Wyndham House Surgery

“Nothing wrong with my driving but they were all over the road!”

Everyone wants to maximise their chances of remaining healthy for as long as possible. The evidence clearly shows that exercising regularly, eating a balanced diet, not smoking, and controlling blood pressure are all key factors. However, there is another major risk that we often choose to ignore. The chance of having a significant injury due to a road traffic accident is something we accept but we rarely reflect on the fact that this risk increases considerably for drivers over 80 yrs old.

You have to renew your driving license every three years from age 70, however, there is no test that you have to take. There are clear rules about how long you cannot drive after suffering from a heart attack or a stroke. If you have had abdominal surgery the guidance is that you can return to driving once you feel ready to do so and can safely perform an emergency stop. However, there is no set age when a person must legally stop driving. Each of us is personally responsible for making sure that each time we get behind the wheel we are fit to drive the car.

Eyesight gets worse as we get older, either as a natural part of ageing or because we develop an eye disease. Cataracts initially cause problems with night time driving due to distorted glare from oncoming headlights. Glaucoma is an increase pressure within the eyeball that can affect peripheral vision. This is essential for driving and so everyone with glaucoma must inform the DVLA and ensure they attend their Ophthalmology appointments.

Problems with hearing will affect someone’s ability to hear important noises, such as car horns or sirens and is perhaps less recognised as a significant driving risk. Pain and problems with mobility may make it more difficult for someone to use parts of the car such as pulling the handbrake, using the footbrake or moving their head to check their side mirrors. We all recognise that reflexes, coordination and speed of decision making, slow with age and someone with memory problems may get lost, confused or disorientated if they are in an unfamiliar area.

You can continue to drive for as long as you can do so safely and this is where it is important to listen to others as we are very poor at judging how well we drive. A formal assessment is a great way to find out if you are safe to drive or not. The assessments in Devon take place in Marsh Barton Exeter and can be accessed via www.olderdrivers.org.uk (01872 254920).

Almost everyone who decides to stop driving saves money as the cost of running a car is a lot more expensive than using other options. Internet shopping and banking are extremely accessible and our Digital Social Prescriber, Joan Povey, is glad to help anyone who needs assistance setting these up. Our Link-up drivers take patients to the hospital and also bring them to the surgery. Our ‘Bertie’ medication delivery service is available for those with difficulties picking up their medication.

We all have a moral duty to be honest with ourselves about our ability to drive. If you have any doubts then go for an assessment or simply bow out early. It is one of the very few health risk factors over which we have complete control.

Anthony O’Brien

Wyndham House Surgery

It was very exciting to see the Artemis 2 rocket launch into space on 1^st April. Less than 20% of today’s population were old enough to remember the first moon landing in 1969 but Neil Armstrong’s memorable words are known to all. At the time NASA needed an airplane hangar to house all their computers. They cross checked their maths using slide rules. It is a marker of how far technology has advanced in over half a century that the equivalent computing power is now available in a smart phone. The Apollo missions of the 1960s reached their zenith with the first moon landing. There were another 6 landings that followed but the only other remembered event from that era of space travel was the Apollo 13 mission. This is because it went wrong, the story immortalised in the Oscar winning Tom Hanks film. His words ‘Houston, we have a problem’ is probably the second most famous space related quotation. Maybe this is because we like stories that involve challenges; the success of the Apollo missions became too predictable and hence less interesting.

I was wondering whether there are parallels with medicine and how much we have progressed since the 1960s. The most obvious advance is our ability to produce vaccines. The Covid vaccine was manufactured in less than 12 months, light speed compared to the development of vaccines in the 20^th century. Over the last 60 years in the UK, Smallpox, Diptheria and Polio have been eradicated. Deaths from measles, infertility from mumps and pregnancy complications from rubella are not seen, apart from in areas where vaccine uptake is poor. Epiglottis, a fatal childhood condition, has disappeared due to the Haemophilus B vaccine and giving Human Papilloma Virus vaccines to adolescents means Cervical cancer will be a rarity in 50 years time. Shingles, Meningitis, Flu and Covid all cause less morbidity and mortality due to vaccine delivery. This is an impressive list of medical successes, however, just like the moon landings in the 1960s we have come to accept them as routine. Once the initial excitement of a new vaccine launch is over, they only make the news when there is a sensationalist link to possible complications. The news stories always get a lot more prominence than the science would advocate. We are quick to forget that vaccine delivery is the safest and most successful medical intervention we have.

Interest in space has been reignited; we have realised again how amazing it is that we can have conversations from earth with astronauts 250,000 miles away, who are travelling at 25,000 miles per hour, towards and around the moon. Less exciting is the fact that we will be running our first Spring Covid Booster clinic for over 75-year-olds on Wednesday 6^th May. However, this is the continuing part of our mission to ensure Covid does not return.

Anthony O’Brien, Wyndham House Surgery

Sunshine can boost our mood and support vitamin D production, but too much ultraviolet (UV) exposure can cause lasting skin damage. Just one blistering sunburn, particularly during childhood or adolescence, can increase the lifetime risk of melanoma, the most serious form of skin cancer. Repeated sunburn increases that risk further.

UV damage begins before you see or feel a burn. UV radiation stimulates melanin production, causing the skin to tan. A tan is therefore a protective response to UV-induced cellular stress and damage, not a sign that the skin is unharmed. UV radiation, both UVA and UVB can damage DNA in skin cells within minutes of excessive exposure, particularly in very fair skin. Over time, collagen and elastin break down leading to premature skin ageing in people of all skin tones, contributing to wrinkles, sagging and leathery skin although risk levels vary. Time of day, season, altitude and certain medications can also increase sun sensitivity.

UVB mainly affects the skin’s surface (the epidermis), directly damaging DNA and causing inflammation, typically seen as hot, red skin. UVA penetrates deeper into the dermis, generating reactive molecules that can damage DNA, proteins, fats and other cell structures.

The skin can repair much of this damage, but the process is not perfect. If damage is not fully repaired, mutations can accumulate and potentially lead to skin cancer.

There is therefore no completely “healthy tan”. If you want a tanned appearance, sunless self-tanning products avoid the UV exposure associated with sunbathing and sunbeds. However, fake tan does not provide sun protection, so normal sun-safety measures are still essential.

When deciding whether you need protection, check the UV Index rather than the temperature. Cool, breezy or cloudy days can still have high UV levels, with 50–90% of UV radiation potentially penetrating cloud cover. When the UV Index is 3 or above, protect your skin. At extreme levels of 11+, fair skin may begin to burn in as little as 10–15 minutes.

Sunscreen works best as part of a wider approach. Wear lightweight protective clothing where practical, seek shade, and use a broad-spectrum SPF 30 or higher on exposed skin. Most people apply only 25–50% of the recommended amount, greatly reducing the protection they receive. Reapply sunscreen every two hours and after swimming or heavy sweating. A wide-brimmed hat and UV-protective sunglasses provide additional protection.

Although sunburn fades, some molecular damage remains. Skin cells repair much of the damage caused by UV exposure, but the process is not perfect, so cumulative exposure matters.

The key message: enjoy being outdoors but avoid getting burnt. Check the UV Index, seek shade when UV levels are high, cover up where practical and use sunscreen properly. A few simple habits can protect your skin now and reduce the future risk of skin cancer and premature ageing.

We tend to measure our fitness in terms of how far or how quick we can get somewhere; to the shops, up the stairs. We recognise that as we get older we will not achieve the same speed but as long as our numbers do not deteriorate too quickly, we are doing well. The research strongly suggests that we should be thinking differently. If we want to ensure we maintain our ability to function independently for as long as possible we need to concentrate on how well we can squat down, raise our legs and stand still. Training to maintain strength and balance is much more important than anything else.

In older adults, poor muscle strength increases the risk of a fall by 76% and those who have already had a fall are three times more likely to fall again. Strength and balance activities not only help to prevent this, but also help improve your mood, sleeping patterns, increase your energy levels and reduce the risk of an early death.

No matter how old we are we quickly lose muscle strength and function if we become bed bound for even short periods of time. Our core muscle strength and balance abilities are the key factors in how quickly we recover. The Otago Strength and Balance exercise programme is an excellent guide to the types of exercise that are beneficial. There is a link to the programme on our website. The exercises are all designed as daily routines that will help maintain our most important core muscle strength.

Our ability to balance is dependent on the brain integrating information from our eyes, our lower leg joints (especially ankle and feet) and our central balance system, located adjacent to our inner ear. The information coming in has to be very quickly processed and then messages sent out to ensure our muscles coordinate to keep us upright. Aging affects both our muscle strength and brain processing speed and this means our ability to balance deteriorates. However, daily balance exercises can counter the aging process.

Standing on one leg is one of the most difficult challenges we can set ourselves. Standing on one leg with your eyes closed is even harder. The length of time we can do each of these changes as we get older and is a good predictor of life expectancy.  50 year olds should be able to stand on one leg eyes open for 30 – 40 seconds and eyes shut for 10 seconds. These times half by the age of 70 years. However, they can be improved by daily practice and this is well worthwhile as better balance means you are less likely to fall and better able to recover after any illness. Start by practicing daily with something to support you close by.  With time you will improve and before long will be able to brush your teeth in the morning and evening whilst standing on one leg.

The Friends of Wyndham House run both Balance Classes and Tai Chi sessions. There is a lot of evidence that shows attending such classes helps us improve muscle strength, coordination and balance. We should see these exercises in the same way as we would if we were training for a race or practicing a musical instrument.  Small daily routines will pay off in the long term race of life where we want to preserve our independent function through to the finish line.

Anthony O’Brien, Wyndham House Surgery

Placebos and Nocebos

If a doctor gives you a big red pill and tells you it will help the symptoms that you are suffering from there is a significant chance that these symptoms will improve. This is known as the Placebo effect; it is well established but not fully understood.  What we are less aware of is the Nocebo effect.  This is when a widely used medication has adverse publicity about possible side effects. This results in patients being more likely to suffer these side effects than would be expected from the blinded trials where they do not know what medication they are taking.

The Nocebo effect has been clearly demonstrated for statins. These are the drugs we use to reduce your chance of a heart attack or stroke by lowering cholesterol levels. Large numbers of patients decline to take them due to worries about side effects that have been nurtured in the media. However, a recent very large trial has now proved these concerns regarding side effects are unfounded.

Statins are one of the most prescribed medications in the world. Nearly eight million people in the UK take them to lower their cholesterol and in turn reduce the risk of heart attacks and stroke. However, currently up to a fifth of people stop taking them due to side-effects such as muscle aches, fatigue, feeling sick and joint pain. We now have two large trials showing that the Nocebo effect may account for almost all the associated symptoms, as statins only cause significant medical problems in less than 1% of patients.

Cardiovascular disease causes a quarter of all deaths in the UK; controlling blood pressure and lowering cholesterol with statins are the most significant tools we have to reduce risks. The higher your risk, the greater the benefit of taking a statin. Getting older increases your risk of heart disease and stroke. The trials are extremely reassuring for patients to whom we offer statins as they move into the higher risk group; over 70 years old with raised blood pressure.

Both the Placebo and Nocebo effects are real. It is wonderful that patients can feel better after being given a pill which has nothing in it. However, suffering symptoms when taking a pill that has been shown not to cause them is a disadvantage. We can now counter this by explaining to patients that any initial statin related symptoms are very unlikely to be directly related to the biochemical effects of the statin and will almost certainly resolve given time. There is no harm in stopping and then restarting statins a couple of times as this will often speed up the resolution of the symptoms.

If you are a patient who has previously been prescribed a statin but stopped taking it due to side effects then this research strongly suggests it would be worthwhile trying a statin again. It is now very clear that the benefits of this group of drugs far outweigh any risks. Trusting the scientific proof over the media speculation will make an enormous difference to many patients by preventing a very large number of heart attacks and strokes.

Anthony O’Brien, Wyndham House Surgery

The NHS App

Most successful political ideas start as grossly exaggerated aspirations that then over many years adapt, jump through administrative hurdles, get changed due to legal requirements and eventually are most often repackaged by the political party who in opposition opposed the introduction in the first place. However, if the idea is a good one and the aspiration apolitical then often this process does lead to success. The NHS App is an example of this and now is the time to get on board with it.

The idea of universal access to the NHS via smartphones started in 2018. The technology stuttered for many years and it was not until 2021 that the App had its first measurable success providing digital Covid passports for anyone travelling abroad. It has continued to slowly develop to the point that it now interacts seamlessly with GP computer systems. This means you can book appointments, see test results and view your medical record via the App. Understandably to set it up on your phone you do need to go through a procedure to prove your identity. This is reassuringly comprehensive but relatively quick, a strong testament to how much potential the App has.

We have therefore now reached the point where the current Health Secretary, Wes Streeting, is strongly promoting the App, making it one of the cornerstones of his 10 Year Plan for the NHS. GP practices are encouraging patients to download the App and register, however, so far not many patients are using it.

In Devon we are fortunate that RDUH is one of the leaders in Secondary Care electronic communication, adopting the MyCare system in 2021. Many patients will have experience of using the MyCare App to look at their hospital records and results. Although it does not directly link with the NHS App yet, almost all of the information is available via both Apps. If you need any help setting them up on your phone then please contact Joan Povey, our Digital Social Prescriber on 07958 190554, leave a message and arrange to meet her or drop in to Silverton Room4U on a Thursday  9.30 – 10.30.

Both the NHS App and MyCare combine well with the systems we have in place at Wyndham House. Our computer system now automatically texts patients when their medication is ready and this year’s Flu vaccine appointments were almost all booked using our on-line system. Sending an email via our website is also an excellent way of dealing with any administrative queries or tasks e.g. updating a medical certificate. However, for any clinical questions we think it is still much more efficient to ring and make an appointment with one of the GPs, either face-to-face or telephone, according to the circumstances.

Anthony O’Brien

Wyndham House Surgery

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Best things come in small packages

We are all keen to take a look under the tree to see what presents have our name on them.  Big ones and small ones are undoubtedly the most interesting. Among the small packages this year will be a large number of multi-functional watches that are able to check your pulse, your blood pressure, your oxygen levels and record your daily amount of exercise. They all come with targets and alarms about what you should be achieving.

However, there are no ‘shoulds’ in medicine. We are all individuals and what might be sensible for one person may be unachievable for someone else. The aim of all medical care is either to cure or optimise our risks of illness.  It is difficult to prevent all disease as the biggest factor in almost all cases are the genes you inherit. Luck is something we cannot control.  We are able to very significantly reduce our risks of lung cancer and heart disease by not smoking but this is the only intervention that makes an enormous difference to the statistics.  All other changes in behaviour are valuable but how much difference they make depends on the context. The analogy I use in consultations is comparing the difference in risks for someone driving a car or a motorbike. We are all comfortable driving cars without wearing crash helmets or protective clothing. However, we would not dream of getting on a motorbike without these on. Patients who have diabetes are at increased risk of heart attack and strokes in the same way that the motorcyclist is at increased risk of crashing.  Blood pressure medication and statins are the equivalent of the helmet and leathers. The same is true for anyone who has already suffered a cardiovascular event. So, what is the best blood pressure and lipid level for those at higher risk? The simple answer to this question is the lowest that causes no problems.  We titrate medications so that they are the optimal dose ie best readings with no side effects. This will be different for each individual.

The optimal amount of exercise is more complicated. Walking some distance every day is undoubtedly beneficial for our bones and joints. Taking some medication prior to exercise if needed is sensible. I have written many times about the enormous mental health benefits of being outside and interacting with nature; there is no optimal number of steps required to take advantage of this. However, cardiovascular health can be improved with short strenuous exercise. The research shows this is surprisingly short.  Raising your heart rate with 1 minute of vigorous exercise everyday has a significant effect. What you need to do to achieve this will vary with age; short sprint for the younger, fast power walk for the older. The aim is to have 60 seconds of effort a day.  As always not too much to cause side effects but sufficient to feel you have done something. A small package of time that will deliver large benefits; no electronic devices or large pieces of exercise equipment required.

Wishing everyone a very Happy Christmas from the Wyndham House Team

Natural Healing

It takes many years to learn a language or play a musical instrument with skill. 10,000 hours is the oft quoted amount of time you have to dedicate to become a consummate Olympic athlete. When you do the maths, this is a number of hours per day over a number of years that is unimaginable for everyone other than those with the evident talent at a young age. However, underlying all these pursuits lies the same formula.  Daily routines and practice. Few of us harbour the talent or the realistic desire to win Gold medals, however, we all have the potential to adopt regular short, simple daily activities that we will benefit from.

A recent study was published reiterating the benefits of regularly interacting with nature. Being outdoors can trigger measurable changes inside your body from lowering stress hormones, easing blood pressure and even improving your gut health. We think the reason for these positive body system responses is due to our autonomic nervous system; a network of nerves controlling unconscious processes. During our early life it learns to respond to stimuli associated with relaxation and recuperation. We are all aware of our flight/flight reflex that occurs the instant we feel danger. This is controlled by our peripheral nervous system and has evolved from when we were monkeys. Adrenaline pumps around the body, our heart races, our breathing rate increases, blood is diverted to our muscles as we prepare to defend ourselves. The autonomic system response is exactly the opposite: lowering blood pressure, dropping our pulse rate, relaxing all of our bodily systems.

Stimuli that we associate with feeling safe will trigger the autonomic nervous system.  Green spaces, birdsong, smell of citrus oils have all been shown to bring about these responses.  It is not surprising that putting our bodies in their ‘resting, safe, stand-by’ mode regularly during the day is of benefit to both our physical and mental well-being.  Our immune system is also bolstered, the theory being that it has time to re-energise.  Studies have shown that our virus fighting ability is increased by 25% after an extended periods in nature.

You don’t have to hike for hours to benefit from exposure to nature as maximum impact happens after just 20 minutes. So, a lunchtime walk to the park and then a sandwich on a bench or in your garden a few times a week will suffice. A diffuser producing the smell of a pine forest can make you calmer within just 90 seconds and that effect lasts for about 10 minutes. Flowers such as white or yellow roses have been shown to create the greatest calming effect on brain activity. Research has also confirmed that pictures of nature as your screensaver can trigger the same calming brainwave changes and reduce stress.

So simple, short and regular relaxing stimuli can be just as healthy as regular visits to the gym. Turning on our autonomic nervous system every day is easy if we set up our environment and our routines to give it a regular and repetitive workout.

Anthony O’Brien

Coughs and sneezes spread diseases

Prior to the Covid pandemic all preparations for how to deal with a rapidly spreading life threatening infection were focused on influenza. The public health campaign in the first 6 months of the 2020 pandemic concentrated on how flu spreads with the slogans: Catch it, kill it bin it and advice to wash our hands whilst singing Happy Birthday. However, as we learnt more about Covid the emphasis changed to social distancing. Over the last 2 years Covid is becoming much more like flu in its pattern of symptoms and the way it spreads. Currently there is a danger that we are becoming complacent about Covid and can be falsely reassured by tests that are not as good as we think.

Covid tests have never been that good as the test depends on how well the sample is taken and none of us are very good with sticking swabs up our own noses. The test does have a very high specificity rating; this means if it is positive then you definitely have Covid. However, the sensitivity of a test is much more important and, unfortunately, Covid tests have never scored well. The test will miss maybe 1 in 3 of all positive cases (more if the sample is not taken optimally). These are the reasons why towards the end of the pandemic, as restrictions were lifted, the health advice was to pay more attention to symptoms rather than the tests.

As we enter the winter months both Covid and Flu will become more prevalent. Vaccination is very important to protect ourselves and others but it is even more important to pay attention to your symptoms. If you have viral symptoms and a temperature, please isolate yourself. Whilst a positive test confirms Covid, a negative test does not mean you have not got it. The evidence strongly encourages any patients with Covid-like symptoms to not do any testing; stay at home, reduce contacts, keep your distance and wait for symptoms to resolve. The title of this article was first used as a health slogan in the United States during the influenza pandemic that occurred after the First World War. It still holds today as a more modern variant – this winter make sure you keep your symptoms to yourself.

Our flu clinics are running on Friday 3^rd & Saturday 4^th October with Covid vaccines available at the same time for those eligible (patients over 75 years and those who are immunosuppressed). We will be running catch up clinics for patients who could not get to these clinics; we will send out information about these later this month.

Anthony O’Brien

Wyndham House Surgery