Crazy Sexy Cancer

Watched an insightful movie this morning (yes – a movie in class!) about a young woman living with a rare, slow-growing metastatic cancer. This movie comes highly recommended for a real, in-your-face perspective on how having cancer can change your life.

Watch the trailer:

The Cancer Menu

As we storm through our whirlwind week on cancer, it’s interesting to consider which cancers you are most likely to get. Please don’t become paranoid, however – this is an exercise in epidemiology, and not doom-and-gloom:

Women are most likely to get:

1. Breast cancer
2. Lung cancer
3. Colorectal cancer

Men are most likely to get:

1. Prostate cancer
2. Lung cancer
3. Colorectal cancer

Note that for both men and women, lung cancer is far more deadly than either breast cancer or prostate cancer. So for both sexes, the cancer you are most likely to die from is lung cancer. That being said, if you are a non-smoker and are able to minimize your environmental exposures (second-hand smoke, asbestos, radon, etc.), your lifetime risk for lung cancer is far lower than these lists might suggest.

Criminalization of Non-Disclosure of HIV Status

I’d like to put forward a lego-ethical question raised during our symposium on HIV/AIDS today. It’s a complex question, and one that I certainly haven’t found an answer for that I’m comfortable with. But here are two contrasting arguments for consideration.

The question was whether or not people living with HIV should be legally obligated to inform their sexual partners of their HIV status.

R. v Cuerrier:

In 1998 the Supreme Court of Canada convicted Henry Cuerrier guilty of sexual assault for having unprotected sex with two women without informing them that he knew he was HIV-positive. Neither of the women actually contracted the virus. I’m mostly legally-illiterate, but as far as I understand it, the court’s rationale went something like this:

Cuerrier was guilty because he knowingly jeopardized the lives of the two women. Although in both cases the women consented to the sex, the prosecutor made a successful argument that their consent was vitiated (nullified) on the basis of fraud. Since Cuerrier had failed to disclose his status, their consent was made with incomplete or fraudulent information. 

Reactions:

Many see the criminalization of non-disclosure of HIV-status as an over-extreme means to address the spread of HIV, which is more-appropriately a public health issue. Read through (only 2 pages – it’s worth it!) this position paper disseminated in June 2008 by the Ontario Working Group on Criminal Law and HIV Exposure.

One of our patient-lecturers this morning expressed his view that criminalization has done worse for the spread of HIV than it has helped. That’s because it has made people even less willing to get themselves tested. Undeniably, the law does not take into consideration the complex array of factors that play into a person’s ability to disclose including limited knowledge about the virus, social stigma, and discrimination.

Does Protection Change the Question?

During unprotected intercourse, there is a 0.2-0.5% risk of HIV transmission from someone who is infected i.e. the risk is small, but real. Using protection such as a condom takes this small risk and vastly reduces it further. Of course, condoms are not fool-proof, and the risk is never zero. But should using protection make a difference for the duty to disclose?

Some say yes. Since the quantity of risk matters, using protection might arguably make HIV transmission pass from the category of a “foreseeable consequence” to “unforseeable”, thus eliminating the duty to disclose.

Your thoughts?

Typhoid Mary

And now, for an intriguing (but horrible) story:

Mary Mallon was an Irish cook who moved to New York City in the year 1900. Only 31-years-old at the time, Mary took up employment in a wealthy man’s home preparing meals for the family.  Sadly however, within a couple of weeks the entire family became very ill. Concerned, Mary soon found another family to work for. It wasn’t long after though that Mary’s new family started falling sick as well. Some became severely affected, and the laundress of the household was overcome and passed away. So Mary moved again, this time to the home of a lawyer. Sure enough a few weeks later, the lawyer and most his family were sick in bed. Mary did her best to care for them, but finally she moved to yet another household.

George Soper, a typhoid researcher, eventually caught up with Mary and heard about her succession of failed employments. George had a theory that he put forward to Mary; he suggested that she might be the very first reported case of a typhoid carrier – that is, someone who can spread the disease without personally suffering from it. Mary was adament that she wasn’t carrying typhoid, and proceeded to infect three more households. In fairness, the Irish were never treated very well in New York City, and Mary may have had good reason to be suspicious of George’s accusations.

Mary was eventually apprehended and taken into custody by the city’s public health department. She was held in quarantine for some time before the city released her on the condition that she change her occupation from cooking to something less conducive for spreading infection! Mary agreed, but later changed her name to Mary Brown so that she could resume her work as a cook. She infected two more households! Eventually Mary was apprehended again and, sadly, held in quarantine for the rest of her life.

Typhoid fever is a disease that results from the bacteria Salmonella enterica typhi. It causes severe, inflammatory gastroenteritis resulting in bloody diarrhea and rapid fluid loss. Before widespread use of antibiotics, it was a fatal disease. Many of Mary’s victims died. Salmonella enterica typhi are spread by fecal-oral transmission. Likely in Mary’s case, bacteria in her fecal matter contaminated her hands, and then as a result of poor hand hygiene were transferred to her clients via the food that she prepared.

Copious Documentation

On Thursday I had my first full history and physical examination with a standardized patient! This proved a really great way to learn. The standardized patients are trained to present with a particular disease, and so the elements of the history and physical all match up to point towards a diagnosis that we have studied, and should know. Our patient (we worked in pairs) likely had angina.

Anyway, the whole experience on Thursday lasted about 40 mins. What blows me away today, is that I’ve just spent more than three hours writing up the case report! Granted that I am an amateur, it is still unbelievable how much documentation is required after every clinical encounter. The results of all questions and tests are recorded, and any that were missed are noted as not having been assessed. Some of my slowness may have been due to that our tutors require us to write out the case reports by hand, as this is more comparable to how they would be done in a hospital.

Court Ruling from the Bedside

Usually the law takes time. Just the words “court case” conjour up impressions of a long, arduous process. So I was fascinated to learn that in rare cases, some court rulings can be made tremendously fast.

The example I learned about involved emergency care for a child. More specifically, care for a child whose parents are Jehovah’s witnesses and don’t believe in blood transfusions. While there are provisions in the law for any capable adult to refuse treatment for themselves, parents cannot refuse treatment for their children when it is deemed medically necessary.

Surely this would be a terribly difficult line to take, since saving the child would, in the parents eyes, be condemning them to hell. But the Canadian legal system has determined that parents who refuse medically-necessary treatment for their children are guilty of child abuse.

In these cases, the law can be applied tremendously quickly from the bedside. I’m not even sure who does it (lawyer?, judge?), but someone comes to the emergency department, assesses the situation, and appoints an alternative attorney of care for the child when necessary. I was impressed to learn that the law could act so quickly.

NOTE: All of this presumes that the child is not capable of making their own decisions! There is no cut-off age for consent. Assessment of capacity is made on an individual basis to decide whether the child is mature enough to make their own decisions.

Palliative Care Visit Reflection

On Friday we had the opportunity to visit with a Palliative patient in their home. We spent some time hearing their story, and asking questions. Afterwards, we were encouraged to right a short reflection on the experience and how it impacted us. I’ve decided to share what I wrote here, as a storage place for that reflection, and as a means to tell other people about the experience.

Before our visit with Mr. C, my beliefs and expectations of Palliative care had already been challenged in the classroom. Our instructor had illustrated the distinction between curing and healing, and addressed the concept of a good death. These were new ideas personally, but ones that resonated with my desire to see the person behind the patient, and to at least acknowledge all aspects of their well-being, not just the physical. When speaking with Mr. C, many of these learning points from the classroom were enlivened by his individual story.

In particular, one aspect of Mr. C’s story that surprised me was the comfort he seemed to have with talking about his own death. I had expected him to be more reserved, either because of personal difficulty with the topic, or because he would not want to burden us with such weighty, personal matters. But to Mr. C, it seemed that they were neither weighty nor personal. He talked about his expectations for death with language and an attitude that normalized the event.

Mr. C told us about his work as manager of a golf course. He had spent a considerable segment of his life outdoors, and felt a distinct attachment to the natural world. He described how, over many years, he had observed life, death, and changing seasons in nature around him. He explained that he saw his death as a natural progression – the expected, and rightful last consequence of leading a human life. I was impacted by the normalizing effect that this philosophy had on my own understanding of death.

One benefit of this normalization, I found, was that it “freed us up” to consider the more practical aspects of Mr. C’s health. With much of the psychological baggage removed from our perception death, there was more room for the consideration of life. I was reminded of another distinction that our instructor had made: that Palliative care is not caring for someone who is dying, but rather caring for someone who is living with a disease that they will likely die from. We spent most of the remaining conversation discussing Mr. C’s hopes, expectations, and concerns for living.

I’m grateful to Mr. C for sharing his story with us, and for contributing to the foundation of awareness we are receiving in this Palliative care unit. I expect that I will encounter patients who have different perspectives on death, some considerably less normalizing than Mr. C’s. No doubt, I will be challenged by that, but I’m fortunate to have gained an insight into one possible understanding of death, and one person’s approach to living with that understanding.

Anatomy: Spelling Matters!

Rather insignificantly, I’m quite sure that I missed a point on my exam yesterday for mis-spelling the name of a body part. Spelling, often shooed under the rug and dismissed as trivial, actually matters a lot in anatomy where one letter difference can mean an entirely different body part!

For example, the mistake that I made was to confuse ileum, a segment of the small intestine, with ilium, part of the hip bone. There’s also a corocoid process on the scapula and a coronoid process on the ulna. Another pair that I frequently mix up (even though they really are quite different) are the carpals and tarsals.

Over-the-Counter Cold Preparations

Over-the-counter drugs are medications that you don’t need a prescription to buy. By governmental regulation, they must be relatively safe to use in the recommended doses. They are intended for short-term use (no more than a couple weeks) as symptomatic relief only (they cannot claim to “cure”).

The difficulty with over-the-counter drugs is knowing when to take them and for what. Advertising has a big impact on our drug use and can be misleading. For example, the efficacy of many over-the-counter drugs hasn’t been properly tested. Sometimes a drug that you think is helping you, provides nothing more than the placebo effect. It’s important to familiarize yourself with the drugs that are available to you and what they actually do, as opposed to what the manufacturer claims.

In this post, I’ll focus on over-the-counter cold preparations. The added difficulty with cold medications is that they tend to be mixtures. Manufacturers will combine multiple drugs together to guarantee that the preparation has some effect. But if you only need one particular component of a preparation, do you really want to be simultaneously taking a bunch of other drugs that you don’t need? Probably not! Instead, it’s a good idea to familiarize yourself with the common ingredients of cold preparations and pick one that addresses only the symptoms you need.

So what do cold preparations contain…

Antitussives

Antitussives suppress coughing. The common ones are codeine and dextromethorphan, which take their action in the brain’s coughing centre.

It’s important to realize however, that since codeine is associated with dependency/addiction, it is highly regulated. The actual amount of codeine allowed in an over-the-counter preparation is far too small to have any effect! Dextromethorphan doesn’t have the same dependency association, so it can be included in slightly higher amounts, but studies have shown that even the amount of Dextromethorphan in over-the-counter drugs is not high enough to have any antitussive effect. 

As such, the recommendation from physicians is usually to avoid antitussives. They really aren’t effective, and furthermore it should be a clinical decision whether to suppress a cough or not – sometimes a productive cough is valuable.

Expectorants

These are the opposite of antitussives – they supposedly encourage a productive cough. Unfortunately, there is no data to suggest that they have any effect at all. Hard to believe, but it’s true. A good steaming, on the other hand, will effectively loosen up your cough! So try to stay away from expectorants, and go the old-fashioned (but effective) way.

Decongestants

Decongestants cause constriction of blood vessels, reducing blood flow and swelling to places like the lining of the nose and the throat. The problem, is that they also take effect in the rest of the body! Now, you’re probably not likely to experience any adverse effects from that, but if you already have high blood pressure then taking a decongestant will only be contributory to your hypertension. Certainly decongestants are not recommended for children because there have been paediatric deaths associated with them.

An interesting phenomenon that I was just reading about is one called “rebound congestion”. The idea is that after taking a decongestant for too long (5-7 days), the nasal arteries will adapt and increase blood flow to the nose to compensate. The result is that when you stop taking the drug, you get all congested again when you wouldn’t have otherwise. People usually then put themselves back on the decongestant, thus worsening their problem.

Because of all these potential difficulties, using a decongestant should be reserved for when you really need it. And in those cases, find a preparation that is only a decongestant and not a mixture. Finally, don’t take it for too long.

Analgesics / Antipyretics

Analgesics are for pain, and antipyretics temper a fever. Finally, these are the ingredients of cold preparations that really work!! Some examples are Acetylsalicylic acid (Aspirin), Acetaminophen (Tylenol), and Ibuprofen (Advil). Each of these are sold within cold preparation mixtures, and individually. Now if they are the only truly active ingredient in a cold mixture, then why not just take them individually? And indeed, that is the recommendation by most physicians. When you have a cold associated with pain or a fever, certainly you will probably feel better by taking Advil or Tylenol (these are better options than Aspirin, because Aspirin is an acid and could cause an upset stomach).

Throat Lozenges

Throat lozenges contain an antiseptic that supposedly attacks any bacteria in your mouth and pharynx. However, as you swallow, the contact time between an antiseptic and the bacteria is far too short to have any appreciable effect. If anything, lozenges might be perceived as effective simply because they increase your salivary secretions which then coat the lining of your throat. You’d get the same effect by sucking on your favourite hard-boiled candy.

Cough/Cold Attack Plan:

So, after reviewing all of those ingredients, how should you use over-the-counter drugs the next time that you have a cold?

1. In general, avoid mixtures!! Most of the ingredients lack efficacy, and you can be much more targeted in your approach by selecting the individual drugs that you need.
2. If you’ve got pain or a fever, take Advil or Tylenol. These have proven efficacy, and are safe to use if the dose recommendations are followed. It’s important to remind people to keep Tylenol well out of reach from children, since Acetaminophen is the most common drug-poisoning seen in the ERs!
3. Steaming works much better to loosen your cough than any expectorant.
4. Use decongestants reservedly.
5. Suck a candy to reduce throat-soreness. Antiseptic-containing lozenges are unlikely to be any better.
6. Chicken soup!!! Most cold preparations are effective through the placebo effect alone. You can accomplish the very same placebo effect by making up a nice warm bowl of chicken soup, and convincing yourself that it will make you feel better !

Wins & Losses for Civil Rights

Quickly, I want to recognize today as an historic one for tolerance in the US. As the American people elected their very first black president in Obama, one could not help but celebrate the immense leaps that have been made for the civil (and basic human) rights of blacks in America. Today feels like a monumental accomplishment for a movement that was started before I was born.

And so, it seems surprising and paradoxical that while the American people were busy affirming rights for blacks, they were simultaneously stripping them from another group. In California yesterday, voters passed a constitutional ban on same-sex marriages. Effectively, this now decreases the number of states where same-sex couples can get married from three to two. As far as I can tell, there’s still uncertainty over what’s to become of those couples who were already married during the period of time that same-sex marriage was legal in California. I believe that California’s decision yesterday violates the civil rights of gay and lesbian people, and shows a residual lack of tolerance.

On the road to tolerance and civil rights, today marks a definite high point. But it’s not the peak, and there’s certainly a lot more climbing to do! In Canada, as well as the US.