Oh hell

Oh Hell, that hurts!  I sat down in a hurry. My first thought was “I’m having a heart attack.”  My second was “Don’t be silly you’re only 49 and probably just gobbled lunch too quickly, again.”  Jess came up to me and said “Gosh, you look pale.”  I mumbled something about a bit of pain.  It bit again, Jess noticed my grimace and said the inevitable “We should call a doctor.”  I tried to argue but to be honest, felt lousy and a little bit scared.  Before, I knew it I was bundled up off to the Emergency department.

Rule #1: Never ignore chest pain!

Rule #1: Never ignore chest pain!

As soon as I got in ED there were nurses and doctors questioning me, taking some blood, and sticking little metal electrodes all over my chest.  I later found out they were measuring in my blood something called troponin which goes up with a heart attack (well… they used the words like myocardial infarction and acute coronary syndrome … but all I cared about was whether I was having a heart attack or not).  The electrodes I learnt were measuring the electrical activity of my heart – they called it an ECG.  They told me that if either the troponin levels were high or the ECG squiggles were not where they were meant to be then I would be admitted to the cardiology ward.  They were going to repeat all the measurements a couple of hours later.  I was a little annoyed by all the questions to start with, but I soon learnt that sometimes the troponin levels are low and the ECG negative but people can still have a serious heart problem.  They use the questions to come up with a risk score which helps them make a clinical judgment.  The questions were about the usual stuff – smoking, family history of heart disease etc as well as some specifically about where the pain was, what kind of pain (mine was definitely sharp), and whether it moved to the arms or shoulders.

Pretty soon after I arrived someone came up to me who called herself a research nurse and asked if I would consider joining a study. She was lovely. She explained the study was all about trying to rapidly rule out a heart attack.  Apparently only a quarter of those presenting with chest pain actually have a heart problem needing attending too.  However, it’s difficult to tell quickly if someone is in that quarter or not and so a huge percentage of patients get admitted to hospital, usually staying overnight, and certainly costing the tax payer heaps.  Well, I’d just paid a massive tax bill so I signed up pretty darn quick.  Also, I can’t stand hospitals and so I’ll support anything that keeps me out of them!  Of course, this research wasn’t going to help me now, but who knows in the future.  Actually, for the price of another round of questions and a little more blood (fortunately they didn’t need to stick any more needles in me) it seemed a small price to “do my bit” for science… ‘All I have to offer you is blood, sweat…’

After a couple of hours and a repeat of all the tests, I was told they had all come out negative and my risk score was low.  The docs saw nothing else that rang alarm bells.  They signed me up for a treadmill test the next day “just in case” (served me right, I’d been avoiding the gym) and sent me on my way.  I felt a bit of a berk, but they were so good to me and kept reiterating that it is much much better to be safe than sorry.  Besides, I got to participate in some science which was rather cool.

____________________________________________________________

Author’s note:  Research in Christchurch Hospital Emergency Department lead by Dr Martin Than has enabled nearly a doubling of the numbers of people in whom a heart attack can be ruled out early.  I have been fortunate to join the team this year as we run a randomised controlled trial of two scoring regimes to see if one will increase the rates of safe early discharge.

A day to celebrate

If it weren’t for your kidneys where would you be?

You’d be in the hospital or infirmary,

If you didn’t have two functioning kidneys.

(with apologies to John Clarke aka Fred Dagg)

Happy World Kidney Day everyone.

This blog started off life as $100 Dialysis because I believe that if we can make a computer for $100 then surely we can do the same for dialysis!  Dialysis is a life saver, yet its cost kills as so many can not afford the treatment.

There’s some good news in the dialysis world.

Schematics of the zeolite nanonfibres and how they may look in practice

Schematics of the zeolite nanonfibres and how they may look in practice

Just last week the MANA – International Centre for Materials NanoArchitectionics announced  they have developed a method to remove waste from the blood using an easy-to-produce nanofibre mesh.  Importantly, they claim it is cheap to produce.  Details were published in Biomaterials Science (free access).  Despite the photograph, there have been no human studies yet, but I expect that won’t be too long in the future.

Dr Victor Gura and the Wearable Artificial Kidney (WAK)

Dr Victor Gura and the Wearable Artificial Kidney (WAK)

In the meantime, the FDA gave approval last month for human trials of a wearable dialysis device produced by Blood Purification Technologies Inc (the WAK).

New Zealand, and Dunedin and Christchurch in particular, lead the way in Home Dialysis.  One Dunedin tradesman has even taken Home Dialysis a step further and turned it into portable dialysis by dialysing in his work van during his lunch hour. Of course, those needing a holiday may go on the road in specially equipped camper vans (http://www.kidneys.co.nz/Kidney-Disease/Holiday-Dialysis/).

Cause for celebration in the New Zealand kidney community was the gong (Office of the New Zealand Order of Merit) given to Adrian Buttimore who for 40 years managed Christchurch’s dialysis service.

These are just a few pieces of good news as doctors and scientists work around the world to improve the lives of dialysis patients.

_________________

Hot off the Press… I couldn’t resist adding this…. Pee, the answer to the world’s energy problems. http://www.bbc.com/future/story/20140312-is-pee-power-really-possible

 

Publish And Perish

I didn’t want to be in a position to write this post.  I’ve procrastinated and debated whether I should or not – mainly because I don’t want it to come across as sour grapes.  However, procrastination over…

2013 was a great year from the academic metrics point of view – many articles were written, twice I published articles which were written up in Nature Reviews, I got a PhD student across the line, I had more citations than every before, and my h-index continued to increase.  My PBRF score came out a “B”, which given it was based on only 4 years work I was happy with, and to top it off 3 months ago my university promoted me to Associate Professor.

PandPYou’d think that would be enough to keep me happy, but, one crucial element was missing.  On 31 Dec 2013 I finally ran out of grant funds and lost my position.  Yes, I Published AND Perished.  Ta daaa…

There are a number of reasons for this situation: (1) I failed to successfully beat other grant applicants to the prize – something I have to do regularly for me to survive in academia, (2) I failed to persuade the university to shift funds from one priority to another, and (3) I have failed to persuade (successive) governments to change the focus of their funding from projects to people. The reality of the situation in New Zealand is that within universities the position of investigator driven grant funded (only) research scientist is under threat.  It is  a “career path” which has all but disappered.  Should this career path be cleared and made navigable once more?  That’s something the policy makers in universities and government departments need to think about.

For me, the consequences are that the work I have been doing on Acute Kidney Injury must slow down dramatically.  I’m still looking to carry on some work part-time – at the very very least I still have the data which patients have volunteered to provide which needs writing up and publishing. I see this as a moral responsibility.

Fortunately, this post is not all negative.  Two weeks ago I began a part-time position as a Senior Research Scientist with the Emergency Care Foundation.   This is a great opportunity to get involved with some world-class research emanating from the Emergency Department of Christchurch hospital.  At a later stage I will post on the studies and trials we are running.

One last comment, Sir Peter Gluckmann wrote recently of the “Impact Agenda” for publicly funded research.  He talked of what are sometimes seen as competing impacts – that of the universities with an emphasis on publications, citations, and that awful pathetic publication metric called the “impact factor”, and that of policy makers wanting research to impact public policy, societal health, the environment and the economy.  I think there is a need for some given and take – academic institutions and academics need to take a breath and re-evaluate the public good of metric driven research – some changes to the PBRF system could help this. Indeed, I wish many of my fellow academics would recognise they are in a service industry, where ultimately they research for the good of the public.  Policy makers and politicians, on the other hand, need to step back from treating scientists as if they were engineers who can be told to build something.  Science just does not work like engineering, it is not a tool to be used to produce a desired output, rather a methodology by which great changes and great good can happen.

To PSA or not to PSA

In light of the controversy over the Ministry of Health’s pamphlet on prostate cancer I thought I would repost a post I published in May 2012:

___________________________________________________

As a male, 40 mumble years old, do I do it?  Do I get a prostate exam and PSA test?  Do I plan to keep doing tests every few years?

PSA (prostate specific antigen) is a blood test where elevated levels may indicate the presence of prostate cancer.  A powerful group, the US Preventative Services Task Force has come out against screening with PSA giving the test its lowest (D) grade.  They conclude “that many men are harmed as a result of prostate cancer screening and few, if any, benefit.”  Strong words. TV3 (misleadingly, but that’s another story!) and other media reported on this last night. The response of the Urological Society (at least its president) is to reject the report and urges men “not to be deterred” and to “discuss the PSA blood test with their GP.

This is approximately how my conversation went a couple of years ago.

GP: We’ll do a PSA test while we are at it.

ME:  Isn’t that a waste of time? Doesn’t it have a lot of false positives?

GP: Yes, but we can monitor for changes.

Hmmm…so it is not just the value of the test, but how it changes in time that is important.  A quick check on the internet I find that this is called the PSA “velocity.”  Interestingly in the evidence provided by the US Task Force I can find no mention of PSA velocity.

In the meantime, a quick check on the Canterbury Health Labs web site (see here) tells me that the test has a reference range of 0 to 4.0 ug/L (this is a concentration in plasma).  If a test is above this range a GP is likely to want to discuss it with you and may recommend a biopsy.

This is where life gets interesting.  A couple of weeks ago I talked of “False Positives” and introduced the diagram below.  A “False Positive” for myself would have been a PSA above 4.0 ug/L which didn’t turn out to be cancer.  The main issue with PSA tests is the high number of False Positives.  The Task Force suggested that in a screening regime after 3 or 4 tests (over several years) 12 to 13% of participants have a positive test.  Most, though, are False Positives.  Approximately 80% of Positive tests are False Positives!  Consider this – if screening happened in NZ and 500,000 men had a test every 5 years then after 15 to 20 years 500,000 * 0.12 *0.8 = 4800 men will have had a False Positive test.  Another 1200 a True Positive test.

Ideally every test result will lie in the dark blue (true negative) or dark red (true positive). In reality, there is always a few false positives and false negatives [A good test would have few (the narrow ellipse), a poor test would have many (broader ellipse)].

Importantly, the Urological Society put it this way “The PSA blood test does not diagnose prostate cancer. But it raises a red flag and identifies those men who need to have prostate cancer excluded through further investigation via a prostate biopsy.”

PSA does not diagnose – this is a very important point that a GP must communicate BEFORE a test is done.  I would be surprised if even 10% of men realize that PSA does not a diagnose.  So what happens to all the False Positives and True Positives?  This is what the Task Force focused on.

First they asked “Does PSA-Based Screening Decrease Prostate Cancer–Specific or All-Cause Mortality? Does PSA-Based Screening Decrease Prostate Cancer–Specific or All-Cause Mortality?

There was no clear evidence it does (contradictory studies).  In their useful “stats at a glance” publication they state “1 man in 1,000 – at most – avoids death from prostate cancer because of screening.”

If this is so, then it could be worth it (by the way – at a cost of $11.92 + GST + cost of GP visit – say $60 (low), then I estimate screening of 100,000 men a year would cost a minimum of $7.2M annually in NZ).

It is the next questions of the Task Force that are revealing.  The looked at the harms of screening.  The harms of those with Positive test (True or False) and then the harm to those finally diagnosed with prostate cancer.  Again the summary is revealing:

Most prostate cancers found by PSA screening are slow growing, not life threatening, and will not cause a man any harm during his lifetime. However, there is currently no way to determine which cancers are likely to threaten a man’s health and which will not. As a result, almost all men with PSA-detected prostate cancer opt to receive treatment. In addition to the frequent complications of biopsy that lead to a cancer diagnosis, there can be serious harms from treatment of screen-detected prostate cancer.

For every 1,000 men who are screened with the PSA test:

  • 30 to 40 men will develop erectile dysfunction or urinary incontinence due to treatment
  • 2 men will experience a serious cardiovascular event, such as a heart attack, due to treatment
  • 1 man will develop a serious blood clot in his leg or lungs due to treatment 


For every 3,000 men who are screened with the PSA test:

  • 1 man will die due to complications from surgical treatment

And they did not attempt to assess social or psychological harm!  Imagine the conversation at home:

Man: Hi honey, I’m home.  I got a positive PSA test today.

Woman:  That’s nice dear.  Did you get an appointment for a biopsy.

Man:  Yes, in 3 months time.

Woman: Great.  Shall we go out for dinner?

Somehow, I don’t think it would be like that, except perhaps the waiting time for a next appointment.

So where does this leave us.  My opinion, for what it is worth, is that:

  1. A PSA screening program should not take place in New Zealand.
  2. GPs should use PSA tests only where there are other risk factors
  3. Prior to any other procedure, repeat tests of positives should be done under strict conditions. Particularly the diet of the person involved should be changed to minimize the risk of false positives (there is still debate about the role of diet in false positives – so some research should be done at the same time: “Does changing diet change PSA levels in the short term?”).  Men – you can ask for this!
  4. GPs should explain that:
  •            a positive test does not mean cancer (most probably already do explain this, but it worth emphasizing),
  •            there are risks with biopsies, and
  •            there are great risks with treatment (prostectomy or radiation normally).

I qualify this with what appears to me to be a lack of assessment of the benefit of “changes in PSA” levels.  The sort of question which comes to mind is “How accurate is the diagnosis of a 2 ug/L or 100% increase (say) in PSA over 5 years?”

I wonder, would you have a PSA test?

How Academia Resembles a Drug Gang

John Pickering:

Worth a read for those interested in how academia works.
In the NZ context, I wonder how people see this. Is there a small cartel controlling the lives of the rest who plug away looking for grants in the hope of making the breakthrough?
Note: The increase in percentage of PhDs between 2000 and 2011 in NZ in the graph in this article is distorted by the large influx of international students in the late 90s and early 00s. This was further exacerbated by the change in rules to allow international PhD students to pay domestic and not international fees.

Originally posted on Alexandre Afonso:

In 2000, economist Steven Levitt and sociologist Sudhir Venkatesh published an article in the Quarterly Journal of Economics about the internal wage structure of a Chicago drug gang. This piece would later serve as a basis for a chapter in Levitt’s (and Dubner’s) best seller Freakonomics. [1] The title of the chapter, “Why drug dealers still live with their moms”, was based on the finding that the income distribution within gangs was extremely skewed in favor  of those at the top, while the rank-and-file street sellers earned even less than employees in legitimate low-skilled activities, let’s say at McDonald’s. They calculated 3.30 dollars as the hourly rate, that is, well below a living wage (that’s why they still live with their moms). [2]

If you take into account the risk of being shot by rival gangs, ending up in jail or being beaten up by your own hierarchy, you…

View original 2,017 more words

A taste of success

Some recent successes of University of Otago Christchurch researchers:

Chlorine bleach key in disease?

Professor Tony Kettle from the Centre for Free Radical Research has won a prestigious Marsden Fund grant to better understand a ‘Jekyll and Hyde’ chemical with a role in heart disease, cancer, cystic fibrosis, and rheumatoid arthritis.

Professor Kettle will investigate chlorine bleach’s role in strengthening collagen by linking to form a resilient mesh. Without this mesh people can develop cataracts and an autoimmune disease that destroys the kidneys and causes the lungs to hemorrhage. However bleach can also have negative effects.

“Chlorine bleach should be viewed as a natural chemical with a Jekyll and Hyde personality. It helps us to fight infections and form strong connective tissue but also endangers our health during uncontrolled inflammation.”

Professor Kettle and his team will work with researchers from Vienna and Budapest on the project.

Improving the treatment and experience for dialysis patients

Chronic kidney disease is common, affecting about 500,000 New Zealanders. It is important because it increases chances of heart disease and death and may lead to needing treatment with dialysis or a kidney transplant. Dialysis therapy is a heavy and costly burden for patients and their families and the health system. However, there is a lack of reliable evidence to improve patient outcomes.

Dr Suetonia Palmer has just been awarded a prestigious Rutherford Discovery Fellowship valued at $800,000 over five years for research project called: “Improving evidence for decision-makers in chronic kidney disease.”

Dr Palmer’s research aims to to provide rigorous overviews of existing research and participant-led enquiry to provide better and more useable information for clinicians, consumers and policy-makers in the field of chronic kidney disease.

Recovering from food addiction

Professor Doug Sellman and his team from the National Addiction Centre have just been granted funding to trial a new treatment for those with obesity called Kia Akina.

“There is a serious need to develop new non-surgical ways of treating obesity because obesity-related diseases are expensive for New Zealand, traditional non-surgical methods are not working, and surgery is very costly,” says Professor Sellman.

Kia Akina uses a ‘food addiction’ approach to obesity. Professor Sellman says the project will test the feasibility, short-term effectiveness and participant satisfaction ofKia Akina within a primary health care setting.

If shown to be effective, Kia Akina will be developed as a non-commercial, low cost network for obesity recovery throughout New Zealand.

Innovation in Indigenous Health

Christchurch’s Maori/Indigenous Health Institute (MIHI) recently won the Australasian award for ‘innovation in Indigenous health curriculum implementation’ at the Leaders in Indigenous Medical Education (LIME) conference.

The LIME conference brings together all 20 medical schools throughout Australia and New Zealand, and hosts attendees from the United States and Canada.

Staff and students of the University of Otago, Christchurch, in Darwin at the Leaders in Indigenous Medical Education (LIME) conference

Staff and students of the University of Otago, Christchurch, in Darwin at the Leaders in Indigenous Medical Education (LIME) conference

MIHI director Suzanne Pitama says she and her team were thrilled to receive the award. As there is much collaboration between indigenous teaching teams at University of Otago’s Christchurch, Wellington and Dunedin campuses, the award recognises the innovation of all these teams.  It also recognised the systemic support within the University of Otago to prioritise indigenous health within the curriculum.

MIHI oversees the Maori health component of the medical curriculum at the University of Otago, Christchurch.

Award nominees are judged on how well their teaching programmes demonstrate their commitment and experience to understanding and furthering the health of Maori and Indigenous peoples.

The award has been presented for four years, says Pitama. MIHI also won it in the inaugural year.

A review panel of academic peers and members of indigenous medical doctors associations judge the award, Pitama says.

___________________________

This guest post was written by Kim Thomas,  Senior Communications Advisor, University of Otago, Christchurch, www.uoc.otago.ac.nz.