The beauty of disagreement

If this skepticism lark has taught me anything, its that disagreeing is a beautiful thing. Disagreeing with someone is a hard thing to do, in any context. Yet as humans, health care professionals, and as skeptics, its one of our keenest tools. Its only by being able to step into disagreement that we can understand our topic, our audience, and hopefully steer hearts and minds away from those willing to mislead.

I recently attended a panel about daring to disagree, which mainly focused on religious debates over Twitter and the like. I'm guilty of wiling away hours of my life arguing with homeopaths over twitter, and I'm often asked why, as I'm never going to change their minds. The short, and most noble answer is that someone undecided might spectate, and I might be able to make some impact into how they think about the subject. The more self-serving version is that its good practice to hone my skills in identifying fallacies and flaws, finding workarounds and ways of wording things, and to understand an argument in advance of the next time. In these types of arguments, the people who you are speaking to are removed from yourself, perhaps not anonymous as such but they tend to be used to arguing. Their position is usually on the defensive in the first place because their chosen subject has usually been the butt of skeptical inquiry for years.

But what of those closer to home? Sticking out heads up above the parapet in other situations is one of the hardest things in life to do. Most of us instinctively see disagreement as a threat and a personal attack, and we react accordingly. Even now, despite all I've learnt about constructing arguments and debates, with all of this practice, I certainly still get physical reactions when someone disagrees with me. My heart will pound, my mouth with become dry, and I'll want to curl up in fear because my body and brain immediately leap to the conclusion that no one likes me, that I'm so insignificant that I must automatically be wrong. I'm thankful to skepticism in that I'm able to take a deep breath and overcome those initial few moments, then can try to reassess my position. Am I actually right, but there are some good points to take away from the other stance? Or actually, is my reasoning flawed? In which case, why? Where could I have found more information, what is the other person bringing to it? Whichever way it goes, I, and the other person, end up learning more. Ultimately, we're not here to be right or wrong- we're hear to learn more, and that's the important bit.

Problems arise though because often our instincts take hold. I can't describe the number of times its all gone tits up. I can spend ages agonising over whether or not to disagree. Once I've decided to do so, I write and rewrite my argument so that it is as objective as possible, structured clearly, evidence based etc., only to have the response be “Eurgh why are you being so mean?! I thought we were friends!” or similar. I've tried all sorts of ways to word things, and I haven't quite come up with an answer on how best to avoid this response. Its not just Facebook etc. where this is a problem- we all hear in the news about irrevocable breakdowns in the doctor-patient relationship (Ashya King, as an example). We've all encountered the patient at the pharmacy counter who believes a random person waiting in the queue over our own expert advice. No one learns anything from these sort of exchanges, and that's a real missed opportunity.

So the question is, how do we go about promoting disagreement as a positive thing that we all need in our lives? How do we turn the tables on the thousands of years of evolution that make us shut down arguments as soon as they begin? Well I think the answer has to initially come from example. I believe the skeptical movement is extremely well placed to start this tidal change in thought, but we all have to practise the heck out of it every single day if we're ever going to get anywhere. We have to start being known synonymously as folk who are really, really good at disagreeing respectfully, and that has to start from within. Its clear that the skeptical community in the UK and beyond occasionally falls short in this regard, and that's a real shame as it appears to be driving good people away.

We need to recognise that we might agree with someone on one thing, but not the other. We can't see a person as synonymous with one of their opinions, and put people in good or bad boxes based on that. We shouldn't be labelling people as anti-this, or anti-that, and then refusing to engage further. We should be experts at digging deeper than that, looking behind the headlines to search for shared humanity underneath. We need to lead the way in disagreeing without bullying, and we should never, ever let up on that. We put ourselves in a position that could so easily be mashed up together with bullying by the general population when we dare to disagree, and we need to be relentlessly exemplary in our behaviour to prove that we aren't. We need to be the type of people who, even if faced with a mutant hybrid of Nigel Farage and Piers Morgan, would manage to keep their cool and be polite.

But then again, feel free to disagree ;)

Hxxx

"I do my own research"

Something that I see a lot in on-line debates about alternative medicine is phrases like “I did my own research” or “people should be allowed to do their own research and make their own decisions”

However, I don’t think that the vast majority of people are able to do their own research. Now, that’s probably a pretty unpopular opinion. It’s patronising, paternalistic, and it flies in the face of patient choice. Who am I to question the intelligence and abilities of other people? Why do I think I'm so clever compared to anyone else out there? Allow me to explain myself.

I've been a pharmacist for a very long time now. From uni, through pre-reg, to my own revision at work, I've been taught critical appraisal skills. Yet to this day, it’s something that I actually find really hard work. It’s a skill that requires continual honing, and every time I use it I feel like I am fighting with my brain.

Even in the last two weeks, I've been revisiting my critical appraisal skills to make sure they are up to date. I've done some in-house work, three on-line courses, and a one to one training session. Yet I still find myself sat here at my desk for several hours, if not days, looking over the same study with a furrowed brow, desperately trying to make the numbers and statistics tell me their story.

There’s hazard ratios, odds ratios, confidence intervals, numbers needed to treat, event rates, absolute risks and other confuddling terms to deal with. I naturally struggle with numbers at the best of times; like most people, I much prefer narratives. That means that I have to constantly argue with myself to keep looking at the results page, rather than just flicking to the discussion. Becasue if I did that, I'd be relying on what the authors, with all of their possible biases and agendas, say their numbers say. Then, when I eventually manage to squeeze the swimming mass of figures into some sort of order in my head, I find out that these numbers aren't the full story, and I need to dig even deeper into other analyses of the same figures to find out what’s really going on.*  

A quick and very simplistic visualisation of all the layers of interpretation that might lead to information found on your common or garden health information website. That's a whole lot of bias. 

I am truly terrible at MS paint, but you get the idea. 

What a typical EMBASE search looks like. This is for a new drug with few synonyms so its a fairly straightforward one. Others can have forty odd lines of searches. 

It’s not a pleasant task by any stretch of the imagination. It really does feel like a mental marathon. I often question whether I am even up to the task- I can end up feeling stupid, and confused. But in order to really figure out whether or not a drug works I need to strip away all the levels of other peoples’ interpretation and start from scratch, with the cold, hard, impersonal numbers. That way I can build my own narrative, uninfluenced by what the study’s authors or sponsors want me to think, by what newspapers want me to believe, by what campaigners want me to know. The only way to know the truth is to start right at the bottom, in a dark dank pit of statistics, then to slowly start building yourself a ladder until you emerge, blinking, into the pleasant knowledge that you've worked out what on earth is going on.

This sort of raw data is not only extremely hard to deal with once it’s in front of you, but its also pretty difficult to come by. Finding it in the first place includes searching multiple medical databases- and these things aren't just a quick free text search like you would do on Google. Constructing a search can in itself take an hour or so, and then you have to trawl through the results to decide which are relevant to what you are specifically looking for. For me, most of the time, a question is structured like this:

What is the evidence that [drug/ group of drugs] works for [disease] in [patient group]?

                                                        

So, in my poorly drawn Venn diagram below, I need to find those holy grail papers that reside in the pink area:

Some of these papers might be pay-walled, so it’ll take me a week or so to get my hands on them. Some of them might initially look promising, but once you start to dig down into the figures you see that there might actually be problems with how they were undertaken or reported, or they might turn out to not quite fit in some way- perhaps the dose they used in the trial is different to the licensed dose in the UK, or the people enrolled into the trial don’t quite fit the population you want to know about, or perhaps the trial just didn't recruit enough people so any results from it are invalidated.

I've been doing this job for years, and I really do still struggle with all of this stuff. That’s not because I'm poor at my job, or because I'm stupid, or because I haven’t put the effort in to understand it. It’s because, when it comes down to it, this stuff is really bloody hard. It’s time-consuming, boring, and unintuitive.

People might well feel like they've done their own research. They might spend several hours digging about on the internet and feel empowered by any decisions that they make. But what they don’t realise is that what they've been researching isn't just the information- it’s the information with many, many layers of interpretation (and therefore bias) added. For a choice to be truly informed, you need to go right back to the start, to those terrifying tables of numbers and statistics. That’s simply not realistic for the majority of people.

Far better, then, to learn how to decide on whose interpretation you’re going to rely on. Will it be those that take the media reports at face value, or who have an agenda or a product to sell you? Or will you go with those that have years of training in how to pull apart complicated data and disseminate it in understandable ways?

Hxxx

*I thought I’d give you a quick real life example here, but I thought it best to asterisk it because I've probably bored you enough already. I'm currently looking at a drug called edoxaban and its use in reducing the risk of stroke in patients with atrial fibrillation. It’s the newest in a series of  novel oral anticoagulant drug- they’re supposedly like warfarin, but less faffy. So I find and look at the main trial, and spend days unpicking the stats. It looks like both strengths used in the trial are no worse than warfarin, and the higher dose might even be a little better. Great, right?

Well, that’s not quite the end of the story. Because it turns out- and this isn't reported in the trial at all, but instead is contained in the FDA’s briefing document- that in people with fully working kidneys, edoxaban is actually worse than plain old warfarin. In people whose kidney’s aren't quite at full capacity though, it might work better than warfarin. So the overall trial results are kind of skewed, and if we didn't dig deeper, we might have been giving a whole group of people a more expensive drug with worse outcomes than warfarin.

why we can still-and should- question charity campaigns.

I wrote last year about how I dislike Facebook “Games” that “Raise cancer awareness” in a vague and most probably pretty useless manner.



There’s another one doing the rounds – that of taking selfies without makeup on the raise awareness of cancer. The specifics of where it arose are shadowy and exceptionally vague. Some people state that it is for breast cancer awareness, some just for cancer.



It actually seems to have arisen from a well-meaning but very misguided campaign by some friends of a girl who recently hit the headlines after dying from cervical cancer – yet not one selfie post which I have seen mentions this particular type of cancer.



This appears completely random. There’s no connection between wearing makeup and “being aware” of breast cancer. The posts do not on the whole give information and advice on how to check your breasts for signs or what symptoms to look out for.



I’ve questioned it on Facebook, as have others. The response has been… defensive. Of course people who are posting selfies and who are supporting them are doing so in good faith, and I have no problem with this. What I do have a problem with is the vagueness of these campaigns, of the fact that adding “for cancer” on the end of any old nonsense seems to be a code for “Do not question this or else everyone will think that you’re a meanie and will get all offended with you.” This leads us down a dangerous path, which in rare cases leads to real, tangible harm. Those cases - though rare - should be enough to make us stop for a moment and question.


I drew a little cartoon to explain this. I’d like to point out that it’s generalised, and simplified, and is no way aimed at well meaning people who take part in potentially questionable campaigns. Its just the process that I go through, and what many other people do, and I would love it if more and more people understood it, and why it is perfectly okay to question any charity campaign.

Scenario One:

Scenario two:

A healthy dose of skepticism can make any campaign worth its salt even stronger in the end.

Medical and Homeopathic information sources: A comparison

My friend Nancy and I are doing another Skeptics In The Pub talk this Thursday, and as a result, I’ve been delving back into the world of homeopathy, and all of the nonsense that it entails.

Part of my research and preparation has been consulting homeopathic texts- materia medica and repertories that are still in use by modern homeopaths.

One thing that I have been repeatedly struck by is the stark differences in the quality of these information sources compared to those used in modern medicine. Let’s take a look at some of those differences.

Up To Date?

Part of my day job’s role is resource management. This means that I need to make sure that all of the resources that we use and have access to are present and up to date. Whenever I use a book as part of my work, I document which edition I have used. If I use a website, I make sure to include when it was last updated. When we get a new book in the office, I find the old copy and cover it in stickers saying “Out of date- do not use”.

I don’t do these things because I am weird, or because I enjoy it. I do it to ensure that I give the most accurate, up to date information so that the patient gets the best care. What we know about medicines is constantly evolving- new medicines, new safety information, and new evidence is emerging daily. What might have been correct to the best of our knowledge last year may now have been subsumed by more recent experiments, and so the information sources I use change accordingly. So, for example, I can reach for a copy of the British National Formulary from 2005, and find information that recommends sibutramine as a weight loss aid in certain patients. However, if I look at the current version, I won’t see it in there, as it has since been withdrawn for safety reasons. If I were to have used the 2005 copy to advise a patient, I might have given them the wrong advice, in the context of what we know today.

How up to date is the information used by homeopaths? According to The Homeopathic Pharmacy (Kayne, S. 2nd Edition, published in 2006 by Elsevier Churchill Livingstone, page 192- I did warn you about the documentation): ‘The most well known are Boericke’s Materia Medica with repertory and Kent’s Repertory of the Homeopathic Materia Medica’. Sadly, the author of this book doesn’t see fit to bother telling us when these were published. Neither does the online version of it, although there is a bit of a hint in that the “Preface to the ninth edition” on there is signed off by William Boericke in 1927.

Nineteen Twenty Seven. Medicine and healthcare is a pretty fast-paced industry, with new innovations and information coming out at an overwhelming rate. So much has happened in medicine since 1927 that there is no way that anyone should accept health care advice based on something written from that time. I know I certainly wouldn’t be too happy if my GP gave me health advice from a dusty tome, or if I went to the dentist’s to find them using equipment from the 1920’s.

Maybe Kent’s Repertory will be more up to date? A Quick look at the website gives us no clues. This time, the preface contains no date at all. http://homeoint.org/books/kentrep/kentpref.htm. The closest thing that we have to a publishing date is the fact that the website is copyright 1998, and appears to have been formatted by a default-font loving child in the early nineties.

Political Correctness

Over the years, medical terminology has changed and evolved along with society and scientific discoveries, and rightly so. In some cases, words that used to be considered as perfectly legitimate scientific terminology (such as ‘Mongol’, or ‘Mongoloid Idiocy’, used to describe a person with Down syndrome) are now considered downright offensive. Even whole swathes of what is now considered normal society (such as gay people) were once declared as illnesses- and of course we know better by now, or at least we should do, and if you don’t- grow the hell up, will you. We generally don’t refer to people as “hysterical”, or “insane” anymore, as we know a lot more about such conditions, so are able to categorise people more helpfully and professionally.

As a result, we healthcare professionals are very aware of how crucial the use of clear, concise, professional communication is, including the information in our resources. No self-respecting modern medical text would ever dream of using out-dated, offensive terms, and if it did, there would be an outcry.

Let’s have a look at the sort of thing that Boericke’s Repertory wants to help us to treat. There are things like “Brain-Fag”, “Cretinism”, “Masturbatic dementia”, “Fears of syphilis”, “hysteria”, “insanity”, “weak memory from sexual abuse”, “Haughty”, “Stupid”, and many others. These were just taken from the “Mind” section, but there are many other examples in the other sections too. These terms are just too outdated and are wholly inappropriate to be used in today’s society.

Having looked through various other Materia Medica entries too, I’ve found statements that are sexist, bigoted, and occasionally racist. Nice eh? You don’t find that sort of thing in an up-to-date copy of Martindale: The Complete Drug Reference.

Clarity

Good, modern medical resources are all about clarity. They need to be- after all if someone gives the wrong medical advice because they have interpreted something incorrectly, patients could be at risk.

Jargon is sometimes necessary, but nowadays medical jargon tends to use standardized, accepted terminology which keeps the risks of misinterpretation to a minimum.

Homeopathic repertories and material medica, on the other hand, are full of vague, odd terms which are massively open to interpretation. What, pray tell, is a “voluptuous, tingling female genitalia” when it is at home? (and I wonder whether Ann Summers offers free delivery on such a thing?). What does “expectoration, taste, herbaceous” mean clinically? How is one supposed to diagnose “Taedium vitae”? When would you class a person as “Obscene, amative”, and when would they be considered as merely “gay, frolicsome, hilarious”?

In Conclusion

Our health is arguably the most important asset that we have. Why would we entrust it to sources which are terribly out of date, inaccurate, and in some cases, offensive?

Homeopaths like to paint themselves as a caring, human alternative to the more business-like, clinical world of real health-care professionals. But when this alternative categorises people as being “stupid”, or “cretinous”, and is happy to use criminally out of date resources which can risk peoples’ health, I wonder just how caring and ethical it really can be.  

Why would you continue to use an abacus when calculators exist, and are proven to have a better record at getting the right answer?

Evidence-Based Ambridge

Ahh. Sunday mornings. They can mean only one thing: bacon.
Okay, two things: bacon and tea
Whoops, no let's make that three things: bacon, tea, and The Archers omnibus. 

So welcome to the first instalment of an occasional series (probably so occasional that this is the only one), in which I critically examine the treatment choices of the fictional residents of Ambridge. 

In today's omnibus, Hell-on's child falls over. There is much hysterical panic, and much bewailing the fact that she wasn't watching him properly. Apparently its hard to look after a child and gaze lovingly off into the distance in the direction of Rob Titchener's house. Who knew. 

But never fear, Hell-on's mother, Pat (who doesn't appear to have noticed that her husband has been kidnapped and replaced by an interloper), is on hand to reassure her that she has done her best with the arnica. 

Arguably, I'd say arnica is one of the most accepted forms of woo in the UK. Arnica cream is a standard item in many pharmacies, and I would say that many people know that it is supposed to be useful for bruises. I wonder just how many first aid boxes have a tube of arnica languishing in them, but I reckon it is quite a few.

Its also a poster boy for the sort of confusion that reigns between the public perception of homeopathy and herbal medicine. herbal arnica cream often sits side by side homeopathic versions with no explanation of the difference. 

Even Nelson's seem rather confused about which modality to use, with both herbal and homeopathic arnica sitting in their "Arnicare" range of products. I can't quite get my head around this to be honest. Imagine going into an off-license and seeing two bottles of Smirnoff, one of which contains vodka and one of which contains water, though the only difference on the label is that one says Smirnoff Vodka 30C. Hmm.

Does the distinction matter? Yes, I think it does. I think its pure, outright deception to sell a homeopathic product to someone expecting a herbal medicine. One has arnica in, one doesn't. 

Anyway, all of this is by the by. Obviously there is no evidence that homeopathic arnica works for bruising. It's homeopathy. It has nothing in it. 

And as for herbal arnica? there's also no evidence that it works, although there is a little bit of prior plausibility, in that some of the chemicals in the arnica plant have an anti-inflammatory and anti-platelet action. There is, however, no information on how clinically significant these actions are, and whether rubbing a bit of cream into an area would get these potentially useful chemicals to the right place in any meaningful amounts.
Let's not forget that bruises are self-limiting. They go away of their own accord (and probably at the same pace), regardless of whether or not you rub some gunk into them. herbal arnica isn't risk free: the cream can cause  contact itchiness, dry skin, and rash. Orally, arnica can be pretty nasty stuff, even causing coma and death in extreme cases. 

So, my evidence-based advice to Helen would be: kiss it better, and leave it be. Henry is a small child, and falling over is pretty common in that age group. Don't apply an ineffective treatment which could rarely lead to side effects, and save your money. 

Blowing A Raspberry

Imagine there is a door in front of you. There is a person standing next to the door:
       
"Hey there, pudgy, do you want to be thin and beautiful without having to do any exercise at all? All you have to do is hand me some cash and step through that door there."

This person goes on to explain that if you step through the magic door, you will step out of the other side with a perfect, slim figure. You won't need to change your diet or do any exercise. You just need to walk through the door. They show you some glossy before and after pictures. There are pictures of beautiful, smiling people holding out the waistbands of their old elasticated tracksuit bottoms, so you can see just how much more skinny they are now.

There is a slight rumble from behind the door. You ask what is behind it.

"Oh, we don't know. But honestly, it'll work."
                                 
"But is it safe?" you ask. 

"Oh yes, its perfectly safe" is the reply. "All you need to do is go through that door, and you will definitely lose all of that stubborn weight and absolutely nothing bad will happen to you whatsoever. Now if you'll just hand me your money there, that'll be great."   

Sounds great, right? You excitedly take a step towards the door.

But before you step through the door, you take a moment to consider what might be behind it.  You don't know, and the person telling you to go through the door doesn't know what'a in there either. 

No one has studied what's behind the door. There are no photos and  no videos of what's in there. All you have is this person's word that it is safe, and it will work. 

Broadly speaking, there are three possibilities of what's behind the door:

1) Nothing. Its just a room. You go through the door, and nothing happens. You don't lose any weight, but you have lost your money.
       
2) It works. You step through the door and emerge as a smiling, happy, beautiful, skinnier you. You quickly run home to find some horrible grey tracksuit so you can smugly show everyone how marvellous you are now you're skinny.

3) Something harmful is in there. Maybe there is a big pile of dog poo right behind the door, and you are destined to step in it, which will be mildly unpleasant for you. Or the door could be perched on top of a cliff, below which is a mesh of razor blades that will cut you into little pieces. Worse than that, perhaps Piers Morgan is through there.

Do you step through the door? 

Now, I really do want to lose weight. But I also don't like being deceived, and I really don't like being harmed. I also really don't like Piers Morgan. 

All of which brings me nicely on to this season's most fashionable weight- loss aid, Raspberry ketone. Its the chemical contained in raspberries that makes them smell nice. Its widely used as a flavouring and fragrance agent in foods, which begs the question: if its so effective, why don't we already lose weight when we eat food that it is in?

You've probably heard about it already. By which I mean that you've probably seen someone on Twitter tweeting about how they lost 3000 kg using raspberry ketone, along with a handy link to a website where you can buy it. You've also then probably seen the follow up tweets, that go something along the lines of "Urgh, my account has been hacked. I've changed my password now, sorry."

And there's the first warning sign. People who make real medicines which work don't tend to need to resort to hacking people's social media accounts in a desperate bid to get people to buy their wares. You don't see Pfizer or Glaxo, for all their faults, hacking into random peoples' accounts and mass tweeting "My cancer is in remission thanks to Drug X. Buy it here!!!!". 

Its not a particularly ethical way to sell healthcare products.

Putting all of that aside, is there any evidence that raspberry ketones work as a weight loss aid?

In short: no, except for 18 mice and a difference of about 5 grams at most. Which also means there is no evidence that it is safe. There are no human studies out there at all. All of this hype about it is based on the fact that its chemical structure looks a bit like two other chemicals (capsaicin and synephrine) which might have some effects on weight loss.

That's a bit of a stretch. Human bodies are complicated things, and we can't always predict how they will react to medicines. Even when we theoretically think that something might work for good, plausible reasons, there's no guarantee that it will (COX-2 inhibitors come to mind as an example). Marketing raspberry ketone as a foolproof weight loss aid just because it looks a bit like some other chemicals is like finding a random key on a street and expecting it to work without fail on your front door, just because it looks a bit similar to your front door key. 

If you were to decide to take raspberry ketone, you would essentially be walking through that door. You might lose a bit of weight, or you might not. You might be harmed, or you might not. There's just no way of knowing right now.

Hxxx

Facebook, breasts, and why the combination of both annoys me.

"I like it on the living room floor!"

"I like it on the kitchen counter!"


Blah blah blah. These are the sorts of bawdy Facebook statuses that surface every year. They're then followed up with a message along the lines of "hey, let's not tell the MEN what we're doing, but according to this arbitrary nonsense below, put something attention seeking as your status update to help raise awareness of breast cancer".

There's always the inevitable guilt trip of "most of you wont bother with this, and you're all terrible, terrible, evil people who don't care about people with cancer and you will all go to hell"

These sorts of statuses/ messages have always bothererd me. The whole Carry On Breast Cancer vibe is just uncomfortable, for starters. They are infused with the same sort of superstitious, guilt-ridden nonsense as the old chain letters you used to get back in the late 80s. And people seem to go to great lengths to defend them, and any even remotely negative comments about them are batted straight back with an unthinking "why wouldn't you want to raise awareness of breast cancer? are you some sort of EVIL PERSON?!"  I have raised the point on my own Facebook and have also seen some friends take flack for daring to question these games.

There is a great piece of writing about exactly this subject that you can find about this subject here. You'll also find a piece from Skepchick here. However, there are a couple of other points that I want to raise in addition and to compliment the points raised in that piece, and some of the arguments used to defend the game that I have seen used on Facebook. These points are in no particular

How much awareness are these "games" raising? 
Given that the messages contain no information on the symptoms or how to check for breast cancer, or any links to good quality information sources, I'm not convinced that it is raising awareness. There have already been huge campaigns to raise awareness of breast cancer- people in the main already know that the disease exists. Therefore this campaign needs to add something specific to that: how best to check for signs of breast cancer, practical tips, or signposting to other good quality sources of information. Furthermore, actively excluding an entire gender or other large group of people from your awareness campaign seems like a very odd tactic indeed. The messages include how the "bra game" made it to the press- this appears to be the case, although not in the way the message would like to imply. But have any of the other campaigns that surface regularly made it to the press? I certainly haven't seen so.

Who has started these campaigns, and what charity etc are they raising money for? its not clear, and it would seem that no one knows who or why they originated. So what sort of awareness are they really raising?

Cold, hard cash
These games aren't asking for money to be donated to any particular charity. Yet, when it comes to cancer research, it is cold hard cash that makes the difference. There is a risk that people may feel that by taking part in the game, they have done their bit already in helping to raise awareness, which might discourage any further action. In actual fact, if you want to help, donate some money to a cancer research charity.Is there any evidence that this sort of bid to raise awareness translate into money being donated? No, of course there isn't, so we should all be focusing our efforts elsewhere.

Dignity
Really people, are we that unimaginative that we require this arbitrary nonsense to put something titilling as a status? Do we so desperately want to feel a part of something that we will lower ourselves to this sort of bawdy crap? Can we really not think up any better innuendos to grab male attention as we appear to be so desperately doing here? These sorts of statuses sit on the same level of annoyance as the ones that are simply an unhappy face so that many people will reply with "what's up hun?" and the original poster will get lots of attention. If you want to be tacky and attention seeking, go right ahead, but do so with a bit of imagination and personality, not according to some formulaic crap involving handbags.

Exclusion

In 2010, breast cancer rates in men were approximately 1 per 100,000. Just imagine how emasculating, shocking, and devastating this diagnosis may be. The fact that bright pink is constantly associated with this disease can't help matters. That awareness campaigns like this one actively exclude men is frankly unforgivable. Campaigns that raise awareness of testicular or prostate cancer are often very inclusive of women (I'm thinking of the Movember campaign in particular, problematic as it may be for other reasons), despite the fact that for obvious reasons the likelihood of women getting these types of cancers is zero.

In addition, as a good friend of mine pointed out, it may be men who notice or feel changes in their partner's breasts before they do. Why would they therefore be excluded from any awareness campaign? It just doesnt make sense.

Humour
"Oh but its just a bit of a laugh isn't it?". I've seen this used as a defence for these games. No actually, no its not a bit of a laugh- its breast cancer, for crying out loud. Humour is undoubtedly a powerful tool in coping with such a diagnosis, but this is going to be different for everyone and needs to be treated as such. some people might find this funny whilst others might find it plain offensive. No Facebook chain message is going to be able to deal with the complexities of when and how to use humour in the face of a potentially devastating diagnosis.

So there is some thoughts to be going on with. I may or may not add to them as time goes on. In the meantime, if you'd like to do your bit, you could always donate a few pennies here. Meanwhile, for information on how to check your breasts, try this Breakthrough Breast Cancer page.

Hxxx

Is Gareth Bale worth more than eradicating malaria?

Many moons ago, in what now feels like a different life, I went on a trip to London. The date was October 12th, 2009, and I was armed with a long pole, a dispensing basket I had nicked from work, and a mosquito net.

I had an hour. An hour, to do whatever I wanted, in Central London. Its not particularly unusual to have an hour to kill in the capital, but it just so happened that I would be spending this hour atop the Fourth Plinth in a moonlit Trafalgar Square. I had been lucky enough to have been selected to take part in Anthony Gormley's One & Other artwork. I decided, after much deliberation, to represent the Malaria No More charity. I gave out packs of sweets and leaflets about the cause, wore a dress made of a mosquito net, and even did a little bit of crafting, sewing the words Malaria No More onto a large blue mosquito net. Mostly, I felt utterly terrified, and had horrendous stage fright, more so than I had ever imagined I would have.

Malaria No More, amongst other things, aim to distribute insecticide-treated bed nets (ITNs), eventually with a view to eradicate malaria entirely. According to them:

"£10 can transport 150 life-saving nets to a community in rural Ghana; enough to protect 300 people."

 Blimey, that sounds far too good to be true, doesn't it? But luckily, there is good, robust, independent evidence that impregnated mosquito nets really do prevent deaths from malaria:

"About 5.5 lives (95% CI 3.39 to 7.67) can be saved each year for every 1000 children protected with ITNs...ITNs are highly effective in reducing childhood mortality and morbidity from malaria. Widespread access to ITNs is currently being advocated by Roll Back Malaria, but universal deployment will require major financial, technical, and operational inputs.." -Cochrane Database Syst Rev. 2000;(2):CD000363.

So the idea is that two people can sleep under one net, but because of the insecticide, there is an area outside the nets which is also protected. If there are enough nets in a household, or even a village, then the whole area could be protected, even when people are out and about and not just when they are sleeping under the net. The available evidence seems to back this up-the little extract I have copied above only refers to deaths, but the results are even better when it comes to reducing the incidence of malaria illness- a reduction of 62% in areas of unstable malaria, for example.

This got me thinking a bit. With the news today that Gareth Bale, a man that I have never heard of, who runs about on a bit of grass after an inflatable round thing is apparently worth a record £85.3 million, I can't help but do some little calculations. Obviously these are all estimates, but it makes for an interesting thought experiment.

• £10= 150 mosquito nets

• £85,300,000/10=8,530,000 mosquito nets

• As each of those 8,530,000 nets can protect two people= 17,060,000 people could be protected.

• 5.5 lives can be saved for every 1000 children protected with ITNs. If we assume all the people protected are children:
• 17,060,000/1000= 17,060
• 17.060*5.5=93,830 children could be saved.

The WHO estimates that there were 660 000 malaria deaths in 2010. So that amount of mosquito nets, could, in actual fact, prevent a large chunk of those deaths (we dont know how many adult deaths it could prevent, either) meaning that over a few years, malaria could potentially be eradicated.

Now, I'm sure this Bale chap is very good and all, but I do wonder whether, in the context of all the World's problems, this sort of amount is appropriate. Personally, I would rather opt for reducing the massive morbidity and mortality caused by a disease that is potentially eradicable given the right resources, but then what do I know?

Before anyone complains, yes I know this is terribly simplistic, and its not as easy as that, and all of that sort of hoohah. I just want to make a bit of a point about how vast sums of money need a context, and in my humble opinion, I don't think it is particularly appropriate or such sums to exchange hands when there are still people dying of hunger or preventable diseases.  I'm sure some men doing footballing makes some people happy and all, but come on. I'm not even convinced that Christian Bale is worth that much, despite that scene of him running around naked, bloodstained, and with chainsaw in hand in American Pyscho.

Hxxx

To self-monitor blood glucose or not?

Today's news greets us with a story about "rationing" of diabetes glucose test strips. Diabetes UK, in a survey of about 2,200 people, found that 39% of people with diabetes have had their prescriptions refused or restricted. Meanwhile, politicians are wading in stating that restrictions are unacceptable.

Now, this sounds bad. But when you start applying some skeptical principles to this area, it all becomes slightly less clear. Here are some brief points to consider about self monitoring of blood glucose (SMBG) to put today's news into context:

Test strips are expensive. Spending on test strips in the UK is pretty high, and has been rising year on year since 2008. In 2010/2011, a whopping £158.4 million was spent on testing in England alone. These things are expensive, and a lot of them are being prescribed. Historically, they have been over-prescribed, and this has been a priority area for the NHS to attempt to prescribe more rationally. (NB: rationally does not necessarily mean rationing, it just means using resources more effectively.)

The UK Guidelines are clear that SMBG has an established place in the management of diabetes controlled by insulin, whether this is type one or type two. Its also accepted in the guidelines that it is useful for patients with type 2 diabetes who are at risk of hypoglycaemia. Reports such as this one from the NHS Diabetes Working Group are also clear that rationing should not be undertaken in patients who are deriving benefit from SMBG. 

SMBG doesn't actually do anything to control diabetes. It isn't an intervention, it's a testing tool. The only way it can have a positive impact on diabetes treatment is if the results are used to guide treatment or behavioural choices. So its useful for insulin dosing, for example, as it is variable and needs to be responsive to what you have eaten that day. However, if you take a twice daily dose of metformin 500mg, say, SMBG isn't going to really help anything. I think this point isn't quite as clear as it should be to some patients, carers, and even healthcare professionals. 

It only gives you a result for one pinpoint in time. It doesn't tell you anything at all about more long term control. This limits how useful it is in assessing lifestyle changes, such as exercise and longer term changes in diet.

Studies have found that some patients are not using SMBG to guide treatment changes or choices- so they are essentially testing for no gain at all. If this is the case, then it is clear that the SMBG can be discontinued with no impact on the patient's overall care- in fact its an all-round win situation, as the NHS saves some cash and the patient no longer has to bother doing a painful test.

Its not a no risk option. Apart from the obvious discomfort of testing, there is some (although limited) evidence that some patients can feel more depressed, anxious, and even obsessive if they are using SMBG.

The evidence that SMBG works is very limited, and is confounded by lots of different factors. You can find more detailed information on the evidence base in this Medicines Q&A. The technology of SMBG was welcomed with open arms by patients and healthcare professionals alike, and it was widely accepted before there was robust evidence that it worked to improve outcomes. In these sorts of situations, where people are used to using a technology or drug etc, it becomes quite difficult to start being rational about it, without people feeling that they are having something taken away from them. If you really want to have a good look at the evidence, you can have a look at this Health Technology Asessment by Clar et al. It's only 156 pages long (!) but it is a really good quality summary of the evidence.

The evidence that SMBG is cost effective is even more limited. We simply don't know if it represents good value for money for the NHS. Meanwhile, there are interventions which we do know are cost-effective. So doesn't it make sense to limit spending on the unknown, and to put funds into the interventions that we know work instead?

Its a real shame if these sorts of issues have been ignored in favour of rationing. Rationing test strips for patients who are insulin treated isn't rational prescribing, its just daft. But there is a serious issue of overuse and over dependence on SMBG, which blanket rationing makes more difficult to address. The UK guidance makes a lot of sense given the state of the evidence we have access to at the moment, and I would be very sorry to see it being misused in some patients, whilst others are fruitlessly undertaking a needless task at a potential cost to their quality of life and the NHS.

Hxxx

Antidepressants in Pregnancy

This morning BBC News are running with this rather terrifying looking story about the dangers of antidepressants in pregnancy. This is an area that I deal with pretty commonly, so I thought you may be interested in my assessment of the situation.

First thing to note: things can go wrong in even a normal, healthy pregnancy. There is always a risk of malformations or miscarriage, and unfortunately these things can happen for reasons that we dont understand. The risks are usually low, but are increased by things like increased age, obesity, illnesses etc.

One of those illnesses can be uncontrolled depression. "But how can feeling a bit sad harm an unborn baby?" I hear you ask. Well firstly, depression can be a very serious illness which should be taken seriously. It may even be terminal. Pregnancy is a time of massive changes, and as a consequence is a high risk time where someone's mental health can destabilise. If you have depression, you may not be looking after yourself properly: you might not be eating well, you might be avoiding exercise etc. In the worst, most tragic cases, suicide attempts might happen. We don't have enough data to put figures on how much of an increase in risk this all adds up to, but we do know that it can increase risks in a pregnancy if not sufficiently controlled.

Of course, this doesn't even take into account the more nebulous risks to both the child and mother- how will having a depressed mum impact psychologically on the child, how will the bond be affected, and what are the long term effects of this? 

So what of the SSRIs, the most commonly used type of antidepressants in pregnancy? Looking at the risk of cardiac malformations,, the BBC article claims that:

"Currently, prescription guidelines for doctors only warn specifically against taking the SSRI, paroxetine, in early pregnancy."

 It used to be the case that we were aware of the possibility of a cardiac malformation risk with paroxetine. Up until, oh, about 2010, when a large review was published which suggested that the increase in risk, if it exists, may be a class effect. The UK Teratology Information Service's Guidance was changed accordingly to be more practical, to remove a heirachy of one particular SSRI, and to make the drug of choice that which is the best for the individual patient (please note that UKTIS are a service for healthcare professionals only, and pateints should not ring them directly). The fact that NICE guidelines haven't yet been updated probably says more about NICE's workload and update schedule than any evil big pharma cover up.

As an aside, you will notice that there are a lot of words in this post which suggest uncertainty. That is because there is a lot of uncertainty in teratology: because we cant do large robust trials on pregnant women because of ethical concerns, we have to scrape together what we can and make the best of it. There are few certainties in this area.

Strange then, that the BBC are quoting a Prof Pilling from NICE:

"He says the risk of any baby being born with a heart defect is around two in 100; but the evidence suggests if the mother took an SSRI in early pregnancy that risk increases to around four in 100."

I'd love to know where these figures came from. The current status of data on the risks of SSRIs is pregnancy is as follows:

• There is lots of data, which has had various statistical analysis methods applied to it. 
• Some of this data suggests no increase in risk
• Some of it suggests a small increase in risk.

So, with some data saying there isn't an increase and with some saying there is, it is virtually impossible to say for certain if there is an increase. The only thing we can say for certain at this point is that we can't say anything for certain. But given that we have lots of data, and SSRIs are commonly taken in pregnancy, I think we can say that if there is a large increase in risk, we would have known about it by now. So any increase in risk, if it is there, will be low.

Of course the BBC are reporting the relative risk, which sounds more impressive: a doubled risk sounds much more sensational than a small absolute risk. But I'm not even sure where this figure has come from, given the conflicting state of the evidence at the moment. Needless to say, research is oretty much constantly ongoing.

All of this is a very long winded way of saying: we dont know at the moment. But the fact that we don't know, in the face of how commonly used these drugs are in pregnancy, could be seen as reassuring.

As with all things in healthcare, this is a balance. A balance between the risks of uncontrolled depression and destabilising a mother's mental health during pregnancy, compared with the -as yet unknown but likely to be small- risks of SSRI antidepressants. Of course some women with minor depression might be taking antidepressants unnecessarily, but in cases where it is required, we need to look at the bigger picture. Just focusing on a drug's teratogenic potential is not enough: we need to consider the teratogenic potential of the illness itself, and the impact on everyone's lives that might happen if treatment is withheld.


The bottom line is, if women are thinking of becoming pregnant or are already pregnant whilst taking an SSRI, and they are worried, they shouldn't stop it of their own accord, but should make an appointment with their GP to have a discussion about their concerns.

Hxxx

UPDATE: I've been thinking about this 4 in 100 figure for cardiac malformations, and last night tried to find the reference source from it.

I've tweeted @bbcpanorama asking to know where this figure has come from, as have a few others. I've also tweeted @shelleyjofre, the journalist who has mad ethe programme, and have been met with a stony silence. This is really unfortunate, given that to be able to deal effectively with any enquiries from patients relating to this programme, I -and all the other health care professionals dealing with worried mums to be- need to be able to see and appraise the evidence for ourselves.

I have managed to find this document from the MHRA, which does mention a 4 in 100 figure. However, I sincerely hope that this isn't the source in question, given that:

• The document refers to paroxetine alone, not the whole class of SSRIs
• There is no date on the document, meaning we have no way of knowing how up to date these figures are.
• the 4 in 100 figure cited refers to the risk of ALL malformations, not just cardiac ones.
• the risk cited for cardiac malformations is 2 in 100. Half that which the BBC and Professor Pilling are quoting.
• The background risk of all malformations cited is 3 in 100, and the background rate of cardiac malformations is 1 in 100. So yes, the relative risk is doubled, but the overal risk remains very low. 

As I say, I really do hope that this isn't the source, and that @bbpanorama or @shelleyjofre are able to provide me with the reference soon. 

Making Clinical Trials Sexy

If you're buying a new TV, how do you go about it? My guess is that you probably have a look around the shops or internet, find a model you like, then get online to find some reviews of it and decide whether or not to buy based on what you've read. You may well scroll down to the reviews if you're buying something on Amazon, before you click the "Buy" button. If you book a holiday, you're probably straight on Trip Advisor to see what other people- humans just like yourself- have got to say about the hotel.

It is perfectly reasonable behaviour. We understand and respond to the personal experiences of other people- its part of our nature, stitched into our being. Each review is a little story, and humans love stories, especially when they are about other humans.

Its therefore a hugely unfortunate problem that, when it comes to healthcare, stories just aren't good enough. When peoples' lives are hanging in the balance, reviews and testimonials just aren't up to scratch. Here's why:

I have guttate psoriasis. Imagine I go on holiday (alas this is merely a pipedream this year, thanks to what feels like millions of large unexpected bills that seem to keep turning up in my life) and lo and behold, when I return, my psoriasis has cleared up. I conclude that it is definitely the sunshine that has cured it, and proceed to proclaim that I have found the ultimate 100% effective cure for psoriasis.

Is it reasonable that I have come to that conclusion, based only on my own experience? No, not at all. Why have I focused on the sunshine aspect alone? Maybe a week spent relaxing is what has actually cured it. Maybe its because I've changed my diet on holiday and have been eating lots of lovely fresh fruit and vegetables and fish?  Maybe it is because there is a magic ingredient in Sangria which miraculously beats rogue skin cells into submission. What if chlorine in swimming pool water is my skin superhero? Maybe-just maybe- its because guttate psoriasis can be self-limiting, and it has just faded away of its own accord. With just my experience to go on, there is no way I will ever be able to know what it is that has made my condition improve.

What I would need to do to be able to decide is to scale things up. Get as many people as possible with guttate psoriasis, and divide them into at least two groups- one exposed to sunlight, one not. I'd have to try to control the peoples' behaviour as best as I could for the other factors like diet, chlorine exposure, sangria intake, stress etc. Whilst I could never completely control for everything, if the group exposed to sunshine experience a significantly better improvement in their psoriasis, then I could say with more certainty that it is the sunshine that did it rather than anything else.

This is the beauty and elegance of a clinical trial. They are simply the best, slickest, most reliable way we have of teasing out whether a treatment actually does make a difference. They're like an anthology of stories, carefully selected and analysed by researchers in a bid to start finding an answer to a treatment question. Whilst they're not 100% perfect, they're certainly the best sort of information we have at the moment on which to base any decisions about which treatment to choose for which disease, and for which patient.

This is, however, very easy to forget when you actually have to read one. I do not have a mathematically inclined brain, and when faced with tables full of numbers, p values, confidence intervals, hazard ratios, relative and absolute risks etc, my grey matter is usually to be found quivering and wimpering in the corner of my skull. I have to really try hard to focus on the stats and results when reading a clinical trial- its a constant fight to wrench my thoughts back onto the page, when they keep merrily skipping away to think about kittens or bunnies or *that* picture of a minipig wearing red wellies. And I say this as a geeky pharmacist who has undertaken a decent amount of training in how to read a clinical trial. What hope then, does an individual patient or regular joe have of understanding trial data?

A quick glance at pretty much any website selling an 'alternative medicine' and you'll notice there is usually a "Testimonials" page on there. Many other types of healthcare sites also use testimonials to prove their treatment works. They're easy to read, often full of personality, and can really seem to speak to you as a reader. They may seem convincing, but as you've (hopefully) seen from my example above, they simply can't be used to decide if a product works or not. A glossy celebrity story endorsing a product in a magazine is infinitely more sexy than ten pages full of stats and graphs in a medical journal.

Testimonials and reviews are, at first glance, more attractive and more seductive than the more dowdy clinical trial. So what can we do to help the clinical trial apply a bit of lippy, spray some perfume on itself, and don its heels to get out on the town and make people weak at the knees? My short answer is I don't know. Campaigns like International Clinical Trials Day help of course, but at the moment it feels like we're swimming against the tide somewhat. My ultimate dream would be a primetime TV series, fronted by a hunky Brian Cox type. If he can make physics sexy enough to be at the forefront of our entertainment, surely there is some way that we can do the same for one of the best inventions in healthcare? I'd like to get to a place were it's second nature for everyone, whether they be a patients, pharmacist, healthcare professional or general geek, instinctively bypasses testimonials to look for clinical trial evidence instead.

Do you have any ideas? Have you had any really good experiences of explaining clinical trials to patients? Are there any techniques we can use to simplify the stats and make trials more accessible to all? My friend Nancy had a great idea of including a Plain English summary as part of an abstract for every trial. Is there anything else we could do? Let me know, however outlandish your idea, either by commenting, tweeting me (@SparkleWildfire), or dropping me an e-mail at my new shiny sparkly e-mail address healthydoseofskepticism@gmail.com

Hxxx

Bad Pharmacy: An example

This morning, I needed to go and buy some medicines.

So, on my way into work, I popped into the nearest pharmacy to my route into work: a branch of a very large chain of chemists. Here's what I bought:

This turned out to be a particularly disappointing example of what I wrote about in my last post- a very lackadaisical, dangerous attitude to OTC sales. And this comes merely a few weeks after publication of the latest Which? report into pharmacy, and about a week after pharmacy was referred to, by Ben Goldacre and Andy Lewis no less, as a "quack profession".

Now, I'm demonstrably not a parent, but you know when you tell off a child for doing something naughty? The usual response is to stop doing the naughty thing, and act extra-specially well-behaved for a period of time until the original naughty thing is forgotten about, then you start doing it again. On second thought, I know some adults that exactly the same thing applies to. The pharmacy profession as a whole should be in that well-behaved phase right now. We should be pulling together, and ensuring that everyone involved- including counter staff- pulls their socks up, shakes off bad habits, and works to the highest quality, to prove a point, but also just because this is how we should be operating all the time.

So, this morning I shuffled into this particular pharmacy (which I'm sure you have no idea which one it is, given I have so cleverly covered the brand in the picture) and asked for "Some Piriton and some co-codamol". The lady who served me appeared to be an experienced member of the pharmacy counter-staff. Here's how the conversation went:

Pharmacy Lady: "Do you want a pack of 30 or 60 Piriton?
Me: 30
Her: And you wanted paracetamol?
Me: No, co-codamol.
Her: Soluble?
Me: No.
Her: have you got a loyalty card?
Me: No
Her: that'll be £5.34
Me: *pays and leaves*

Here is how the conversation *should* have gone, as a bare minimum:

Pharmacy Lady: "Do you want a pack of 30 or 60 Piriton?"
Me: 30
Her: We've got a cheaper generic version, if you want that?"
Me: "lovely, yes please"
Her: "These can cause drowsiness, mind, so make sure you don't drive or anything when you've taken them"
Me: okay, I wont.
Her: And you said you wanted co-codamol?
Me: Yes.
Her: soluble or tablets?
Me: just tablets is fine
Her: Have you used these before? Do you take them regularly
Me: No, just when i have a headache now and again.
Her: Because of the codeine content, they should be used for no more than 3 days at a time. If you feel you still need to use them after that, see your doctor. They also contain paracetamol, so make sure you don't take any other paracetamol products with them, and no more than 8 tablets in a day.
Me: okay
Her: Do you take any other medication at all?
Me: no, just the contraceptive pill
Her: have you got a loyalty card?
Me: No
Her: That'll be £5.34
Me: *pays and leaves*

That extra counselling would have added on about 20 extra seconds, which might have seemed like a minor inconvenience to myself, but lets have a look at the theoretical consequences of not saying them:

Piriton: Causes drowsiness. I take one, get in my car, fall asleep at the wheel, and have an accident.
Co-codamol: I don't realise it has paracetamol in, and take 2 co-codamol tablets and 2 paracetamol tablets four times a day for a while. I get liver failure, and die a slow, painful, unpleasant death because a suitable liver isn't available for transplant.
Also: I take co-codamol regularly for a week. I then try to stop taking co-codamol, and start getting headaches, and generally feeling awful, so I restart taking it. I am now dependent on the codeine content of it.

Yes, I am a pharmacist, so I already know the potential risks and consequences of taking these drugs. But I wasn't wearing an "I'm a pharmacist" T-shirt this morning, so its not like the member of staff knew this. Just because I asked for the products by name does not instantly mean that I know all about them and do not require full counselling on how to use them appropriately. And yes, I do also know that there is no good evidence that co-codamol is more effective than paracetamol alone, and I know I'm daft to be buying them, before anyone starts with the "aren't you supposed to be a skeptical pharmacist?"- sometimes even skeptical pharmacists like to utilize the placebo effect the promise of a tiny opioid hit provides.

Any of these theoretical problems can-and do- happen to people. We simply cannot go on providing such poor service over the counter and yet at the same time expecting the profession to be taken seriously. This is not safe selling of medicines- this is irresponsible and dangerous, and unacceptable. It makes me pretty angry because it not only gives a bad name to myself, and all the other great, conscientious pharmacists I know, but more importantly because it endangers patients on a minute-by-minute basis.

The Magic Blankie

When its cold and dark outside, I like nothing more than snuggling on the sofa under my blanket with a good book or a film. Some would even say its medicinal. No, really, they would. They'd go on to claim that its excellent for treating chronic diseases and that everyone should have a Magic Blankie of their very own at home.

Enter the healing blanket TMB-01, which stands for Treatment Multilayer Blanket. I prefer The Magic Blankie, though to be honest. Or Truly Mad Bollocks, that would also work. I love how they think also assigning it a number will make it more scientific sounding. Mind you, coming from SCENAR (Self-Controlled Energo Neuro Adaptive Regulation), we can be fairly confident that they have a robust, experienced Department Of Shoehorning Random And Sceince-y Words Into Acronyms (DoSRASWIA) on the case.

NO Kermit! Don't you know that by saying bye bye blankie you are denying yourself the health benefits of Magic Russian Technology?!

They're all the rage in Russia apparently. And I suppose, given how cold their winters are, it's only natural that every household would have a cosy blanket lying around. At only $325 a pop, why wouldn't you?

So what can the healing blanket actually heal? Lets see what Scenar have to say about it:

"The healing blanket TMB-01 can be combined with other therapies for a treatment of a wide range of diseases as well as stand alone independent treatment for psycho-emotional regulation, insomnia, stress and reduction of muscular spasm. The TMB blanket also helps to regulate psychosomatic conditions, relieves constant tiredness, and improves feelings of well being."

Insomnia, stress, tiredness, psycho-emotional stuff. Well we all have problems with those, don't we. Lets have a look at how we should use the blanket: 

"Maximum effects are achieved when the patient is wrapped completely and sleeps... One procedure takes around 40 minutes and could be repeated 2 – 3 times a day. The course of treatment is between 15 – 20 days 9 up to 1 – 3 procedures a day)".

Right, so to make yourself feel less sleepy, or to stop insomnia, what you should do is get cosy in your Blankie and sleep. Yep, seems perfectly plausible to me that the effects on conditions caused by lack of sleep are purely down to the blanket itself and nothing to do with sleeping, or just having a bit of a relax. Although frankly, having a 40 minute nap three times a day for 20 days is unlikely to help my stress levels as I'd have time to get sod all done in the rest of the day. 

How is The Magic Blankie supposed to work? Similarly to a tin foil hat, it would seem. It's made of layers of metal, which apparently shields the body from all external electromagnetic fields and radiation. Except, presumably, your head, which you'd probably not be covering with the blanket to avoid the minor inconvenience of suffocating. Its a reverse tin foil hat, I suppose.

"No, no its fine. We don't care if any electromagnetic evil rays of death  get into their angelic little heads,. It's not like there's any useful organs in there that might need protection. What's a brain ever done for us?"- SCENAR Department of Making Excuses (DoME) Spokesperson. Probably. 

Physicists, forgive me if I'm wrong here, but aren't there some forms of electromagnetic radiation that even several feet of lead won't stop? But those clever Russians have found a way to stop all of it. Makes you wonder why X-ray departments aren't simply tents made of these blankets held up with curtain poles. They could be renamed X-ray dens.  

Anyway, what about evidence? There is some, of course. It's just been blown away by the electromagnetic fields of reality.

Hxxx

P.S.I hope the sarcasm is clear enough in this post. Don't want to end up with quotes being used as testimonials or anything. "AT $325 A POP, WHY WOULDN'T YOU?"- H-Jo, Skeptic Pharmacist 

MMR: the blame hot potato

I shouldn't be having to write this blog. We shouldn't still be having to see news stories about measles outbreaks in 2013. We have an effective, relatively safe vaccine which should have massively reduced the incidence of this potentially fatal or life-changing disease. But no, here we are in the midst of an outbreak which is starting to reach scary levels. The first fatality has been reported, in 25 year old man, although it hasn't yet been confirmed that measles is the reason for his death.

So why is it still one of the main topics of conversation at the moment? Well I'm pretty sure you're aware of the truly awful, entirely discredited research by the now-struck-off the register Andrew Wakefield. If anyone is unsure about whether or not its unfair to think of Wakefield as a nasty piece of work, remember that he was struck off because of 4 counts of dishonesty and 12- yes, 12-counts of the abuse of developmentally challenged children. Its been 15 years since the publication of his "elaborately fraudulent" paper which suggested a link between the MMR vaccine and autism- and yet still to this day a dark cloud of fear surrounds the big scary needle that evil big pharma and nasty doctors want to inject into innocent children.

A quick history of events goes thus: Wakefield's paper is published in The Lancet---> Wakefield's paper is picked up by the media---> all hell breaks loose---> Children aren't vaccinated---> Wakefield's paper is discredited---> media continues panic-mongering--->Children still aren't vaccinated--->Other research says MMR isnt associated with autism---> media continues panic mongering---> Children still aren't vaccinated---> Measles outbreak---> media continues panic mongering ---> Wakefield denies responsibility ---> media denies responsibility. And that pretty much brings us back up to date.

So, are the media right to deny any responsibility? Are they hell, and there's evidence to prove it. Anecdotally, I found myself a few months ago having a lengthy, in-depth conversation with a customer about whether or not his first child should be vaccinated. "I thought it was all sorted out and was rubbish" he said. "But then I read about it in the Daily Mail and they said it was proven." Luckily it was quiet, and I had a chance to spend some time with him, discussing the problems with the Daily Mail report, the original research, and the risks of not being vaccinated. "Oh", he said: "we hadn't thought of the fact that measles might be dangerous." He left hopefully feeling reassured, but concerned that his girlfriend still wouldn't believe him and wouldn't want to vaccinate their child. One of my best friends isn't vaccinated, because his Mum read the seemingly terrifying stories in the press and refused to allow him to have the vaccine. As a result he caught measles, and german measles, (and whooping cough too), bless him. This got me wondering about whether or not there is good, hard evidence that the media is to blame.

In short, the answer is yes, a bit. In a telephone survey of the parents of 177 children who hadn't had the MMR vaccine, fear of side effects was the most common reason given, and the most common source of information was the media. Another study found that parents were more influenced by the fear of harm from the vaccine than fear of harm from measles itself. In another, parents seem to have thought that the information on vaccines given to them by healthcare professionals was poor. A qualitative study again found that parents did not rate science or evidence as important factors when making a decision about whether or not to vaccinate their child.

All of this leaves us with an unfortunate dichotomy. We healthcare professionals usually deal in science and evidence- and so we should, as this provides us with the safest and most objective method of treating patients. But it seems like this is a currency that the general public not only don't often deal in, but on occasion actively reject.

Yes, vaccines have risks associated with them, but these risks are nowhere near as bad as the risks of the disease itself- its a simple case of harm reduction.  If your teenager is going to have a drink, would you rather that they had one glass of wine at the dinner table, in your house where they are safe, or a bottle of vodka on a street corner in an area surrounded by drug dealers and murderers? Wouldn't you rather give a small, highly controlled dose of a disease in a vaccine than take the risk of your child getting the whole, dirty, nasty disease itself? It does seem that the potential for harm of the disease itself can be forgotten in the decision making process.

So how do we go about changing this? I have no idea, to be honest. Its amazing to me, and quite mystifying, that one utterly rubbish- and rather cruel-piece of research can still- 15 years later- hold so much weight over the safety of children. Is it the misguided fear of a poorly understood condition in autism, or the terror of  big pharma, or an unquestioning faith in what the papers say? It seems to me that all we can do, as health care professionals, is continue to attempt as much as we can to give rational, evidence-based advice to our patients. We can improve our communication skills, but i'm not convinced that we will ever be able to truly "win" the good fight if the media continues on with such atrocious health and science reporting. 15 years on and some of the newspapers still insist on calling him "Dr" Andrew Wakefield, when he is very demonstrably no longer a doctor. They use scary photos of massive needles, and continue to give space to the idea that MMR can cause autism, when all of science and rationality disagrees. They reach for emotional language at any opportunity, pitting devastated parents against the picture of a cold, uncaring healthcare profession that they paint. We can try as much as we like to convince our patients on a one-to-one basis, but its like trying to take a drink from a firehose with such irresponsible reporting reaching millions of people every day.

The short answer here is that the blame for the current measles outbreaks lies in all sorts of places. ITs a comedy of errors, but not a very funny one. But, it seems clear to me that the media in particular needs to sit up and realise the harm that it is reaping on a daily basis.

Hxxx

Prevalin: Pollen & Prevarication

There's yet another shiny new product on the pharmacy shelves this spring. In plenty of time for the hayfever season, Prevalin(TM) (which, as someone has already pointed out sounds like a bad name for HRT, not a hayfever medicine) promises us "Fast allergy relief at the onset of symptoms. Acts 5 times faster than hayfever tablets"

It's being advertised by a real-life Pharmacist, Mr Nick Kaye, who appears, resplendent in a white coat, in the advert, in front of what looks to me like a photo-shopped sign saying "Effective Hayfever Treatments". In the still from the video on the website, Mr Kaye looks less than happy and indeed even a tad embarrassed to be there. Having had a good look at the website for the product, I don't blame him.

First things first: this is not a medicine. It takes quite a bit of digging, but you can just about find on the website where it says in small letters that its a medical device. You can also tell by the trademark, and the "clinically proven" claims splashed liberally all over the website.

So what is it supposed to do? According to the advert, it has a unique thixotropic formula. That sounds science-y and cool, eh? It basically means that when you shake it, it's a liquid (therefore able to be sprayed), and it'll then thicken up at rest- i.e. on the inside of your nostrils. So it's supposed to form a barrier on the inside of your nose to stop the nasty allergens getting through. According to the website, this is a unique approach, the next generation of hayfever treatment. This is totally untrue: for many, many years we've been advising to put vaseline on your nostrils as a barrier. A product called HayMax which has been around for years claims to be a "natural balm that acts as a barrier to pollen, dust and dander.". This is, in no way, shape or form, a new concept or breakthrough.

Let's look at what's actually in it, shall we? This is actually very difficult to find, as it doesn't appear to tell you anywhere at all on their website. At first I thought it was cellulose-based, given that most of the references they cite for it being "Clinically proven" are about cellulose powder.  However, according to Netdoctor, it contains "mixture of inactive ingredients, including bentonite (a form of purified clay), xanthan gum, glycerol stearate and sesame seed oil." So, basically, gunky stuff then. gunky stuff that becomes a bit less gunky so it can be sprayed, but that will dry to be more gunky in your nose (although given the inside of noses are actually fairly moist, it's probably, I should imagine, unlikely to dry completely, which would presumably lessen its ability to form a full barrier). It's basically like PVA glue for your nose and it apparently feels like wallpaper paste when its up there, according to @ianthunderroad. Mmmm, sounds lovely.

The "evidence" they show on their website as proof that it works is frankly laughable. Check out this chart:

'% of patients experience improvement' it reads. Well, how many patients? What do they mean by improvement? Hopefully we'll find the answers in the accompanying text:

"Prevalin™'s efficacy has been proven in 2 clinical studies, where over 9 out of 10 people experienced significant improvement of their allergic symptoms^6,7."

Two studies? that's all? Even if they were pretty big studies, I'd be happier if there were more than two of them. and what is "over 9 out of 10 people"? Surely that would be 10 people then? Given a person is a discrete being, you can hardly have 9.25 people experiencing significant improvements. And what do they mean by significant- statistically? or, what we would be more interested in, clinically?

The referencing on this page is very odd to say the least. I'm expected a reference for two studies, presented in the usual, standard (formerly Vancouver, or similar) format. I'm presented with this:

 6,7. Efficacy of thixotropic nasal spray for seasonal allergic rhinitis assessed by a 4-hour and 3-hour allergen challenge in an environmental exposure unit.

 No authors, no information about date, or where it is published, etc etc. A quick google search finds what I assume to be the paper, although I have no way of confirming that due to the very poor referencing. Even the article itself tells you how to reference it, but the makers of Prevalin have happily ignored this

Luond-Valeskeviciute I, Haenggi B, Gruenwald J. Efficacy Of Three Thixotropic Nasal

Spray Preparations On Seasonal Allergic Rhinitis Assessed By Allergen Challenge In An Environmental

Exposure Unit . WebmedCentral ALLERGY 2010;1(10):WMC00993

So let's have a look at the three nasal sprays being used in this study then, they are referred to as IQM 11, IQM12, and IQM 13. The first study is a pilot, which uses IQM11. The other two are used in the second study.
Here's the ingredients for IQM 11: liquid paraffin, gylcerol, emulsifier (Glucate SS and Glucamate SSE-20), and water.

It's pretty unclear what the ingredients of the other two are, as they're not fully described. However I think the inference is that they have the same ingredients except for the emulsifier.

See any bentonite in there? any xanthan gum? any of the other ingredients that appear in Prevalin at all? No, me neither. There are other methodological problems with the studies too, but to be honest its not worth going into them now because they are unrelated to the product they are supposed to prove efficacy for.

So in summary: the two studies that the manufacturer's quote are actually the same study, poorly conducted and poorly written up, and about completely different products.

Would I buy this product if I had hayfever? Probably yes initially, because the nice trustworthy pharmacist man on the telly said its good and it works. Would I buy it having looked at the appallingly shaky evidence base for it? abso-blummin-lutely not. This is a shoddy effort, if you ask me, and at a cool £9.95 there is absolutely no way that its worth it.

If any patients ask me whether it works on my locum shifts, I will be very clearly telling them to put their money away and use the vaseline they've probably already got in the house instead.

UPDATE: 10/05/13 I'm reliably informed by a friend who is using this product out of desperation (and in spite of my ranting about it) that this product has an inconvenient habit of dripping back out of your nose at inopportune moments without much warning. Doesn't sound great, does it? In fact it reminds me a bit of the 'flatulence with oily seepage' side effect you can get with orlistat, only from your nose. Distinctly unpleasant.