Wake up and smell the (green) coffee

The media is raving about it. Waif-like celebrities like Demi Moore are swallowing it like there's no tomorrow. Any internet search results in a tidal wave of websites and blogposts screaming that its the new "100% safe and natural!" weight-loss secret. In short, the world seems to be falling over itself to get its soon-to-be-no-longer-chubby hands on a green coffee extract supplement. We'll all be size zeros in a matter of days.

Of course you know where this story is from. But its also being advertised in stories in glossy magazines and other newspapers too.

Green coffee beans are normal, every day coffee beans before they have been roasted. The roasting process decreases the amounts of chlorogenic acid contained in the products. Chlorogenic acid is thought to moderate effects of glucose metabolism and inhibit fat accumulation- sounds brilliant, right? Well, before I go off, burger in hand, to eat lots of cake safe in the knowledge that I'll be shopping in the size 8 section in no time thanks to green coffee, lets have a look at the evidence.   

Coffee beans. Just more green than usual ones.

First things first: does it work? The short answer is it might do, a little bit, but we don't really know yet. There are a couple of little trials here and there, but they're limited by their size and trial design, so the results could just be fluke. There's one systematic review, which found that overall the data from the better quality trials suggested that green coffee extract could lead to modest weight loss differences (about 2.47kg (95% CI -4.23 to -0.072kg) over about 12 weeks. That's hardly enough to transform my size 16 lumpen frame into a lithe size 8 overnight, or indeed over a year, despite what all the before and after pictures on the manufacturer's websites say.

And what of its safety? Well, in short we have no idea. I've done loads of research into this and have been unable to find any good, reliable information on its safety. Green coffee contains a similar amount of caffeine as normal coffee beans, so we can assume that all of the nasty side effects from drinking too much coffee could also happen with a green coffee extract. Palpitations, anxiety, insomnia, diarrhoea, and heart problems may result, and even anaphylaxis in the worst cases. Some products claim to be decaffeinated, but as none of these products are regulated, there is no guarantee.

There is nothing out there on the safety of chlorogenic acid. It seems to have been used in chinese medicine injections, and seemed to be thought to cause allergies. However it seems that there is some debate about this. One study in dogs seems to suggest that it could have an effect on the liver and kidneys, but whether it could damage human kidneys or livers is unknown.

So there we have it. We basically know very little about green coffee extracts, despite what the websites that are selling it will tell you. It might work a bit, but its certainly not a miracle cure, and we don't really know whether or not its safe yet. It may well be safe, but we just can't say for certain yet. Instead of waiting until more evidence is known, however, it seems that manufacturers are gleefully happy to sell it far and wide.

What's particularly uncomfortable is that the sellers of green coffee extracts are taking the more and more common approach of marketing their products. Google "Green coffee extract safety" and instead of finding reliable sites or those actually looking at the safety of the product, the search is flooded with marketing sites masquerading as genuine safety sites. This sort of marketing feels really icky, and I don't like it at all.

Its yet another opportunity for unscrupulous people to make money from our insecurities. I'm overweight myself, and I know that I have to struggle against the urge to throw my skepticism to the wind and throw money at anything that claims it will help. The simple fact is that there wont be a miracle cure, and losing weight takes time, effort, patience and willpower, not to mention the fact that the desperation to be unhealthily skinny is dangerous in itself.

Hxxx

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. 

Homeopathic Harms Vol 7.1: Professional Ethics

In February 2013, my friend Nancy and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where's The Harm? As a follow up to this, we've decided to write a series of blog posts about a number of points we covered in the talk:  

"Ethics is the science of morals, or moral philosophy. The principles, written or unwritten, that are accepted in any profession as the basis for proper behaviour are the ethics of the profession" -Dale and Appelbe's Pharmacy Law and Ethics

As you'll know by now, I'm a pharmacist. And as such, I have to be registered with the General Pharmaceutical Council (GPhC) to practice in the UK. I'm therefore governed by the GPhC, and in particular their code of conduct, ethics and performance, which has seven main points:

1. Make patients your first concern
2. Use your professional judgement in the interests of patients and the public
3. Show respect for others
4. Encourage patients and the public to participate in decisions about their care
5. Develop your professional knowledge and competence
6. Be honest and trustworthy
7. Take responsibility for your working practices.

If I-or any of my colleagues- were to act against this code of ethics, we could be held to account by our regulator and reprimanded accordingly. Other healthcare professionals- Doctors, nurses etc- all have similar codes of conduct produced by their regulatory bodies. They all have one thing in common- that the patient is central to everything you do, and if a member steps outside this code of conduct, there is a clear and organized route through which complaints or concerns can be raised. This is as it should be: healthcare professionals have the lives of patients in their hands, and need to be held to account if anything goes wrong. As I've written before in this series, homeopaths don't have to register with a regulatory body and anyone can set themselves up as a homeopath with no training whatsoever. Whilst some 'professional' bodies exist in the UK, they have no regulatory powers so are unable to reprimand anyone if they receive a complaint.

Health care professionals who also practice homeopathy still have a duty to ensure that they abide by their regulatory body's code of ethics. In my opinion, however, it is very difficult to reconcile some of the clear guidance with homeopathic principles. Let's take a look at what I mean, using some selected points from the  the first two standards of the  GPhC's Code of Ethics July 2012 as a guide. (I'll cover the rest of the points in another post)

1. Make Patients Your First Concern
Under this heading, the GPhC states that we must "Make sure the services you provide are safe and of acceptable quality". Given the lack of high quality information that homeopathy works, we are unable to guarantee that such a service is of acceptable quality. You'll also know if you've read the rest of this series of blog posts that there is a lack of evidence regarding the harms- both direct and indirect- of homeopathy- so how could we guarantee that it is safe?

2. Use Your Professional Judgement In the Interests of Patients and The Public
There are a couple of relevant points here. firstly we are told that we need to make sure that professional judgement is not affected by personal or organizational interests or incentives. If you're going to charge for a homeopathic service on the side of your usual practice, then there is already a clear personal incentive to promote homeopathy.  We can minimize the possibility of such things affecting our professional judgement by making sure that we use evidence to guide treatment decisions wherever we can: evidence-based medicine is not perfect, but its the most objective method we have at the moment. And, as you'll know, there is no good evidence at all that homeopathy works.

We are also advised to:

 "Be prepared to challenge the judgement of your colleagues and other professionals if you have reason to believe that their decisions could affect the safety or care of others"

I myself-and other pharmacists-have done this: I've spoken out about Tony Pinkus, for example, a pharmacist who endangers patients' lives by promoting unlicensed homeopathic vaccines or sugar pills to prevent malaria. In Nancy's latest blog post, she covered some of this, and I know Adam at Dianthus Med has also been discussing this point on twitter and his blog lately. Its clear-from our own professional guidance-that where patient safety is in danger, we do not protect our own- we need to report, speak out, and denounce those amongst our colleagues who let the profession down.

Homeopaths, on the other hand, seem to have no such obligation. We've been struggling to think of one single example of where homeopaths have spoken out against other homeopaths where patient safety has been endangered. In a conversation on twitter, for example, no homeopath would say that it was inappropriate for a homeopath to have said that a homeopathic remedy could have saved someone who died due to injuries sustained in a horrific gang-rape and disembowelment.  I recently asked some homeopaths on Twitter whether they would speak out against a colleague who put patients in danger. The answer I received from one was shocking:

"When its so easy 2 wink at 1's own sins, seems impossible 2 find judge orjury before whom 2arraign the 1st law breaker. KENT" (sic)- @22VenkateshN

Admittedly this particular homeopath that responded (he was the only one) has a reputation for obfuscation, but this reply seems to suggest that no, he wouldn't report, in case someone did similar to him. I tried to clarify : "so to clarify: you wouldn't speak out in case someone else did the same to you? A yes or no would suffice, thank you". The reply:

"some questions can't be replied with a simple 'yes or no'. for example_ 'are you still mad ?'"- @22VenkateshN

I'm not sure what he is trying to imply by asking about being mad, but we'll give him the benefit of the doubt and ignore any insinuations he might have been trying to make. What is staggering is the reluctance to admit that he would put patient care first and report a fellow homeopath in a situation. As a health care professional-and a good person- the code of ethics  becomes deeply ingrained in your being. Its second nature- and pretty obvious- that you would put the needs of a patient first. I persisted further,  trying to make it easy for him to agree that you would report a colleague: "It's very easy, if you work under clear ethical guidance. homeopaths do have that, right?: patient safety comes first: therefore yes, you would report and denounce a colleague who endangered it." Again, the reply astounds:

"Its not that easy, every one accusing everyone else would result. That's why I tweeted the appropriate observations of Kent"- @22VenkateshN

Wow. So it would seem- on the basis of this sort of conversation and the complete radio silence from any other homeopaths- that no, they wouldn't report or denounce a fellow homeopath because some sort of petty slanging match would ensue. Instead of a clear referral process to deal with complaints, accusations would be flying all over the shop- and one very, very important aspect gets forgotten: patient safety.

I'd love to be proved wrong here. I'd love to think that medical homeopaths or pharmacists who also practice homeopathy would do otherwise, in accordance with their code of ethics. But I'm currently deafened by their silence. If I were one of the more professional, caring homeopaths who really did want to do the best for their patients, I would be utterly horrified and disgusted by some of the claims and actions of others, and I'd want to-nay I'd feel obliged to- speak out against them for the good of my own practice. I'd be embarrassed to be associated with them.

So here's your chance, homeopaths. Speak up against bad practice and drown out the previous deafening silence. Go right ahead: I'm listening intently. And while you're at it, please do take a few minutes out to respond to Adam's Challenge to the Society of Homeopaths too

To be continued...

Take all of it, every scrap

There are many things in life that are not black and white. There are many arguments in which I can see where all sides are coming from, and I can understand the root of why people would disagree with me. Yet there is one area which is consistently contentious, and yet my brain can genuinely not comprehend the other side of the debate.

I'm talking about organ donation.

The news yesterday was good: there has been a 50% increase in organ donation since 2008. And yet there is still a long, long way to go.

"Last year, 125 families overruled an individual's intention to donate."- BBC News

I really, really struggle to understand why anyone would object to organ donation. I just cannot get my head round it. And overturning an individual's decision to donate their organs seems particularly bizarre to me. I understand that in the acutely shocking and devastating situation of a death you might not be thinking clearly, but... I really just don't get it.

Maybe its my atheism. Maybe its the fact that I see death as just that and no more. I don't see it as the start of a new journey into the afterlife, or the first step on my way to meeting my maker. You just die and that's that. So I suppose its easy for me to disassociate myself from the shell that's left. I don't feel creepy about the idea that there could be bits of me in other people: in fact I feel positively proud that I might be able to help in any way.

Religions offer us a legacy. They give us the promise of a new beginning after our death, and so go some way to assuage the fear of nothingness that might follow. But it's a legacy that, in my opinion, is pretty useless. It might be comforting to our loved ones, but in the long term view of things on this planet, that doesn't mean a great deal when there are people whose lives could be made better by a chunk of my flesh being implanted into them when its no longer any use to me.

Not that I think every objection to organ donation is on religious grounds, but I suspect it may be a fairly important part of it for some people. Atheists are often told that we're evil, that we have no morals, and that we are going to hell, but to me it seems that organ donation is clearly the more morally good choice when the alternative is wanting to keep a dead person intact for ceremonial reasons.

Some people just think its icky: the idea that a bit of you will be in someone else. I had an ex-boyfriend who thought organ donation was wrong "because its just weird" (he's an ex for a number of very definite reasons, and this is quite a prominent one). Well, I think a lot of things are icky, but they still get done because they have to be done. I can think of more pleasant things than having a smear test, for example, but I do it because it is a necessary evil. And, one has to remember a key point: you're dead. Things don't seem so icky or weird to you any more because you no longer exist.

Fig 1. Handy flow chart for deciding whether to sing up for organ donation

Surely there is no better legacy than giving parts of ourselves to allow other people to go on living healthier, longer lives. 

And so, your homework is to (if you haven't already), think about it, speak to your loved ones about it, and sign up to the Organ Donation Register

Hxxx

Don't worry 'bout the 'Bute

"Corned beef, with chips or with salad

It's corned beef, even Buckingham Palace eats

Corned beef, so why don't you try corned beef hash"

-Jerry, Phoenix Nights

So today's news (well, what news has managed to slip through the ridiculously large amount of attention Margaret Thatcher's death has been receiving) brings us the revelation that Asda's Smart Price corned beef contains phenylbutazone. I had sort of thought that the FSA's statement after the initial horsemeat scandal might have gone some way to assuage peoples' fear, but it would appear that the media are pretty hysterically reporting about it, and a small sampling of the general public (i.e. my mum) would suggest that people are still worried about it. 

"The levels of bute that have previously been found in horse carcasses mean that a person would have to eat 500 - 600 one hundred per cent horsemeat burgers a day to get close to consuming a human's daily dose."- FSA

Let's have a think about phenylbutazone then. It's a member of a group of drugs called the non-steroidal anti-inflammatory drugs (NSAIDs), the same group as ibuprofen and aspirin. This is reassuring- its not some horrifically toxic chemotherapy agent, or poison, or anything like that. It's a painkiller, related to one of the most commonly used OTC painkillers. That's already looking reassuring. It used to be used in humans as a painkiller, but it was discontinued as it was superseded by other NSAIDs which have a better safety profile.

Whoah there, I hear you say in a panicked fashion. It was withdrawn for safety reasons? What safety reasons? ARE WE ALL GOING TO DIE BECAUSE OF CORNED BEEF? Well, in short: no. Yes, phenylbutazone can be associated with some nasty side effects, as can pretty much every drug going, but these are incredibly unlikely with small (I'll come onto how small later), acute doses from the occasional corned beef hash. Aplastic anemia, for example, is associated with long-term therapeutic use of the drug- usually after about a year. Likewise with leukemia, which has an even less clear association with phenylbutazone. I sincerely doubt that there will be many people who eat Asda Smart Price corned beef in large quantities every day for a year, and if there are, I suspect their heart may be more likely to give out than them suffering from any drug toxicity.

Deadly killer? Definite artery clogger, if nothing else.

Let's say though that you had eaten some. This doesn't necessarily mean that you will have ingested all of the drug. Drug companies invest quite a bit of money in their drug delivery systems: tablets, capsules, injections etc. There's a reason why corned beef isn't used commonly as a drug delivery system: there's no data on stability of drugs within it or its dissolution properties. For all we know, phenylbutazone may well be broken down if its stored in such a substance for any appreciable length of time. stability. When you take a tablet, you don't absorb all of the drug within it immediately. Some of it wont even get through your GI tract or into your blood stream. Some of it will tag onto blood proteins, whilst some might be converted into inactive metabolites by the liver. Only the free drug portion that remains will actually exert any effect. And in this case, the drug has had to go through all this process already in the horse before it even gets into you.


All of this is by-the-by when you get down to looking at amounts.  If you eat 1kg of horsemeat containing the highest possible levels of phenylbutazone, the dose you would get in the worst case scenario is 0.0019 milligrams. Back in the days when it was used therapeutically, the dose given was 100mg every 4 hours.

The corned beef in question has been found to contain 1% horse DNA. Lets say that's all horsemeat. And lets say this horsemeat had the highest possible levels of phenylbutazone in it.

If you ate an entire 340g tin, you'd  a)be fairly greedy or hungry and b) eating 3.4g horsemeat:

3.4g horsemeat= 0.0000019 milligrams phenylbutazone

Now, by my reckoning, that works out as having to eat 100,000,000 tins of Asda Smart Price Corned Beef to get the equivalent of two therapeutic doses (and its only half of the recommended loading dose). Even by Adam Richman's standards, that is a hell of a lot of corned beef. And remember, you'd have to eat that for approximately a year before you got any of the nasty side effects.

So really, don't worry about the 'bute. The amount of salt in there is more likely to cause toxicity first.

I'll leave you with this video: It's been running through my head all day so I feel like I should make you all suffer too :)

Hxxx

Happy Birthday, Dr Hahnemann!

I baked you a cake for your birthday! A homeopathic one, obviously.

In defence of Dirty Dancing

A little while ago, I asked for feminist film suggestions on Twitter. I was almost drowned with enthusiastic responses, and will hopefully be able to categorise them all into some sort of blog post at some point.

One suggestion really stuck out in my mind. @ayiasophia suggested Dirty Dancing, but also mentioned that she had gotten some stick for suggesting it as feminist in the past. Now I must admit, I did scoff a little myself for a few seconds. But then I thought about it. Could Dirty Dancing, in actual fact, be one of the most quietly fervent feminist films around?

Firstly: allow me to declare that I love this film. I've watched it many, many times: on my own, with friends, in a packed cinema with smuggled in wine (yes, we ended up dancing in the cinema, but its okay because everyone else in there was too), I've seen the stage show twice. Most of all though, I remember this film from my childhood. If the weather was bad, they used to let us watch it on video instead of PE. My mum and I knew the soundtrack off by heart. To this day, She's Like The Wind makes me weak at the knees. However, its always felt a bit guilty, loving this film. After all, its pretty frivolous, right? or is it?

When I was younger, the subtleties of it totally passed me by. It was, as far as I was concerned, a film entirely about kicking bridges, pretty dresses, dancing, and of course watermelons. I even remember vaguely wondering what was dirty about it. Of course, when you watch it as an adult you realise they're lolling post-coitally around in bed for a lot of the time. And they used to show us it in school!

Baby is, it's safe to say, not defined by her looks or sexuality at the start of the film. She's smart, and she's going to change the world. She's not what would be considered particularly beautiful. Her sister, on the other hand, is defined by her looks. She's that stereotypical, air-headed woman who thinks her appearance is what matters.


My views of feminism are strengthening constantly these days. It's tempting to define it as not needing a man, but I think it's a real shame to exclude men and relationships from a working definition of feminism. In my opinion, a feminist heterosexual relationship is one in which you are free to be consumed by love at its frightening best, and yet its about not being defined by your relationship with men.

At first glance, this film is about getting the guy (and what a guy!). But when you think about it more deeply, the reasons why she gets the guy are really important and quite admirable. It is her ideals, her intelligence, and her ability to be an all-round decent person that gets her the guy rather than how drop-dead gorgeous she is. Her sister, who does try to use her looks to get her way, fails miserably. There's also that pro-choice storyline, and who could possible forget Jonny's speech about how he's used by rich women- he's the one who is objectified here, not Baby. 

What? This blog post needed a picture. Its hardly my fault if a half-naked picture of Patrick Swayze just happened to present itself to me. Its not objectification, honest.

So, when you think about it, its actually the perfect film for the school to have been showing us as children, and for my Mum to watch with me time and time again. Its about a young woman who learns that she'll be loved because of who she is, rather than what she looks like. Its about her learning about and pretty freely enjoying sex and love but not being defined by it. She is her own person throughout and at the end... Well, off she goes, like the wind.

I've noticed that a few of the feminist films that were suggested centre around revenge, usually against men. But there's none of that here. There's an acknowledgement that men are

So anyway, that's what I think about it. And its only a co-incidence that its my birthday soon, and I'm planning a little get together at a local cinema with a private viewing of a film of my choice. As I'm known as being somewhat of a self-styled-but-very-terrible-at-it film snob, I would need some good justification for choosing this film over something Korean or existential. Being a leading feminist flick would be a pretty good justification, right?


Hxxx

A particularly awkward situation.

I've written once before about my decision to be child-free, when I wrote a bit about the generic awkward conversation which invariably happens. This time I want to tell you about one particular situation in which child-free women frequently find themselves: The Holding Of The Baby.

Shamelessly stolen from GodlessGirl.com, but very, very apt.

Now I'm lucky in that my friends and family are, on the whole, very supportive of my decision. It's become a running joke at work that if there Is a baby about, I get forewarned so that I can find somewhere safe to hide in time. I'm lucky in that my workmates and friends know what I'm like, and they don't tend to take it as a personal slight when I don't turn into a gooey mush at the sight of their cherubs. They even usually manage to smile politely when I refer to their child accidentally as "it".

However, I'm not always so lucky, and the Holding Of The Baby ritual can be one that is so cringe-worthy that even writing about it now sets my teeth on edge.

I have no interest in holding a baby. I'm clumsy, and likely to break it, which apparently isn't the done thing. I also just don't see the point of it: I can see perfectly well that its a baby from where I'm standing, thank you very much. I'd go so far as to say that holding a baby or child terrifies me. I remember on one occasion being at the ex-husband's sister's house with her two kids snuggled in cuddling me. Whilst I was informed that this was a touching scene externally, I was in total, full-on terror mode internally, with cold sweats, palpitations, and adrenaline generally screeching RUN AWAAAAY!! In my ear.

At first, they act like its a game. "Ooh, let's see if we can get H to hold the baby, that'll be funny". I can cope with the joviality initially, skipping around and performing various feats of ducking, diving, and slapstick comedy to get away. And then there's a point when it's not that funny to me actually. I really, really do not want to hold it-I mean him or her- thank you.

"Oh go on"
"No, really, it's fine. I'll just break it- erm him or her I mean"
"No go on, it'll be fine"

And so, I am trapped. There is nothing At all that I can do to get out of this situation, so I'm going to have to hold the baby. And I know exactly what's coming, and I know that it's going to end up in disappointment for us all.

So, the bundle of joy is handed over, usually with the involvement of a precarious moment in which I narrowly avoid accidentally breaking its neck, and the following happens;

......
......
......

That's it. Nothing at all. All I think about is "when will this be over?" Or 'please cry so I can hand you back' or 'if you release any form of bodily fluid onto me I will be very, very unhappy'. And then I look up to observe a sea of expectant faces, all waiting in unison to see the miraculous conversion of the child-free to broody desperation to have a thing of such perfection in my life.

'After all', the parents might have been thinking, 'my child is THE most beautifully cute, wonderful,  overwhelmingly brilliant bundle of perfect genius that has ever lived. My baby is special, and better than everyone elses' normal, run-of-the-mill babies. She probably just doesn't want children because the only children she's been introduced to so far pale in comparison to my child. "As soon as she sees my child, that's when the maternal instinct will hit' Of course, I have no idea if this actually is how parents do think, but it may be one explanation for why The Holding Of The Baby is often forced upon the child-free.

So what is one supposed to do in this situation? Well, I could lie, but I'm a truly a terrible actress. So instead I imperceptibly shake my head sadly and try to say something bland and apologetic. I'm sorry that your child isn't special enough to convert me, I really am, but it isn't. The doting parents are left disappointed, the spectators slump away like they've just witnessed a thorough trouncing of their favourite team, and I'm left crushed and embarrassed  that I'm the reason for all this disappointment.

It's really not a nice feeling. And it could be very easily avoided by just acknowledging that not everyone wants to hold babies, not even yours.

If you're a parent, you might think that I'm being confrontational and unfair here. But all I'm asking for is that my life choice is respected. I wouldn't bring my cat into work and force those who dislike cats to hold him, as I respect the fact that some people don't like cats or want them in their lives (I also know my cat is a particularly violent individual and I don't want any lawsuits for loss of eyes or limbs, thank you very much.). It would just be lovely to have a refusal to Hold The Baby accepted unquestioningly.

Hxxx  

Homeopathic Harms Vol 6: Self-awareness & self-criticism

This post is a taster of the the next in our series of blogposts following on from our SITP talk about the harms of homeopathy It's written by the marvellous @Skanky_fish

You can find the full blog post over at her blog, Evidence-Based Skepticism

One of the most important mechanisms that people have for regulating their own behaviour is feedback from other people.  This happens from the day we’re born – babies learn that some behaviours earn a smile so they repeat them; toddlers learn that other behaviours get attention, so they repeat them.  As adults we do exactly the same thing – we learn behaviours that make us successful friends, partners or parents based on how people react to us.


This carries over into professional life too, and in some professions is even put into words as codes of conduct, or ethics.  We learn what is and is not acceptable by seeing how people respond to our actions.

Amazon Sometimes Frightens Me, If I'm Honest.

A while ago, +Adam Jacobs or @DianthusMed brought to my attention to the fact that Amazon UK are selling unlicensed medicines imported from the US via its Marketplace whilst he was looking for some anti-allergy medicines. Adam got in touch with Amazon, and the particular brand he bought are no longer available on their website, but of course there are still a whole range of other unlicensed loratadine brands available to buy with just one click.

I dug a little bit deeper and discovered that this could actually be more dangerous than some non-drowsy anti-allergy medicines- along with some problems selling licensed medicines as well. 

Some inane browsing brought me to a page selling Syndol. I noticed it because of the price- its being sold at a whopping £39.99 for 30 tablets. I presume this is due to the fact that Syndol are currently on a long term manufacturing problem. Syndol do have a UK product license, and are sold over the counter in pharmacies. They're kept behind the counter for a number of reasons, and require quite a lot of patient counselling for appropriate use: they contain paracetamol, therefore shouldn't be used in conjunction with any other paracetamol products (they're one of those shiny combination products which people might not realize contains paracetamol). They contain codeine, which is very addictive and should be used for no more than 3 days at a time. They contain doxylamine, which causes drowsiness, making them even more abusable and dangerous. I use these occasionally myself if I get horrible, migraine-type headaches. They seem to work, but I also sleep the sleep of the dead for 5 hours, then wake up feeling zombie-like for a good few hours after that. If I sell these over the counter, I check that the patient isn't using them regularly, that they understand about the paracetamol, and that they will make me drowsy. Whilst the sellers do state they might need more information from you before selling them, they seem to me to be pretty inappropriate for an internet sale- sometimes you can tell if a patient is misusing them by their body language etc. the largest pack size it is available in is 30, for all of these reasons.  And charging £39.99 for an addictive substance which is out of stock elsewhere just seems manipulative.

And here's the  most horrifying thing: Amazon, trying to be helpful, suggest a package that we can buy, based on what other customers have bought together:

Umm, right. So Amazon have been selling Syndol + Syndol+ Sleep Aid, an unlicensed US product (doxylamine) together, and they're suggesting we do the same. This combination, if taken together, could well be deadly. There's the issue of paracetamol toxicity, codeine and doxylamine addiction, and  the potential for self-harm to consider here.

This is, of course, just the tip of the Iceberg, Click on the Sleep Aid tablets and you're encouraged to buy Sleep Aid, Sleep Aid and Unisom. Click on Sominex (a UK-licensed product) and you're advised to buy it alongside Sleep Aid and Nytol. Any of these combinations have a huge potential to harm.

I'm going on about licensed and unlicensed products here. So what am I on about? Well, in the simplest terms, a product that is licensed in the UK, and used according to the manufacturer's instructions, is guaranteed to have met certain standards of quality, efficacy and safety. If it hasn't got a license, you haven't got that guarantee. It might be fine, or it might be made of rat poison and brick dust, you just don't know.

I know I get taken in by these packages on Amazon all the time, when I'm buying DVDs or books, or other items. At least none of these are going to have that much of an effect on my health (although I'm sure some would argue that my love for Korean extreme horror must be having some effect).

This sort of multi-product purchase encouragement goes against many of the reasons why products are sold through a pharmacy in the first place.

Amazon have been through the mill lately, what with the Keep Calm and Rape T-shirts and their selling of unlicensed cancer medicines. Well, I'm going to add my little chirp to all that noise too. I'm sure there are complicated technical reasons behind why they have this frequently bought together sections on medicines, but frankly I don't care.

Hxxx

Some thoughts on quality and quantity.

The sad news about Iain Banks has gotten me thinking today.

I'll be honest here and say I've never read any of his books (so many books in the world, so little time!). I know nothing at all about him. Yet when I read his statement at work this afternoon, I had tears in my eyes. His words were so dignified, so stoical, and so noble that they really touched my heart. The ability to have humour at such a time is something I admire hugely.

I'm sure his words are the tip of the iceberg. I really can't even begin to understand what a lengthy, horrific process it must be to come to terms with such news. But what struck me most of all was his plans to spend his remaining time with his family, friends and loved ones. Isn't that, when it comes down to it, what we would all want? And yet it seems to me that cases such as his appear to be in the minority of those that are reported in the media.

Many moons ago, at university, I went to a lecture by Sir Michael Rawlins. He discussed the thorny issue of how NICE assess drugs, and he touched upon quality of life measures. I remember being utterly shocked when he said that the majority of terminal patients choose longevity over quality of life. That's always stuck with me, as it seems so starkly counter-intuitive to me that I genuinely can't get my head around it. I also know that's very easy for me to say, and that I have absolutely no idea what it must be like to have to face such decisions. A few years ago I did my Diploma in Therapeutics, and we had to try out some of the quality of life rating scales that are used at NICE. Believe me, this really gets you thinking about how difficult these sorts of choices are. I also remember a really brilliant workshop with Claud Regnard, a palliative care consultant and author of some highly-esteemed books in the field. I remember being bowled over by how positive and creative such a potentially depressing subject could be.

We're a nation (and potentially a planet) that are very medicalised. We hunt for a cure for everything, and a miracle pill to make us cleverer, slimmer, healthier. When given the choice between taking a tablet and changing our lifestyles, I think it's safe to say that most of us would rather opt for the former. This is fuelled by any number of things, but I think the media has a lot to do with it: there's always a story about how some new drug is going to cure Alzheimer's, or obesity, or heart disease, and there's story after story of families desperately searching for a cure or treatment that can cure their love ones.

And here's what I've been thinking about: when all the options have been explored, and there is no cure, practitioners of conventional medicine (by which I mean medicine which is proven to work) will usually tell you so.

At this point, the quest for something else, perfectly understandably, kicks in. Of course you would grasp at any straws, any vestige of hope. And so, right at the time where people should be spending their days doing what they love with the people they love, as Iain Banks is doing, some of them turn to alternatives.

It could be weird diets, it could be homeopathy, it could be a certain well-known quack's clinic in Texas, it doesn't matter. What all of these things do is sell hope when all else has failed. They're a very seductive prospect, and it may well seem perfectly logical that you'd spend every penny in trying them, and you'd leave no stone unturned trying to find the perfect treatment for you, or your loved one.

Just at the time when you should be kicking back and enjoying your time as much as you can, you end up on a plane across the world, which is stressful enough for anyone at the best of times. Or you might end up on a strict diet regime, having to deprive yourself of the foods you love just when you should be enjoying them more than ever. You might end up a slave to a complex regime of megadose vitamins, enemas, pills and injections when you should be being made as comfortable as possible with palliative care.

These people who sell false hope rob patients not only of their money, but of their precious time as well. And that, in my opinion, is the most evil and unforgivable of sins.

I hope that, eventually, we get to a place where a quality life and death become the most important thing to anyone with a terminal illness.

This is yet another blogpost where I feel the need to write "hope this all makes sense" at the end. I probably should just plan posts better, but I've always found I'm usually better at just writing as I think at times. My humble apologies also for any typos... I'm absolutely rubbish at touch screen typing


Hxxx