Monday, 5 August 2013

How to die without dying

Have you ever watched someone die? Almost everybody has. Ok, so not in real life but on TV or in a film? Deaths are used by writers to make us laugh or cry, but I've watched two this week which, well, irritated me. Instead of being sucked into the emotional tragedy unfolding before me, I sat muttering ”well that wasn't very realistic”. Now, I am the queen of suspending disbelief- I've watched Neighbours for over 25 years, my Freeview recorder has 169 episodes of Murder, She Wrote on it (Angela Lansbury makes me want to be old) and I believe that Jack Bauer really could do all that AND MORE in 24hrs. But even my imagination couldn’t keep me in TV land when faced with Queen Eva's death in Once Upon a Time this week. I was sucked out of the story and spat out onto the sofa by the absurdity of it. An immaculately beautiful woman imparted an eloquent, heartfelt message before dying in a neat, quick and quiet way. You could almost feel her holding her breath. No death rattle for Queen Eva.

But that was a fairy-tale, she was poisoned, maybe magically cursed people do die just like that. (The Oxford Handbook of Clinical Medicine was no help in this matter). But Queen Eva wasn't the only irksome death of the week- I felt just as bothered by the departure of Raj from 90210. Yes, my name is Catherine and I watch 90210…it’s like the crack of TV, so bad, yet you just can’t stop it, and your husband doesn't understand why you keep going back to it. Anyways, there I was, enjoying my fix of emotional highs and lows delivered by the beautiful people. Raj was in hospital looking a little hungover. We know he’s close to death, purely because we've been told so, but he's chatting away, being witty, romantic and thoughtful. Then his girl pops out for a second and returns to find him dead. We know he's dead because his eyes are shut and she drops a glass of water. Again it’s neat, quick and quiet. Bothersomely so.

You see people in TV land, like Raj and Eva, die without dying. In the real world, death is an event, but dying is a process. Noisy, irregular breathing, semi-consciousness, confusion, a dry mouth, restlessness- these are often very normal parts of dying.

Yet we don’t often see this on TV, despite the fact that a LOT of people die in soaps. A study of soap characters in the BMJ found that “standardised mortality ratios for characters were among the highest for any occupation yet described”. The authors noted that “Their lives are more dangerous even than those of Formula One racing drivers or bomb disposal experts”. But despite this obsession with death, TV hates people dying. Perhaps because it’s too upsetting? Yet, think of a soap wedding- we expect it to be upsetting, we KNOW there are very few happily ever afters in soap land. TV expends a huge amount of effort in creating drama and wringing every ounce of emotion from an audience. So it seems strange that dying a soap death is as simple and sanitized as you could hope for. Does this suggest dying, more than death, is a taboo too shocking for TV?

I know that reality isn't what these programmes are made for, but they are based firmly in our world. Music we know plays in the pub, there are frequent references to Facebook and everyone in Ramsay Street has an ill-disguised mac book. These shows tell stories about people and they're watched by millions. That means they have incredible potential to influence our expectations of what normal is. Is TV making us think it’s normal to die without dying? If so, a lot of us are ill prepared for when death forces its way from our screens and into our lives.

Think back to the last time you watched someone die in TV or film land. Did you really watch them die, or just see a death?

Monday, 6 May 2013

Poo, glorious poo

C. diff. Courtesy of Marcus007 at de.wikipedia [Public domain], from Wikimedia Commons
 When is it medically advisable to eat some one else's poo? When you need a poo transplant.
Poo transplants could be the solution to one of the biggest problems facing the NHS today- the bacterial infection Clostridium difficile. C.diff, as its known to its friends, infects about 18,000 people in England and Wales every year and is involved in the deaths of about 2000 people.
C.diff typically arises due to imbalances in your normal gut bacteria. You see your gut is like a city, a city with about 100 trillion bacterial residents happily munching away on a banquet of bowel contents. The average person has about 1000 different types of bacteria in their gut, and about 3% of healthy adults have C.diff in that mix. The C.diff doesn't cause them any problems because its numbers are kept in check by the other gut bacteria. However treatment with broad spectrum antibiotics can disrupt this happy community, killing off vast swathes of bacteria but crucially not the C.diff which is particularly hardy. Given free rein the C.diff multiplies rapidly and produce toxins which damage the gut. In some people this causes mild diarrhoea and abdominal pain, in others it can lead to torrential diarrhoea, perforation of the colon and death.
Traditional treatment involves stopping the broad spectrum antibiotics and prescribing antibiotics which specifically target the C.diff. However C. diff is becoming resistant to these antibiotics and about 22% of patients who are treated then relapse. This can result in a cycle of illness and hospital admission which is costly to the patient and the hospital.

So it's time to start thinking outside of the box. Cue the poo transplant. The thinking goes like this- if the cause of the problem is disruption to the normal community of gut bacteria, why not just pop those bacteria back in to crowd out the C.diff? Simples. Practically, the first step is to identify a donor, usually a close relative of the patient, and screen them for a range of infectious diseases and parasites. You should also make sure they haven't recently consumed anything the intended recipient is allergic to, before asking them to make their "donation". You then pop it in a household blender, adding salt water or milk to achieve a slurry consistency and blitz it down. Next you need to strain your concoction to remove large materials- one medic in the UK uses coffee filters. Top tip. Then you're ready to administer it- about 25ml from above (via a tube into the stomach), or 250ml from below.
Now, its important to note that poo transplants are experimental. To date only small case studies have been carried out, but with 200 total reported cases, an average cure rate of 96% and no serious adverse events reported to date, it's worth carrying out a large trial to assess it thoroughly.
So, poo transplants-the ideal treatment for a cash strapped NHS. Its cheap, plentiful and it seems to work. We just have to convince people to consume someone else's poo....or, let us pop it in their bums. Bottoms up!

Sunday, 3 March 2013

A Medical Mystery for Mother's Day...

I'd like to tell you a curious story. Jane was a 52 year old woman in need of a kidney transplant. Thankfully she had 3 loving sons who were all very happy to give her one of theirs. So Jane's doctors performed tests to find out which of the three boys would be the best match, but the results were surprising. In the words of Jeremy Kyle, the DNA test showed that Jane was not the mother of two of the boys... Hang on, said Jane, childbirth is not something you easily forget. They're definitely mine. And she was right. It turns out Jane was a chimera.

Chimerism is the existence of two genetically different cell lines in one organism. This can arise for a number of reasons- it can be caused by medics, like when someone has an organ transplant, or be naturally occurring. In Jane's case, it began in her mum's womb, with two eggs that had been fertilised by different sperm creating two embryos. Ordinarily, they would develop into two non-identical twins. However in Jane's case the two balls of cells fused early in development creating one person with both cell lines.

Thus when doctors did the first tissue typing tests on Jane, just by chance they had only sampled the 'yellow' cell line which was responsible for one of her sons. When they went back again they found the 'pink' cell line which had given rise to the other two boys.

This particular type of human chimerism is thought to be pretty rare- there are only 30 case reports in the literature. (Though remarkably both House and CSI's Gil Grissom have encountered cases.) What happens far more frequently is fetal microchimerism- which occurs in pregnant women when cells cross the placenta from baby to mum. This is awesome because we used to think the placenta was this barrier which prevented any cells crossing over. Now we've found both cells and free floating DNA cross the placenta, and that the cells can hang around for decades after the baby was born. Why? As is often the case in medicine we're not sure but one theory is that the fetal cells might have healing properties for mum. In pregnant mice who've had a heart attack, fetal cells can travel to the mum's heart where they develop into new heart muscle to repair the damage.

Whilst we're still in the early stages of understanding why this happens, we already have a practical application. In the United States today, a pregnant woman can have a blood test which isn't looking for abnormalities in her DNA, but in that of her fetus. The DNA test isn't conclusive enough to be used to diagnose genetic conditions in isolation, but it is a good screening test for certain conditions including Down's syndrome.

Now, we started with a curious tale, so let's close with a curious fact and one that's appropriate for Mother's Day: This exchange of cells across the placenta is a two way process. So you may well have some of your mum's cells rushing through your veins right now. In my case they're probably the ones that tell me to put on sensible shoes and put that boy down...

This post is based on a presentation I gave at the 2013 FameLab regional finals.