Clinical Views
Watch this space for (hopefully) useful advice on dealing with common medical conditions, and possibly some opinion pieces on pertinent clinical topics of the day. Of course if you are unwell and unsure of this advice in anyway, or if you do not fit into the category of patient described under each subject heading it is important that you give us a call and ask for tailored advice.
Public health aluminium update.
October 10th, 2011 by Dr Wheeler.Public health have now forwarded me a document outlining their latest information – you can download it here.
How much aluminium is too much?
October 9th, 2011 by Dr Wheeler.I hope my previous post helps reassure you that there is no need to panic about the current situation. That does not however mean that I am particularly happy with how things rest. Aluminium levels in water supplies was not a topic that ever aroused my interest before – but now that it has, I am happy to share some of my thoughts on the matter if anyone is interested.
1) What level of aluminium is acceptable in our water? This is an interesting question. The WHO have set international accepted levels in a document which can be accessed here. These levels have been selected as being the lowest that could be reasonably expected in public water supplies given the question marks over the risk that oral aluminium poses to human health. The level is in fact 0.1mg/litre of water, but 0.2mg/litre is stated as being acceptable in areas with small populations. It seems to be unfortunate but true that the 0.2mg/litre level that is used for Uist is far from ideal – it is instead a pragmatic response to the fact that it is very difficult to keep aluminium levels low in small water treatment works such as ours. As far as I am concerned this makes breaches of the 0.2mg/litre level even more important than would be the case if breaches occurred elsewhere in the UK where the 0.1mg/l limit is generally adhered to.
2) How high have the aluminium levels been? I have seen the figures for this but unfortunately have not been given permission to publish them. I strongly feel that this kind of information should be freely available in the public domain and would have preferred it if the early figures were highlighted at a much earlier stage than they were. I can tell you that in general the levels have consistently been higher than the 0.2mg/L standard since the 19th September – often several times higher. For a few brief periods the levels went between 9-10 times the accepted level for small water treatment plants – which equates to 18-20 times the level that the WHO indicates that we should generally aspire to.
3) What does all this mean? Good question – I wish I knew the answer. As I stated in my previous post – I am reasonably reassured after looking at various papers and editorials on the Camelford disaster that it is very unlikely that we in Uist will see problems in the future from this short term breach of aluminium levels – but I still have underlying concerns.
The WHO document I linked above summarises the findings of 6 different studies – 3 of which pointed towards a link between levels of aluminium above 0.1mg/l in water (note that in Uist 0.2mg/l is accepted) and 3 did not. It summarises these results by saying…
‘On the whole, the positive relationship between aluminium in drinking-water and AD, which was demonstrated in several epidemiological studies, cannot be totally dismissed. However, strong reservations about inferring a causal relationship are warranted in view of the failure of these studies to account for demonstrated confounding factors and for total aluminium intake from all sources. Taken together, the relative risks for AD from exposure to aluminium in drinking-water above 100 µg/litre, as determined in these studies, are low (less than 2.0). But, because the risk estimates are imprecise for a variety of methodological reasons, a population attributable risk cannot be calculated with precision. Such imprecise predictions may, however, be useful in making decisions about the need to control exposures to aluminium in the general population.’
So – not clear cut, but some cause for concern.
Unfortunately for us there has been a much more thorough and as far as I can tell methodologically sound report in recent years which many of the resources on the net reassuring us about aluminium have not taken account of (presumably because it is relatively recent).
This study looked at almost two thousand French people over 15 years, and for the first time was able to factor in total daily water consumption at different aluminium rates. In a nutshell, their conclusion was that aluminium levels over 0.1mg/l were statistically linked with an increased risk of dementia (a relative risk of 2.26 – or just over twice the risk of matched controls with low levels of aluminium in the water supply).
This does not sound great – though like with any research we need to be careful before drawing conclusions.
Putting all this together what kind of questions do we need to be asking Scottish water / public health over the coming weeks?
1) Since we are already forced to adhere to a lower standard of aluminium levels in our water than on the mainland – why were we not informed as soon as the breach of levels became known? (As far as I am aware this would have been within a few days of the 19th September).
2) Why is there not full public disclosure of the levels of aluminium in the water supply even now – several weeks after the event?
3) Given the slow public response to these aluminium levels… how often have aluminium levels breached the 0.2mg/l limit in the past – and were the public ever informed of these breaches?
4) Have there been breaches of the 0.2mg/l limit at the other Uist treatment plant in the past?
5) For the longer term – given the continuing question marks hanging over aluminium levels in our water supply. Is it time to start having public debate about alternatives to using aluminium in our rural water treatment plants? If this is impossible – then at the very least I think we should insist on knowing when the levels go above the 0.2mg/l limit – even transiently.
Aluminium in the water.
October 9th, 2011 by Dr Wheeler.I have now had a few queries regarding the possible health effects from the recent aluminium scare in North Uist. On this occasion I do not have to rely on my reserves of sympathy and empathy however as my family and I have been directly affected – living as we do in the area that has had problems (the water from Grimsay to Scoplaig on the West side has been affected).
I found out about the high aluminium levels in our water supply at the same time as everyone else (Wednesday night). Most doctors will know from seeing dialysis patients during their training that aluminium toxicity is a serious problem to be avoided in that section of the population. But my knowledge beyond that was pretty much zero.
As such I, and by extension we, need to rely on Scottish water and public health to help guide us through the crisis. Hopefully they are accessing expertise at the highest level relating to the issue. I have to say however that I am disappointed at the lack of hard factual evidence concerning the scale of the problem / the effects that it might have on health that have so far been given to the community.
In this information vacuum I am sure that a lot of you will be doing the same as me – googling aluminium to see what the score is. Unfortunately the net is full of the kind of sites that make the medical profession in general despair. A quick search reveals a multitude of poorly researched and hysterical resources about all sorts of environmental toxicities… and it can be hard to separate fact from fiction if you are not used to analysing evidence/ reviewing medical material. I suppose this post is an attempt to a) show that I am trying to keep abreast of the issue, and b) help guide you in a limited way to some resources that may be better than others.
The first thing to say is that as far as I have been told, there is very little chance of the recent water changes causing any acute problems with our health. You need to take in a lot of aluminium to feel acutely unwell, and compared to (for example) the Camelford disaster in 1988 where aluminium levels where hundreds of times higher than recommended, our problems are much less serious. In the severe exposure at Camelford initial symptoms included nausea and vomiting, skin rashes and mouth ulcers – but there haven’t been any of these acute symptoms locally as far as I am aware.
What about long term effects? Again – I think the evidence is in general reassuring (with caveats which I will come to). Although there is some controversy over the issue (litigation has continued for many years in Cornwall) repeated reviews over time have suggested that there have been no clear cut long term effects on health from that incident. Particular concern has been raised over the years about possible issues with cognitive function including dementia like syndromes. On this point I would direct people to the statement regarding the issue on the Alzheimer’s society website -
‘There is no conclusive medical or scientific evidence of a link between aluminium and Alzheimer’s disease. There have been three independent scientific enquiries into the Camelford incident, none of which have found a causal link with dementia.
Whilst this is a sad and tragic incident, it should not lead to wider panic. Aluminium is one of the most abundant minerals in the world, and worldwide research has not found any evidence that exposure to everyday levels of aluminium is a risk factor for Alzheimer’s disease.
The Alzheimer’s Society offers help and support to families affected by dementia throughout the country and we would be happy to offer advice to any families living in the Camelford area.
We still do not know what causes Alzheimer’s disease, and until this time the Alzheimer’s Society supports all research into potential causes and cures.’
So – in summary. This acute exposure to excess aluminium should have minimal if any short term health effects.
The long term health effects from aluminium exposure of a short duration also seem to be limited if we can rely on the extensive research that has been carried out over the years into Camelford, but in the process of my research I have come across some concerning information about aluminium exposure over the longer term which I will outline in another post later today.
As most of you will now know – Scottish water will be holding drop in sessions -Monday 10 October and Tuesday 11 October at Paible Primary School, Ashdail Cottages, from 4pm to 7pm to answer questions that you have, and I believe representatives from public health will be in attendance also.
In the meantime if you have any significant physical symptoms of any nature – the advice as always is to phone the practice and seek advice.
It is easy to get a thousand prescriptions but hard to get one single remedy. ~Chinese Proverb
December 16th, 2010 by Dr Wheeler.15. At 09:43am on 07 Dec 2010, Alan Hammond wrote:
“When will they make up their MKNDS about Asprin
First they say that one a day is good for you
Then thay say it is NOT good for you and one should stop taking it
And NOW again they are saying it is Good for you
I was told NOT to take it and that STILL stands as far as I am concerned”
I have no idea who Mr Hammond is (if that is his real name.) He is a random poster on the BBC news site who has expressed a view which I fear is probably quite widespread at the moment.
When you are given medical advice you want it to be authoritative. You want it to be based on good evidence… and most importantly you want the advice to cause you more good than harm. This is all very reasonable – but the recent aspirin debacle brings into sharp focus the fact that unfortunately doctors often operate on a level where there is constant uncertainty as to best practice.
The BBC article on the recent research in ‘The Lancet’ (read it here). Is a good precis of the new information available on aspirin therapy. In a nutshell, it states that taking aspirin will in the long run reduce deaths in individuals through a combination of vascular disease prevention and reduced cancer risk. This contradicts other advice that has been coming out over the past 2 years regarding the use of aspirin in healthy individuals because of the risk of gastrointestinal bleeding which has been guiding my practice over the past 6 months or so.
Over the years I have learnt to be sceptical about any new research that tries to overturn long held ideas. Often those who jump on new medical bandwagons early on end up with egg on their faces when new evidence comes to light a few months or years later. But in the case of aspirin therapy I think the majority of GP’s in the UK have been increasingly convinced that giving aspirin to their healthy patients was a bad idea. This meant a lot of difficult discussions about coming off pills that had been used for decades in some cases – raising the question “why had we been treating these patients with aspirin for all these years if it wasn’t the best thing for them?”
The reasons are mainly related to the technical details of how hard it is to do gold standard medical research – a subject of interest to me, but possibly not to the majority of patients who just want to be well. There is no simple way to resolve the issue – we just all need to accept that what we think is good for you today might be thought to be bad for you tomorrow… and muddle through as best as we can.
So should you take aspirin?
In a nutshell the figures as far as I can tell are this…. taking an aspirin a day from the age of 50 onwards… for at least 5 years – but potentially until you are 75… could reduce your risk of dying from cancer by 25% in the short term, 20% over the long term.
Not related to this new study – the latest data would suggest a possible reduction in heart attacks by 20% in addition to the cancer risk improvement. The old idea that it would also reduce your stroke risk is now no longer thought to be true.
The downside is an increase in risk of bleeding from your guts…. which can be fatal. The figures from the BBC are that it doubles your risk from 1 in a 1000 to 2 in a thousand. In fact my reading of the data is that in fact the figures are 0.7 in a thousand and 1 in a thousand respectively – so not quite as bad.
So…. from an objective statistical point of view it would seem to be a no brainer… the advice now would be to take the aspirin after all as the pros outweigh the cons (assuming you are otherwise fit and well / not on other medications – those patients who don’t fit this description would be wise to phone for tailored advice.)
Beware though… ask me next week and I might have a different answer… and remember the old chinese proverb quoted above next time you get contradictory advice about your medication.
A little bit of politics.
May 3rd, 2010 by Dr Wheeler.
The purpose of this post isn’t to support any one political viewpoint over another. All of the main parties have aspects of their health policy which to me seem problematic.
I do get irritated when information regarding health is misrepresented however – especially when facts and figures are bandied around with little understanding.
The first leaders debate was particularly egregious in this regard – with David Cameron either failing to understand or wilfully misrepresenting information that is highly emotive. Almost as bad – the other leaders failed to grasp the problems with what he was saying, either suggesting that they agreed with his ideas or (more likely) they are unable to grasp the concepts involved.
The subtext to this is the often repeated idea that the UK is a dreadful country to get cancer in. Compared to just about anywhere else in Europe your number is up before your time… despite our hugely expensive NHS. This statement might be true… but there is a good chance that it is a load of rubbish. All of these comparative figures come from ‘EUROCARE‘ studies – which unfortunately are highly suspect. The UK has a very comprehensive cancer registry and nationwide reporting systems. France only records cancer diagnoses for about 10%-15% of its population… Germany on the other hand has figures for 1% (yes that’s right – 1%) Comparing our comprehensive data with countries that have wildly different levels of coverage and recording is of limited use as you can imagine. In fact there is a lot of evidence that the UK does things very well in cancer diagnosis and treatment, but until the reporting systems in Europe are standardised we can never really know for sure. (There are steps to redress these problems in future EUROCARE reports I believe.) It is of course politically expedient to try and scare the public rather than accept nuances in the data however…..
Which leads on to the next point. Mr Cameron raised the issue of cancer drugs approved for use in the NHS. In particular ‘Sutent’ an oral drug licensed for use in advanced kidney cancer. Conservative policy is to create a £200 million cancer drug fund to pay for cancer drugs which aren’t currently available in the NHS.
In the debate he said that “I have a man in my constituency … who had kidney cancer who came to see me with seven others. Tragically, two of them have died because they couldn’t get the drug Sutent that they wanted..”.
This sounds tragic and scary at first glance… but it doesn’t take a lot of thought to realise that there is a major problem with the statement in a logical sense. The idea that if these two unfortunate souls were given sutent they would live long and happy lives is simply not credible. For an excellent and easy to understand explanation of what taking drugs like this can achieve I urge you to read this excellent post on the subject from the ‘Understanding uncertainty’ web site.
In a nutshell the author highlights the fact that no drugs work for all people, and that it is impossible to predict an individuals exact outcome from a treatment with any certainty. This is because drug trials deal with populations (the larger the better) – meaning that the data we base decisions on relates to populations in general – not individuals. With some interesting maths (albeit maths which needs to make a number of assumptions for it to be valid) it can be calculated that taking Sutent would have given each of those two patients just a 58% chance of living longer than if they didn’t have it. Even if they were responders however it is impossible to say what benefit they would have gained… or what quality of extra life they would have enjoyed.
The bottom line is that a lot of the incredibly expensive cancer drugs that have hit the headlines over the past few years a) have been approved by NICE (the National Institute of Clinical Excellence) anyway (Sutent for example HAS been approved for the NHS – but only for patients where trial evidence has been supplied demonstrating efficacy), b) have minimal effects on prognosis – often at best giving some patients a few extra months of life, and c) are (in my view) horribly and cynically overpriced by the drug companies involved.
In a world where we had unlimited resources then of course giving drugs to cancer patients that may extend their life by a few months is worthwhile… but in the real world, the 200 million pounds earmarked for the Conservative drug fund must (by definition) be 200 million that isn’t spent on other things. Other things that could potentially make huge differences to the health of millions of people rather than providing marginal benefits to a few thousand.
The real story here is that the drug companies are somehow flying under the radar. It is a scandal when a health board won’t approve an experimental cancer drug for a patient that hasn’t been assessed by NICE, but on the other hand it seems to be perfectly acceptable for drug company’s to charge tens of thousands of pounds for a few tablets?
The average yearly cost of taking Sutent in the UK (after a recent deal that meant the first course of treatment is given free) is £24,168. Why does it cost so much? Research and development costs have to be recouped… advertising… share holders profits. Maybe the company that makes it is struggling financially?
In fact Pfizer (the drug company involved) in just the last 3 months of 2009 (the most recent figures I can find) made £481 million in profit. Worldwide revenues for Pfizer are said to be $16.5 billion!
They (along with the other companies) will no doubt be rubbing their hands in glee that politicians will be helping push forward cancer drugs based on the number of votes available rather than analysis by experts who take cost effectiveness into account. Where better for that £200 million to go than into the big pharmaceutical companies coffers after all?
