[Al Jazeera] US healthcare: Profits before patients

US healthcare: Profits before patients

What is the point of having the world’s best medical facilities if citizens don’t have the money to access healthcare? Rose Aguilar Last Modified: 24 May 2011 16:45

As many as 45,000 people in the US die every year because they can’t afford healthcare [Photo: Rose Aguilar] When Stan Brock started Remote Area Medical (RAM) in 1985, never in his wildest dreams did he think his services would be needed in the United States, the wealthiest country in the world. RAM began as an all-volunteer mobile medical clinic that provided free and immediate health care to people living in remote areas of the Amazon rainforest. In 1992, he was asked to bring the clinic to Knoxville, Tennessee. He was shocked by what he saw. “People were in desperate need of the most basic care,” he said at RAM’s most recent expedition in Oakland, California last month. “It didn’t occur to me when I first came to this country, but it wasn’t long before I could see there were similarities between people who don’t have access to healthcare in a place like the Amazon and people who have access but can’t afford it in America – and they’re all in the same boat.” An estimated 50 million Americans are uninsured and another 25 million are underinsured, meaning they can’t pay the difference between what their insurance will cover and the total cost of their medical bills. Someone files for bankruptcy every 30 seconds in the US because of a serious health problem, according to a Harvard University study. Since 1992, RAM has conducted 640 expeditions in the US. When the travelling medical clinic comes to town, the lines begin forming at around midnight. An average of 3,000 people are treated at a typical four-day event. Over 90 per cent of the patients are in desperate need of basic dental and vision care. Each clinic costs roughly $100,000 to run, requires over 1,000 volunteers, and takes an entire year to organise. When patients entered the clinic at the Oakland Coliseum, they were greeted by smiling volunteers, rows upon rows of dental chairs, optometric stations, and tables covered with medical tools, gloves, and equipment. When Milka Guiterrez heard that free healthcare was being offered, she moved her schedule around to get a good place in line. On Sunday night, long after her three kids were sound asleep, she left her house at 1am. She was number 474 in line. Shortly before patients began entering the makeshift clinic five hours later, Guiterrez ran home, grabbed her kids, and returned with her fingers crossed. She got lucky. She and her kids had eye exams and dental work. Her eight-year-old daughter Paloma was in pain from the drilling, but managed to crack a smile. “When I used to smile, there was yellow stuff everywhere,” she said wiping away tears. “I was so embarrassed. I stopped smiling when I was six. It hurts, but now I’m happy.” After 12 years with the US Postal Service, Anita Moore was hurt on the job and lost her health insurance. She got in line at 3:30am. By 6pm, she had her eyes checked, her teeth cleaned, two fillings, and four extractions. Six months ago, she had an injury and hasn’t been able to lift her arms above her shoulders. The pain went away after 15 minutes of acupuncture at the clinic. “I was so happy because I couldn’t lift. I was just shocked. Now I can move them around,” she said. “It’s a blessing.” Les Kuller, an unemployed construction worker who got in line at 5:30am, lost his health insurance when his wife passed away two years ago. He got a molar fixed, had his blood pressure checked, was given a pair of eyeglasses, and had chiropractic and physical therapy work. He was so touched by the care he received and the volunteers he met, he came back the next day to join them. “The least I could do is give back,” he said. “On one hand, this is so incredibly amazing that all these volunteers can pull this together. On the other hand, it’s a sad commentary about what the hell is going on in Washington and why the hell these knuckleheads can’t walk across the aisle and shake hands and figure this thing out.” Kuller says he hopes people standing in overnight lines for basic medical care “embarrasses the hell” out of politicians. I heard similar sentiments from several people receiving care at the clinic. When profit comes before care Democratic politicians proudly point to the Patient Protection and Affordable Care Act, the bill that was signed by President Obama in March 2010, as real progress, but Physicians for a National Health Program (PNHP), an organisation of doctors who support healthcare for all, say the bill is nothing more than a false promise of reform. Instead of eliminating the real problem, the new legislation will enrich and further entrench the profit-driven, private health insurance industry, and leave 23 million people still uninsured in 2019, according to PNHP. If Republicans have their way, the 45 million seniors and people with disabilities who rely on Medicare will see their out-of-pocket costs double – or do without treatment altogether. RAM founder Stan Brock doesn’t like to talk about politics. He’s too busy making sure people get treated. RAM’s next stop is in Pikeville, Kentucky. From there, he and his team will head to Cocke County, Tennessee, Wise County, Virginia, and Chicago, Illinois. Because he’s has had so many requests from all over the country, he sees no end in sight. This is what happens when profit comes before care. UnitedHealth’s first quarter profits this year rose 13 per cent to $1.35 billion from $1.19 billion last year. UnitedHealth CEO Stephen Hemsley’s total compensation of $101.96 million last year made him the highest paid executive in the country. The US is the only major country in the industrialised world that doesn’t guarantee healthcare to all of its citizens. It’s unconscionable that 45,000 people in the US die every year because they can’t afford care. Senator Bernie Sanders, an independent from Vermont who believes that the US should put patients over profits, recently re-introduced the American Health Security Act, which would provide every citizen with healthcare coverage through a state-administered, single payer program. Here’s a fact from the PNHP that never made its way through the noise machine during the so-called healthcare debate – which was shaped by the insurance industry from the beginning. It should be repeated over and over again. the bureaucracy and paperwork of the profit-making health insurance industry consume one-third of every healthcare dollar. Streamlining payment through a single-payer system would save more than $400 billion per year – which is enough to provide comprehensive, high-quality coverage for all. RAM’s Stan Brock says a single-payer system, as long as it covers dental and vision, would put him out of business in the US. “That would allow us to go back to the Amazon, Central America, Haiti – and other places where we belong.” Rose Aguilar is the host of Your Call, a daily call-in radio show on KALW in San Francisco. She’s the author of “Red Highways: A Liberal’s Journey into the Heartland.” The views expressed in this article are the author’s own and do not necessarily represent Al Jazeera’s editorial policy.

 

Critically appraisal of the current contract for community pharmacists in context of laissez faire economics

Alhamdulliah my summarative assessment for pharmacy management module, For those who want an easy read of Irish healthcare politics!

Critically appraisal of the current contract for community pharmacists [Regulations 2009] in the context of laissez faire economics

“If one rejects laissez faire on account of man’s fallibility and moral weakness, one must for the same reason also reject every kind of government action.”

Ludwig Von Mises

A very staunch advocate of state-free interventions, The Austrian economist Mises proposed similar theories to proceeding economists such as Adam Smith (1723-90) that the pursuit of self-interest being the ‘invisible hand’^1,2 would guide the economy to into achieving economic harmony. With the exception of a few sectors (primarily military, legal, judicial system and provision of adequate infrastructure), Smith describes in his magnum opus The Wealth of Nations the theory of laissez faire “Let (people) do (as they think best)”¹ being a ‘principle that government should not interfere with the actions of individuals especially in industrial affairs and in trade’¹. Smith proposes that such a model would ensure efficiency, productivity & quality. However with such a system that has dominated the global scene for 30 years³, has not gone without criticism in both national and international stage by the emergence of developing-world elites favoring rich-world corporations that is deepening the gap of inequality and resulting in increasing poverty and indebtedness worldwide³.

In light of the above paragraph, the Republic of Ireland has a mixed economy that is somewhat free from the problems that arise from both free-markets and command economies. The Irish government has control over the economy via production/consumption legislation, and fiscal policy, which allows for intervention to potentially rectify various failings of the market.

One sector in which the Irish government has phenomenal influence is the health sector. Under the Health Act 2004⁴ , the health service executive (HSE) was established for the provision of health and personal social services for everyone living within the state. It would act as the middle man in coordinating contracts between the pharmacies under various schemes that would fulfill its objective in improving, protecting and promoting public health in an accessible manner to all citizens residing in the country according to their levels of income. The different community schemes include: General Medical Services (GMS)⁵ with currently 1.3 million cardholders⁴ in the state, High-tech drugs (HTD) for provision of medication used or prescribed from primary setting, Drug payments scheme (DPS) for residents of the state who are illegible for GMS, European Economic Area (EEA) residents from member states that are on temporary visit to Ireland and Long Term Illness (LTI) for people who suffers from one or more scheduled disorders. Under such a contract, the HSE would reimburse the community pharmacy contractor a certain percentage of fees for the provision of medication including the trade price + mark up (under DPS/LTI/EEA schemes) + dispensing fee + VAT (if applicable).⁷

In 2007 the total expenditure on the provision of medicines under the umbrella of community drugs schemes was approximately €1.74 Billion which accounted for roughly 13.5% of the total healthcare budget⁴.

Taxes collected from residents of the state (both PAYE & health contribution from PRSI) and service fees collected from the HSE are among the revenue generators that have helped drive the community drugs schemes. The HSE has increased its spending on drug reimbursements over a period of 7 years⁵ with an increase in GMS claims by 9.7%, increase in DPS by 7.5% and LTI claims by 12.9%.⁴ However with this rapidly increasing expenditure (by 9.3%), newly designed costly medication development, greater patient population and various other factors it is inevitable that such policy is unsustainable in the long run especially in the current economic depression.

Pricing of the supply of medicines to the Irish health services came about after an agreement between the HSE & the umbrella body for pharmaceutical companies IPHA (Irish Pharmaceutical Healthcare Association) in September 2006 provided the template for the prices & reimbursement of medicines. In 2007 the reimbursement fees & mark-up for pharmacies cost the HSE approximately €283.83 million⁵.

In July 2009, the minister for finance Mary Harney made amendments to the contract for community pharmacists by reducing the payments reimbursed by the HSE due to community pharmacy contractors⁶. The dispensing fees for drug & non-drug items (excluding extemporaneous compounded products) was reduced significantly:

• Reduction in wholesalers reimbursement from 17.66% to 10%,⁷
• €5 dispensing fee for each of the first 1677 items dispensed by community pharmacy contractor in a month.⁶
• €4.50 dispensing fee for each of the next 833 items dispensed by community pharmacy contractor in that month.⁶
• €3.50 for each of the other items (balance) dispensed by community pharmacy contractor in that month.⁶
• Reductions in retail mark up for LTI⁷/EEA/DPS from 50% to 20%⁷.

The impact of the new pricing affects has a resultant domino effect on the pharmaceutical sector in various aspects: whether it is financial, patient, employees⁷.

Financially the pharmacy will have a much lower turnover as the price paid for the drugs is lowered, the percentage of value of turnover accounted for by the sale of prescription medication is 60.9%⁷, which does not include the sales for non-prescription items along with other goods and services. The gross profit margins will decline, costs for the drugs remains the same where as the sales will be reduced as will operating profits averages⁷.

The retail pharmacy sector as a whole is affected because the new pricing cuts means pharmacies whose revenue is low profits will cease to earn sufficient revenue for survival and hence might force a premature closure, large scale pharmacies profits will also be significantly reduced.⁸ This in turn will cause patients to have a lesser variety of choice for pharmacies and depending on where they live in the republic it might make it very difficult for them to access their local pharmacist. Fewer pharmacies in locality could result in lesser times for pharmacist to engage effectively with all patients due to constant demand on time.⁸ An independent research initiative was carried out (lead by Sean Dorgan) which proposed dispensing fees that would try to overcome some of these challenges mentioned above⁴.

The HSE had always intended to have a realistic, fair, transparent and affordable professional fee to be payable on a flat basis to contractors and striving to focus on the professional role of pharmacists in a much more patient orientated service⁴, It also had to take into account the increasing ingredient costs of developing medical technology and the increasing number of items per scheme⁴. However, it has been criticized for abusing its position of responsibility by intervening with the right of the pharmacists to negotiate with their suppliers for efficiencies in their business dealing⁴.

Nevertheless, the HSE also prevents price extortions from taking place by pharmacies to the public, which would have been very probable in a free-market economy. It also ensures that regardless of an economic boom or recession there is always an adequate supply of health service to the resident of the state. By providing these health care schemes, it has allowed for a very long period of time smaller scale pharmacies to establish and flourish where as a purely laissez faire environment would have seen it either bought off or shut down due to inability to keep up with the competition.

In comparison, the bastions of laissez faire, the USA have long been criticized for its healthcare insurance system due to the sad reality that it is too much of a financial catastrophe upon millions of Americans and has lead to productive excessiveness & waste⁹.

“One of the major threats to the American economy…increase in healthcare costs…. primarily because of the privatised healthcare system which is highly inefficient….leading to huge administrative costs, bureaucratization, surveillance costs and so on.” ⁶

Noam Chomsky [Professor emeritus, MIT, USA]

Estimations that 30% of the $2 trillion that is spent on the USA healthcare goes into unnecessary and in some cases harmful treatments⁹. For such a staggering investment the Unites states has minted hospitals with state-of-the-art technologies, but unfortunately also has a population whose health & life expectancy is far behind that of other industrialized democracies.⁹ Hence why the USA administration under President Obama has decided to enact the new Health reform law to bring about a strategic change in lowering the costs of Medicare & Medicaid and expanding the coverage to an additional 32 million Americans over the next decade.⁹

In conclusion although a review was needed for the reimbursement status due to the inability of the Irish government in sustaining such a growing sector in the long run. The current legislation will inevitably dent community sector thereby ensuring all pharmacies will need to analyze and implement long term strategic planning in order to survive the current economic downturn. It might result in better quality of service from pharmacies but will also resulted in closure of many that are unsustainable in this current recession which could create a new challenge for the government, of whether there will always be a supply of healthcare in rural and less developed regions around Ireland in order to prevent shortage of healthcare services. A purely traditional laissez faire policy will only bring about long-term deficit and exacerbate the cost of service just as the USA has experienced. Rather it’s about bringing the scales to equilibrium that is easier said than done.

References

1. O’Riordan T. Laissez Faire. University College Cork. [Citied 2010 May 2] ; Available from URL:  http://multitext.ucc.ie/d/Laissez-Faire
2. Sloman J. Economics. 6^th Ed. Introduction: Different Economic Systems. Pearson Education Limited: 2006, Page 24-25.
3. Random D, Baird V. People First Economics. New Internationalist Publications Ltd: 2009.
4. Dorgan S, O’Dea M. Independent Body on Pharmacy Contract Pricing. June 2008.
5. Barry M. Economics in Drug Usage in the Irish Healthcare Setting. National Centre for Pharmacoeconomics.
6. Health Professionals (Reduction of payments to community pharmacy contractors) Regulations 2009. S.I. No. 246 of 2009.
7. Gallagher P. Senior Cycle 6 Pharmacy Management. Lectures 1-4. Royal College of Surgeons, Ireland: 2010.
8. Lawlor B. Acquiring and financing a pharmacy. Senior Cycle 6 Pharmacy Management. Royal College of Surgeons, Ireland: 2010.
9. Tumulty K, Pickert. America, The Doctor Will See You Now. Times Magazine. 5^th April 2010.

 

Introduction of prescription charges doesn’t uphold the principles of distributive justice

Our ethics debate topic, although we lost the debate due to popular vote (Which was largely by peoples own personal opinions, slightly influenced by some of our academic staff who are pro-fees), I have to say that the opposition had extremely poor presentations of their side of argument: fact of the matter is that Rx charges go completely against distributive justice principles because these principles want to ensure that everyone gets equally treated whilst taking their individual status and ability into account. 2ndly the issue of medications wastage is a fault on the government for having a pathetic healthcare model which badly needs cooperation form all healthcare practitioners and patients in working together to ensure a much better delivery of healthcare.

Distributive justice concerns how individuals and societies distribute benefits and burdens in a just or moral manner.¹

The Irish Constitution states: The State shall strive to promote the welfare of the whole people by securing and protecting as effectively as it may a social order in which justice and charity shall inform all the institutions of the national life.²

According to the World Health Organisation, justice requires that health cases that are considered to be similar be treated alike, and that cases considered to be different be treated in ways that acknowledge the difference.³ When the principle of justice is applied to dependent or vulnerable subjects, its main concern is with the rules of distributive justice.³

Weaker members of communities should not bear disproportionate burdens…from which all members of the community are intended to benefit, and more dependent communities and countries should not bear disproportionate burdens…from which all communities or countries are intended to benefit.³ – WHO

Strict equality is a fundamental principle of distributive justice. Every person is due equal respect and on this premise they should have the same levels of access to goods and services based.⁴

Economies are restricted by the amount of resources available to them. Money is a limited resource. Money is used as an index for the value of material goods and service. Once resources have been distributed beyond their means other criteria beyond value for money must be applied. ⁴

The most widely discussed theory of distributive justice was proposed by John Rawls. He highlights two principles in his 1993 book Political Liberalism:

1. Each person has an equal claim to a fully adequate scheme of equal basic rights and liberties, which scheme is compatible with the same scheme for all; and in this scheme the equal political liberties, and only those liberties, are to be guaranteed their fair value.

2. Social and economic inequalities are to satisfy two conditions: (a) They are to be attached to positions and offices open to all under conditions of fair equality of opportunity; and (b), they are to be to the greatest benefit of the least advantaged members of society. ⁵

Pharmacists are bound by a code of ethics which was proposed by Beauchamp and Childree. In this four principles are addressed, Autonomy, Beneficience, Non-maleficence and Distributive justice. These principles are intertwined and raise many questions in the context of healthcare, particularly with regards our motion that the introduction of prescription charges does not uphold the principle of Distributive Justice.

For the purposes of the debate we focused on three key points:

1. Contravenes Basic Principles underpinning society resource allocation:

Basic Principles outline earlier in the document infer that persons should have equal access to a fully adequate scheme. As healthcare professional we should act in the best interest of the patient and the government is bound to provide adequate resources to ensure this occurs. Duty is not diminished by the patients degree of illness or status. Healthcare is a social right for all people. Ireland spends less on public and private health as a proportion of GDP than the majority of other EU-27 countries. The government should consider increasing the contribution to healthcare as a whole. In Gross National Income (GNI) terms this expenditure translates into a figure of 8.4 per cent. Germany spends 10.9 per cent and Portugal 9.8 per cent. Ireland has the eight lowest expenditure on health (measured as a percentage of GDP) according to EU-27 data.

2. Penalising the vulnerable:

Patients who are under the GMS scheme are vulnerable and tend to fall into a low income bracket. As at January 2009 a single person earning less than 184 euros a week was eligible to benefit from the scheme. While the income thresholds for a medical card increase annually in line with inflation, it has meant that the population eligible for a medical card fell steadily from 35.8% in 1993 to 2.8% in 2005. Ireland spends 15% of its healthcare budget on medications, this is inline European expenditure. ⁶ Research has shown that the absence of financial disincentives has been an aid to compliance. Are there not alternative measure, such as generic prescribing, which should be considered before implementing this charge? The medical card for over 70’s has already been targeted. Our population is aging and therefore the dependence on the healthcare industry is not going to be reduced or be offset by this measure. It is merely a short-term answer that will place an already disadvantaged social group at a further disadvantage.

3. Short term benefit V’s Long Term risks and costs:

And finally early investment in health and health promotion will help to achieve long term population-based benefits and ultimately reduce health care costs in the long run. 2 of the 3 patients admitted as medical emergencies have exacerbations of their chronic diseases. According to the IPHA, 50% of all cardiac admissions are due to non-compliance. Introduction of this prescription levy will run the risk of increasing these figures by creating an unattainable health care system.

The HSE itself claims that it works towards narrowing the gap by influencing all the major factors which help to determine the health and well being of the population by targeting resources towards those most in need of assistance. Those with chronic illness are members of the population that only have the means to manage their symptoms. Their care should be optimised in order to ensure they have the maximum quality of life that modern healthcare can provide. Psychiatric patients are also another at risk section of society should this charge be imposed. Their compliance is of paramount importance.

It is critical for the HSE to use specific health outcome targets and measure them against specific achievements in order to calculate predicted return but also to allow for the more worthwhile treatments to be prioritised.

REFERENCES

1. Hsu M, Anen C, Quartz SR. The Right and the Good: Distributive Justice and Neural Encoding of Equity and Efficiency. Vol. 320. no. 5879, pp. 1092-1095. [Citied 2009 Dec 03] ; Available from URL: http://www.sciencemag.org/cgi/content/full/320/5879/1092
2. The Irish Constitution. Directive principles of social policy. Article 45 Part 1. Page 60.
3. World Health Organisation. Ethics & Health. [Citied 2009 Dec 03] ; Available from URL: http://www.who.int/ethics/indigenous_peoples/en/index13.html
4. Stanford University, USA. Distributive Justice. First published Sun Sep 22, 1996; substantive revision Mon Mar 5, 2007. [Citied 2009 Dec 01] ; Available from URL: http://plato.stanford.edu/entries/justice-distributive/#Scope
5. Rawls, J 1993, Political Liberalism p.p5-6
6. Layte R. Projecting the impact of demographic change on the demand for and delivery of health care in Ireland. Economic and Social Research Institute (2009) Research Series No. 13 Available from URL: http://www.esri.ie/publications/latest_publications/view/index.xml?id=2878

 

The Question of Hubbely Bubbely (shisha) answered to the community

According to the world health organisation 5 million die every year because of smoking (all types and forms). This article is sincere (advice) naseehah to everyone about this plague that is NOT ‘fun’ or ‘fassionable’ but a disgusting and foolish habit that is becoming more and more ‘cool’ with the youth because they know that smoking cigarettes (one Islamic scholar who is also a cardiologist have given an opinion that its just as bad as taking khamr ie intoxicants) and drugs are hara’am but are deceived by this misconception that shisha is ‘ok’ or ‘halal’.

Firstly what do the ulema say on this issue, Checking out a website which is supervised by a prominent contemporary scholar Shaykh Muhammad Salih Al-Munajjid (May Allah SWT protect him) has given numerous fatwas that shisha is 100% hara’am & otherrelated issues to smoking. Please check out these link for your own satisfaction.

• Fatwa that ‘hubble-bubble’ pipes (ie shisha & hokka pipes) is hara’am
• Fatwa that sisters must refuse a proposal from a man who smokes, drinks and does’nt pray regularly
• Fatwa that smoking,  growing tobacco is one of the al-khabaa’ith [evil things]
• Fatwa for a woman to divorce her husband because he smokes
• Fatwa that smoking breaks the siyam (fast)
• Fatwa to abandon the company of a smoker by Shaykh Uthaymeen

Finally I would like to share this article with everyone, It is from the BBC health section which can be found here.

May Allah SWT protect us all and our children from any types of fitnah and fawahish and guide us all to the straight path. Ameen

Shisha ‘as harmful as cigarettes’

By Perminder Khatkar BBC Asian Network

Smoking a shisha pipe is as bad for people as smoking tobacco, the Department of Health and the Centre for Tobacco Control Research has found.

People who smoke shisha, or herbal tobacco, can suffer from high carbon monoxide levels, its research revealed.

It found one session of smoking shisha resulted in carbon monoxide levels at least four to five times higher than the amount produced by a cigarette.

High levels of carbon monoxide can lead to brain damage and unconsciousness.

Shisha is an Arabic water-pipe in which fruit-scented tobacco is burnt using coal, passed through an ornate water vessel and inhaled through a hose.

Dr Hilary Wareing, director of the Centre for Tobacco Control Research, told the BBC’s Asian Network she was shocked by the results of the research.

“Our mouths opened at the level of harm – none of the tests we did showed anything other than shisha is hazardous to health.”

Paul Hooper, regional manager at the Department of Health, said the findings made the dangers of shisha a “major issue”.

He said many people regard shisha “as not even smoking”.

Misconception

Shisha bars, which are typically decked out with low stools and soft cushions to create an inviting atmosphere, have become popular in cities across the UK, particularly London, Manchester and Birmingham.

At the worst, shisha was 400 to 450 times more dangerous than having a cigarette Dr Hilary Wareing Centre for Tobacco Control Research

An activity largely associated Middle Eastern customers and a young crowd, there is a growing trend of themed shisha parties.

Many people who go to “shisha evenings” think it is a safer alternative to smoking cigarettes.

“You never see it in the news – ‘that is terrible, don’t do it’ – there’s no shock tactics like (there is with) cigarettes,” said one young woman.

“If my mum sees me smoking shisha, she isn’t going to take it as seriously as if I was smoking cigarettes,” said a British Pakistani man.

It was this misconception – and finding dangerous levels of carbon monoxide in a pregnant woman who had stopped smoking tobacco, but continued to smoke shisha – which prompted the research.

“We found one session of smoking shisha – that’s 10 milligrams for 30 minutes – gave carbon monoxide levels that were at the lowest four and five times as high as having a cigarette,” said Dr Wareing.

“But at the worst, shisha was 400 to 450 times more dangerous than having a cigarette,” she added.

Informed choice

Shisha smokers in a cafe in Edgware Road, London, said the findings would make them think twice about smoking.

“You know you can die from cigarettes, but you don’t know you can die from shisha,” said one.

“I’m now going home to research it,” said another.

But not everyone is convinced.

Akram, a 27-year-old who runs a restaurant and shisha bar in Birmingham, has his own views.

“There is a health risk but it’s all down to consumption and all the evidence I’ve seen is that smoking shisha is nothing like smoking even one cigarette,” he said.

He said he did not actually inhale shisha smoke.

It is not just the level of carbon monoxide that is causing concern.

Qasim Choudhory, a youth worker at the NHS Stop Smoking Service in Leicester, said sharing a shisha pipe could pass around infections.

“There’s a heightened risk of getting TB, herpes and infections like that,” she said.

“Now you know swine flu is on the top of the agenda right now – there’s no kind of direct correlation, but at time when we’re up on our hygiene, it’s not the best type of activity to be taking part in.”

Dr Wareing said more research on exactly how dangerous shisha was needed to be conducted to enable people to make an informed choice.

Paul Hooper said the department was working hard at “how best to get the message – that it is dangerous – across to the consumer”.

“But how do you label the tobacco and the shisha pipe? It’s not as simple as labelling a packet of cigarettes,” he added.

The Trouble with Hubble-Bubble will be broadcast on the BBC’s Asian Network at 1800 BST on Monday 24 August 2009.

Below are some disturbing images and scientific evidences (links to respected & credited websites) for the destructive consequences of smoking.

Peripheral disease (gangrene) caused by smoking which needs amputation

Mouth cancer

Fatty deposits in the carotid artery which can be a cause of stroke

• Cancer institute NWS Health warning campaign
• Tobacco by the World health organisation
• FAQ answered by the National Cancer Institute
• Patient tutorial on the facts of smoking by Medline Plus

 

The new age of infanticide

An interesting article I found by Dr. Tawfique Chowdhury from the AlKauthar website. Its a well worth read for all the medics and health care professionals out there with this current debate about infanticide etc. Interesting perspective from someone who has studied both Shariah & medicine. Insh’Allah i will update on later articles under the “Medical Ethics” section about a few issues e.g. organ donations/transplants, blood donations, contraception etc.

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Recently the Australian Medical Association asked our medical department for our vote on legalizing Mifeprestone (RU486) in Australia in yet another attempt to make non-invasive abortion more accessable to Australian women. At the moment it takes a woman about AU$120 to get an abortion done as medicare pays for the rest. There are about 84,000 abortions performed in Australia in 2003. Pro-choice argue that even this is too restrictive on women, especially on those women in rural areas, so they want the medicare itemed RU486 to be legalized. It is for this reason that attempts are underway to de-criminalize abortion in those states that require a ‘lawful’ abortion to be performed, even though there has not been a successful prosecution for unlawful abortion since 1970s. At 84,000 abortions a year, I strongly doubt that they are all legal abortions and in reality, practise is more common than we are led to believe.

Is there a need to make abortion even more accessible to women, especially since the age of women asking for abortion is getting lower and lower?

I watched with amazement at the 60,000 signatures and hand prints collected to prevent the capital punishment in Singapore being applied on convicted Australian drug smuggler, Nguyen, arguing to save his life. ‘Life is sacred’ we are told, ‘Life is the greatest gift’ – amazing statements from a people arguing for every ease to end that very life! On one hand, remove the life of an innocent soul because of perceived inconvenience and on the other hand, save the life of one guilty of a crime that will destroy thousands of others!

This, I believe, is attestament to the perversion of logic in the minds of those who hold these views – those who, in their struggle to have the perfect lifestyle, crown convenience and ‘choice’ as king and queen. To make abortion even more accessible, is I believe, completely amoral. Such an act would put the monumental decision of termination of life to even younger women, and at a time when their judgement and wisdom is clouded by circumstance.

I do not believe that society can ever learn to forgive women who kill their living children. Considering the fact that 90% of abortions are performed in the first 90 days since inception, the problem seems to lie in people’s interpretation as to when life truly starts. 

The Carnegie stages of human development show that the development of all body organs are completed by 56 days. The heart starts beating at 25 days and the first impulses from the brain can be felt at 40 days. Islamically and medically, life ends with brain death so too it must start with it as well. If 90% of abortions are performed before 90 days, then it seems the vast majority of abortions are actually performed on a living soul. I believe, to not provide this information in counselling women who want to have an abortion, is moral and medical negligence and perversion, and not in accordance with medical ethics of beneficience and non-maleficence.

Islamically the doctor who performs abortion is obliged to pay 5% blood money since classical scholars of fiqh consider the baby inconception, to have the probability of life, but not fully alive as life in those times could only be proven on delivery. In our time, I believe modern technology has changed all that and abortion must carry 100% blood money – approximately AU$45,000 in 2006.

If morality and human ethics will be neglected for convenience and choice, then perhaps it is the blood money that will stop them. If that too fails then all that is left is the hadeeth of our beloved Prophet sallallahu alaihi wa sallam: “If you have no shame, then do as you wish.”

“And when the infant buried alive with be questioned, for what reason she was killed.” [81:8-9]

Abu Yusuf Tawfique Chowdhury
Director
AlKauthar Institute

 

Performance enhancement in sports using supplements and nutraceuticals

Our Pharmacognosy project 2009 on Performance enhancement in sports using supplements and nutraceuticals

The use of ergogenic products to increase athletic performance and increase mass is common amongst athletes. This includes supplements of creatine, glucosamine, chondroitin, glutamine, L-Carnitine, whey protein, caffeine, leucine and its metabolite hydroxymethylbutyrate. Despite their popularity, there is a degree of scepticism surrounding both effectiveness and safety of these products.

A comprehensive literature review was undertaken in Australia to determine what substances were being promoted in the most popular sports magazines. Results indicated that that one quarter at 54% were for creatine. 24% glutamine, 20% Hydroxymethylbutyrate (HMB) and 2% branched chain amino acids (BCAA) ¹. This review was conducted on trials to ascertain the effect that such supplements had on the performance of athletes.

Carnitine and Leucine Metabolite Hydroxymethylbutyrate (HMB)

Results indicated that Creatinine supplementation is both safe and effective both enhancing performance and allowing high- intensity training. However results from this review claimed that Carnitine is only effective in disease states.¹

“Supplementary carnitine has been touted to increase the uptake and oxidation of fat in the mitochondria. However, muscle carnitine levels are not augmented following oral carnitine supplementation and the majority of well-controlled studies have reported no effect of carnitine on enhancing fat oxidation, Vo(2max) or prolonged endurance exercise performance” ²

Carnitine is obtained from both diet and endogenous biosynthesis. Meat and dairy produce are common sources. Claims on its ability to enhance athletic performance include

1. Increased muscle fatty acid oxidation,
2. Decreased rate of muscle glycogen depletion,
3. Improved muscle fatigue resistance
4. Replacement of carnitine lost during training.

All of the above would result in delayed development of fatigue due to delayed used of muscle glycogen as a result of increased fatty acid oxidation.

The leucine metabolite Hydroxymethylbutyrate (HMB) is found in small quantities in for example catfish and citrus fruits. Claims include the fact that it promotes increases in fat free mass and increased strength during resistance training. This is believed to result from inhibition of protein degradation. Leucine is understood to prevent protein degradation therefore although the exact mechanism of action of HMB is unknown; it is believed to effect protein metabolism. It is also believed that it may regulate protein synthesis via hormone receptors or interfere with enzymatic activity involved in muscle breakdown. Other possible effects include modulating metabolism of leucine or glutamine or decreasing gluconeogenesis and therefore amino acid oxidation. It does however appear to be non toxic. Studies provide limited evidence to support claims of HMB supplementation improving strength or body mass, however in 7 studies it was illustrated that “HMB resulted in significantly less exercise induced proteolysis and muscle damage. There was also evidence of increased gains in fat free mass or larger gains in muscle function and resistance training”.¹

According to one study a dietary supplement of HMB 3g/daily during intensive resistance exercise training results in increased strength, a decrease in muscle proteolysis and lower plasma levels of enzymes indicating muscle damage.³

The conclusion is that both Leucine metabolite HMB and L Carnitine supplementation are effective for athletes initiating training rather than individuals who are already well trained athletes.1,4

Further trials are necessary to validate their effectiveness.

Glucosamine and Chondroitin

Athletes who have trained intensively over a long period of time are often suseptible to joint problems due to extensive ‘wear and tear’ of cartilage.5 Cartilage is composed of chrondrocytes which produce an extracellular matix composed of collagen fibres. Cartilage is rich in proteoglycans and elastin fibres. Cartilage is classified under three main types – elastic cartilage, hyaline cartilage and fibrocartilage. It is hyaline cartilage that is implicated in the wear and tear effects that atheletes often suffer.

Glucosamine is a natural component of cartilage and is a normal constituent of glycosaminoglycans in cartilage matrix and synovial fluid. It is a hexosamine sugar formed by a combination of glucose and glutamine which is primarily found in cartilage.6 The mechanism of action of glucosamine is not fully understood; however it is thought to produce glycosaminoglycans (GAGs) which are the proteins that bind water in the cartilage matrix. It is a major precursor to the GAGs which go on to form the tissue framework that bind collagen. Glucosamine has also been seen to inhibit collagenases and phospholipase A2 in conjunction with inhibition of O22- and lysosomal enzyme.5 Together collagen and GAGs continoulsy construct and reconstruct cartilage.7

Glucosamine may have an effect on joint pain. Glucosamine is thought to be a building block of hyaluronic acid (HA). In the past HA has been seen to have an effect on both pain and function in degenerated joints; this may therefore attribute glucosamine affects of reduced pain to HA as glucosamine is a primary building block of HA and also HA is present in high quantities in articular joints. This effect of increased HA production in the synovium has only been seen with glucosamine hydrochloride.8 Glucosamine has been shown to inhibit activation of NFκB; a pro-inflammatory cytokine that is released by synovial cells, chrondrocytes and invading macrophages in inflamed joints. Glucosamine has also been found to normalize articular cartilage metabolism, alter collagenase activity, restore dysregulation balance of GAG metabolism by stimulating their production and preventing their degradation. The mechanisms of these actions are not well understood.9, 10

^{Chondroitin is often used in combination with glucosamine to stop or prevent the degeneration of joints often experienced by athletes. Chondroitin is the most abundant glycosaminoglycan that is found in cartilage and is responsible for its resilience.6}

^{Chondroitin is a long-chain negatively charged molecule. The molecule encases proteoglycans and causes a space to be formed between each. This helps to form the fluid matrices which allow flow of fluid throughout the cartilage. In addition to this role, chondroitin also inhibits the enzymes responsible for cartilage breakdown.}

The use of glucosamine and chondroitin by athletes should be encouraged as it is in the best interest of their long-term health. If left unchecked the articular cartilage degradation would lead to osteoarthritis, a degenerative disease without a cure. The main aim of treatment is to reduce pain and prevent worsening of the disease.

Whey protein

Whey protein is a high quality protein powder that is extracted from cow’s milk. Cow’s milk contains two main types of protein, Casein that accounts for approximately 80% of the protein and Whey that accounts for the remaining 20%.12 Whey protein is more soluble than casein protein and also contains a very high concentration of essential amino acids; as a result it is often referred to as the “gold standard” of protein as it is the most nutritious protein available.13 It is the richest known source of branched chained amino acids in particular leucine, which is a precursor of muscle protein metabolism and is a key regulator in the translation initiation pathway of muscle protein synthesis.12

Whey supplements contains 10g leucine, 6.5g isoleucine and 5.5g valine per 100g of protein with minimal fat and carbohydrates.12, 14 A leucine rich diet has been proven to promote muscle anabolism, healthy blood glucose metabolism and maintain a healthy body mass, all of which are of benefit to athletes.14 The body requires higher amounts of branched chain amino acids during and following exercise as the amino acids are metabolised in the liver and are then taken up directly by the skeletal muscles.14 Many athletes consume whey protein both before and immediately after exercise to help repair and rebuild lean muscle tissue.  As whey is a natural product found in dairy sources it exhibits limited adverse effects, only allergies have been reported in the literature.

Branched chained amino acids are said to aid recovery and delay fatigue. Exercise can be seen as a metabolic stress similar to trauma or injury, as a result muscle tissue is progressively catabolized to provide the liver with glucose.11 Whey supplementation can provide the branched chained amino acids in the diet of athletes as an aid to recovery.  Increased concentrations of serotonin can impair central nervous system functioning during exercise. This is due to increased levels of the amino acid precursor trytophan.11, 12 Transportation of free tryptophan across the blood brain barrier is shared with branched chained amino acids.  Supplementation with branched chained amino acids therefore inhibit the amount of tryptophan entering the brain, hence delaying fatigue in prolonged aerobic exercise such as cycling and long distance running.11, 12

Whey protein supplementation is commonly used in a variety of sports, particularly by athletes that require strength and muscle hypertrophy.11 Their use is commonly seen in sports such as rugby, boxing, athletics and weightlifting. They are seen to benefit these athletes in three ways. Firstly when supplementation occurs close to resistance exercise (weight training) it is seen to stimulate muscle anabolism in response to this activity.12 Secondly, whey protein supplementation between meals is said to promote muscle protein synthesis, thereby resulting in a higher net gain in muscle protein on a daily basis.12 Finally, whey protein helps athletes maintain a healthy immune system by increasing the levels of glutathione in the body. Glutathione is an anti-oxidant required for a healthy immune system and exercise and resistance training may reduce glutathione levels.12 Whey protein helps keep athletes healthy and strong to perform at their best. Alongside its obvious benefits in sport, whey protein supplementation has also shown benefits in areas such as wound healing, infant nutrition and long term illness recovery.13

^Caffeine

^{Caffeine is a methylxanthine which has the effect of producing CNS stimulation, diuresis, stimulation of cardiac muscle an relaxation of smooth muscle. It is thought to accomplish this through inhinition of phosphodiesterase and also thorugh antagonism of the adenosine receptors.15}

^{Caffeine falls under the class of stimulants used in performance enhancement in sport. Despite having proven endurance benefit in athletes, caffeine is unique, in that it remains legal to take in sport provided urine levels do not exceed 12mcg/ml, as set by the International Olympic Committee.16}

^{Caffeine is used as an ergogenic agent by athletes in many different sports such as sprinting, swimming , field events and cycling. It is used to increase exercise capacity and time to fatigue.17}

^{One purported benefit is an ability to enhance the breakdown of fat in adipose tissue while sparing muscle gycogen. However this theory is incomplete and the amount of  glycogen breakdown limited is actually inconsistent.18}

Caffeine has been demonstrated to affect the CNS so that fatigue signals are overrided.19 Studies have been done where subjects have shown an increased time to exhaustion and improved performance, where a fixed amount of work has to be acomplished in the shortest time possible.19 It improves aerobic endurance during exercise lasting 30-60 minutes.17 Speed and power output may also be improved.17 However the evidence for this is less clear for ultra-endurance sport events.17 Other benefits are increased speed in athletes following caffeine consumption.17

^{It is true that many studies demonstrating ergogenic effects of caffeine measure endurance performance using a time-to-exhaustion test.20 However this gives variable results with lack of consistency.20 One study hence measured performance using time with best effort.20 The study found that there was a mean improvement in performance with caffeine ingestion.20 However it was highly variable with a large range that included 1. The investigators concluded that caffeine can be effective as an ergogenic agent before and during exercise.20 This study again outlines the fact that caffeine has been clinically demonstrated to produce an ergogenic effect yet like so many other studies, variability in results leaves the debate open on its true effect in sport.}

The risks of adverse effects with caffeine intake in large doses is minimal.15 However like other stimulants, it does have the potential to cause increased heart rate, imapired motor control which would affect perfromance in sport and insomnia which may affect recovery between training and competitions.21

One often cited concern, is the weak diuretic effect that caffeine has.22 This may cause dehydration in athletes and cause electrolyte imbalance that would hamper athletic performance.22 However this has been shown to be false and hence the risks posed to athletes in this regard are deemed not to be of great concern.22 Tolerance to caffeine actually reduces this risk even further.22

^{In conclusion caffeine remains a neutraceutical that does have a positive effect on performance enhancement in sport. It is difficult to reliably measure performance in experiments that improve over time.23 However controlling for these factors has demonstrated an ergogenic effect of caffeine during exercise >40 mins.23 It is not clear however that caffeine has much ergogenic effect on shorter bouts of exercise, <20 mins.23 The shear variability of results makes any clear cut evidence in favour of caffeine debateable but further study in this case is warrented to investigate factors that cause the large range observed with results.}

Creatine:

Explanation: 24

Creatine, a nitrogenous organic acid is an important component of skeletal muscle that is commonly taken as a supplement by athletes for performance enhancement. Ingested creatine is capable of dramatically boosting the creatine content in muscle – which is used as an energy source by skeletal muscle. Creatine is a vital component of the ATP-PC system, one of the most important energy systems in the body. In human and animals, approximately 50% of creatine stored in the body is taken in from food sources, mainly red meat.  95% of the total creatine is stored in skeletal muscle.

Of the 95% creatine stored in skeletal muscle, two thirds is stored as phospho-creatine, the other third as creatine. The recommended daily allowance is approximately 2g per day, which is dependant upon body weight and level of activity. The endogenous creatine produced by the body is mainly produced by the liver, as well as by the kidneys and pancreas.

As well as being popular among body-builders and athletes, creatine is also being investigated as a potential therapeutic approach for the treatment of muscular, neurological, neuromuscular and neurodegenerative disease, for example, Parkinson’s disease, arthritis and muscular dystrophy.

Health-food stores sell creatine supplements in capsule, chewable, and powdered form, the most popular being the powder. One teaspoon of powder contains 5 grams of creatine monohydrate. The recommended daily dose is 1-2 teaspoons dissolved in 8 ounces of water or sweetened beverage.

Creatine Supplementation:

Creatine monohydrate has become one of the most popular ergogenic sport supplements used by athletes and body builders. The main aim of athletes who use creatine supplements is to maximise their intracellular pool of total creatine. The fact that creatine supplementation is capable of enhancing athletic performance and cellular bioenergetics is supported by a multitude of evidence, but it should be noted that variability does exist. This variability is believed to be due to the biological process that controls the influx and efflux of creatine across the cell membrane, ie the expression of the creatine transporter CreaT1. ²⁵

The recommended regime of creatine supplementation is as follows: an initial loading period of 5 – 6 days of 20-30g/day followed by an unlimited period of a maintenance dose of 2-5g/day. Dosage is dependant upon body size and level of activity. A more accurate dosing of 0.3g/kg/day during the 5-6 days of the loading period, followed by 0.03g/kg/day during the maintenance period have been suggested, which takes these variables into account. ²⁴

The use of creatine supplements has been associated with the following positive effects:

• Increased muscle bulk
• Decreased fatigue
• Decreased recovery time
• Improved performance

Reported side effects associated with Creatine supplementation include:

• GI upset
• Tendon pain
• Headaches
• Hepatic and renal function
• Muscle cramps
• Possible death

Evidence:

There have been a multitude of studies carried out regarding the safety and efficacy of creatine use in athletes and non-athletes. These mostly consist of short-term studies that investigate the effects of creatine monohydrate use over a period of 5 – 6 days. The majority of these studies were performed as double blind, randomised control trials. They mostly focus on the use of creatine supplements by athletes involved in high intensity, repetitive exercise, for example weight lifting.

The findings of these studies are as follows:

• An increase in concentration in muscle of creatine and phospho-creatine (i.e. total creatine) is observed. ^{27, 25}
• Body mass and fat free mass increases, but no change in body fat levels are observed. ²⁸
• A decrease in fatigue during high intensity, repetitive exercise is observed. ²⁹
• An improvement in athletic performance is also noted. ²⁹

None of these studies noted a significant occurrence of side effects, and some, including Lopez et al, found that the deaths of professional athletes that had been attributed to creatine use were actually caused by exertional heat stroke that was not associated with creatine use. ³⁰

How does Creatine work? 24,26,27

The exact mechanism of action of creatine is unknown, but a number of hypotheses have been put forward, including:

• Effect in ATP concentration:
• A higher concentration of creatine phosphate in muscles leads to a “lesser dependence on anaerobic glycolysis for the re-synthesis of ATP.”
• Improved buffering effect on ADP leading to a relatively greater supply of ATP.
• It is believed to enhance re-synthesis of ATP and to improve performance in short bouts of exercise.
• Effect on protein synthesis:
• The direct or indirect stimulation of protein synthesis or decreased protein degradation.

In summary, from the literature reviewed, the use of creatine supplements appears to be beneficial for athletes who wish to enhance their athletic performance and body composition. This does appear to be targeted at a fairly specific population, with young males who participate in some form of physical training and sport benefiting the most from creatine supplementation. The literary evidence shows no side effects associated with the use of creatine as a supplement.

Conclusion

Research has shown that supplement use occurs at all levels of sport from professional sports men and women, to young amateur athletes. Although some supplements do enhance athletic performance, many have no proven benefits and have serious adverse effects. Currently, access to sports supplements is readily available via health food stores and the Internet. It is important that athletes from all disciplines are provided with education and access to scientific and un-bias information regarding these products. Both doctors and pharmacists should be prepared to counsel athletes on the effectiveness and safety of supplement use, whilst also promoting the benefits of a healthy diet and appropriate training program in order to achieve there desired goals.

References

1. Beduschi G. Current popular ergogenic aids used in sports: a critical review. Nutri Diet. 2003;60:104-18
2. Spriet LL. Perry CG. Talanian JL. Legal pre-event nutritional supplements to assist energy metabolism.Essays in Biochemistry.2008; 44: 27-43
3. Mero A. Leucine supplementation and intensive training. Sports Med.1999;27(6):346-58.
4. Bloomer R.J. The Role of Nutritional Supplements in the Prevention and Treatment of Resistance Exercise-Induced Skeletal Muscle Injury.Sports Med 2007;37(6):519-32
5. Maughan R, Depiesse F. Geyer H et al: ‘The use of dietary supplements by athletes’ School of sport and exercise science, Journal of sports science, Vol. 25 Iss. S1, Dec 2007; Pages S103-S113
6. Tanveer E. Towheed, Tassos P. Anastassiades: ‘Glucosamine and Chrondroitin for treating symptoms of OA: Evidence is widely tested but incomplete’ JAMA 2000; 283(11):14 83
7. Braham R, Dawson B, Goodman C: ‘The effect of glucosamine supplementation on people experiencing regular knee pain’ Br J Sports Med 2003; 37:45-49
8. Uitterlinden EJ, Koevoet J, Verkoelen CF et al: ‘Glucosamine increases hyaluronic acid production in human osteoarthritic synovium’ BMC Musculoskeletal Disorders 2008, 9:120
9. Largo R Ph.D, Alvarez-Soria MA et al: ‘Glucosamine inhibits IL-1b-induced NFκB activation in human osteoarthritic chrondrocytes’ Osteoarthritis and Cartilage Volume 11, Issue 4, April 2003, Pages 290-298
10. McAlindon T.E. LaValley M.P. Gulin J.P. Felson D.T. ‘Glucosamine and Chondroitin for treatment of osteoarthritis’ JAMA 2000; 283 (11): 1469-1475
11. Pasin G and Miller S.L. US whey products and sports nutrition. US Dairy Export council. www.usdec.org cited: 1/4/09
12. Hayes A and Cribb P. J. Effect of whey protein isolate on strength, body composition and muscle hypertrophy during resistance training. Current Opinion in Clinical Nutrition and Metabolic Care 2008, 11:40-44
13. Whey protein institute www.wheyoflife.org cited: 1/4/09
14. Bucci L, Unlu L. Protein and amino acid supplementation in exercise and sport. In : Driskell J, Wolinsky I, editors. Energy yielding macronutrients and energy metabolism in sports nutrition. Boca Raton: CRC Press; 2000 191-212
15. Rang, Dale, Ritter, Flower 2007, Rang and Dale’s Pharmacology, 6th edition, Churchill Livingstone Elsevier.
16. Driskell, Wloinsky 1999, Macroelements, Water, and Electrolytes in Sports Nutrition [online], CRC Press, 256,  Available from: www.books.google.com
17. Driskell, Wloinsky 2004, Nutritional ergogenic aids [online], CRC Press, 536,  Available from: www.books.google.com
18. Graham, Terry E 2001, Caffeine and Exercise: Metabolism, Endurance and Performance, Sports Medicine, 31, 11, 785-807
19. Maughan, Burke 2002, Sports nutrition [online], Wiley-Blackwell, 200,  Available from: www.books.google.com
20. Ganio, Klau, Casa, Armstrong, Maresh 2009, Effect of caffeine on sport-specific endurance performance: a systematic review, Journal of strength and conditioning research, 23, 1, 315-324
21. Burke 2007, Practical Sports nutrition [online], human kinetics, 531,  Available from: www.books.google.com
22. Armstrong LE 2002, Caffeine, body fluid-electrolyte balance, and exercise performance, International Journal of Sport Nutrition and exercise Metabolism, 12, 2, 189-206
23. Maughan, IOC Medical Commission, International Federation of Sports Medicine 2000, Nutrition in sport [online], Wiley-Blackwell, 680,  Available from: www.books.google.com
24. Fillmore CM, Bartolli L, Bach R and Park Y.Nutrition and Dietary supplements. Physical Medicine and Rehabilitation Clinics of North America. 10(3)673-703
25. Schoch RD, Willoughby D and Greenwood M. The regulation and expression of the creatine Transporter: A brief review of creatine supplementation in humans and animals. Journal of the International Society of Sports Nutrition 2006; 3(1): 60-66.
26. 26. Schilling et al. Creatine Supplementation and health variables: a retrospective study. Med Sci Sports Excer. 2001 Feb;33(2):183-8
27. Van Leemputte M, Vandenberghe K and Hespel P. Shortening of muscle relaxation time after creatine loading. J App Physiol. 1999 Mar;86(3):840-4
28. Mihic S, MacDonald JR, McKenzie S and Tarnopolsky MA. Acute creatine loading increases fat free mass, but does not affect blood pressure, plasma creatinine or CK in men and women. Med Sci Sports Excer. 2000 Feb;32(2):291-6
29. Balsom PD, Harridge SD, Soderlund K, Sjodin B and Ekblom B. Creatine in humans with special reference to creatine supplementation. Sports Medicinne 1994 Oct;18(4):268-80
30. Lopez, RM et al Does creatine supplementation hinder excersize heat tolerance or hydration status? A systematic review with meta analyses. Journal of Athletic Training 2009;44(2):215-223

 

The psychological and social aspect of Parkinson’s disease

Project for behavioral science module….

Parkinson’s disease (PD) is a progressive neurological condition affecting the mechanical movements (walking, writing & speech). There are no exact global figures for the total patient but it’s estimated that 4 million people worldwide have the condition2. 1 in 500 people have Parkinson’s in the UK, which are roughly around 120,000 individuals3. Every year about 10,000 people in the UK are diagnosed with Parkinson’s3. It is 1.5 times more common in men than in women4. 

1.2 Definition:

Parkinson’s disease is a progressive disorder that occurs primarily in the elderly. It can be recognised by its characteristics symptoms⁴ such as:

• Resting tremors- About 70% of people with Parkinson’s experience a slight tremor in the early stage of the disease – either in the hand or foot on one side of the body, or less commonly in the jaw or face. The tremor appears as a “beating” or oscillating movement.4
• Muscle rigidity. In rigidity, the muscle tone of an affected limb is always stiff and does not relax, sometimes resulting in a decreased range of motion.
• Slowness at movement, shuffling gait and hesitancy.4
• Secondary motor symptoms may be prevalent in some patients but not all, such as speech problems, drooling, sexual function dimish, fatigue and difficulty in swallowing.4

 As symptoms of Parkinson’s worsen, people with the disease may have trouble walking, talking or doing simple tasks. They may also have problems such as depression, sleep problems or trouble chewing, swallowing or speaking. Shuffling gait is a distinct characteristic of Parkinson’s patients, they find it very difficult to move but also find it hard to stop or change direction once they start movement.

Parkinson’s usually begins at a later stage in life, but it can start earlier. Hoehn & Yahr rating scales, United Parkinson’s disease rating scales and among other neurological tests are used as diagnostic criteria in Parkinson’s disease.¹

 1.3 Causes:

 PD is caused by the progressive degeneration of the substantia nigra, The substantia nigra normally co-ordinates movement and produces a chemical called dopamine but because of its degeneration in Parkinson’s this results in low levels of the dopamine being released in the brain. Dopamine is a chemical messenger, or neurotransmitter, involved in passing messages within the brain and from the brain to the muscles. Low levels of dopamine cause the symptoms of PD.1,6

 The causes can be due to cerebral ischaemia, viral encephalitis or any other pathological damage.6 It can also be drug induced from depletion of dopamine stores or blockade of receptors of dopamine receptors from the use of neuroleptics (e.g. Haloperidol) in schizophrenia.6 

 It can also be due to environmental factors such as neurotoxins, oxidative stress, head injury and exposure to other substances such as pesticides and herbicides.

 There have been many cases of individuals with a history of substance abuse that developed Parkinson’s after self-injection of MPTP. MAO-B metabolizes MPTP to its toxic form MPP+.4 MPP+ accumulates in mitochondria of dopaminergic neurons and interferes with the function of complex I of the respiratory chain. This causes MPP+. Induced Parkinsonism.5,6

 Parkinson’s disease has also been known to be associated with development of protein aggregates called Lewy bodies6. Hereditary mutations of the a-synuclein cause these Lewy bodies to bulk excessively and hence cause neuronal death.5

 1.4 Treatment options:

Figure 1.1

Figure 1.1 Illustrates the treatment options that are used in Parkinson’s patients.

The treatment for Parkinson’s disease is symptomatic; none of the current therapy will affect the progression of the disease.

1.5 Psychological and social aspects of Parkinson’s:

Among the major concerns with patients that suffer from PD is the gradual onset of depression. It is one of the main non-motor complications in PD patients who may also have signs of anxiety, fatigue and sleep disturbances. In Ireland over 300,000 men and women suffer from depression every year⁷. The ratio of women is to men who suffer from depression is greater. However, research has shown that every year more men commit suicide or attempt suicide than women, perhaps because men are more reluctant than women to seek help for depressive symptoms or discuss it with others⁷. Depression is secondary to Parkinson’s disorder and the disability associated with it such as dementia, diminished self-esteem due to loss of independence, sexual complications. When an individual has a depressive disorder, it interferes with their daily life, normal functioning, and causes pain for both the individual and their carers.

The signs of depression⁸ include:

• Persistently sad, anxious, apprehensive.
• Fatigue and decreased energy
• Extreme feeling of unhappiness.
• Irritability, restlessness, sleeping difficulty.
• Loss of interest in pleasurable activities e.g. sex.
• Feelings of pessimism
• Difficulty concentrating and memory problems.
• Persistent aches or pains, headaches, cramp or digestive problems that do not ease even with treatment.8

 According to some studies almost 50% of the patients with PD displayed symptoms of anxiety, whereas nearly 40% showed signs of depression9. Which shows the prevalence of these complications in PD patients. In another study whose aim was to analyze the frequency of depression in patients with PD, it was discovered that there was more severe motor disability and considerably lower quality of life in PD patients.

 Other risk factors8 that can help contribute to depression in PD patients:

• Unexpected life events.
• Severe motor disability with reduced quality & outlook on life.
• Previous incidences of depression.
• Higher prevalence in females than males.

 There are some similar symptoms that are shared between patients with PD and depression.

• Slow movements, and stooped posture.
• Poor memory, concentration and indecisiveness.
• Poor appetite, and impaired sleep.

Patients can also be isolated from society due to the restricted movement, also they might be hesitant or shy in participating in social gatherings due to their tremors, physical deterioration and motor complications that they perceive might cause them embarrassment and shame in public. Depression can be predicted in PD patients fail to comply with their treatment. Poor compliance is uncommon in PD, but a large percentage of depressed patients show poor compliance as a result of decreased attention, poor concentration and poor memory. To identify the presence of depression in PD patients, The Geriatric Depression Scale (GDS)10 is used to screen recent to advanced depression in PD patients. The scores will indicate the severity of depression, the higher the score the more severe depression.10

Fatigue is one of the most common symptoms in patients with PD that is underestimated by health-care providers, and its impact on the quality of life is substantial.11 Fatigue is partially associated with sleep disorders or depression, but not all patients who are fatigued suffer from depression or sleep disorder.11 Drugs used for PD may exacerbate or reduce fatigue. Its treatment however is still not established.11

In another research paper it investigated whether the severity of depression and severity of anxiety were associated with particular types of sleep disturbance in patients with Parkinson’s disease12, in this trial Patients were assessed for nightmares and rapid eye movement, sleep behavior disorder using a structured questionnaire and dream log. It was discovered that out of the 38% female participants, 41.7% had a psychiatric history, 53.3% had nightmares, and 30% had sleep behavior disorder.12 the severity of depression and anxiety is related with poor sleep quality, daytime somnolence, and nightmares. The severity of depression played a major role in causing overall variance in poor sleep quality and nightmares.12

1.6 Management of the psychological and social aspects of PD:

The diagnosis and management of depression in PD is very important given the negative impact it has on motor symptoms and quality of life especially if compliance with the patients medication is compromised. Traditional antidepressants, electroconvulsive therapy and psychotherapy are also shown to be effective13. It should be noted though to treat PD before treating the patient for depression. NICE guidelines14 recommend exercising due to the increased risk of heart disease in depression. Selective serotonin reuptake inhibitors such as prozac13 are well tolerated and are the preferred drugs of choice in PD patients with depression, the side effects profile of it include sweating, insomnia, sexual problems and complications motor functions13. Behavioural therapy and psychosocial support14 should also be offered to the patients to alleviate the feeling of extreme unhappiness and low self-esteem that is associated with depression.

The first step in sleep disorder management in PD is to diagnose which type of insomnia and the possible factors that may disturb nocturnal sleep15. Increasing the dosage of dopaminergic drug treatment will often increase sleep disruption and should be avoided unless the patient’s sleep is primarily disturbed by the motor manifestations of parkinsonism during the night.15 If it becomes necessary to treat the patient with an hypnosedative agent, it is important to use a medicine with a short half-life and one that has the least side effects. Patients with Parkinson’s disease should be informed about the possibility of developing sleep problems during the day when prescribed new drugs.

References

1. Kirby B. Lecture PD 1 & 2. Neurodegenerative diseases. Pharmacology. ICB3. Royal College of Surgeons in Ireland.
2. Parkinson’s disease. Published by Bupa’s health information team, April 2009. [Citied 2009 April 17]; Available from URL: http://hcd2.bupa.co.uk/fact_sheets/html/Parkinsons_disease.html
3. Parkinson’s disease society. How many people have Parkinson’s?.[Citied 2009 April 17]; Available from URL:  http://www.parkinsons.org.uk/about-parkinsons/what-is-parkinsons/how-many-people-have-parkinson.aspx
4. Hauser RA, Pahwa R, Lyons KE, McClain T. Parkinson Disease. [Citied 2009 April 17]; Available from URL: http://emedicine.medscape.com/article/1151267-overview
5. H.P.Rang, M.M.Dale, J.M.Ritter, R.J. Flower. 5th ed. Rang and Dales Pharmacology. Neurodegenerative disorders. Churchill Livingstone publications: 2003, p. 497-499.
6. H.P.Rang, M.M.Dale, J.M.Ritter, R.J. Flower. 5th ed. Rang and Dales Pharmacology. Neurodegenerative disorders. Churchill Livingstone publications: 2003, p. 497-499.
7. VHI. Understanding depression. Last updated September 2001, Reviewed March 2005. [Citied 2009 April 17]; Available from URL: http://www.vhi.ie/hfiles/hf-008.jsp
8. National Institute of Mental Health. Depression. Reviewed March 30, 2009. [Citied 2009 April 17]; Available from URL: http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml#pub3
9. Marinus J, Leentjens AF, Visser M, Stiggelbout AM, van Hilten JJ. Evaluation of the hospital anxiety and depression scale in patients with Parkinson’s disease. Clininical Neuropharmacology. 2002 Nov-Dec;25(6):318-24. [Citied 2009 April 17]; Available from URL: http://www.ncbi.nlm.nih.gov/pubmed/12469006
10. The Merck manual of Geriatrics.[Citied 2009 April 17]; Available from URL: http://www.merck.com/mkgr/mmg/tables/33t4.jsp
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Thinking outside the box!

Although this story is popular urban legend in academia, Its lesson is still relevant. You can acquire a lot of knowledge but thinking outside that spectrum is a trait of true genius.

The following is a question on a physics exam at the University of Copenhagen:

“Describe how to determine the height of a skyscraper with a barometer?”

One student replied: “You tie a long piece of string to the neck of the barometer, then lower the barometer from the roof of the skyscraper to the ground. The length of the string plus the length of the barometer will equal the height of the building.”

This highly original answer so incensed the examiner that he failed the student who immediately appealed on the grounds that his answer was indisputably correct.

The university appointed an independent arbiter to decide the case.

The arbiter ruled that the answer was indeed correct, but did not display any noticeable knowledge of physics. It was decided to call the student in and allow him six minutes in which to provide a verbal answer which showed at least a minimal familiarity with the basic principles of physics.

For five minutes the student sat in silence, forehead creased in thought. The arbiter reminded him that time was running out, to which the student replied that he had several extremely relevant answers, but couldn’t make up his mind which to use.

On being advised to hurry up the student replied: “First, you could take the barometer up to the roof of the skyscraper, drop it over the edge, and measure the time it takes to reach the ground. The height of the building can then be worked out from this formula I have worked out for you on my text paper here.”

Then the student added, “But, Sir, I wouldn’t recommend it. Bad luck on the barometer.”

“Another alternative”, offered the student, “is this: If the sun is shining you could measure the height of the barometer,then set it on end and measure the length of its shadow. Then you measure the length of the skyscraper’s shadow, and thereafter it is a simple matter of proportional geometry to work out the height of the skyscraper. On the paper is the formula for that as well.”

“But, Sir, if you wanted to be highly scientific about it, you could tie a short piece of string to the barometer and swing it like a pendulum, first at ground level and then on the roof of the skyscraper. The height is worked out by the difference in a gravitational formula, which I have determined here this time on a long sheet of paper with a very long and complicated calculation.”

“Or, Sir, here’s another way, and not a bad one at all. If the skyscraper has an outside emergency staircase, it would be easier to walk up it and mark off the height of the skyscraper in barometer lengths, then add them up.”

“But if you merely wanted to be very boring and very orthodox about the answer you seem to seek, of course, you could use the barometer to measure the air pressure on the roof, and on the ground, and then convert the difference in millibars into feet to give the height of the building.”

“But since we are constantly being exhorted to exercise independence of mind and apply scientific methods, undoubtedly the best way would be to knock on the janitor’s door and say to him ‘If you would like a nice new barometer, I will give you this one if you tell me the height of this skyscraper’.”

The student was Niels Bohr, the only Dane ever to win the Nobel Prize in physics.