The Thin End

He is back. UK Prime Minister, Boris Johnson, is back at the helm following his illness with COVID-19. At the media conference this evening, he seemed to have much of his old bounce. He had at least some good news. The UK is now turning the corner in its struggle with COVID-19. The curve of deaths appears now in a downward direction. The UK has passed its peak of COVID-19 deaths, and this is all good news. We now have a better idea of the numbers of COVID-19 deaths because we are no longer merely counting those in hospitals. Testing has undoubtedly gone up, even if it hasn't reached the target of 100,000 set by the Health Secretary. The emphasis is now turning to reduce collateral deaths (from cancer, heart disease, etc.) due to patients not accessing vital health care. We still don't know how many may die as a result of this. This needs more effort and should be a key factor now and in coming out of lockdown. It would be wrong to sacrifice cancer patients and others. After...

The UK government won't tell us who sits on the body advising them on how to deal with the COVID-19 pandemic. It isn't surprising because what we do now know is that it lacks critical expertise in virology, immunology. This lack of expertise certainly shows at the daily media briefings, which seem more to do with putting a government spin on stories than revealing what is happening. To the greatest extent, we are being kept in the dark. Take today, for example. The Health Secretary Matt Hancock came up with this shockingly misleading statement. He told us that “The UK has already gone past the number of tests per day for instance that they carry out in South Korea, we’re approaching the levels that Germany undertakes" This just is not the case by any reading of the statistics. The UK’s daily testing average over the past week has been just shy of 23,000 tests a day. Germany has been carrying out 450,000 tests a week, according to its foreign minis...

The virus vector for COVID-19 pandemic is a novel zoonotic coronavirus,  SARS-CoV-2,  most likely originating from bats.  One problem in combating the virus is that we know so little about it.  We don't know, for example, whether any immunity developed in humans will last, or how long it will last.  Nor do we know to what extent it jumps from species to species.  Is it possible that our livestock, or our domestic pets,  will become infected?   Whether SARS-CoV-2 can also infect other animal species is being investigated by various research institutes worldwide. The Friedrich-Loeffler-Institut (FLI) started infection studies in pigs, chickens, fruit bats, and ferrets several weeks ago.  First results show that fruit bats and ferrets are susceptible to SARS-CoV-2 infection, whereas pigs and chickens are not. The susceptibility of ferrets in particular is an important finding, as they could be used as model animals for human infection...

Public health bodies are worried that an alarming drop in childhood vaccinations is leading to a resurgence of diseases in childhood that we had all but eradicated.  Misinformation and scare stories about the harmful effects of vaccines abound on the internet and in social media.  Where they are based on 'science', it is highly selective, and often reliance is placed on falsehoods.  Conspiracy theories also abound - cover-ups, deception, lies. As a result, too many parents are shunning vaccinations for their children.  So, what does the published, peer-reviewed literature tell us about vaccincations? Are they safe and effective, or are there long term harmful effects?  A new report now provides some of the answers. New evidence published in the Cochrane Library today finds MMR, MMRV, and MMR+V vaccines are effective and that they are not associated with increased risk of autism. Measles, mumps, rubella, and varicella (also known as chickenpox) are infecti...

Family history has always been important in medical diagnosis and treatment.  In the treatment of cancers, early detection can improve the chances of survival.  Now a new study published online in  CANCER  shows the importance of family history in the detection and prevention of colorectal cancer. In the analysis that included information on adults diagnosed with colorectal cancer between 40 and 49 years of age, almost all patients could have been diagnosed earlier if they had been screened according to current family history–based screening guidelines.  In many countries, colorectal cancer rates are rising in adults under 50 years of age. To identify those at risk, current guidelines recommend early screening for colorectal cancer among individuals with a family history of the disease. For example, for individuals with a first-degree relative with colorectal cancer, several medical societies recommend initiating screening at 40 years of age or 10 ye...

While the UK Government is not doing enough, our doctors and nurses are struggling at the frontline. Some are losing their lives to COVID-19. Instead of addressing the issues, the government are asking doctors and nurses to use personal protective clothing in ways that are considered dangerous. The Royal College of Surgeons has issued a statement saying that doctors should not be coerced into putting their lives at risk. Meanwhile, doctors and nurses are being gagged from speaking out about the shortages. Responding to criticism that Prime Minister Boris Johnson missed five emergency COBRA meetings, the Education Secretary said at the press conference today, Sunday: "This is a whole government effort. We are doing everything that is required, everything that is needed." Well, what is needed is PPE and testing, among other things, and on both these fronts the government is failing to do everything required. Our doctors and nurses are being asked to put their lives at f...

When you approach a plant or a tree, you would perhaps be surprised how much it senses your presence. This isn't surprising when you consider the intimate relationship between animal and plant life. The trees harness the sun's energy, and we scatter its seed.  When we take from our ecosystem, we must give something back. We could share our planet instead of assuming it was ours. Plundering our forests, laying waste with our concrete jungles, polluting our rivers and streams, making noise, a mountain of human detritus, like a scar on the landscape.  Imagine, while we are driven into lockdown by a virus we cannot see, imagine how the forest feels about us...now it takes a moment to breathe, and the silence allows the birds to fly free, imagine. There stood a tree in my childhood days And there grew grass under sunlight rays But where are these now so rare? Under the concrete lain so bare. My children will not know In the world in which they'll grow. They'll re...

Doctors should not be coerced into risking their lives if there is a shortage of PPE, says the Royal College of Surgeons in response to the new PHE guidelines on PPE. Instead of addressing the dangerous shortage of PPE, the guidelines are being changed to enable levels of protection to be reduced. This is unacceptable. Professor Neil Mortensen, President-elect of the RCS, said: “We are deeply disturbed by this latest change to PPE guidance, which was issued without consulting expert medical bodies. After weeks of working with PHE and our sister medical royal colleges to get the PPE guidance right, this risks confusion and variation in practice across the country." It is utterly disgraceful that the new guidelines have been introduced without consultation of health care representative bodies.   Professor Mortensen continues:  “The new guidance implies that, even in the operating theatre, surgeons and their teams may not require proper PPE. This is simply unac...

As we move to the 'surge stage' in the coming weeks of COVID-19 deaths in the UK, we do need to get more detailed information on deaths outside hospitals. This week the Office for National Statistics reported the highest total number of deaths since ONS weekly death reporting began in 2005.  That gives us some idea of what the underreporting of COVID-19 deaths might be. It is extremely difficult to be sure.  One question is to what extent the virus is the cause of deaths that would not have happened without an infection, and to what extent it is hastening deaths that would have occurred in any event.   The provisional number of deaths registered in England and Wales in the week ending 3 April 2020 (Week 14) was 16,387; this represents an increase of 5,246 deaths registered compared with the previous week (Week 13) and 6,082 more than the five-year average.   COVID-19 was mentioned in 21.2% of all deaths registered in that week - a significant ...

Reports today that the UK government have decided not to go ahead with the plan to get ventilators manufactured by Formula 1 teams like Renault and Red Bull. Ventilation of the lungs isn't like filling a balloon with air. The use of PEEP, positive end-expiratory pressure, isn't how the lungs function usually.  Inflation of our lungs occurs by developing a negative pressure in the thorax by contracting the diaphragm and raising the muscles between our ribs. This both keeps the air sacs (alveoli) open and inflates them, producing airflow. It is the negative pressure compared to the air surrounding us that pulls air into the lungs.  The air moves down the pressure gradient.  Applying a pressure inside the air sacs can cause damage t o the delicate lining leading to pulmonary oedema and worsening hypoxemia that can prolong mechanical ventilation, this can then lead to multi-system organ dysfunction, and increased mortality.  Not all COVID-19 patien...

The UK government has now published its plan for Personal Protective Equipment) for frontline health workers. The plan incorporates 3 strands for guidance, distribution and future supply.  It seems to follow the kind of line adopted by the Health Secretary when he urged doctors and nurses to treat PPE as a 'precious resource' and not to misuse it.   This wasn't well-received by bodies representing the various strands of Health Care workers, not least the Royal College of Nurses.  The plan instead restates the obvious.   1) guidance: being clear who needs PPE and when, and who does not, based on UK clinical expertise and WHO standards. This will ensure workers on the frontline are able to do their jobs safely, while making sure PPE is only used when clinically necessary and isn’t wasted or stockpiled 2) distribution: making sure those who need PPE can get it and at the right time. The government will ensure those who need critical PPE receive...

If health care resources and staff are stretched to the limit, difficult life or death choices must be made.  Who to treat? That will be the question. At ordinary times decisions might be made based on whether treatment will do more harm than good.  It might even be the patient who decides.  End of life decisions are more often like that.  Will further treatment help? But these are not regular times. The British Medical Association guidance on pandemics says "In dangerous pandemics the ethical balance of all doctors and health care workers must shift towards the utilitarian objective of equitable concern for all – while maintaining respect for all as ‘ends in themselves’." If resources are spent on saving the life of one person at the expense of many others, how then is that balance to be made? One thing is sure.  Our actions are also part of this ethical mix.  Our efforts will determine whether or not the anticipated surge in those requiri...

A new study suggests that the dramatic fall in stillbirths is not due to the adoption of new growth assessement protocols in pregnancy. In 2015, the Secretary of State for Health in the UK announced a national ambition to halve the rates of stillbirths, neonatal and maternal deaths and brain injuries at birth by 2030, with a 20% reduction by 2020. The target is well on track to be met.  But what lies behind its success.  It was thought that it was the result of new protocols for assessing the growth of the baby in the womb. By comparing the growth of the fetus with expected growth for gestational age can indicate if something is going wrong.  For this vital assessment, growth charts are used.  The problem with the older growth charts was that they took no account of heterogeneity in the population.  More accurate growth assessment could save the lives of babies if problems could be detected sufficiently early in pregnancy. One approach in recent years...

Scientists across the globe are searching for a vaccine against the virus that causes COVID-19.  Let's applaud them too. A vaccine for the COVID-19 virus is still said to be 'a long way off' with best estimates being early next year.    The first potential vaccine entered clinical trials on 16th March 2020.  Vaccines cannot be conjured with a magic wand. Ordinarily, vaccines can take up to ten years to produce. The first Ebola vaccine took five years, and that was considered fast. The imperative is now to find a COVID-19 vaccine a lot faster.   Teams across the world a working flat out developing and testing possible agents. One reason it usually takes so long is what is termed the attrition rate - that is, the number of potential vaccines that don't make it through trials. The failures could be hundreds.  Safety and effectiveness are of paramount importance, and that means rigorous testing. The production of a vaccine isn't what we see in t...

There is some good news on the horizon.  The government might meet its target of 100,000 tests for COVID-19 by the end of the month. Testing is vital to bringing us all out of lockdown, getting people back to work, and gradually returning to normality. The US company producing the tests here in the UK has ramped up the facilities for its manufacture.  But initially, the tests will be for the antigen, indicating whether someone has got the virus.  We also need to test for the presence of antibodies, showing whether someone has had the infection and has developed an immunity. Meeting the testing target offers hope that the lockdown can be released gradually, perhaps first, with those who have recovered from the virus. Slowly, people can get back to work, getting the economy moving once again and critically enabling key health workers to return to the frontline. One thing the lockdown has demonstrated is just who our key workers really are.  The many we...

Harmful neoplastic agents from cancer therapies are leaching into the environment but do we know enough about what this is doing to wildlife and other humans? Chemotherapeutic drugs, also known as antineoplastic agents, that are prescribed to treat a range of cancer types, enter the aquatic environment via human excretion and wastewater treatment facilities. A review published in  Environmental Toxicology and Chemistry  indicates that very few studies have characterized the effects of antineoplastic agents that are released into aquatic environments. Cancer is a leading cause of death worldwide.   With an increasing incidence of cancers in growing and ageing populations, there has been a massive increase in cancer therapeutic drugs.  Agents from these drugs are leaching into the environment through human excretion and wastewater.  Yet, we know little of the consequences on other humans and animal life in general.  So, what do we know ...

In the 1950s, children played in the streets.  They ran around playing 'cowboys and Indians' or re-enacting some wartime exploits, or they pulled themselves around on make-shift carts made with pram wheels, or played games like hop-scotch.  We ran around in circles pretending to be this and that.  Now children play outdoors less and sit indoors more.  Were we healthier for it?  Many of the baby boomers, those born in the late 1940s to early 50s were obese in later life.  Their lifestyles changed as they moved into the consumer society.   They moved around less and diets, on the whole, became 'richer', but probably more unhealthy.  They were the baby boomers.  The majority of baby boomers are now obese in later life.   But for each subsequent generation, the age at which obesity sets in appears to be getting younger.  A recent study of Americans showed that obesity rates increased markedly for the baby boomers, be...

It is said that COVID-19 doesn't discriminate. This isn't strictly true. If you live in poor housing conditions and overcrowding you are more likely to be affected by the virus. More than a quarter of a million households in the UK are living in overcrowded private rented housing. 300,000 households are squeezed into inadequate social housing. People living in poor housing are more likely to have underlying respiratory conditions, more likely to find social distancing difficult. It will be more difficult to maintain hygiene levels. More overcrowding means greater stress and mental health issues. Little of the problem of overcrowding is being addressed by the government, and there is little to no help being offered to help these families cope with the COVID-19 lockdown. Poor housing conditions and overcrowding has increased over the last decade as the most vulnerable have been affected by austerity.  This is why we have said before that austerity kills.  It increa...

Consuming a diet high in fibre has been linked with a reduced incidence of breast cancer in an analysis of all relevant prospective studies.  The findings are published early online in CANCER , a peer-reviewed journal of the American Cancer Society. Because studies have generated inconsistent results regarding the potential relationship between fibre intake and breast cancer,  Dr Maryam Farvid of the Harvard T.H. Chan School of Public Health, and her colleagues searched for all relevant prospective studies published through July 2019. By pooling data from the 20 observational studies they identified, individuals with the highest consumption of fibre had an eight per cent lower risk of breast cancer. Soluble fibre was associated with lower risks of breast cancer, and higher total fibre intake was associated with a lower risk in both premenopausal and postmenopausal women.  Dr Farvid says that the study “contributes to the evidence that lifestyle factors...

The sad truth is that the UK was strategically poorly prepared for COVID-19. We seem to have learnt very few lessons from previous virus pandemics. South Korea learnt those lessons, and they also followed the WHO advice to "test, test, test." We are not alone in acting too little too late.  Most European countries and also the USA appear equally ill-prepared.  Our strategies are led more by panic than clear thinking.   To fight a virus such as COVID-19 preparedness matters.  To save lives, we have to be ahead of the curve.  Most authorities are behind it. We seem to be at that point in a game, when the enemy is coming so fast that we really can't keep up with it and so we shoot, shoot, and shoot, only to find we have run out of ammunition.  The lesson is that we need the resources if a strategy is to work. A plan without resources just isn't worth the paper it is written on. Logistics matters.  We should not have frontline medical staff c...

We have heard enough excuses from the UK government.  They keep promising to deliver on protective clothing for our doctors and nurses, and they promise to roll out testing in the population.  In both, they have failed to deliver.  In the next two weeks, we will see a massive increase in the numbers of COVID-19 cases and deaths here in the UK and across the world.  We must stand by our frontline staff. They must have the protective equipment they need. We also need urgently now to roll out testing to the public so we know what is happening and who has built immunity, else we are acting in the dark.  We need honesty now from the government about the difficulties in doing that. It is vital that the authorities maintain public trust. That can only come from honesty. This is why it is vital that our doctors and nurses must be free from threats so they can also be honest in their appraisal of what is happening on the ground.  There should be...