Pharmacists of the world, unite and take over.
Pharmacy has been hit hard over the past few weeks. We've had MPs accusing us of being smartie counters, and a badly written BBC News expose implying that we are all merrily dealing benzo's to make a quick buck. (I may attempt another blog post on this at some point)
I believe that historically, pharmacy has drawn the short straw. In my opinion. our professional body, the Royal Pharmaceutical Society, seems to lag behind other bodies when it comes to media savviness, and it often feels like we have very little impact or voice when it comes to the healthcare profession as a whole. Even now, its still a rare occastion that a pharmacy-related story will actually have a pharmacist commenting on it in the news- GPs, doctors and nurses are simply much more vocal and recognisable to an audience.
But here is an opportunity, and it has been handed to us on a silver platter by Ben Goldacre and the BMJ. I'm sure you may have heard by now, but there is a pretty large campaign on the go to allow for more transparent reporting of clinical trial data. This has been prompted by the case of Roche's Tamiflu, but its wider implications on patient safety and care are huge.
All the information you need about the BMJ's Open Data campaign can be found here.
Today I tweeted Ben Goldacre to ask what involvement there has been from the pharmacy bodies. The answer? A big fat zero. There has been no involvement at all, from any of them.
So here is my call to arms. If you are a pharmacist, or if you are affiliated with the pharmacy profession, lets contact the RPS, the GPhC, NPA, PSNC, and anyone else who will listen. Lets tell them how important this is to us and how we want them to represent us and get our voice heard.
After all, to be experts in medicine, we need to have access to information about medicine. And that information has to be accurate, reliable, accessible, and unbiased. Without open data, we simply cannot do our jobs properly or with the degree of safety that we would like to. It may seem like a trial not being published is far removed from handing over a prescription to a patient over the counter, but the fact of the matter is that patients are dying due to the lack of transparency. How can we counsel a patient on side effects, for example, when patient level data from trials has been withheld? How can a patient be prescribed the best medicine for their condition when most of the trials involving the drug haven't been published?
Moreover, what a great way to represent ourselves as a profession who, more than anything, care about the health- and safety- of our patients, and who are willing to speak up when it counts. What a fantastic opportunity for our professional bodies to prove what they can do.
H xxx
Tuesday, 18 December 2012
Friday, 7 December 2012
The importance of being human
The more I talk to homeopaths and other alternative medicine practitioners, the more I realise that the distinction between in vitro and in vivo testing is unclear to many.
It may be due to ignorance, or it may be in a desperate bid to pad out the lack of real-life clinical evidence, or to stun us all into silence with impressive looking sciencey stuff, but it seems that alternative medicine supporters are desperate to throw in vitro studies my way as "evidence" that their treatments work. But here's the thing: it's not evdience that it works at all. In fact, for the purposes of informing treatment decisions, any in vitro data might as well be discarded before you even bother reading it.
Why do i say this? Well, the easiest way to explain this is in picture form (drawings are courtesy of my marvellous friend Haymond Lam) :
As you can see from these pictures, a few cells in a petri dish actually look (and act) rather differently to a functioning, whole human body. So positive (or negative) results in an in vitro study actually bear very little resemblance to real life clinical situations. What in vitro testing is great for is as preliminary evidence- to make new discoveries and to guide further research, and to find out the all-important details of how something may work. But we can't use some cells in a petri dish to say "Yes, this will definitely work for this or that illness". The only sort of evidence that we can use to decide if a drug is effective in any particular illness is a robustly designed clinical trial, and even then we can't use that as a cast iron guarantee.
I'm hoping that you will forgive me for this horrendous oversimplification, but it is hopefully a useful point to make. So, the next time you come across some in vitro studies being used as "evidence" that homeopathy works, you know that they're actually scraping the barrel, particularly gievn the fact that homeopathis is supposed to have been around for 2000 years. I'd expect after that amount of time that they'd have more than cell culture studies to their name.
H x
It may be due to ignorance, or it may be in a desperate bid to pad out the lack of real-life clinical evidence, or to stun us all into silence with impressive looking sciencey stuff, but it seems that alternative medicine supporters are desperate to throw in vitro studies my way as "evidence" that their treatments work. But here's the thing: it's not evdience that it works at all. In fact, for the purposes of informing treatment decisions, any in vitro data might as well be discarded before you even bother reading it.
Why do i say this? Well, the easiest way to explain this is in picture form (drawings are courtesy of my marvellous friend Haymond Lam) :
 |
| Figure 1: A Petri dish, with some cells in it. (in vitro) |
 |
| Figure 2: A human being (well, okay, I know some people might think scientists aren't quite human beings but, y'know, we thought we'd still use one as an example). (in vivo) |
As you can see from these pictures, a few cells in a petri dish actually look (and act) rather differently to a functioning, whole human body. So positive (or negative) results in an in vitro study actually bear very little resemblance to real life clinical situations. What in vitro testing is great for is as preliminary evidence- to make new discoveries and to guide further research, and to find out the all-important details of how something may work. But we can't use some cells in a petri dish to say "Yes, this will definitely work for this or that illness". The only sort of evidence that we can use to decide if a drug is effective in any particular illness is a robustly designed clinical trial, and even then we can't use that as a cast iron guarantee.
I'm hoping that you will forgive me for this horrendous oversimplification, but it is hopefully a useful point to make. So, the next time you come across some in vitro studies being used as "evidence" that homeopathy works, you know that they're actually scraping the barrel, particularly gievn the fact that homeopathis is supposed to have been around for 2000 years. I'd expect after that amount of time that they'd have more than cell culture studies to their name.
H x
Alternative medicines and brain tumours
There's been a lot of press attention in recent days about the case of Neon Roberts, whose mother had apparently ran away with him in order to avoid him being given post-surgery radiotherapy.
I will admit at this point that I haven't looked too closely into the case. I'm writing this on my lunch break so don't have time to go into all the details, but it appears that after being found, Neon has been taken into foster care and has been given the treatment he requires.
If the press reports are to be relied upon (and bear in mind my main source is the Daily Fail), this seems like a striking case of the sort of harm misinformation about alternative medicines can cause. Reportedly, the mother only wanted him to receive "natural remedies" as he recovers from his surgery. The implication is that natural remedies would be safer for the child, whereas conventional treatments like radiotherapy and chemotherapy are evil, toxic poisons.
And yet this distinction between "natural" and conventional medicines is highly blurred, particularly when it comes to chemotherapy. Some of our most powerful (and potentially toxic) chemotherapeutic agents are derived from plants- the taxols for example. Ultimately, the main difference between these agents and alternative medicines is that they have been tested and have been proven to work. If other natural, alternative medicines went through the same testing processes and also had positive results, they too would cease to be alternative and would become conventional medicines. Radiation, similarly, is an ultimately natural process. So how do the public at large decide what constitutes a "natural" remedy? We can see from this case the potential consequences of such misinformation.
Another thought that occurs to me is the distinction between complementary and alternative medicines. I think we can all agree that there is a potential benefit from some natural remedies for some cancer-associated symptoms or problems. So as an example I have no problem with a patient who decides to try a herbal remedy to treat say anxiety alongside their conventional treatment, providing they are doing so with a knowledge of the pros and cons of the treatment, and with their healthcare provider's knowledge. Complementary therapy, in other words. What's infinitely more worrying is the concept of alternative therapy, e.g. where a patient makes a decision to not use conventional medicine but to use a herbal remedy(or homeopathy, or acupuncture etc) instead. The evidence base for alternative medicines is absolutely nowhere near the level required to justify a patient using them instead of conventional medicines for something as serious as cancer.
And this brings me on to homeopathy. Yes, homeopathy again. I'm not going to cover how homeopathy works, as its been done much better at this site: http://www.howdoeshomeopathywork.com/ . What is particularly worrying about this modality is the advice given that conventional medicines need to be avoided to allow the homeopathy to work. This is bandied about in an inocuous sort of a way by websites such as this. So, by recommending a homeopathic treatment for a serious condition, homeopaths are directly harming their patient by encouraging them to not take conventional medicines (which may have a chance of working at least) and to replace them with Magic Woo Memory Water Sugar Pills (which have zero chance of working). One of the most heart-breaking things i have ever read on the internet are the letters of Penelope Dingle to her homeopath, who treated her pancreatic cancer. If you haven't seen this already, I highly recommend that you have a look, but warn you that it is likely to induce tears, then rage.
I've noticed that a few homeopaths on twitter have already picked up on the story of Neon Roberts, and are gleefully tweeting things like "UK Boy to Be Forced Into Chemotherapy" (forgetting the fact that it's actually radiotherapy that he will be receiving). Of course I'm Not Actually A Doctor Nancy Malik is involved. So I thought I'd have a look at what evidence there is that homeopathy can treat brain tumours, before they all start claiming that it can. So I've checked Medline and Embase, the leading medical literature databases in the world. My search stratedy was: Search for homeopathy. Search for brain tumours, and limit to therapy or treatment. Add the two together. See what comes out. Makes sense, right?
So here are the results for EMBASE (links are only available to athens users):
And here are the results for MEDLINE:
Now, you don't have to be an expert in literature searching to realise that that's a bit fat zero.
I'm Not Really A Dr Nancy Malik, however, has other ideas, and has helpfully sent me links to 4 sources that she claims are evidence that homeopathy can work in brian cancer treatment. Three of which are studies looking at tissue cell culture, and one of which is for treatment of side effects (ergo as complementary, rather than alternative therapy, and which bears no resemblance to whether or not it could actually treat a brain cancer). The in vitro studies are very interesting i'm sure, but to use them as evidence that homeopathy can treat brain cancers in humans is an enormous stretch. With something so serious, would you really be willing to base a treatment decision on what happens to a couple of cells in a lab? Or would you rather base it on what happens to thousands, if not millions of other people in real-life? I know which one I would go with.
One other footnote to this news story is one which I fear may have been forgotten about. Imagine being a child, who has just undergone surgery for a brain tumour. Imagine the fear this poor boy feels on a daily basis, not to mention how physically ill he may be. Now imagine being taken by your mother on a trip elsewhere, then being taken into foster care and having to be given radiotherapy, whilst a court case battles on around you. I can't even begin to imagine what this child is feeling. This time would have been bad enough for him as it was, without any of this being added onto his trauma.
I will admit at this point that I haven't looked too closely into the case. I'm writing this on my lunch break so don't have time to go into all the details, but it appears that after being found, Neon has been taken into foster care and has been given the treatment he requires.
If the press reports are to be relied upon (and bear in mind my main source is the Daily Fail), this seems like a striking case of the sort of harm misinformation about alternative medicines can cause. Reportedly, the mother only wanted him to receive "natural remedies" as he recovers from his surgery. The implication is that natural remedies would be safer for the child, whereas conventional treatments like radiotherapy and chemotherapy are evil, toxic poisons.
And yet this distinction between "natural" and conventional medicines is highly blurred, particularly when it comes to chemotherapy. Some of our most powerful (and potentially toxic) chemotherapeutic agents are derived from plants- the taxols for example. Ultimately, the main difference between these agents and alternative medicines is that they have been tested and have been proven to work. If other natural, alternative medicines went through the same testing processes and also had positive results, they too would cease to be alternative and would become conventional medicines. Radiation, similarly, is an ultimately natural process. So how do the public at large decide what constitutes a "natural" remedy? We can see from this case the potential consequences of such misinformation.
Another thought that occurs to me is the distinction between complementary and alternative medicines. I think we can all agree that there is a potential benefit from some natural remedies for some cancer-associated symptoms or problems. So as an example I have no problem with a patient who decides to try a herbal remedy to treat say anxiety alongside their conventional treatment, providing they are doing so with a knowledge of the pros and cons of the treatment, and with their healthcare provider's knowledge. Complementary therapy, in other words. What's infinitely more worrying is the concept of alternative therapy, e.g. where a patient makes a decision to not use conventional medicine but to use a herbal remedy(or homeopathy, or acupuncture etc) instead. The evidence base for alternative medicines is absolutely nowhere near the level required to justify a patient using them instead of conventional medicines for something as serious as cancer.
And this brings me on to homeopathy. Yes, homeopathy again. I'm not going to cover how homeopathy works, as its been done much better at this site: http://www.howdoeshomeopathywork.com/ . What is particularly worrying about this modality is the advice given that conventional medicines need to be avoided to allow the homeopathy to work. This is bandied about in an inocuous sort of a way by websites such as this. So, by recommending a homeopathic treatment for a serious condition, homeopaths are directly harming their patient by encouraging them to not take conventional medicines (which may have a chance of working at least) and to replace them with Magic Woo Memory Water Sugar Pills (which have zero chance of working). One of the most heart-breaking things i have ever read on the internet are the letters of Penelope Dingle to her homeopath, who treated her pancreatic cancer. If you haven't seen this already, I highly recommend that you have a look, but warn you that it is likely to induce tears, then rage.
I've noticed that a few homeopaths on twitter have already picked up on the story of Neon Roberts, and are gleefully tweeting things like "UK Boy to Be Forced Into Chemotherapy" (forgetting the fact that it's actually radiotherapy that he will be receiving). Of course I'm Not Actually A Doctor Nancy Malik is involved. So I thought I'd have a look at what evidence there is that homeopathy can treat brain tumours, before they all start claiming that it can. So I've checked Medline and Embase, the leading medical literature databases in the world. My search stratedy was: Search for homeopathy. Search for brain tumours, and limit to therapy or treatment. Add the two together. See what comes out. Makes sense, right?
So here are the results for EMBASE (links are only available to athens users):
| 1 | EMBASE | *HOMEOPATHY/ | 4263 | |||
| 2 | EMBASE | BRAIN TUMOR/dt, th [dt=Drug Therapy, th=Therapy] | 7758 | |||
| 3 | EMBASE | 1 AND 2 | 0 |
And here are the results for MEDLINE:
| 1 | MEDLINE | HOMEOPATHY/ | 3941 | |||
| 2 | MEDLINE | BRAIN NEOPLASMS/th [th=Therapy] | 7433 | |||
| 3 | MEDLINE | 1 AND 2 | 0 |
Now, you don't have to be an expert in literature searching to realise that that's a bit fat zero.
I'm Not Really A Dr Nancy Malik, however, has other ideas, and has helpfully sent me links to 4 sources that she claims are evidence that homeopathy can work in brian cancer treatment. Three of which are studies looking at tissue cell culture, and one of which is for treatment of side effects (ergo as complementary, rather than alternative therapy, and which bears no resemblance to whether or not it could actually treat a brain cancer). The in vitro studies are very interesting i'm sure, but to use them as evidence that homeopathy can treat brain cancers in humans is an enormous stretch. With something so serious, would you really be willing to base a treatment decision on what happens to a couple of cells in a lab? Or would you rather base it on what happens to thousands, if not millions of other people in real-life? I know which one I would go with.
One other footnote to this news story is one which I fear may have been forgotten about. Imagine being a child, who has just undergone surgery for a brain tumour. Imagine the fear this poor boy feels on a daily basis, not to mention how physically ill he may be. Now imagine being taken by your mother on a trip elsewhere, then being taken into foster care and having to be given radiotherapy, whilst a court case battles on around you. I can't even begin to imagine what this child is feeling. This time would have been bad enough for him as it was, without any of this being added onto his trauma.
Monday, 5 November 2012
A quick thought on some complementary medicine modalities
Hi folks,
I'm working on a little project about complementary and alternative medicines- a quick reference guide to the most common modalities, and how they differ in effectiveness, safety, theories etc. I've been using the Natural Medicines Comprehensive Database- a great (but unfortunately rather expensive) site for balanced, evidence-based information on alternative medicines- for information on different modalities, and I came across a statement that I hadn't considered so far, but one which I think may actually be quite persuasive to some when it comes to alternative medicine. It's quite simple, but the thought just simply hadn't occurred to me before.
This is the fact that a lot of modalities were developed prior to any sort of scientific knowledge about how the body works, or pharmacology. For example, homeopathy was developed at a time where it was thought "humours" were to blame for illness- a time where blood-letting was treatment of choice for much sickness. And as for Traditional Chinese Medicine (TCM), developed over 2000 years ago:
"At that time there was no scientific concept of disease or pharmacology in terms that can be related to our modern understanding of medicine. Therefore, the principles of TCM were formed based more on philosophy than on science"
The same goes for Ayurvedic medicine as well.
So, on this basis, why should we believe that any of these modalities are scientific, or likely to work? How can homeopathists, for example, claim that it is "science-based medicine" when it fact it predates the science of medicine?
Why, in days where calculators are easily available, should we be expected to believe that using an abacus will be more effective and safer?
H xxx
I'm working on a little project about complementary and alternative medicines- a quick reference guide to the most common modalities, and how they differ in effectiveness, safety, theories etc. I've been using the Natural Medicines Comprehensive Database- a great (but unfortunately rather expensive) site for balanced, evidence-based information on alternative medicines- for information on different modalities, and I came across a statement that I hadn't considered so far, but one which I think may actually be quite persuasive to some when it comes to alternative medicine. It's quite simple, but the thought just simply hadn't occurred to me before.
This is the fact that a lot of modalities were developed prior to any sort of scientific knowledge about how the body works, or pharmacology. For example, homeopathy was developed at a time where it was thought "humours" were to blame for illness- a time where blood-letting was treatment of choice for much sickness. And as for Traditional Chinese Medicine (TCM), developed over 2000 years ago:
"At that time there was no scientific concept of disease or pharmacology in terms that can be related to our modern understanding of medicine. Therefore, the principles of TCM were formed based more on philosophy than on science"
The same goes for Ayurvedic medicine as well.
So, on this basis, why should we believe that any of these modalities are scientific, or likely to work? How can homeopathists, for example, claim that it is "science-based medicine" when it fact it predates the science of medicine?
Why, in days where calculators are easily available, should we be expected to believe that using an abacus will be more effective and safer?
H xxx
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