Friday, July 07, 2006

Do not adjust your set....

I may have to apologise to my old friend the controller of Radio Four. Regular readers (bless you all) may recall a running spat I had with Radio Four, and particularly the Today Programme, a few months ago. They appeared to have taken over the collective consciousness of the citizens of Borsetshire so that every little health problem mentioned over the airwaves immediately presented to me in surgery, and without any of thos affected having heard the news reports in question. Well after yesterday it appears it might have been me all along. Apparently I have psychic powers verging on the supernatural. I've thought it through and it's the only explanation that makes any sense...

I'm feeling your skepticism here, but once I have recounted the events that follow, I am sure that even you, gentle reader, will be convinced of my newfound ability.

Oh yes you will!

*teeters precariously on the brink of Panto before pulling us back to relative sanity*

There, glad that's all behind me....

*somewhere off in the distance the screams of hundreds of children all frantically pointing- only to be ignored*

It all begins, as so many of these posts do, with the drive in to work. I like the drive. Leafy lanes, thrashy music, and time for thinking. The kids have been left behind at school, the mobile is either off or inaudible (Jethro Tull's "Aqualung" at eleven on the car stereo), so there are few distractions (sheep and pigeons excepted).

This particular drive in I am pondering asthma. And it strikes me that the past decade or so has seen the presentation of asthma change quite a bit. The condition remains the same, i.e. cough and / or wheeze depending on age. What appears to have changed is the number and frequency of acute exacerbations. In the good old days we used to just have two broad treatments to offer, relievers (like Ventolin) that relieved wheeze quickly only to wear off after about 4 hours, and preventers (steroids like Becotide) that reduced the severity of attacks and helped prevent them in the longer term.

But, preventers need to be used all the time, and the inhalers are not nice to take, often being quite "peppery" on the tongue. Worse still they have sife effects -- sore tongue and hoarse voice, and they are "steroids" which in may people's books make them nasty. Especially when their use, and indeed the use of the relievers, is banned in certain compettetive sports unless you have a "note from the doctor". Add to that the fact that most of our new asthmatics tend to be children, so we are asking mums and dads to give their little darlings something with all the appeal of nerve gas, and it's no wonder preventers meet with a degree of resistance.

In the past this led to significant under treatment and fairly frequent exacerbations. Especially when there were lots of viral coughs about or the air was very cold / hot / polluted. During these episodes, surgeries would be full of wheezy, coughy people all queueing up for a "go" on the nebulizer- a wizzo machine that makes an aerosol of medication that you can breathe, spaceman-like, through a mask. This is a huge hit with the seven to twelve year olds, a source of terrour to the pre-schoolers, and a monumental pain in the wossname to the rest of us. But it does help turn around exacerbations. That and bucketfuls of steroid tablets.

Anyways, in the past few tears other inhalers and pills have become available that bridge the gap between prevention and relief. These (drugs like Salmeterol and Montelukast) have made a big difference to tolerability of treatment and symptom control. This has meant we have seen fewer severe exacerbations and our nebuliser instead of seeing constant use has been relegated to a hidey hole under the sterilizer most of the time.

Back in the car Jethro Tull have moved on to the Dambusters march* as I am musing that we seldom seem to need the nebuliser anymore. So guess what I had to do for three patients yesterday morning....

So there you have it. Convincing proof I think you'll find the power of my immense intellect to forsee the future and influence human behaviour. Now if only I could put it to good use.

So go on. How many of you are now thinking about chocolate digestives then eh?

*name that album for a bonus point.

12 comments:

Z said...

It just so happens that at about twenty past four I had a strange urge (given in to, of course) to eat a chocolate digestive.

I am a bit afraid of you. Can you think positive thoughts for a while, please? - as I feel quite well and would like to
remain so.

Geena said...
This comment has been removed by a blog administrator.
Dizzy said...

Bursting Out, CD2, is that two bonus points?

Good old Amazon...

Yup, your too good, just thinking about those chocolate digestives....

Shinga said...

We've had a heat-wave that makes us hotter than Brazil, it has been unbearably muggy during the night near London, there have been smog alerts and you have only now had people popping up in need of the nebuliser? Kudos for how well your asthma/COPD self-management plans are working for your patients.

Regards - Shinga

PS Chocolate digestives? Depends on your definition, my husband is a chocolate Hobnobs fan - plain or milk, he's not fussed.

Doctor Jest said...

Sorry all. Not been on the net til now...

Z-- positive waves en route. (And hob nobs apparently).

Geena-- Hi, and bye. No need to run away, honest. Hope it's not being too scary right now. Chin (and bottoms) up! And why not have a hob nob or suitable gallic equivalent. Best if it contains a big thick layer of chocolate somewhere about its person tho'. (oh, and in answer to your final, retracted, question... I think he was an Orc in Return of the King. HTH)

Dizzy-- I'm impressed, but can't help thinking you might have a little too much time on you hands. Have a packet of hobnobs on the house...

Shinga-- thanks for that. Of course Borsetshire is leafy so no real smog issues here, but till today it was bleepin' hot.

Oh, and hob nobs work for me too (as evidenced above). I think I could grow to like Mr Z;-)

Calamity Tat said...

How I miss hobnobs....and hobnobbing...

Geena said...

The Gallic equivalent of hobnobs (which I have enjoyed on past occasions, to be sure) is, in fact, far far better than anything you can imagine....

a large, humungous slab of Cote d'Or milk chocolate..which has been consumed and heartily enjoyed.

Nothing like a bit of cocoa for an uplift. Unless of course you're into hang-gliding and find a jolly good thermal.



*bottom facing the ceiling*

Shinga said...

My husband would like me to point out that he firmly believes that chocolate Hobnobs and Choco-Leibnitz are both forces for good.

On a different topic, given that GPs seem to have been inundated with concerned phone calls after the coverage of the NICE guidelines and beta-blockers - did you get any blowback from the Salpeter meta-analyses, the first on LABAs and the second on COPD medications (crudely characterised as anticholinergics are safer than bronchodilators but the former account for only 5% of the prescriptions)? Or do people not fret about their breathing and medications the way that they do about their heart and meds?

Regards - Shinga

Z said...

Mm, hobnobs. Chocolate hobnobs.
Thank you very much DrJ, I've had a superb weekend and it's all due to you.

euro-trac said...

It's a miracle!

I'm thinking chilled white wine and guess what?

I'm off to my fridge right now!

Hello by the way...

p.s listening to Jethro Tull whilst driving can be very dangerous as sometimes it can cause an overwhelming desire to play the flute whilst standing on on leg!

euro-trac said...

That's supposed to say 'on one leg!' obviously!

I hope you drive an automatic!

Doctor Jest said...

Calam'-- commiserations :-(

Geena-- welcome back. Hmm, Cote d'Or logged for future reference. Methinks I have seen them making a stab at the UK market lately, will keep my eyes peeled.

Pro'lly not built for hang-gliding. Don't mind Balooning tho'.

*lovely view ;-)*

Shinga-- Of course I confuzzled myself last time. I meant to say I could grow to like Mr S. The thought stands.

Getting serious for a mo' the Atenolol thing hasn't really hit us yet (though the CHD team might be feeling it, I must ask them.... ) Interestingly the Salpeter metanalysis made no impact here at all. I must say I am reluctant to put too much trust in metanalases. More often than not they are trying to compare apples, oranges and aardvarks. What we really need are good prospective analyses but there isn't, I suspect, enough money in the respiratory market for the Multinationals to be interested. FWIW I'm a big fan of anticholinergics myself, but equally of LABAs. It is very likely that Salpeter has extrapolated a step farther than is appropriate. In well educated patients with good supervision I doubt there is any significant increase in risk with LABA.

In brittle asthmatics with poor eductaion and limited access to healthcare the risks are everpresent. In such cases reaching for LABA is a clutch at straws. Given their morbidity any improvement might well be worth the purported "one extra death per thousand years of use" LABA might represent.

z-- glad to hear it. Ours wasn't bad either.

e-t-- welcome. No worries. More of a steering wheel bongo man myself. I may need to issue a public health warning now though. You've only got me thinking of chilled white wine before the sun has cleared the yardarm... oh well...