Friday, 31 May 2013

My Fantasy Pharmacy

People are allowed fantasy football teams, so why shouldn't I be allowed my own little fantasy pharmacy?

Now people, I want you to contribute to this post. So let me know if I haven't included your desert Island drug and why you think my pharmacy should stock it, and I shall put it on the shelves if I deem it worthy. Tweet me @SparkleWildfire, leave a comment, or drop me an email at I'm going to start off small with this post, and add to it gradually.

With all this talk of pharmacy as a quack trade, and the lack of evidence base for many OTC products, my pharmacy is going to have the bare minimum. Only the drugs I want to sell, ad that I think are necessary, with none of the extraneous, shiny combination packs that are purely there for profit. 

So, welcome into my emporium of evidence-base, and help yourself to some expert advice, a healthy dose of skepticism, and a pinch of thriftiness.

Shelf One: Pain Relief
Paracetamol: because it is an effective painkiller and antipyretic with few side effects. 
Ibuprofen: again, an effective painkiller and antipyretic. Needs more caution because of side effects, but still useful to have over the counter.
Sumatriptan: a good shout, thanks for your comment, Joanne. This is actually a really useful product to have OTC, in my opinion- its for migraines, so its great for regular sufferers to have easy access to if they don't have their usual meds to hand. But it does needs to be sold very carefully, with good questioning and counselling. 

Shelf Two: Coughs and Colds
Sudafed: just the plain old pseudoephedrine variety. Its the most effective decongestant over the counter (phenylephrine has much less of an effect orally) and can be combined with paracetamol or ibuprofen if there is pain associated with blocked sinuses.
Lemons and Honey: for combining with hot water for soothing throats and coughs. About as effective as any other cough mixture.
Glycerin, Lemon and Honey Mixture: as above, but ready made for when you don't have access to a kettle. Also: its quite delicious. 
I would include a night time product too, but I'm not sure which one yet. I don't want to include Night Nurse because its got far too many ingredients in it, and no one should have to take medicines they don't need. My product would just have diphenhydramine and paracetamol in it, probably, just something to help you sleep when you have that awful achey can't breathe feeling that comes with colds. 
Menthol crystals: for adding to steam inhalations. Inhaling the vapours of a  couple of those bad boys in boiling water will have your mucus cowering and crying in a corner. 
Xylometazoline nasal spray: an option for people with bad congestion who can't take pseudoephedrine.
Pholcodine cough medicine: As voted for by Kev. Its cheap enough, and acts to suppress a dry, tickly cough. Shouldn't be used in chesty coughs though. 

Shelf Three: Ear problems
Olive oil: there is no reason whatsoever for any of the other products to exist. Plain old cheap olive oil will do the job just as well as anything else.
Dropper: for administering the olive oil. 

Shelf Four: Allergies
Generic beclomethasone nasal spray: cheap, works if used in advance of the hayfever season.
Antihistamine tablets (generic): Chlorphenamine, loratadine, and cetirizine. Exactly the same as the hugely expensive branded varieties. chlorphenamine can cause drowsiness, the other two tend to be much of a muchness- some people find one works for them, some the other.
Cheap anti-allergy eye drops: great for people that have predominantly eye symptoms.

That's a little start, and I shall add to it when I think of anything else or get a chance.


Dermalex: a superficial skin miracle?

I've written before about the guttate psoriasis which suddenly appeared at the start of this year and the impact it has had on my life.

I'm pleased to report that, after 9 weeks of phototherapy, it is much better. It has virtually gone on my top half, but the plaques on my legs are still stubbornly visible, although much better. The fact that it hasn't gone away entirely yet means its probably not going to clear up. Without wanting to sound over-dramatic, it actually feels like quite a bit to deal with- I've never had any long-term health conditions before, and although I've become slightly more confident, I'm still really conscious and nervous of having to expose any affected skin.

A while ago, my Mum rang me. "There's this new product out that says its for psoriasis, shall I buy you it so you can try it and see if it works?". To be honest, it was tempting, but when she told me the price £29.99 for just 150g, I declined. Skin diseases really can have an enormous impact on your life, and leave you desperate to try anything to find that one miracle that will get rid of it once and for all. Since then, I've seen it prominently displayed in quite a few pharmacies, hailed on shelf-edges as a 'breakthrough in psoriasis treatment'. So the big question is, is there any evidence that it works?

The product is Dermalex, and it is made by Omega Pharma. If their name sounds familiar to you, that may be because they also produce Prevalin, the overpriced, overcomplicated, under-evidenced Vaseline substitute for hayfever. This leaves me with a slight prickling of my skepticism, but lets keep an open mind for now.

This poor chap obviously has some practical joker friends who like to write words of skin conditions in his sun tan lotion when he is sleeping in the sun.

How is it supposed to work? Well, the fact that the website itself titles this section "How its works?" (sic) begins to worry me slightly. I know this blog is liberally sprinkled with typos and spelling errors, but at least I have the courtesy of being shameful about it. In a professional website selling a quality medicinal product, I don't think spelling errors are acceptable, and there are a few dotted around the whole website. Nowhere on the website does it actually tell you what is in the product. Its said to:

"Reduce Psoriasis symptoms by: Normalising skin cell production and Acceleration of the recovery of the skin barrier 


Fortify the skin barrier through: The creation of a protective shield on the skin by means of Alumino silicates against outside to inside insults (bacterial superantigens & toxins) through the non-intact skin barrier.
Providing a barrier to water loss"

This is helpfully illustrated by a diagram of the skin, which has labels that don't correspond to any numbers at all- either they're deliberately trying to make it look all science-like and confusing, to make the patient think "this is too complicated for me, so it must work", or its just sloppy oversight. Either way is bad enough.

Some labels on those numbers would be nice. Unless there really are little blue circles with random number in them floating about in the layers of our skin.

We can pretty much entirely discount the claims for "fortifying the skin barrier". All this means is moisturing the skin, and a plain old (cheaper) emollient will do just as good a job at that. Once again, this seems to be Omega Pharma reinventing the Vaseline-greased wheel. As for the former claims, well, I need to see some evidence to corroborate them and decide if they are reasonable or not. So let's have a little lookie, shall we?

Having had a bit of a dig about on the website, I could see no clinical evidence. So of course I emailled the manufacturers, and got back a curt response after several days telling me to look at this page for references. So, here it is, the grand total of the evidence that Dermalex Psoriasis works:

"PASI based clinical efficacy study of Dermalex Psoriasis cream for the treatment of Psoriasis Vulgaris symptoms in a mono application therapy, Józsefváros Health Center, Budapest, Hungary; Open Label Clinical Study into the overall efficacy of Dermalex Psoriasis Cream, 2008, Dermatology and Psoriasis Clinics Laudau and Kandel, Germany"

For some reason, Omega Pharma seem to want to throw away the usual format of referencing- the one that is accepted and good enough for use in the rest of the medical profession. These references do not give me enough information to find the original studies, so what use are they? I've emailled them back to ask for standard reference formats, including where the studies are published, and have been greeted with a loud silence. I've tried googling the titles, and this brings up nothing, suggesting that they haven't even been published.

Why isn't the evidence published anywhere? How many patients were involved? What are the study designs? What were the results, and the statistical analysis of the results? Without answers to any of these questions, all I can do is discount this as evidence at the moment. 

Of course I didn't just leave my research there, in the hands of the manufacturers. I've also had a look myself at the medical literature. And could I find anything at all for whether Dermalex works for psoriasis? Not a sausage. 

You're supposed to apply this stuff  three times a day. 150 grams will not last you long at that rate. That makes this a whoppingly expensive product. The national minimum wage in the UK is £6.31, meaning one pack would be equivalent to just under 5 hours work. I simply don't think that a couple of unpublished trials that may or may not say it works is a good enough reason to justify the expense. They're either being deliberately evasive about the evidence, or remarkably blase with people's hard earned cash.  

They say beauty is only skin deep. It would seem that the evidence that Dermalex is even more shallow than that.


Update: I was contacted by the manufacturers of Dermalex, who promised to provide me with the references I asked for above. Here is the response I've gotten, with my response to the points they have raised below. .

Thank you for your enquiry regarding Dermalex.

As you may be aware, the Dermalex range contains a number of different products to treat the following conditions; atopic eczema, contact eczema, psoriasis, rosacea, atopic eczema for babies and children. Please rest assured that all Omega Pharma products have been produced under strict guidelines and regulations.

A range of proprietary studies have been conducted across the Dermalex product portfolio and as medical devices, these products have undergone statutory trials to ensure they meet the safety and efficacy standards required by regulatory bodies to demonstrate an impact on skin pathologies.

Medical devices are designed, engineered and formulated, in compliance with the UNI EN ISO 14971:2009 and 13485 guidelines. This means that each step of development and marketing has been strictly regulated to ensure the safety and efficacy of the products.  All testing is carried out by medical device status certified organizations, which include leading dermatology research centres. In addition, all studies were conducted by practicing clinicians. Please note that these studies include varying number of participants and study designs.

The research behind the Dermalex range is ongoing - we are working towards publishing data on the product range this year to ensure we are able to communicate the efficacy and safety of these products to healthcare professionals. We are working closely with the University of Amsterdam and are looking to publish the first set of results in the International Journal of Contact Eczema. We will also be presenting this data at the upcoming conference on ‘impaired skin barrier in the pathogenesis of atopic and contact dermatitis’ in Amsterdam in June.

To date, we have conducted six trials across the product portfolio involving nearly 200 patients. The products have also been used in in Belgium, France, The Netherlands, UK, Italy, Portugal, Austria, Switzerland, Ukraine, Czech Republic, Slovakia, Turkey and Australia, among nearly 3 million sufferers.

All Dermalex products are well tolerated and have been clinically proven to work. In summary, the trials showed:
·         Dermalex Contact Eczema produces symptom improvement comparable to prescription drug treatments
·         Dermalex Atopic Eczema (Babies & Children and Adult formulations) effectively relieves both objective and subjective symptoms of contact or atopic eczema
·         Dermalex Psoriasis is effective against objective and subjective symptoms of psoriasis
·         Dermalex Rosacea & Couperose is effective against objective and subjective symptoms of rosacea

We hope that this information is useful and thank you for taking the time to contact us."

Firstly: I was aware that Dermalex is being sold as a medical device, but only because of those telltale words "Clinically proven!" and based on knowledge of Omega Pharma's other product, Prevalin. the fact it is classed as a medical device (and therefore not subject to the rigorous clinical testing of a real medicine) is even less prominent on the Dermalex website than it is on the Prevalin website. 

The rest of the e-mail appears to be a lengthy way of saying "We don't have any trials published yet, and no, you can't have any results in order to make up your own mind whether or not it works, you'll just have to take our word for it.". 

What's particularly interesting is that the International Journal of Contact Eczema doesn't appear to actually exist, as nothing at all is coming up for it on a Google search.

They say they have conducted six trials, which initially sounds reasonable. But this is across the product range, which includes at least four products and also children's versions. 200 people over six trials is not a lot- if shared equally that is only 33 patients per trial, and assuming they're placebo controlled, that would only mean that 16 patients per trial are actually exposed to the product- nowhere near enough to claim clinical significance of any results. Stating that the product has been used in other countries is meaningless, unless it is backed up by good, robust clinical trials. Its a logical fallacy- an appeal to popularity. Just being used doesn't mean it works- people might just try it once, or use it on the basis of advertising alone, but the product could still be ineffective.

So here's my main problem. How do Dermalex justify charging such an enormous price for a product before they have proven its efficacy. If good quality research had been undertaken prior to marketing, and robust results said that it worked, then that's one thing. But charging people £29.99 for "We think it might work, but we don't know yet because we're still doing research now, and the trials we've done so far that haven't been published yet in a non-existent journal are too small to decide" is, to my mind, entirely unjustified.

Bad Pharmacy: An example

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

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

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

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

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

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

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

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

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

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

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

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

Friday, 24 May 2013

Are we selling our souls Over The Counter?

There's something beautifully logical and satisfying about a good Over The Counter consultation.

I know what you're thinking, and yes, I should get out more. But it is true. The way I think of it is in a stepwise approach, using a systematic series of questions to eliminate products leaving you with a limited number of options to recommend. I suspect the way a patient views it may vary somewhat from "hey! I'm really being listened to!" to "oh for goodness sake shut up, I'm going to be late for the bus.".

A good consultation goes like this:

Step One: Establish the symptoms and check diagnosis.
Fairly self explanatory: to decide what medicine to select, I need to know what I am trying to treat in the first place. I'm also finding out if the patient has any danger symptoms which might be suggestive of a serious illness, so I can signpost them appropriately to the right services.
Once I know what the problem is, I think about what products are available to treat it over the counter

Step Two: Find out about the patient's medical history.
I'm looking for anything that means the patient is at high risk of complications of the problem, meaning they need to be referred. I'm also thinking of the cautions and contra-indications of the available products to treat the problem and eliminating any products that these apply to.

Step Three: Find out about the patient's drug history.
I'm thinking about what drug interactions each of the available products has, and whether or not they are relevant to what the patient is already taking. I'm also thinking about whether or not any of the patient's medicines contain the same or similar ingredients to any of the OTC products- i don't want to risk an overdose. I then eliminate any products that have relevant drug interactions.

Step Four: Consider the evidence.
At this point, there may be only a couple of products that are suitable for the patient. If there aren't any left, I refer them to their GP or other appropriate healthcare provider.Out of the ones that are left, I think about which ones the evidence says are more effective and safe and I'll steer the patient towards that one. If there's no good evidence for at treatment, I'm always clear with the customer about it. Sometimes they listen, sometimes they don't, but its an obligation that I think needs to be done in order to sell medicines honestly and with integrity.

Step Five: Consider the price. 
Where two products are equally efficacious, I always recommend the cheapest. Because I don't want to waste a patient's hard earned cash, and I think patients appreciate that.

Step Six: Counsel the patient.
This involves giving them all the useful little snippets of information about how to use the product effectively and -crucially- safely. It might be pointing out that the product contains paracetamol, or that it causes drowsiness, or that it works best taken at a particular time of day.

Hopefully all pharmacists will recognize this process, although everyone does-and should- have their own style to go about it with. These sorts of encounters can be really satisfying for both pharmacist and patient, and its often in these moments that I have the most amount of pride in my role. Here I am, giving the patient trusted, evidence based advice which will hopefully bmake the patient feel better. However, you also need a willing patient, and I'm finding more and more often that patients are unwilling to engage in such exchanges. I've also noticed through personal experience as a customer, that some pharmacies are using what i consider to be a cop-out approach to OTC sales. An offhand "you should read the leaflet" whilst I'm handing over my money does not, in my opinion, constitute provide expert advice on medicines.

So why am I on about this at the moment? Well, there's the Which? report, which has found a disappointing quality of over-the-counter information being provided in some pharmacies. Others have given a more detailed analysis of this report, so I won't go into it too much, except to say that yes, there are methodological problems with it. However, it may well be indicative that in a world where pharmacists are under massive pressure to deliver services and dispense ever-increasing numbers of prescriptions whilst working longer hours for less pay, some are starting to lose pride in the basics. Its understandable. In the rush to get everything done, its easy to start seeing the patient as an inconvenience, who we need to get in and out of the door  as quickly as possible. I'm not saying this is what is happening in every pharmacy or in every case, but based on how I used to feel when I managed a pharmacy, I suspect it is a factor.

The other reason I've been thinking about this is the issue of self-selection of pharmacy medicines. In my humble opinion, this is a giant backwards step for the pharmacy profession. Self selection reduces the process I described above down to a bare minimum, and reduces the possibility of introducing quality into it. Sure, we can say there will be information on the packs, but lets be realistic about this. Patients very rarely read the leaflets before purchasing, and if they have to do so in the middle of an aisle in a high street pharmacy or supermarket, i think it becomes even more unlikely. In my experience, if a patient has a preconceived idea of the product they want to buy, its very difficult to persuade them otherwise, even when there is a safety concern with their chosen product.

I remember one customer asking for Sudafed, when she was also taking phenelzine. A combination of these drugs could provoke a potentially fatal hypertensive crisis, but no matter how much I explained this, the customer was adamant that she still wanted it. It turned out her daughter, a medical student, had advised her to use this product, but when I spoke to the daughter it turned out she thought that Sudafed just had paracetamol in it.

Now imagine this situation in a self-selection age. The customer picks up the pack, wanders to the pharmacist, who then has to try to wrangle it from their fingertips in order to ensure their safety. Okay, maybe not that dramatic, but the fact that the customer has the product in their hand, and has been able to "choose" it themselves, reinforces to them that it is their right to buy it. But in pharmacy, the fact of the matter is that the customer isn't always right, and its poor customer service- and downright dangerous- to always allow them to think so.

Imagine that self-selection scenario is also coupled with a curt "read the information leaflet first" as the only form of counselling. Why would the patient bother reading the leaflet, when she already thinks its safe for her to use? And so, what appeared to be a quick, convenient shop for the customer could so easily turn into a fatal drug interaction.

The shopping experience is becoming more and more depersonalised. With chip and pin and contactless payments, you barely even have to glance at the cashier during a transaction- if you're even in contact with a cashier at all. This may be fine when you're buying groceries, but medicines are not commodities. We're different to other shops in that the wares we sell can have fatal effects if they're not used in accordance with expert knowledge and instruction. We simply cannot safely reduce the over the counter consultation to the bare minimum of words required to take money from people as quickly as possible. 

Of course, its not like we pharmacists, will get that much say in the matter, and we'll carry on regardless if self selection goes ahead. Indeed it seems to be a near certainty, despite support from "very few" pharmacists. And it may even be the case that such scenarios never happen in real life. But all I want to do is make medicines safer for people, and to do so we have to identify areas of risk before they happen, and take action to minimise them. 

When it comes to patient care, just hoping the worst doesn't happen isn't good enough.


Tuesday, 21 May 2013

Apostasy: a heathen's perspective

Sometimes, you come across things in life that really open your eyes and you find yourself gazing into a world that you had no idea about. The Apostasy Project is one of those things.

Being a lower-middle-class-ish white girl with a loving, secure, and easy-going family, I've never really had to think about a lot of the things I am. I can breezily make declarations about my lack of faith and no one would really bat an eyelid, even those that are more religiously inclined. Not everyone has access to this privilege.

I know I've said this before, but I really can't thank my parents enough for their laid back -some would say lackadaisical- attitudes to my religious upbringing. They purposefully didn't force any religion on me as a child, their conviction being that it was my choice-when I was old enough to make that decision- what to believe in. They gave me the gift of a neutral baseline on which to impose my own beliefs, or lack of them, as I wished.

I went to a Christian school, but all that really meant was sitting through a couple of minutes of prayer in assembly. There were no consequences of not praying- it was just another boring part of assembly to accept and get through before the more interesting bits of the school day started. School plays were religiously themed sometimes, (but also, on one notable occasion, Neighbours themed) but none of this really had any effect on me or the rest of my life decisions and was viewed by most of us kids as vaguely ridiculous and uncool.  I have very little knowledge of any religion, to be honest, because I just don't really need it in my life- I'm a modern day heathen, in the unruly, uncivilised sense of the word, you could say.

So I've been pretty much oblivious to the sorts of issues that people who have to walk away from a religion can experience. Recently, thanks to The Apostasy Project, I've been reading with interest the accounts of people who have walked away from their religion. It had, to be honest, never really occurred to me that 'coming out' as an atheist is potentially just as traumatic an experience for some as the more traditional version of 'coming out' that people would think of- as being gay. Like some gay people, apostates also risk losing respect, family, friends, and their whole communities simply for stating that they no longer subscribe to the same belief system. What I'm realising too is that these sorts of issues can apply across the board religion-wise too: it's not just those that people assume to be more fundamentalist.

Given all of this, it's amazing really that anyone ever does come out about losing their faith. But, when the alternative is living a lie, why should people have to keep their lack of faith secret? The more apostates speak out, the more normalised it becomes, and hopefully a more open, civilised and accepting society follows. Making the decision to question and walk away from a religion which shaped your childhood is an incredibly brave thing to do, and those of us who are lucky enough not to have to do so might not appreciate that.

The Apostasy Project has been set up to support people in this position, and its an important role to play. If any of you lovely people can help them out, please do. 

Atheists are, by definition, a ragtag, diverse bunch. Some would say that with only a lack of belief to unite us, it's impossible that we could build the sort of religious community one would find in, say, a church. But I don't think that's true, and I think it's important that we build a sort of atheistic extended family in order to be more visible and frankly, just because its much nicer for us all to feel that we belong somewhere. This is my little chunk of solidarity to apostates everywhere, then, for what it's worth.


P.S. Be sure to also read John Sargeant's account of leaving Jehovah's Witnesses, which are beautifully written: Part One and Part Two

Sunday, 19 May 2013

The Magic Blankie

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

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

NO Kermit! Don't you know that by saying bye bye blankie you are denying yourself the health benefits of Magic Russian Technology?!
They're all the rage in Russia apparently. And I suppose, given how cold their winters are, it's only natural that every household would have a cosy blanket lying around. At only $325 a pop, why wouldn't you?

So what can the healing blanket actually heal? Lets see what Scenar have to say about it:
"The healing blanket TMB-01 can be combined with other therapies for a treatment of a wide range of diseases as well as stand alone independent treatment for psycho-emotional regulation, insomnia, stress and reduction of muscular spasm. The TMB blanket also helps to regulate psychosomatic conditions, relieves constant tiredness, and improves feelings of well being."
Insomnia, stress, tiredness, psycho-emotional stuff. Well we all have problems with those, don't we. Lets have a look at how we should use the blanket: 
"Maximum effects are achieved when the patient is wrapped completely and sleeps... One procedure takes around 40 minutes and could be repeated 2 – 3 times a day. The course of treatment is between 15 – 20 days 9 up to 1 – 3 procedures a day)".
Right, so to make yourself feel less sleepy, or to stop insomnia, what you should do is get cosy in your Blankie and sleep. Yep, seems perfectly plausible to me that the effects on conditions caused by lack of sleep are purely down to the blanket itself and nothing to do with sleeping, or just having a bit of a relax. Although frankly, having a 40 minute nap three times a day for 20 days is unlikely to help my stress levels as I'd have time to get sod all done in the rest of the day. 

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

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

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

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


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

Thursday, 16 May 2013

Lessons and a legacy

On the 7th November 2007, my life changed forever.

In a very small ceremony in Toronto's Civic Hall, I married the man who completed me. Together, we embarked on a three year journey characterized by security, comfort and love. We had our moments and arguments, but we enjoyed a really good marriage. The overwhelming feeling I remember experiencing in those days is safety.

People are often surprised when I tell them I'm divorced. In my head, I desperately tell myself this is because I look far too young to have been through this particular mill, or because I'm simply so amazingly wonderful that no-one could possibly imagine anyone wanting to divorce moi. I tell myself these things to stave off the fear that they're astounded that anyone would be daft enough to marry me in the first place. And of course, the next natural question for them to ask is "What happened?!"

I find it hard to know how to pitch my answer. Its pretty much impossible to hit the right tone in an everyday conversation. I have no idea if its even possible to convey-within a few sentences of a polite conversation- what it feels like to have your entire world shattered, being forced to give up all your hopes and dreams and worldview in the process, and yet also how you are utterly amazed at yourself for getting through it all relatively unscathed. At least I can now just give them this link and tell them to get back to me in twenty minutes

I usually find myself sounding far too dismissive of it, as if it was all a bit of a breeze and I barely even noticed it happening. But the other alternative is to sound like I'm still a gibbering wreck because of it, which I'm really not.

It was all very sudden. There was an inclination that something wasn't quite right for a week or so before, but nothing too terrible. On Christmas Eve I was feeling a bit wistful. I told him I was worried, to which he said "Don't be so daft. We'll be together for ever." That's an exact quote, by the way. I feel like its burned into the inside of my skull, and can actually see the words scrawledin sooty black. Two days later, on boxing day, he told me he wanted to divorce. He had decided he wanted children, and there was no longer any place for me, and my lack of desire for children, in his life. This was not negotiable. There was no room for trying, marriage counsellors, pleading, nothing. He'd decided that I just wasn't worth fighting for, and that was that. This may have been the best and worst part of the whole thing. Its utterly crushing to know that you're not worth any effort, but his absolute certainty that this was It meant that I was saved from having to hang on for months on end, telling myself that he might just change his mind. I was saved from limbo, but tipped into hell.

The embarrassment is possibly the worst bit. Having to acknowledge that you've failed at what you consider to be the most important and central bit of your life- if not your entire life itself- is truly awful. To this day, I'm terrified of meeting anyone who i haven't seen since it happened. I'm going to a wedding soon in which there will be people there who I haven't seen from school, and I'm already preoccupied with how much of an utter failure they will think i am. I don't think I'll ever quite shake this feeling.

I used to honestly believe that he was my world. I used to worry about him getting ill and dying and whether or not I'd survive without him. I always concluded I wouldn't. I used to think that love was the single most important thing that could ever happen to me, and that if I didn't have it with this man then my life meant nothing at all. I thought I was quite pathetic, emotionally, and that I would never be able to cope with half of the things that most people go through as part of their daily lives. Other people could cope with divorces, but not me, I thought. I'm left both terrified that I won't ever feel like that over someone again and terrified that I will. I thought he made up for all my faults and that as part of a couple they would be forgiven, whereas on my own I wasn't worthy of anyone's consideration.

However, approximately two weeks after that fateful Boxing Day, I had my own flat and I was absolutely loving living on my own. My friends- who I had mildly neglected during my marriage- rallied round and were and still are properly, properly amazing. All of that love that used to be directed at one man is now spread liberally over all of them. I've discovered a fierce loyalty that I didn't know I had. I've gotten myself involved in many things that I would never have dreamed about being brave enough to do during my marriage. these things would seem tiny and inconsequential to anyone else, but to me they are a lifeline.

I totally surprised myself. I didn't sail through it all, by any means, but I surpassed my own expectations of how I would cope with flying colours.  I know now that I have a capacity to cope with things that I would never have discovered if this hadn't happened to me. I have a renewed confidence that, when terrible things happen, I'll survive in my own right. I have faith in my own personality, and know that I don't need another person as a prop. A relationship is an optional extra, not a baseline requirement. My friends come first, above all things. I've learned that support comes from the most unexpected places (@eyeswideshut75, I'm looking at you, amongst others), and that asking for help is not in any way shameful. These are lessons that I'm bloody glad I now know.

I'd love to end on that positive note, I really would. But alas, its not that simple. I'm left with an inherent distrust of anything nice that's said to me. All of my beautiful ideas of love are shattered and I now know that its most definitely not All You Need. I've been unable to say and feel the word ever since in relationships, and have purposefully shied away from a few opportunities because of the terror of letting myself go. I have to fight with the cynicism that raises its ugly head every time a friend announces an engagement, or I go to a wedding. It's not the done thing to laugh bitterly out loud at the vows, I hear. This doesn't mean I'm not genuinely happy for them, I really am. I just hate the fact that my right to feel the excitement and happiness that blissful ignorance brings has been taken away from me.

If you ever visit Toronto Zoo, you'll find a little brick in the pavement just outside the gift shop which commemorates my wedding. It'll be there forever (or at least whilst the Zoo is still there), but the concept of forever has been ruined for me, and I don't think I'll ever get it back. Sometimes I think about how we have let that little brick down.

Anyway, there you have it. I'm not one for mystery, and prefer to have things out in the open. It's cathartic to tell you all, dear readers, this sort of thing, and I'm pretty sure that if this really was just a blog about skepticism in healthcare you'd be bored shitless by now. So forgive my oversharing, and this muddy little puddle of melancholy in an otherwise bright and beautiful day.


Tuesday, 14 May 2013

Harry, who had seven hairs on his head.

I've been thinking a lot about my Grandad Harry recently. I'm not entirely sure why- it's not his birthday, or the anniversary of his death or anything in particular. I'm not going to bother trying to shoehorn this post into any recent news events or make any great points about skepticism or science in it. My intentions are purely to tell you about him, because he is a worthy subject.

At school we had to do an English project on someone who had inspired us.   Of course, it being the early nineties, my English teacher found himself wading through twenty or so biographies of Michael Jackson. But I did mine on my good old Grandad. I wish I still had a copy of that project now.

He was brought up in a Catholic orphanage. I believe his mother died and his father couldn't take care of him and his siblings. I know he had a horrible time there, but the details are sketchy. I know the orphans there were very starved of love and attention. I remember him telling me how, one Christmas, the nuns had told them all how they were getting a very special treat. The boys were each presented with a bit of spice cake, which in their eyes might as well have been manna from heaven. It gave them all a tiny ray of hope, of excitement. When they bit into it, it was full of cobwebs. Those nuns must have been having a right old laugh at that. 

Despite- or perhaps because of- all of this, he vowed that his life-and the life of his family- would be filled with nothing but love and warmth and joy. Where he could so easily have been consumed with anger, he instead became what I consider to be the very pinnacle of what everyone should strive to be. He was a true gentleman. 

He met my Grandma briefly, then again through some mix-up with ration books, and so it began. (i need to check that story actually, i remember it being desperately romantic, but I can't recall the details.) Those two have taught me everything I know about love. Through some hard, poor, and difficult times they were the most loving and romantic couple I have ever encountered. You know when you're in the first flush of a relationship, and you do everything you can think of for someone before the fatigue of familiarity sets in? They seemed to be like that despite being together for many, many years. Their flat was full to the brim of knick-knacks, those little impulse purchases they had bought each other over the years just because they were thinking of each other all the time. 

He was gregarious, and would welcome anyone to his home with a massive smile and a huge hug. Whenever I took boyfriends round to meet him for the first time, he'd welcome them with "hello, bonny lad!" along with a (often to their embarrassment and my amusement) big sloppy kiss. Within about 5 minutes of arriving, he'd be offering you food, tea and whisky, and you'd be totally charmed by him.

He loved whisky, so much so that on his 80th birthday he got 18 full size bottles of it as presents from his friends. I used to go round to see him for a few hours and emerge into the afternoon staggering somewhat from all of the "wee drams" we'd share. Highland Park was his favourite: for his birthday I bought him a bottle of the expensive stuff. The next time I went round he said he had drank it all already, but later on, when he was more sick and I had to retrieve some from the cupboard for him I could see the only-half-empty bottle there, the cheeky devil. 

He had an amazing sense of humour. When he and my Grandma came to stay with me once to look after me when my parents were on holiday they told all their friends they were going to Kingston for the week, neglecting to mention the Park bit which would denote a sleepy suburb of Newcastle rather than Jamaica. He tried his best to be modern: he loved playing on the wii, pottering about on a computer, and listening to his iPod. He had a better mobile phone than me at one point. And he-and my grandma, still- also had modern attitudes. They knew the world was changing around them and they did their best to understand it, not be set in their ways and disapproving if us unruly youngsters. They didn't bat an eyelid when I would traipse in looking all sullen in my goth days, they just gave me a massive hug and told me I looked lovely all the same. 

When he became very ill, there were about four or five occasions when we seriously thought he was going to die. Each time he fought back, but became more and more frail each time. I remember his consultant pretty much saying after the first time that he shouldn't have still been with us, and that he wish he knew his secret. My auntie probably put it best: "he'll do anything he can to stay with her (my grandma)". Perversely, I actually remember the first time this happened as one of the best times I have spent with my family. Waiting in the relatives room, us assembled cousins, aunties, uncles and parents roared with raucous laughter at everything going. We made our own hilarious entertainment using nothing but an old copy of the Evening Chronicle and  some plastic packaging. Some would think that's weird, but I know Grandad would have wanted nothing less. At his wake we holed ourselves up in a room with copious amounts of port and wine, and screamed with laughter as more distant friends and relatives turned their noses in the air and probably thought we were disrespectful.

But he would want us crying tears of laughter rather than sadness.

Now, as you'll probably know by now, I don't believe in an afterlife. But I do believe in a legacy, and if I manage to have a legacy that's even a quarter as powerfully loving as Harry's, I'll know I will have led a good life. 


P.S. The seven hairs thing was a long standing joke. He used to count them and declare that he had seven hairs on the top of his head. No more, no less, always seven.

P.P.S. Its been requested that I mention something else also, something that I actually can't believe I forgot about: The Toilet Of Joy. I have no idea why The Toilet Of Joy came about, but it stems from a family trip to Ilkley for one of Grandad's birthdays. We had a meal in one particular area of a pub which had been roped off for us, and for reasons best known only to the god of wine, the entire family ended up spending much of the night in a toilet cubicle, in hysterics over a hand-dryer. This became known as The Toilet Of Joy. Something very odd, very noisy, and very wonderful happens when my family get together. 

Friday, 10 May 2013

Nose Gunk strikes again: AllergieBLOCK

What is it with people trying to produce "Revolutionary" new versions of rubbing vaseline on your nose whilst charging vastly over the odds for the privilege? Someone, somewhere has obviously decided that our noses just aren't greasy enough. Thanks to my friend Paul for bringing this to my attention.

Enter the new kid on the over-the-counter hayfever market block (see what I did there?): Nasalguard AllergieBLOCK. Firstly, how am I supposed to trust a product that can't even manage to spell allergy properly? Secondly, is that Comic Sans font that I spy on the packaging?! Okay, so it seems like the UK packaging is different, but that doesn't matter. The damage is done, and the use of Comic Sans is an unforgivable crime.

A Crime Against Humanity
Thirdly, on trying to find the UK site, it seems that this is yet another company who has taken to giving free stuff to people so that they will say on their personal blogs how very marvellous it is. This sort of publicity just doesn't wash with me. It feels grimy and seedy and smells faintly of desperation. I therefore imagine this is also what Allergieblock gel smells of.

Let's have a look at what the manufacturer's say:
"NasalGuard AllergieBLOCK® Regular is a revolutionary topical gel based upon patented technology containing cosmetic grade ingredients. The FDA-approved gel creates a positive charge which blocks negatively charged allergens on contact before they enter the nasal passages."

Right, it's really not revolutionary, is it? It's hardly going to free the downtrodden masses from the grips of the evil dictatorship of pollen. It's exactly the same principle as Prevalin and Haymax, and of course good old Vaseline. I've said it before in the Prevalin post, but the idea of putting vaseline on your nostrils to reduce hayfever symptoms is as old as the hills. There's nothing revolutionary about this. This positive charge thing is new, however. It sounds like something that a bunch of marketers sat in an office having a "thinkstorm" session would come up with as being suitably science-y to wow the masses.

But surely this can't possibly be the case, not when there is a heart-warming "Inventor's Story" on the website:

"About 20 years ago, New Jersey Professional Engineer Ashok Wahi's daughter Aikta frequently suffered from allergies after exposure to her friend's cat. He wanted her to be relieved from the constant sneezing, runny nose and congestion without taking drugs.  The conventional over-the-counter remedies made her sleepy at school, he got motivated to create a drug-free solution for his daughter that wouldn’t cause drowsiness, dry mouth and similar side effects.

The project's goal was to prevent the inhalation of allergens rather than treating the allergy symptoms after the fact.

With this in mind, Wahi put his engineering skills to work and developed a unique gel that blocks allergens on contact, therefore alleviating allergy symptoms. Hence the birth of NasalGuard® technology."

So its taken this dude 20 years to reinvent the wheel and come up with a fancy version of Vaseline. Shame really, he could have saved himself the effort if he had only spoken to a decent pharmacist or GP. Whilst I'm sure being a "Professional Engineer" is awesome and all, I'd really rather like it if people who are trying to improve my health have some sort of background or training in healthcare, thank you very much.

Anyway, all of this is by-the-by, because of course there is going to be a wealth of good quality clinical trial evidence to say that it works, right? Dear readers, you probably know the drill by now. There's some testimonial videos on the website, a grand total of 4 of them. With Prevalin, the manufacturers tried to pass off two methodologically poor trials about products that bore no relation to Prevalin at all off as clinical proof that it works. These guys don't even bother going to that amount of effort. There is no mention anywhere on the website about any trials at all. They don't even bother cursorily referencing the Principles and Technology bit:
 "NasalGuard AllergieBLOCK® uses patented technology that works on a simple principle of electrostatic charges: opposite charges attract each other.
AllergieBLOCK gel has a slight positive charge which attracts negatively charged allergens. Allergens like pollen, ragwort/ragweed, hay, dust mites, pet dander and house dust all carry a slightly negative charge. The allergens are blocked on contact. You do not inhale allergens, which means you don’t suffer from allergic reactions"
Now, it does seem to be the case from this PLoS One study that allergens are negatively charged whereas non-allergens are more likely to be postively charged. But until there's some evidence that a mixture of "Dl Water, Polyquats, Propylene Glycol, Octoxynol-9, Glycerin, other cosmetic grade ingredients and preservatives" can definitely produce some sort of nasal forcefield against the nasty pollen, and the manufatcurers can demonstrate an ability to spell properly, I'm not interested.

I'd also rather not apply something to my face which is going to actually attract the very things I am expressly trying to keep away it, thank you very much. Without evidence to the contrary, there is nothing to say that all of those positively-charged allergens which are supposedly now attracted to the gunk on your nose will get stuck on the gunk. A few allergens with probably make it through, given that nostrils are relatively big holes in comparison to how small the allergens are. So if anything, there is a potential that you end up with more allergens than you would have done had you not bothered applying it in the first place. Imagine Justin Bieber in a young girl's school, with only one or two bouncers for protection. a fair proportion of the screaming pre-pubescent youngsters are likely to get through the bouncers to plant a kiss or two on the fresh-faced child-adonis. (If I'm honest, I have only a vague knowledge of who Justin Bieber is, but I understand he's the Jason Donovan of modern time)

How much does it cost? oh, only the princely sum of £11.99 for 3g at Boots. ELEVEN POUNDS AND NINETY NINE PENCE for THREE GRAMS!!! Think of all the other things you could buy for £11.99.

Save your money, people.

Wednesday, 1 May 2013

e-cigarettes: accidents waiting to happen?

We all know smoking is bad for us, and we all know that giving it up is a good idea. E-cigarettes have been around for a good few years now, and they seem to be the answer to a lot of our prayers to some people: That lovely nicotine hit, without having to traipse outside, and without any of the nasty tar or other chemicals that makes smoking bad for you.

There's currently a bit of a kerfuffle going on about them as the EU look into tighter regulation of them. A quick search on Twitter reveals lots of folk stating that they save thousands of lives, are much safer than other pharmacological smoking cessation methods, and are totally safe, therefore shouldn't be banned by the EU. Others have covered the fact that e-cigarettes are unregulated, that they may actually contain chemicals and ingredients which can be carcinogenic, that they might have adverse safety effects so I'm not going to cover all of those potential issues here. .But there is one aspect of their use which I think is easily forgotten about, but has the potential to be very worrying.

It seems that e-cigarettes come in a variety of forms- none of which are regulated. Some are disposable, some have refillable cartridges, and some require refilling with a liquid. There are even some sites which encourage mixing your own nicotine liquid: a complicated process requiring mixing a nicotine concentrate with a flavouring and a diluent using a dropper.

Now, as a fairly young pharmacist (or so I keep telling myself), it has been a long time since I compounded any medicines myself, but I do remember doing so in university and I have a pretty good idea of how to work out and produce mixtures. I'm a keen baker, so used to following recipes which can be complex at times. And yet a quick glance at some of the mixing guides for nicotine liquids makes me worried. They look complicated enough for a pharmacist like me to follow, never mind anyone else. Milligrams, drops, milliliters, colours, parts etc are all terms used on the same instruction sheet, and the medicines safety part of me is crumpled and crying in a corner, wailing "HIGH RISK COMPOUNDING PROCEDURE!" loudly to anyone who will listen. And yet, because these things aren't considered a medicine, anyone can sell this stuff, and anyone can buy it. There are risks at every step of producing these mixes: not understanding the instructions, not accurately measuring amounts, mixing up the different liquids, storage of the liquids, spillages etc etc. Some sites even suggest using a syringe- complete with needle- to inject the nicotine solution into devices. A little bit of me is dying inside.

Even the ready made liquids are problematic enough. They come in little eye-dropper type bottles, and are often pleasantly flavoured. In short, they're probably rather attractive to children.

In my day job, which partly involves advising on poisoning cases, I have come across quite a few cases where nicotine liquid intended for use in e-cigarettes has been accidentally ingested. A lot of people don't know that nicotine itself can be horribly toxic, particularly for children. It only takes a small amount orally to get some pretty nasty, potentially fatal effects. And yet, freely available to buy without any regulation at all, a variety of attractively flavoured and packaged -and really highly concentrated- nicotine liquids are sitting ready to be bought by eager punters. You can even buy multi-packs of large bottles of highly, highly concentrated nicotine liquid. They don't even have child-resistant tops on them- and why should they, as they're not even considered a medicine? The websites selling these things aren't particularly clear about the dangers of them- again, why should they be, when they're trying to sell them as a safe alternative to smoking?

I've had a quick look around the medical literature and as of yet there is very little information published on this aspect of e-cigarette usage. And that's part of the problem: the technology has been widely adopted without a thorough understanding of all the different aspects of its safety. Even if they were tightly regulated and highly safe, this aspect of accidents with refills will still remain, and in my opinion it is only a matter of time until there are some very serious accidents of this nature.

So, whilst e-cigarettes might be a useful ally in giving up smoking for some people, we really need to put some thought into the safety issues surrounding them, and not just the obvious ones which might affect the person using them.

All of this is without even considering the fact that using them can sometimes make you look a bit daft, especially the ones that light up at the end like a pretend-y cigarette. Others, frankly, look like "discreet" vibrating devices for ladies. You'd be better off with those yummy candy cigarettes from the eighties, if you ask me- they look more like an actual cigarette than most of the e-cigs and they're a whole lot cheaper too.