by request...

A monosaccharide is a single sugar molecule such as Glucose, Fructose and Galactose. These bind together via glycosidic bonds to form disaccharides and water in a condensation reaction. To separate them again water needs to be added and a hydrolysis reaction takes place.

Glucose and Glucose create Maltose.
Glucose and Galactose create Lactose.
Glucose and Fructose create Sucrose.

The two Glucose molecules in Maltose are joined by a 1-4 glycosidic bond. This is because the Carbon's that form the bond bind to the Oxygen on Carbon 1 and Carbon 4. When there are branches in the structure they are linked by a 1-6 glycosidic bond as well as 1-4 glycosidic bonds, illustrated in this image (http://tinyurl.com/7qfy8zd).

The main structures (tested at AS level) are Amylose, Amylopectin and Glycogen. Amylose and Amylopectin are used to store energy in plants and Glycogen is an energy store in humans (broken down in respiration for ATP).

-Amylose (starch store) is a spiral structure with 1-4 bonds only and is not branched.
-Amylopectin (starch store) has more branches than Amylose as it has 1-4 and 1-6 glycosidic bonds.
-Glycogen has a lot more branches than Amylopectin and is used in humans due to the number of branches speed at which it can be hydrolysed, as humans need a higher energy rate than plants.

All three molecules are insoluble so have no osmotic effect on the cells, and are polysaccarides (many saccharides).

Transcription and Translation

This is one for those doing AS Biology this week...

The difference between RNA and DNA is that RNA is a single strand, has a ribose sugar opposed to a deoxyribose sugar, and uses the base Uracil as a replacement to Thymine.

-Transcription
This is the process where mRNA (messengerRNA) is formed when the DNA unwinds in a certain section. The strand of DNA is copied via free nucleotides coming together opposite their complementary bases and being stuck together into the mRNA by RNA polymerase. The mRNA then leaves the cell through the nuclear pores and attaches itself to a ribosome. Once it has left the DNA, it winds itself back up into its double helix structure.

-Translation
This process involves tRNA (transferRNA) and ribosome's. The ribosome acts as a holding site for the tRNA and mRNA to come together and for the mRNA to be translated. On the tRNA there is an anticodon. This anticodon is complementary to a codon (triplet base sequence) on the mRNA and the i.e. if the mRNA had a triplet code of UGC the anticodon would be ACG. The tRNA therefore has complementary bases to the mRNA and this is the start of the formation of the amino acid chains.

Attached to the top of the tRNA is a certain amino acid and this amino acid forms a peptide bond with the amino acid on the next tRNA, which has an anticodon that is complementary to the next triplet code. This is how the proteins are formed, where they then form a tertiary (3D) structure to create the final product.

I found a video on YouTube (http://www.youtube.com/watch?v=TfYf_rPWUdY&feature=related that sums it up quite well.

Platelet Donation

Carrying on from the topic of blood donation I will move onto platelet donation. The method used of taking the platelets out of the blood is called plateletpheresis. This term derives from apheresis which "involves removing whole blood from the donor and separating the blood into individual components" (http://www.medicinenet.com/hemapheresis/article.htm), in plateletpheresis it is the removal of platelets from the blood and then pumping the blood back into the body.

All types of apheresis involve "connecting the blood in the patient/donor's veins through tubing to a machine that separates the blood components, separation is done by either a centrifuge process or a filtration process" (http://www.medicinenet.com/hemapheresis/page2.htm). Once the components have been removed the blood is directed back into the body via another blood vessel.

But although it sounds all well and good to donate platelets, what are they needed for? Platelets are a part of the blood that assist in blood clotting by coming together and forming a platelet plug. The platelets that are taken from the donors are given to those who are "unable to make enough platelets in their bone marrow" (http://www.blood.co.uk/platelets/). This could be because of a "disease such as leukaemia or other cancers or the treatments they have had" (http://www.blood.co.uk/platelets/). However, the donors are able to make enough platelets to replenish the ones that have been taken "(only 20% taken) very quickly" (http://www.westred.org/BldAphr.htm).

The issue with platelet donation is that unlike blood, "they can be stored for only a few days" (http://www.blood.co.uk/platelets/about/). This means that there need to be frequent platelet donations to keep stocks up.

This clip on YouTube shows the process of donating plasma, which as I said earlier is the same as donating platelets but extracting a different component of the blood, (http://www.youtube.com/watch?v=hDsdY8-_lCo).