Acupuncture has been suggested as a form of treatment to induce labor in particular in those women who are past their delivery date. There were some reports of it being effective but the question was would the woman have gone into labor anyway.

We now have a proper controlled study from Australia which looked at this problem and recruited 364 women into the study and divided into those receiving acupuncture and the other group watchful waiting. The group receiving acupuncture had the procedure done on two consecutive days.I am afraid there was no benefit to those having acupuncture. Both sets of women had the same outcome ie. the same number in each group required their membranes to be ruptured or required prostaglandin induction to get them into labor. Also there was no difference in the time to delivery of either group.

Good study and at last an answer to a recurrent question albeit negative for acupuncture.

Choose and book has been part of the cornerstone of new changes in General Practice whereby you have an option to choose one of four hospitals you can visit to sort out your complaint. Furthermore it gives you the chance to book an appointment which is convenient to you.

How does it work in reality.

One ENT Hopsital in London decided to look at their attendances since the introduction of Choose and Book and compared the Traditional referral done by letter to the Consultant and the referrals made by Choose and Book. They found that attendances were higher in the traditional way compared to choose and book. Non attendances were 18% choose and book and 12% via GP referral system. Another study has found that most patients are not experiencing a significant choice in appointment time, date or hospital as well.

Their conclusion is Choose and Book has failed to achieve its goal of improving patient satisfaction and attendance at outpatient clinics. This leads to unnecessary extra cost to the NHS that this system has to be implemented but also jeopardises the process whereby Consultants were able to decide which patients ought to be seen urgently rather than on a waiting list.

I knew the NHS was improving! There are other reasons why this system is failing and will be tackled in another article.

Several patients complain of the inability to get a good nights sleep. Once anxiety and depression have been excluded most patients ask for hypnotic or sedative drugs such as Temazepam or Zimovane (zopiclone).

If you are unhappy taking these chemical products then help is now at hand with more natural remedies.

Melatonin, a hormone released by the brain in response to the dark has been used to successfully treat patients suffering from jet lag. However, recent evidence suggests that it can help you sleep naturally, especially if taken 1 - 2 hours before bedtime. The dose required is 2-10mg at night. Melatonin can now be prescribed on the NHS. The name of the melatonin that can be prescribed is Circadin and comes in 2mg doses. Alternatively other preparations are available if you are not able to obtain this on prescription.

The beauty of this product is that it augments your own natural sleep hormone and has no side effects even in large doses and can also be prscribed for children. So if you are not sleeping then try Melatonin.

Interestingly another natural product Valerian in the same studies analysed failed to be of benefit in many patients with sleeplessness and cannot be recommended.

The answer to the above question  appears to be probably no as it seems that taking these drugs does not appear to both reduce mortality or affect the incidence of heart disease in women. This stems from a study on 11,000 women treated with statins for 5 years. These were women who had no evidence of cardiac or peripheral vessel disease at the time they were put on statins. This would be in keeping with the the majority of women patients in Genearl Practice that are prescribed these drugs.

Before we say categorically that statins have no use in this group we should look at two other studies involving women.

The first is the so called 4S study done in Scandinavia. These were women who had evidence of cardiac disease in association with raised cholesterol levels. Over the study period of 5 years, 4 more women were alive taking statins than the group taking a dummy tablet involving a total of 4500 patients. However to put this into perspective 100 women would need to be treated with a statin for 6 years to prevent one death from heart disease.

Another study the Heart Protection Study on 5000 women with evidence of  heart disease ie angina or previous surgery for blocked arteries to the heart, peripheral vessel disease or diabetes did show protection with statins. The patients on statins  developed fewer heart attacks and required less further surgery for their blocked arteries than those on dummy tablets but mortality was only reduced marginally. The study showed that if you treated 2500 women for 5 years that it delayed death in only 36 patients. However if you want to put it more simply, in this high risk group 30 years of taking statins would  increase your life exspectancy by only 1 month.

The above articles have led people to question whether we should be giving statins to women at all in view of the fact that overrall mortality is not significantly reduced by those taking these drugs. These drugs have side effects, cost the NHS money but also tie up a lot of GP and nursing time monitoring patients especially blood tests to see if chlosterol has been reduced. The argument against their use is that these resources and money could be better spent improving the quality of life of individuals say with arthritis of their hips/ knees by increasing joint replacement surgery or even surgery for cataracts etc. All these would improve the quality of life with thses disabilities.

This begs the question is longevity of life  better than quality of life. You decide.

Coproxamol, since Januay 2008, can now only be prescribed on a named patient basis only.

Named patient basis prescribing is a scheme which allows a doctor to prescribe an unlicensed drug to a particular `named patient'. It is only an option for drugs whose manufacturer is prepared to release it on this basis, and has to be arranged by the doctor on an individual basis.

The next step is for your doctor to find out what conditions are attached to the use of the drug. In the case of coproxamol it would mean that other analgesics have either been ineffective or have caused side effects that prevent further prescribing.The drug company may require you to have passed certain medical tests before providing the drug, in order to avoid damaging side-effects.

The doctor must inform the patient that the drug has unproven benefits ( in the case of coproxamol evidence suggests that it is no better at controlling pain than paracetamol ) and that there are known risks attached to the use of the drug ie. if taken in an overdose that it is more dangerous than paracetamol. This protects a doctor against liability. A GP can only be proved liable if he/she has not taken reasonable steps to treat you according to his/her experience and knowledge of the particular illness. This distributes the responsibility between you and your doctor when choosing this therapy, but doesn't protect the doctor against incompetence.

So yes your GP can still prescribe the drug for you especially as there is some evidence that dextropropoxyphene has some analgesic properties that work differently to codeine based products. Keep asking if this is the only analgesic that works for you.

The prostate cancer test is for PCA3 which is elevated only in cancerous prostatic tissue and is also named the Progensa test.

This new prostate cancer test that has recently been developed is better than the current PSA test which is elevated in some benign conditions as well as in patients with prostate cancer. In men with enlarged prostates the PSA level can rise leading to a possible diagnosis of cancer. Very often these men have to undergo a prostatic biopsy. PCA3 levels weres not associated with enlarged prostate glands unlike the PSA test. Also as the level pf PCA3 rose so did the likelihood of a diagnosis of prostate cancer. In men with levels over 100,  69% men had a positive prostatic biopsy for cancer. 

This  test offers an alternative to painful prostatic biopsies which sometimes miss the cancer. Only those patients with a positive PCA 3 test will now need to undergo prostatic biopsies.

The test is expensive at around £200 but its value may be in targetting those patients that have a strong family history of prostatic cancer or an abnormal prostate gland on rectal examination.

The above question is often asked by patients.  But is there an easy way of finding out how many puffs are roughly left in an inhaler?

Well the answer is yes. 

Get a bowl of water. Take the inhaler canister out of its plastic coating be it blue, brown, green or orange and place the inhaler in the bowl of water as per diagram. The inhaler will now float in a number of ways as shown in the diagram demontrating the rough number of puffs left in your inhaler so you know when to renew your prescription.

Under the new guidelines to GP's all patients over 75 are being given statins to prevent them having heart attacks or strokes, especially if they suffer from dIabetes, have hypertension or suffer from heart disease. The question that needs to be answered is, does this prolong their lives?

Answer is I'm afraid-NO. A study with over 5000 patients were either given a statin or nothing at all to reduce their cholesterol and then followed up for several years. Overrall the statins did prevent some heart attacks over this period but to do this 48 patients needed to be treated to prevent a heart attack. What was worse was that this only applied to men and not women ie. women taking these drugs had no benefit whatsoever.

What is even more depressing is that both groups lived the same amount of time ie. the statins did not increase your life expectancy. Finally even more depressing was the fact that those taking the statins died of cancer more than those not taking the statins. This does not mean that the statins gave you cancer, although this is not ruled out, but that instead of having your heart attack and dying you developed cancer instead and died.

What does this all mean

• Statins in over 75's does not prolong  life expectancy
• Statins may prevent some heart attacks in men but not in women but at the expense that you then died of cancer

The question then is should we stop wasting vast amounts of money giving statins to over 75's as well as the vast amount of medical time wasted in monitoring and prescribing these drugs?

The answer is yours to make but money like this could be put to better use by improving the quality of life of the elderly by providing better hearing aids, more cataract surgery as well as joint replacements because we know that these do improve a patients life although not prolong it! What is more important?

There is now increasing evidence that Vitamin-D prevents the development of both breast and colon cancer. Two studies looked at Vitamin-D levels in healthy people and then followed them up for up to 25 years.

In the Breast cancer study 1760 patients were studied and those with the lowest levels of Vitamin-D were more likely to develop breast cancer. They were able to calculate that by taking in 2000 international units of Vitamin-D per day was able to give you a 50% reduction in developing breast cancer. To obtain the 2000 units of Vitamin-D / day they calculated you would need to spend at least 15 minutes in the sun / day. To ingest this quantity of Vitamin-D / day was difficult as there are only 400 units in a pint of milk although oily fish has a high content. It was suggested that you may need to take vitamin-D supplements to reach this level of intake if you were not able to get out in the sun.

In the Colon cancer study 1448 patients were studied and followed-up for up to 25 years. Again by taking 2000 units of Vitamin-D / day they calculated that colon cancer was reduced by 66% in the patients studied.

In summary you need to take 2000 units Vitamin-D / day which needs to be obtained by using a combination of means such as going out in the sun for 15 minutes / day and ingesting food known to be rich in Vitamin-D such as dairy produce and oily fish. If either of these cannot be achieved adequately then a Vitamin-D supplement needs to be taken daily.

Many patients with sciatica that is not resonding to therapy such as physiotherapy are or can be offered an epidural steroid injection into the back to not only help their pain but also prevent surgery.

Does it work? The simple answer is NO unfortunately.

Over 200 patients with sciatica not resonding to therapy were divided into 2 groups those that had an epidural with steroid and those that just had an injection in their back. Even at 3 weeks post injection only 13% of patients in the steroid group had responded as opposed to 4% in the salt injection group. When you analysed the patients from 3 months onwards there was no difference between them. The more worrying thing was that at 1 year only 33% or 1 in 3 patients were 75% better in either group.

What does this mean. I have never understood how a steroid injection can relieve sciatica when the disc prolapse is obviously pressing on the nerve. I have also never understood why surgeons do not operate early on these patients when with keyhole surgery they claim to obtain 90% patients get complete relief from sciatica.

What this study shows is that unless you begin to get relief from sciatica within 3- 6 months then it is unlikely you will get any further improvemennt in pain relief and maybe we ought to be more forceful in saying to neurosurgeons  get keyholing on my back and stop sticking needles into my spine!

Update May 2007

American Doctors have now come to a definite decision on the use of epidurals in patients with back pain in association with sciatica. They have concluded after looking at many scientific studies that they may improve pain only for two to six weeks after the epidural has been given. After this period no benefit was seen in terms of pain, day to day activity and the subsequent need for surgery to relieve the sciatica pain described above.

By the way they also found that epidurals carried a risk of infection and non-infectious meningitis in some patients. My thoughts on this have been outlined above and now have been strengthened. So patients you have now been told so act accordingly when offered this procedure.

Heavy periods are a common problem in women over the age of forty and many ask for advice on how best to treat this condition. Very often contraception or treatment for irregular bleeding need to be considered when treating this condtion. The following is a summary of treatments that can help this problem:

• Ibuprofen (nurofen) or mefanamic acid (ponstan) Both these drugs are non steroidal anti-inflammatory drugs and can reduce blood loss by up to 30%. The drugs need to be started at the start of menstruation and continued until menstruation finished. 
• Tranexamic acid This is a drug that can also reduce up to 30% blood loss at the time of a period. It works by increasing the clotting ability in the uterus so that blood loss from blood vessels in the uterus is reduced. This drug needs to be taken for the duration of menstruation only.
• Combined contraceptive pill This pill has been shown to reduce the amount of bleeding in both young and older patients with heavy periods. This method is also useful in patients that have irregular as well as heavy menstruation in that it lengthens the time between periods to approximately 28 days and can also be useful in patients that require contraception.
• Depot progesterone injection This is a hormonal form of contraception using a progesterone type compound.This can be given either by injection (every 3 months) or as an implant (Implanon) every 3 years. This works by flattening the lining of the womb such that periods disappear or are reduced to a trickle each month either as a small bleed or as spotting of blood. This can be useful for those patients that have irregular bleeding or need contraception as well as reducing blood loss.
• Mirena coil This coil has some progesterone hormone on it and reduces blood loss by the same action as the depot injection above. This device has reduced the need for hysterectomy in a large number of patients with heavy periods.The device needs to be changed every 5 years.
• Norethisterone This is also a progesterone type hormone but really is useful for irregular periods. Unless it is taken for at least 21 of the 28 days of the menstual cycle it does not reduce blood loss.

Recent evidence suggests that men who develop erectile problems may also have underlying heart disease.

We all know that men who develop erectile problems have an underlying blood supply problem to their attachment. Now we have evidence that this could be a signal that they also have blood supply problems to their heart.  How do we know this? Well when patients who had undergone angiography to the heart were then questioned about erectile problems it appeared that up to 22% men who had one vessel blocked had erection difficulties. However if they had two vessel disease 55% men had erection problems but with 3 vessel disease a massive 66% had erectile dysfunction.

In those with angina and diagnosed with blocked arteries by angiography it was shown that these same men had erection problems upto 2-3 years before they developed their angina and chest pain.

The take home message from this study is that all men who develop erection problems should see their doctor and have a blood pressure check, and diabetes and cholesterol check. If they are smoking they should stop and if overweight lose some. If you have any of these risk factors you may require an exercise ECG to exclude any silent blocking of your arteries. Erection problems are an early warning sign. So men do not lose the opportunity to do something about it otherwise heaven may beckon you before your time.

To quote from an eminent Cardiologist "Just as there is more to sex than an erect penis, there is more to erection problem prevention than simply restoring an erection.”