Special Investigation: Is Santa Really A Pharmacist?

Despite him being one of the most famous people on the planet, we know a suspiciously small amount about Santa Claus's background. I've had the suspicion for some time that he may in fact be a pharmacist throughout the rest of the year. 

A quick check of the GPhC register brings up no S. Claus’s, though of course that only rules out pharmacy practice in theUK. Unfortunately it would seem thatLapland does not have a similarly searchable pharmacist register, so we are unable to confirm his registration status in his home country. However, if Santa were to be working overseas, it would seem that Your Family Pharmacy, 15 N Kringle Place, Santa Claus, Indiana would be his first choice, especially given its prime location near to Lake RudolphCamping Park. (honestly, this place exists)

Santa is, of course, most famous for operating a highly efficient free delivery service. No doubt these skills have been honed throughout the rest of the year, as he organises a prescription collection and free delivery service to his patients.

As the song goes: “He’s making a list, he’s checking it twice”, demonstrating that Santa is following robust self-checking procedures. It is clear that he has the sort of attention to detail that is required by pharmacists. It’s also clear from this song that he is aware of NICE guidelines.

It seems clear that Santa’s system of working, is synonymous of that in a community pharmacy. He works alongside a team of highly skilled and well trained elves, though retaining legal responsibility for all that goes on in his workshop. One assumes that, on visiting the workshop, his Responsible Father Christmas sign is clearly displayed.

Perhaps the most convincing evidence is that of his links with the Coca Cola company. Santa has a long history of advertising the product, adding a splash of red and a liberal helping of fur to his usual pharmacy white coat. Its good to see that Santa is so devoted to advertising the invention of  fellow pharmacist John Pemberton, who originally invented the drink as a cure for his own morphine addiction. Santa is clearly interested in harm reduction and no doubt works closely with local drug and alcohol teams during the rest of the year to dispense opioid replacement therapies for patients.

Santa Claus, however, does have some flaws as a pharmacist. As discussed in the BMJ, he appears to pose a number of public health risks, including as a vector for infectious diseases, and in the promotion of drink-driving. It would seem that he would benefit from a visit to his nearest Healthy Living Pharmacy, where he can access advice on reducing his weight and brandy intake. It is good to note that he successfully quite smoking and seems to have remained abstinent.

Hxxx

The Difference A Year Makes.

“Maybe this Christmas will mean something more
Maybe this year love will appear
Deeper than ever before”

-Tracey Thorn, Maybe This Christmas

This time last year, I was writing this post, collecting together songs that I felt best summarised why I find Christmas such an emotional time.

Of course, I’ve been listening to that playlist on repeat for weeks this year too, but it sounds different to me this time round. Its transformed from a quietly melancholic collection to one of optimism.

This time last year, I was steadfastly single. I refused to believe in love in the same way I used to do in the past. I had never even said the word to anyone else (except for friends) for years. I was stubbornly resisting the advances of a man who I knew to be very wonderful, on the basis that I would likely just mess it all up anyway and hurt him, given that I was, in my own head, such an awful and cynical heartless monster who would clearly ruin his life.

Luckily, my willpower (helped along by a fair amount of beer) failed me eventually and we went on a date in January. This is probably the best decision I have made, ever. What has followed has been better than I could have ever imagined. I’ve gone from refusing to acknowledge the L-word to telling him many, many times a day that I love him. He puts up with me and my mood swings, is happy to leave me alone when I need social recharge time, and is just really quite marvellous. He makes me laugh despite his cracker joke-level sense of humour, gives great hugs, and most importantly buys me Lego. For the first time in blummin’ yonks, I feel safe, and like I’ve come home.

“So happy new year, this is the one we talked about and

Happy New Year, this is where it all works out

This is where is comes together and everything comes through

Happy ever after all comes true”

-Simma, Happy New Year

So going into this new year, everything seems different. We’re moving into a new house together, and I really can’t wait. The cat and the hamster have double-barrelled surnames. I have a new job lined up, though it’s in the same centre and will involve moving a mere several metres across the office to a different desk. I still worry that it’ll all come crashing down at some point, but I’m managing to keep those thoughts in check and just enjoy it all for the most part.

Hopefully I’m not sounding too smug here. I just want you all to know about the good things that happen, since I tell you probably far too much about the bad stuff. I’ve had some amazing e-mails in the past from readers who have been through similar experiences to me, and I’d like you to know that things can change and can end up even being miles better than they ever were before.

I hope you all have a wonderful Christmas and New Year. I know this time of year can be really hard for some. I send my love and hugs to you. 

Hxxx

The Prometheus Pants Problem Explained

Prometheus. It’s the film that disappointed pretty much everyone. The internet is flooded with in depth critiques of it, many of which refer to the lack of real science, along with the deep metaphysical and philosophical issues with it. All of these posts, however, have missed what I found to be the most problematic feature of the film: Underwear.

And yes, I know it came out two years ago, and it’s a bit weird to be writing a blog post about it now, but I’ve found myself trying to explain the Prometheus Pants Problem (PPP) to a few people, both verbally and on Twitter of late. Its complexity and importance means that 140 characters will just not do, and I think it is important to have a robust reference source to refer people to when explaining all aspects of the PPP.

It is important to note, I think, that in actual fact I vaguely enjoyed Prometheus. When I saw it at the cinema, I hadn’t seen any of the Alien films (I know, I know), but I thought it was worth a shot anyway. I found the running about with lots of alien goo stuff flying about fairly entertaining. The problems came when they kept interrupting the frivolous alien romp bits with Important Thinly Veiled Stuff About God, which made me rather lose patience. And, of course, I ended up pretty fixated on the PPP, which meant that I couldn’t think about anything else in the film. I’m like that- I’ll fixate myself on one tiny thing that happens for a millisecond, and then spend the entire rest of the film thinking and internally ranting about it.

1.       The Need for Pants At All.

Let’s be honest with ourselves here. You get in from a hard day’s work. You’re not expecting anyone. You’ve got a whole night of delicious nothingness stretching ahead of you. Its toasty warm in your home. What’s the first thing you do? You take off your uncomfortable outer wear, and let it all hang out, right? I mean, no one is going to see you and you’re in the comfort of your own home, so why the hell not wander around in all of your naked birthday suited glory if you want to?

Perhaps you wear your PJs instead, or a pair of comfy pants. That’s probably because, deep down, you’re sort of somehow worried that someone might see. You might get an unexpected visitor, or the pizza man might be arriving at any point. But imagine for a second that you are the only person alive at that point in time. What’s the point in clothes then? Especially if you can absolutely, categorically be sure that you’re the only one, because you’re the person who creates lifein the first place, and you haven’t yet drank the wormy goo that you need in order to do so yet.

So, in the opening seconds of Prometheus, we’ve got our engineer guy, on a planet in which he hasn’t yet created life (except for, well, all the plant life that is already there, but I think we’re supposed to ignore that). Now, never mind your front room, imagine having an entire planet all to yourself. Would you wear pants? Of course you wouldn’t. Any sane person would be running about joyfully, jiggling here there and everywhere, enjoying the sense of freedom. You’d let every little bit hang and flop about as much as you like, because who is going to be there to judge?

2.       The Need For Pants At All Part 2.

We don’t ever see any Female Engineers at any point in Prometheus. Thanks for that bit of everyday sexism, Ridley. The Baldy One does not seem to require any sort of sexual act to create life: just a shot of tarry goo, and that’s that.

 So on this basis, would they even have genitals at all? And even if they did, why would they be considered a special part that needs to be nestled away from prying eyes, if the reproductive act doesn’t need to take place? 

3.       Disappointing Pant Technology

Let’s play devil’s advocate here for a while and accept that pants are required for some unknown reason. This then leads on to another problematic issue.

These engineer types appear to be pretty smart. After all, they are the purported creators of life itself, right? Yet with all of their super advanced technology and supremely high IQs, the best they can come up with is a couple of bandages wrapped around themselves, nappy-like.

That just doesn’t ring true to me. Even our lowly human selves can come up with better pant technology than that. We have all sorts of colours, fabrics, designs, access holes, fastenings, elastic etc. But no, this superior life form instead decides to wrap some bandages around its crotch. How much of a faff must those things be to get into? They’d be a right clart on to get back out of if you need a wee. Do they need someone else to help them put them on in the morning, holding the bandages while they spin themselves around? How undignified and inconvenient.

4.       Lack of Pant Technology Evolution

This first engineer scene is Prometheus presumably takes place thousands of years prior to all of the kerfuffle depicted in the rest of the film. And yet, we are supposed to believe that pant technology has remained starkly primitive through all of this time?

The evidence for this is Noomi, who is merrily wandering around, post-surgery, wearing what is clearly another pair of low tech bandage pants, along with a matching bra. What’s happened to underwire technology? Why are people from this time still wearing the same design of crap pants as their creators? Surely, in the intervening millennia, someone would have realised elastic exists.

And that, dear friends, is a brief examination of the Prometheus Pants Problem. I’ve seen it creeping into other films since (most recently Guardians of the Galaxy), and I won’t rest until these important questions are answered, in full.

Other things to note about Prometheus:

-They appear to use Joseph Joseph kitchen implements. Nice to know that this mid-range kitchenware design brand is still going strong that fair into the future.

-Wandering around important historic sites that have been sealed off for thousands of years should probably be done in a more respectful way, if you’re wanting to preserve it for proper research. One guy says at some point “We’ve changed the atmosphere in here”. Well, yes, yes you have, though its nowt to do with the inherent evilness of mankind, and everything to do with barging in, blithely breathing your modern germs all over everything. If a door has been shut for thousands of years, I’d imagine that yes, it might get a little musty in there. Opening the door and allowing a bit of fresh air in is likely to change the atmosphere somewhat.

-The Dead Head that explodes: Apparently the theory behind this is that this head, reawakened after a very long time, can’t cope with how crap, evil and corrupt the world now is so it explodes. Now, I’m no expert in these matters, but I’m pretty sure that exposing a thousand year old corpse to all sorts of new atmospheres might well lead to a build up of some gases, which on electrocution, may well then explode.

-The most obvious plot hole of them all, which has most probably been covered in great detail elsewhere, still annoys me. Noomi’s oxygen is about to run out, and its all very tense indeed, but then phew, she is okay. However, it appear to magically recharge itself somehow whilst she tends to her errant offspring, as when she needs it again afterwards the oxygen level in there is just fine. Grrr.

Anyway, I’ll shut up for now, though I won’t apologise for bringing this important matter to your attention. And yes, you will now be forever destined to notice intently all pants being worn in any sci-fi movie, and yes, it will probably ruin all enjoyment for you. You’re welcome :D

Hxxxxx

Advert Annoyances Vol 1: Senokot

Welcome to the first installment in what is likely to be a very sporadic series. As you've probably guessed by now, I have a tendency to be irrationally annoyed by small things, especially when it comes to medicines. Adverts for OTC meds can be a prolific  source of cringes. Even leaving aside the requests for "you know, that one on the telly, where there is a guy and a dog and its a blue box", there will occasionally be a little phrase or image used in these adverts that makes me stop and seethe a little.

The current one at the moment, is Senokot. I can't find a link to the new advert, but when I do, I shall pop it in here so you can see for yourself.

There's all sorts of naturalistic fallacies going on, but that's not what annoys me the most. It's the phrase " works in harmony with your body" that i'm finding hard to stomach (geddit?)

Put simply, senna works by irritating your bowel. Your bowel notices that it is being hurt by something, therefore starts contracting and producing secretions to hastily get rid of the thing hurting it.  This then might make you poo, but from your bowel's point of view that's a side issue- its just trying to protect itself from harm.

That doesn't really sound to me like "working in harmony". You might as well say that fire works in harmony with human skin to make you walk faster- in actual fact, one is just out to hurt the other, meaning something else happens as an unintended- but sometimes useful- consequence.

Hxxx

it's Thyme to Bronchostop this nonsense

I’m sorry, I just could not resist that headline.

Whilst working a locum shift the other week, I noticed a couple of new products had leapt their way to the pharmacy shelves. “Bronchostop”. Sounds interesting, I thought, until I moved a bit closer and noticed that they are, in actual fact, a herbal cough remedy, and my vague excitement was replaced with a bit of my soul dying. Then I saw the price tag, and the anger kicked in.

Brought to us by our old friends at Omega Pharma, Bronchostop syrup contains thyme extract and marshmallow root, whilst the lozenges just contain thyme extract. Omega claim that it “relieves any type of cough”, and that it “takes the hassle out of choosing a solution”. Well, I must say, I’m pleased to hear that, because I find one of the main stressors in my life is choosing which cough remedy to use. I mean, it’s just so complicated to decide if you have a dry or a chesty cough, then realise that it makes no difference anyway as most cough medicines don't work, so you then just by a cheapo honey and lemon thing to make yourself feel placebo-ey better. 

So, given that the great all-consuming cough medicine dilemma of my life has now been sorted out by Omega, I can spend some quality time looking up the evidence to see if it works.

It turns out that there are some preliminary trials which suggest thyme might improve cough symptoms. However, these all use specific cough syrups with different combinations of ingredients compared to Bronchostop, so they’re not very helpful. Because the product is being sold as a traditional herbal remedy, the manufacturers don’t need to bother collecting any evidence that it works before it goes on sale- their claims are based entirely on “traditional use”, which means nothing at all scientifically.

One attempt at a clinical trial compared thyme syrup with a “real” expectorant, bromhexine, and found no difference over a five day period. There are a number of problems with this though- firstly, bromhexine isn’t commonly used in cough medicines. Secondly, there’s little to no good evidence that expectorants work anyway, so we’re comparing something that may or may not work with something that doesn’t.

Worryingly, the websitewww.bronchostop.co.uk contains absolutely no safety information whatsoever. It doesn’t tell you who can’t use it, who needs to be careful using it, or what any of the side effects might be.

What side effects could it possibly have, you’re wondering. After all, its just a herb. We eat it, so it can’t be that bad, right? Well, sort of. The amounts used in food tend to be a lot lower than when it is used as a herbal medicine.

On the whole, thyme is well tolerated, but occasional gastrointestinal effects can occur. Uncommonly, and more seriously, people can have allergic reactions to it. It can interact with drugs, including those that thin the blood, those used in Parkinson’s disease, those with anticholinergic or cholinergic effects, oestrogens (research suggests it may decrease the effects of HRT, but theoretically also the contraceptive pill), and non-steroidal anti-inflammatory drugs. It may cause problems in people with bleeding disorders, who are undergoing surgery, or who have hormone sensitive cancers. We have no idea of the effects that medicinal amounts of thyme can have in pregnant or lactating women.

It seems to me, however, that its main adverse effect will be on your bank balance. This stuff is £8.99 for a 200ml bottle or £4.99 for 20 pastilles- that’s a whole lot more than simple linctus, which is about £1.50 and which will probably do just as good a job.

Hxxx

In memory of Rachel

I didn’t know Rachel at all. But I was told her story last night, and all of today I have been thinking about her. I don’t know how old she was, what her life was like, the colour of her hair, whether she spelt her name with just an 'e' or if there was an 'a' in there too. 

It sounded like Rachel was a nice person. It sounded like she was enthusiastic (I think she met the teller of her story whilst volunteering for something).

Rachel was diagnosed with bipolar disorder. She was encouraged to try homeopathic treatment for it, and to stop her conventional medicines.

Several days after stopping her medicines, Rachel took her own life.

Many of you might remember that I blogged about a homeopath’s response to my good friend’s request for help for her own bipolar disorder. At the time, I theorised that, had my friend followed this homeopath’s advice, she would have destabilised and it would have killed her. 

I’m so, so sad that this happened to Rachel. I often get questioned about why I do what I do, why I rant on about homeopathy and alternative medicine so much. If other people want to use it, I’m told, then just leave them be. But how can I sit back and not do anything, when there are other people out there just like Rachel? If I can make any difference at all, even a tiny one, then I will do. If I can make even just a couple of people raise their eyebrows and wonder why homeopathy is still used in this day and age in place of effective treatments, then I’ll keep doing what I’m doing.

Sorry, Rachel. I’m really sorry that this happened to you. I didn’t know you, but I’m sorry that you went through all of that, and I’m sorry that your friends and family and the world lost you.

Hxxx

to study pharmacy, or not to study pharmacy?

I always wanted to be an archaeologist, growing up. I knew, however, that this was probably a pipedream- partly because I dislike creepy crawlies, but mostly because I was pretty sure in my childhood brain that everything interesting would have been dug up already by the time I was old enough to work.

Turns out I was wrong about that, but I’m still really proud of the profession I ended up in. I remember wandering up to the local shops with my Mum when I was little. We were talking vaguely about the future, when we had a little nose around the local chemist’s shop, cooing at the colourful bubblebaths and hairgrips that they had in stock.

“I know”, Mum said. “Why don’t you become a pharmacist?”

“What’s one of those?”, I asked. As far as I was concerned, the chemist’s shop was a place to buy cheap make-up and bath salts.

“Well, they stand in the back and mix up the medicines”. That’s it, I was hooked. I had images of brewing potions, mixing up gloopy ointments, and all sorts of stuff that, it turns out, in real life you only actually get to do for a couple of hours as an undergraduate. But my decision was made, and all the rest of my life I knew I was going to be a pharmacist.

As I got older, and I started telling people what I wanted to do, I used to hear nothing but positive things. I worked as a counter assistant in my local super market, and locums always used to tell me “You’ll never be out of work. Everyone is always desperate for pharmacists.”

At the time I graduated (2006), it still hadn’t been that long since the Great Pharmacist Shortage. This happened because the old style three year degree now became a four year Masters degree- so there was one year where no newly qualified pharmacists came on the scene. Everywhere you looked, people were crying out for a full time pharmacist to work for them. Whatever happened, you always knew that you could locum as a back up, and earn a good wage doing so.

As university went on, and I started applying for pre-reg places, I got worried. Not because I didn’t think I would get a place- in actual fact I was being courted by several companies, all of whom were clamouring to fill their pre-reg spots. I think I did maybe 10 interviews, and I got job offers from every one of them (and believe me, some of those interviews I was really quite atrocious in). No, I was worried, because I wanted to do my pre-reg in hospital, and I knew that pre-reg places really were limited in my local area- only 7 for the whole city.

I was lucky, and I got in. My year was really lucky, as it turns out there were enough jobs going for each of us pre-regs- though I actually went elsewhere. Whilst community pharmacy jobs were plentiful, hospital pharmacy was a lot more difficult to get a job in.

Nowadays, it has changed so much. I don’t think I can ever really hear myself saying the sort of things I was told to an enthusiastic school child now. “You’ll never be out of a job” would just simply be a massive lie.

When I was choosing universities, there were only a handful that actually offered pharmacy as a degree. In recent years there has been a proliferation of universities offering it now though, and as a result, the number of graduates is increasing year on year. I’m sure this isn’t the whole reason, but we have now reached a point where pre-registration places are becoming really hard to come by. There is a group of potential pharmacists, year on year, who will simply never be able to get a place anywhere.

So what does that mean? Well, you can’t register as a pharmacist, so you can’t work in your chosen profession. You’ve still got a Masters degree- but you’re actually pretty limited as to what you can do with it. Sure, its equivalent or better than a pharmacology degree, but you’ll always have a question hanging over your career, whatever you choose to do: “If you’ve got a pharmacy degree, why aren’t you a pharmacist?”. There’ll always be a slight, unfair, cloud of suspicion there. It means, even for those lucky enough to get pre-reg places, that jobs are more and ore difficult to come by, wages are being lowered despite responsibilities and workloads being higher, and locum shifts are both hard to get and pay an awful lot less.

Several places that I do locum shifts for have an email alert system for new shifts. On several occasions, I have received an email, checked my diary for my availability, then rang back immediately only to be told that all the shifts have gone already. The good thing that comes out of this is that, once you get your foot in the door, there is an incentive to work hard and become known as one of the best, most hardworking locums, because then you will get offered shifts first. The bad thing is that its now really hard to get that first step on the ladder.

How do we fix it? I have no idea, as it’s a multifactorial problem. A cap on the number of students studying pharmacy does seem logical, but that’s already been stamped upon by the Minister for Universities, science and cities Greg Clark MP, who has said:

“Having considered the evidence I have decided that it is not necessary to introduce a specific student number control for pharmacy. The government's objectives for pharmacy can best be achieved outside of a number control system. It is the government's policy to remove student number controls wherever possible to enable students to have greater choice and to encourage universities to offer better quality courses to attract students. I believe pharmacy students can and should benefit from this reform and not be restricted. Therefore there is no need to consider further options for a pharmacy number control.”

It seems to me that the one thing that Mr Clark isn’t considering is those students. Yes, they might have greater choice, but I wonder, if asked, where their priorities lie- would they rather have more choice, or would they rather have some security in their future. I wonder if it has occurred to him to ask them directly.

So it is that I, and a number of other pharmacists, are sadly starting to discourage students from looking at pharmacy as a profession. Its through no fault of their own, and its brilliant that so many young people want to be pharmacists- but its hard out there, and its only going to get harder. Our bright young potential pharmacists might be better off opting for a less focused, vocational degree.

Hxxx

Coldzyme: a result of real science being left out in the cold

There’s no getting away from it, folks. Its sniffle season. For the next 6 months or so, the sounds of sneezes, coughs, and millions of noses being blown will echo throughout the nation.

We all know by now that the common cold is a virus. We all know that there is no cure. We also all know that, although you feel like crawling into a small dark warm cave and dying at the time, its usually much better after a few days, and it goes away of its own accord. Cold and flu remedies do nothing to actually get rid of your cold- they are there to make you feel better during it, although many of them are actually irrational combinations of products in shiny boxes with a redonkulously high price.

It is often said that if someone did come up with a cure for the common cold, they would be millionaires. I was, therefore, surprised to read this week in Chemist + Druggist magazine that indeed, the first ever product to not only treat the symptoms but to act on the virus itself was winging its way to pharmacy shelves as we speak. Really? Because blimey charlie, if that's the case, then this product should be Big News. 

Image source: http://www.sourcewire.com/news/84612/by-cod-now-your-plate-of-fish-chips-could-stop

The product is ColdZyme, a mouth spray that costs £8.99 for 20mLs. Seems a pretty fair price to pay for a product which claims to cure the most prominent infectious disease in the western hemisphere. It seems odd, though, that instead of this marvellous scientific breakthrough being plastered all over the media and medical literature, the article announcing it is tucked away quietly in a barely read corner of a trade journal.

What is this breakthrough, miracle product that will powerfully break down viruses? Well, an enzyme called trypsin. An enzyme that already merrily and plentifully kicks about in your digestive system, breaking down proteins. An enzyme which, for the purposes of this product, is inexplicable being derived from cod (which has meant that I have had to resist the urge to refer to it as somewhat fishy.) An enzyme which should be stored at temperatures of between -20 and -80 degrees Celsius, to prevent autolysis. Now, I've seen some fancy medicine packaging in my time, but never a simple mouth spray bottle that can manage such cold chain storage feats. So, if trypsin really is present in this product, then it seems fairly likely that its going to be inactive, unless the manufacturers have found a way of warping room temperature. Or you happen to be in Winnipeg in the middle of winter.

Medicine vs. Medical Device

The manufacturers make some really very extraordinary claims on their website, including one textbook example of special pleading. Their product, they state, isn’t a medicine. It’s a medical device, because it has no systemic effect. They then of course go on to helpfully tell us about the systemic effect it has:

“The medicines currently on the market only treat the various symptoms of a cold. ColdZyme treats the cause of the symptoms – the virus itself – and thus works both preventively against the common cold and shortens the duration of illness if you have already been infected.”

Right. So in the same breath, they are claiming that the product only forms a barrier, no more. But then they are also claiming that this barrier affects the ability of the virus to produce illness if you are already infected- viruses which are already through that barrier and inside your body. Come on, Enzymatica, you can’t have it both ways.

The Evidence

All these claims are backed up by evidence, right? Well, there is a tiny trial performed on only 46 people, which isn’t published anywhere. I can’t say whether or not it is a well designed trial, because I can’t see it in full, so to be honest, we pretty much have to just discount it. What we can do, however, if have a look to see if there is any other decent published information looking at the effect of trypsin on the cold virus. So I turned to the medical databases Medline and Embase, to trawl through the published medical literature. 

I did find one experiment which looked at the trypsin sensitivity of several human rhinovirus serotypes(1). And this appears to have found that viruses are only really susceptible to trypsin when there have been exposed to low pH, followed by neutralization- something which wont have happened to your common or garden cold viruses. I couldn’t find much else suggestive of a clinically significant antivirus action of trypsin.

The practicalities

This isn’t a simple, one-off- couple of sprays and away flies your cold sort of product. You have to use it every two hours, as well as after you brush your teeth and before you go to bed, and you have to continue this “until your symptoms are relieved”. That’s one hell of a regime. I have difficulty remembering to use medicines twice daily, never mind every two hours. I’ve never used this product, but I’d imagine that if it really does leave a “barrier” coating in your mouth, its a pretty unpleasant sensation. I can’t imagine many people sticking closely to these dosage instructions, and if the mechanism of action is as the manufacturer’s claim, skipping doses would cause the product to fail (if, indeed, it works in the first place)

We are also directed to “Start using ColdZyme^® as soon as possible when you detect symptoms of a cold.”. Now, those of use who suffer with cold sores who have ever used aciclovir cream will know that this is often easier said than done- you probably haven’t got the stuff in the house, or at work, and by the time you’ve managed to get your hands on some, its already too late- your cold sore is out loud and proud, and using the drug will be pointless. Its likely that the very same thing will apply here. And remember that the incubation period for a cold is about 2 days- so the virus will already be cosily settled into your body before you even know about it. Its therefore completely ludicrous that this product claims to be able to reduce the length of a cold simply by forming a barrier.  

I know it can be used as a cold preventative, but how many people who feel completely fine are going to remember to use the product every two hours, every day, for the entirely of the cold season?

To Summarise

So, do I think there is scientific evidence to back up the extraordinary claims being made by ColdZyme? I might do when hell freezes over. Or at least when some decent trials are published, which might take just as long.  Do I think that this product should be sold through pharmacies? Absolutely not- this isn’t, if you ask me, real medicine. This is pure pseudoscience, trying its best to fool you into buying real medicine. Do I think lots of people will buy this, use it once or twice, then leave it to languish in their bathroom cabinet? Absolutely.

Here’s the problem though: this stuff will appear on the shelves of pharmacies all over. The pharmacists wont have a clue what this stuff is, and because they are really busy and probably quite tired at the end of each day, they wont be able to do the sort of evidence review I have managed to squeeze into a quiet moment. So they’ll get asked about it, and they’ll sell it. Some people will buy it and will feel better after a few days, and will think that the spray has made them better, forgetting that colds are self-limiting anyway. A customer might come back in the pharmacy one day, and say something like “hey, that new-fangled spray got rid of my cold!”, and the pharmacy staff will end up making recommendations on the basis of customer feedback and anecdotes, rather than on the basis of rational, scientific evidence. In my eyes, this really is a shame, and by selling this sort of nonsense, we really are cheapening our profession, and we're causing our customers to waste their money. 

If patients ask me about it, when I’m working behind the counter, I’ll tell them something along the lines of: “there’s no evidence or logical way that it works. It seems to be a bit of an expensive gimmick, with no decent basis to it. You’ll feel horrible with your cold, but it will start to go away of its own accord, I promise. In the meantime, you’d be much better off looking after yourself, having plenty of fluids and rest, and taking paracetamol according to the packet.”

Hxxx

A Miracle Migraine Machine?

Cefaly. No, it's not a village in Wales, nor is it a type of cheese (actually, it might be for all I know, but nevermind.) It is instead a new all singing, all dancing miracle cure for migraines, according to its manufacturers anyway. So, in our usual fashion, let's take a look at the evidence and see what on earth it is, and whether it is worth spending money on.



It's a medical headband device that you wear on your noggin, around your forehead. This means that you can easily pretend to be the Empress from the Never Ending Story. The downside is that you'll have to pay somewhere in the region of £250 to do so, plus electrodes and batteries. So, for that amount of money, you want to know that what you're getting is going to provide you with a bit more than simply cosplaying as a child-like film character.



It is essentially a TENS machine, which applies an electric current to the middle of the forehead via self adhesive electrodes. Anyone who has ever used one of those godawful Slendertone thingies on their stomach is probably right now recoiling in horror at the idea of having to endure such torture right between their eyes- I know I am. But first I suppose we need to see if it works- after all, migraines are horrible things which can massively impact on the quality of life of sufferers. Those who are desperate may be quite happy to have their foreheads electrocuted.



Its been approved by the FDA, which is nice. What isn't quite so nice is the fact that this approval is based on one trial- the one and only trial in existence, despite what the manufacturers would have you believe.



This trial included 67 patients who suffered at least 2 migraine attacks per month. Although small, this trial is well designed, with an identical sham stimulator being used as a comparison to the test product. After three months of daily 20 minute usage, the mean number of migraine days in users of Cefaly was significantly reduced (6.94vs 4.88, p=0.023), but were not significantly changed in the sham group. But here's the thing: the difference between groups was not significant (p=0.054).



There was significantly higher percentage of responders (defined as ≥ 50% reduction in no of migraine days per month) in the Cefaly group compared to the sham group (38.24% vs 12.12%, p=0.023).



There was no significant difference in severity of migraine.



Although some of the results in this trial are encouraging, it is limited by its very small size. It is worth noting that the authors and manufacturers claim that this trial proves that the product is effective at preventing migraine, despite the lack of a significant between-group difference in the primary outcome of migraine days.



Other papers have been published in the literature regarding this product, and the manufacturers try their best on their website to make them look like they are real trials. However, these range from letters, conference abstracts, experiments in healthy adults, and case studies- not robust clinical trials.



An uncontrolled survey of 2313 Cefaly rental users found that roughly just over half of patients were satisfied with the treatment and would be willing to buy the device. The rest of the patients stopped therapy- that's a pretty high number of people. There are a number of methodological and confounding problems with this study, so the conclusions drawn from it should be considered unreliable.


Being a rental user is one thing- at least they were able to try it out before taking the plunge and handing over a rather large wad of cash. In the UK, though, it seems that the rental option isn't readily available. £250 is an awful lot of money to spend on a product, especially when, for roughly half of its purchasers, its going to be used a couple of times then lie in a cupboard, forlorn and forgotten about.



Let's have a think about compliance. To get the best results, you are supposed to use it for 20 minutes per day. Now, initially that might not sound like too big a deal, but if you work, have a social life, go to the gym, or spend every waking minute building a house in Minecraft, finding 20 minutes a day for something that could be, in most cases, painful, is probably pretty unappealing, and impractical. I can't see too many people who will be able to religiously use this product exactly as intended in the long term. I'm guessing that in most cases its going to go the way of that bit of exercise equipment that you bought 5 years ago and that you've used twice and now only trip over on occasion.



So to summarise: there is a little bit of encouraging data, though it's not as compelling as the manufacturers would like us to think. It's extremely expensive, impractical, and probably pretty unpleasant to use. Its an interesting device, but one that I am placing firmly in the "Yet to be convinced by larger trials" pile.



Hxxx

Dear Kate

I’ve still not quite been able to come up with an adequate phrase to describe having social anxiety. Sometimes the old clichés are the best, and so I go with the duck- calmly floating above the water, but paddling like mad beneath.

I can be so good at hiding the furious paddling that even my closest friends have doubts that it exists. But if I were to invite you under the water, you’d see constant, frantic movement. You'd experience my physiological reactions going mad for no reason, reacting to the unforeseen horror of merely having a pleasant conversation with someone.  You'd be hit with tidal waves of thoughts, rushing over and over in a jumble. You'd hear that nasty, mean little internal monologue of mine telling you what other people are thinking (although they are probably not), how stupid you look (although you probably don’t), how boring you are (although you’re probably not). Then you'd feel the confusion and shame of cutting all these thoughts up with a knife of rationality. You'd see how that knife then turns on yourself because you just can't keep up with all of the mean thoughts, and you feel so weak for letting them take over you. 

Eventually, this state becomes your norm. It becomes background noise, and the peaks of it get even higher in moments where you feel threatened. Our metaphorical duck spends his days thrashing relentlessly under the water every second of everyday, and the tiniest of waves sends him into free-fall. Of course, Kate, you probably know how this feels already to a degree: it is stage fright that kept you away from touring for so long.

Moments of true calm are few and far between when you reach this point. When they do occur, you start worrying about them- internal silence starts to feel alien. Constant anxiety becomes your default position, and the otherworldliness of calm feels dangerous somehow.

That’s how I was this time last year. Things have now improved somewhat- thanks to the CBT, thanks to those around me, and in no small part thanks to my own stubbornness. I’m now at a point where the peaks are still there, but they’re not quite as insurmountable. My default position is no longer fight or flight, and I'm more able to quell the thought onslaught. True moments of stillness are, however, still relatively rare.

I’m never usually able to lose myself in a moment, as this stupid anxiety makes me constantly self-aware. The other night though, I experienced several blissful hours of basically forgetting that I existed. All thanks to you, Kate.

You’ve always been able to lift me out of terrible moods. One of the joys of living on my own is that I can get home, and crank up your music as loud as I like. I can sing, I can let go, and I can dance about with the cat without anyone laughing at me. I often find that you’re able to lift me out of an approaching mist. You've been the manufacturer of one of my most reliable coping mechanisms.

I saw Before The Dawn the other night. I was scared of going in alone, but within minutes I was chatting away with other people. We couldn't believe our luck. I've honestly never seen so many utterly excited people in one place before.

I know that everyone else has loved it. I've read the reviews, and I've seen the tweets. I expected it to be good, but what I didn't expect was to be completely enraptured- with you, with the story of a woman in the water, of a dawning day, with the detail. I had expected a couple of tears, perhaps a couple of whoops if I was feeling brave. What I hadn't expected was to realise that I was so taken in by it all that I was no longer self aware. I sort of came to, whilst dancing madly away to Cloudbusting, and realised that the waves had stopped for me for 3.5 hours. Here I was, on my own, in a situation that would usually scare me, completely and utterly swept up in the world of your making.

Thank you, Kate. Thank you for that gift.

Hxxx

It's time to reclaim holism

Holistic. It's one of those words that's sure to set any skeptic’s teeth on edge. It's basically a codename for woo, bandied about by supporters and pushers of all sorts of magic, unicorn tears, and snake oil.

But should it be? Is it time for the medical profession to reclaim the label holistic as its own, and start shouting from the rooftops about how we are holistic practitioners? I think it is, and here’s why.

holistic

həʊˈlɪstɪk,hɒ-/

adjective

Philosophy

adjective: holistic

1. characterized by the belief that the parts of something are intimately interconnected and explicable only by reference to the whole.

o    Medicine

characterized by the treatment of the whole person, taking into account mental and social factors, rather than just the symptoms of a disease.

There is a general perception, gleefully pushed by proponents of alternative healthcare,  that somehow conventional healthcare and holism are at odds with each other. The image of an uncaring, white-coated medical professionals hell-bent on simply treating that one particular symptom, with no regard for the fact that a patient is attached to that symptom seems pervasive.

We don’t help ourselves, I suppose. With a limited time on GP appointments, for example, its easy to feel like you’re being rushed through the system. Some surgeries ask that you book one appointment per ailment. Our health care professionals tend to specialise in one particular type of illness, and you can start to get the impression that they only care about that particular bit of your life, despite the fact that it’s very often all interconnected. You can feel passed from pillar to post, one day an appointment with a diabetes nurse, the next day an appointment with someone else for your arthritis, and two days later an appointment with a mental health specialist. So I do understand that it can seem like, as healthcare professional, we only care about your symptoms. 

But, even at the most basic level, it is impossible and really quite dangerous  to practice healthcare without looking at the patient as a whole. We’re all trained to do it, and its become so second nature to us that we have all sort of forgotten to be proud of it. As a result, we've lost control of the word holistic and we’re allowing unscrupulous charlatans to creep in to the public’s consciousness on the back of it. Of course, there are improvements to be made, but I think on the whole we do bloody well in the NHS, given the knowledge, funding and time constraints we’re lumbered with.

Now, in my day job as a medicines information pharmacist, I actually have no direct contact with patients. But I still, fundamentally, operate as a holistic practitioner. Here’s a basic example of what I mean:

GP: “Ah, hi there, I’m just wondering if there are any interactions between Champix and CellCept?”

In this sort of seemingly simple interaction enquiry, it is imperative that I look at the patient as a whole, rather than simply as two drugs out there on their own. 

• Champix®▼(varenicline) is a drug used to help patients stop smoking
• CellCept® (mycophenolate mofetil) is an immunosuppressive drug used to stop organ rejection in transplant patients. 

If I were to look at interactions of these two drugs,  I wouldn't find any,So fine, we’re good to go, right? I mean, I’ve answered the question, done my job, and all is well, yes? 

No, not at all. If I’m going to safely answer this question, I need to look at the patient as a whole. I need to acknowledge that they’re not simply a smoking machine that needs to stop but they’re a living, breathing complicated human.  I need to look at the patient holistically, not just as some isolated drugs.

So our patient is in his mid-forties, using the mycophenolate mofetil because he has previously had a heart transplant. He has a history of depression (understandable really, given how ill he has been in the past), and takes a couple of other medicines too (no major interactions on checking). He wants to stop smoking, which is great, a really positive step for him, but he’s failed a few attempts already whilst using nicotine replacement therapies. He's found these failed attempts frustrating in the past,which has then triggered bouts of depression. His liver and kidneys are working just fine.

So, looking at the patient as a whole, I need to think about how using varenicline will impact him as a person. Some of my thoughts go thus:

• Stopping smoking itself might affect some drugs, as there are chemicals in cigarette smoke which can affect the enzymes that metabolise some drugs. Is this the case with any of these drugs?
• Quitting smoking itself can be a trigger for depression or suicidal ideation. 
• There is also an association between varenicline and changes in behaviour and thinking, including depression and suicidal ideation. Given this patient’s history, this will need to be discussed with him and he’ll need to be monitored carefully.
• Certain cardiovascular events were reported more frequently with varenicline than placebo in trials: we need to bear that in mind and monitor him for any adverse reactions, especially given his heart transplant
• Not succeeding in giving up smoking has made him depressed in the past. Continuing to smoke increases his cardiovascular risks. A good old risk vs benefit decision needs to be made.

So I discuss all this with the Dr, and her response is:

“Ah that's great. Yep, I knew about the depression stuff but to be honest I hadn't really thought about the cardiovascular risks. I'll discuss it all with him, and I think we'll go ahead and prescribe it but I'll make sure to keep him closely monitored”

By looking at the patient holistically, his Dr and I have made sure that he will know to look out for any cardiac effects and to report it as soon as possible if he does experience any side effects. We can make sure that he's also prepared for the fact that his mood might change, and knows to report any of that too. He’s willing to take these risks for the sake of stopping smoking, so we’re helping him to take a really positive step in his life, aimed with all the information he needs to do it safely.

That’s just a small example of how I practice holistic medicine in my daily life. All over the NHS, at every level, other healthcare professionals are doing the same thing in their practice. We don’t declare ourselves to be holistic, because its such second nature that we don’t even realise we’re doing it. Maybe its time to start reminding people-and ourselves- that conventional medicine does, fundamentally, mean holistic medicine. 

Hxxx

Album Review: Lychnobite by Simma

There is a particular pub in Gatesheadwhich I rather like. It’s called The Central Bar and it holds good memories for me. It’s a traditional haunt for my good friends and I on Christmas Eve, it has an excellent range of beers, and does some good nosh too.

And so it was that on one particular Sunday afternoon just before Christmas, three friends and I were in there. We were suitably adorned in tacky, sparkly Christmas attire and were festively tipsy, when a chap started playing his acoustic guitar and singing in the corner of the pub.

Given our rather jolly state at the time, we showed our appreciation of this man’s lovely voice by bellowing along to some of the songs and inventing new interpretive dance routines to others (And thus, the great Gateshead Sit Down dance was born). We were a source of amusement for the singer, who declared that he’d never had anyone invent dances for him before and patiently explained that no magic was at play when we had loudly declared that we wanted him to play Fairytale Of New York then he actually did, prompting us to look drunkenly confused. “Girls, I’m not on the radio you know. I can actually hear you.” It was a really fun afternoon, and we left giggling hysterically and wondering if we could ever show our faces in there again.

The singer in question was Simma, and I’ve since seen him play several times. He fairly recently released his new album, Lychnobite, so I snapped up a copy of it and thought I would review it for you dear people.

On first listen, it’s on the whole a cheery affair, with upbeat tunes perfect for having on in the background while you do something else. Subsequent listens via headphones reveal a more melancholic, complex side to the album.

A particular highlight for me is “Black Dog”, a song about depression which combines a nifty little toe-tapping rhythm with an almost monotonous melody. This makes for an atmospheric juxtaposition, much like the illness itself. Next up is the joyous “Sing”, a marching, uplifting little song that I tend to happily belt out when I have it on at home.

Other songs are more calmly folky, all with a touch of cleverness to the songwriting that I find really pleasing. There is a clever use of vocals throughout the album (see Whisky Highway as an example), something which I find quite pleasingly different, given my previous experience of Simma is limited to him and one guitar in the corner of the Central Bar

“The Drink” is gorgeous, plaintive, and full of feeling. Meanwhile, “Sixteen Tons” is bluesy and pleasingly cynical, managing to blend together a very American sound with tales of Benwell woe. “Happy New Year” is likely to make its way onto my Christmas Songs For The Existentially Wounded list this year, with its mix of optimism and sadness for times gone by.

The other thing that I really like about Simma is how his Geordie accent creeps into the edges of his songs, lending them a little bit of added personality. All in all, this is a lovely, complicated album which is likely to be on heavy rotation in my household, nestled in nicely between Great Lakes by John Smith and Under Mountains by Rachel Sermanni. 

Hxxx

life with social anxiety: a poorly drawn cartoon.

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.