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 website www.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

Is pharmacy a good career choice right now?

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

 

When real science gets left out in the Coldzyme

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. 

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.

 What I love about pictures like this is that it's always perfectly made-up women in them. As if anyone can be arsed to think about makeup when they're vomiting everywhere and their head feels like its being crushed. 

What I love about pictures like this is that it's always perfectly made-up women in them. As if anyone can be arsed to think about makeup when they're vomiting everywhere and their head feels like its being crushed. 


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
 

Thank you, 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

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

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

 

Lychnobite, by Simma: An album review.

There is a particular pub in Gateshead which 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

Why it's okay to question a charitable cause

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. Being open and honest when questioned only serves to strengthen a cause. Defensiveness doesn't help anyone.

Hxxx

Postscript: This selfie craze ended up making a lot of money for breast cancer charities, which is great. No one has ever denied that making money for charities is wonderful. I'd argue that donations started for this- as well as the ALS ice bucket challenge that followed- not instead of, but because of, healthy skepticism about the purpose of the craze. 

Making it up as I go along

What better way to spend a Sunday than an eight-hour long improvised comedy workshop?

Now, I know that there are a lot of people who would jump for joy at the suggestion. I also know that I am really not one of them. I can be pretty reserved, and of course there is my social anxiety to factor in.

My good friend Shandy suggested it. She had been to similar sessions before, and thought it would be good for me. I trust her judgement, so I signed us up for it before I had a chance to regret it. And what a day it turned out to be.

Social anxiety is an odd creature. Recently, I’ve been learning about the main thing that makes it particularly odd- self-focus. It’s a weird dichotomy- the same diagnosis that ruins your confidence and makes you want to disappear also manages to persuade you that you are the entire centre of everything that exists. It simultaneously makes you completely hate yourself, and become an insufferable narcissist in your own head.

I think I’m really pretty good at challenging myself. I force myself into social situations that I don’t want to be in on a fairly regular basis. More importantly, I force myself to social situations that I really do want to be in but am completely effing terrified of. I’ll say yes to parties in London where I basically know no-one at all. I’ll arrange and go to tweet ups. I go to lots of bake clubs, and I’m out of the house on most evenings of the week, seeing various different friends and going to all sorts of different events. I’ll merrily agree to SITP talks here and there. Yet no matter how much I push myself to do things, and no matter how well these things turn out, the fear remains the same.

I know the theory. I know that anxiety is supposed to lessen the more you are in a situation, and the more you are exposed to that situation. Yet mine.. doesn’t. I know that I have been in a similar situation before, and it was absolutely fine, yet I still end up a gibbering wreck each and every time. It’s the self-focus that does that. With my social anxiety, its not the other people who are scary, it’s myself, and that can be really difficult to get around. Its this aspect that makes it refractory to exposure therapy.

One of the most exhausting parts of it is self-censoring. I constantly dismiss my own thoughts as not being worthy enough of being said out loud. I’m scared of sounding stupid, boring, of being judged, of not being interested enough. Instead of allowing the person I am speaking to make those judgements, I do it myself, and discard things that I want to say before they leave my mouth.

These things do not make me an ideal person to perform improvised comedy. I am the person who will eventually come up with a killer comedic line about six hours after the opportunity to use it has gone, then will proceed to beat myself up about it for days, weeks, sometimes months afterwards. I have never performed any sort of drama or anything like that, and the opportunities for creativity in my adult life have been pretty limited.

 Bev Fox, one of the wonderful teachers at the Improvisation Foundation and co-founder of The Suggestibles

Bev Fox, one of the wonderful teachers at the Improvisation Foundation and co-founder of The Suggestibles


So, you’re asking, how did it go?

Pretty well I think. I was completely exhausted and nigh-on broken afterwards, but it felt like one of the most productive things I have done so far to subdue my social anxiety monster.

The group of people attending the workshop were warm, welcoming, and kind. Bev, who was leading it, was marvellous. I didn’t feel pushed into anything at any time, though I spent the entire day not just outside my comfort zone but pretty much in another continent to it.

Luckily, my ultimate goal for the workshop fits in quite nicely with one of the fundamental basics of improv- turning off your self-filtering. I didn’t achieve it fully- I still felt pretty shy and reserved by the end of the workshop- but I did take some big steps towards it. I found myself taking part in the games much more enthusiastically than I had expected, and even managed to be funny on the odd occasion.

One of the most beneficial parts was towards the start. As part of a game, one of the guys asked who was nervous about coming today. As dictated by the game, this then led to a mass vacating of seats, followed by a scramble for another one. There followed “who has ever had stage fright”- again, mass movement.

When I found myself stuck in the middle of the circle, I went with the emotionally deep and existentially important question of “Who gets excited when they are about to eat spaghetti hoops?”

There followed a pretty amazing discussion with everyone in the group about their experiences of stage fright and nervousness. They were all so honest, and although I am constantly told that I’m not the only one, it was still good to see that perfectly well-functioning adults still suffer from the stomach-butterflies and brain-freezes just as much as I do.

There were games involving eye contact, which is something that I can sometimes struggle with. There was a really interesting part where you had to walk around in either a high status or a low status mode. It occurred to me as I was doing it that the way I naturally walk, giggle, play with my hair, hunch down etc was pretty much a text book version of the low status walk, whereas high status mode, striding around and holding eye contact with people, I felt really weird and unnatural.

So much of what we covered fits in with what I am covering in therapy. Even the terminology is the same. There was one task where we walked around the room and had to quickly name all the objects. Then we slowed down, and asked more questions about each object in turn, eventually getting to a point where we explored our feelings as well. It reminded me of mindfulness therapy- it was all about being in the moment, rather than rehearsing what might happen in the future or dwelling on what you said five minutes ago.

So it basically felt like an 8 hour long group CBT, mindfulness, and counselling session with a whole load of humour thrown in for good measure. Honestly, I have seen Paul Merton’s Improv Chums three times now and there were moments in this workshop which were just as funny.

I’m not convinced that I am destined for a comedy career, but I have taken a whole load of positivity from that one day, and I’m really pleased and proud of myself for doing it.

You can find out more about the workshops at www.thesuggestibles.com. Bev and Ian's improv group, The Suggestibles, do regular gigs in Newcastle upon Tyne so keep an eye out for a performance if you are in the area- they're a right good laugh, and a blummin' lovely people too.

Hxxx 

The importance of a fluffy pen

Many years ago, in my pre-reg year, I was pulled into an office by my tutor and told that I needed to sober up. She didn't mean that in an alcohol sense, but instead that I needed to start being more serious, dour, and less quirky. She told me that my personality, as it was, wasn't right to be a professional.

At the time, I believed her. She told me that I would never make a good pharmacist if I carried on the way I was. I was terrified, as all I wanted to do with my life was to be a pharmacist. If I couldn't be a good one, then I would really need to change my personality.

All of this started because I had a Christmas pen. It played tinny music for an alarmingly long time when pressed, and it became a bit of a joke in the dispensary to sneak up behind me when I was working and set it off, making everyone dissolve into giggles. A dispensing assistant, who was wearing a Christmas tie, was also told off, and strongly advised to not wear it again.

But nowadays, I disagree heartily that you have to be serious to be professional. I think a little bit of well-placed silliness and a lot of humour can add to our professionalism.

We need to be approachable to patients. And what makes a person more approachable than a little bit of personality? Nothing, except perhaps a novelty pen. On a couple of occasions, women who have come to see me about the emergency hormonal contraception pill, and who have been very nervous, have ended up giggling at a ridiculously fluffy pink flamingo pen I used to have. It broke the ice, and they could see that I was a person just like them, and I wasn't going to sit there all business-suited and high and mighty at the other side of the table and judge them. They felt a lot more comfortable because of that pen, and I think I was able to help them a lot more as a result.

At the moment, I have a Special Pen in my desk drawer. It is comedically large, pink, and slightly phallic, with some floppy rubber spikes on the end. I like to take it out of my desk drawer and offer it up, straight-faced, when people ask to borrow a pen. 

 my special comedy pen, with a banana for scale

my special comedy pen, with a banana for scale

We health care professionals deal with a lot of dark stuff on a daily basis: sickness, death, disability, anger, frustration etc. We need to balance that darkness out with something lighter. Whether its doing something daft in the dispensary to make your staff laugh for a few seconds when times are stressful, or donning a fox mask and writing silly things on the internet, it all counts. 

As long as we put the patient first, we treat others with respect, and we work within our limits, true professionalism doesn't have to mean that we all walk about with serious faces.


Hxxx  

A comparison between medical and homeopathic information sources

Recently, I’ve been delving back into the world of homeopathy, and all of the nonsense that it entails.

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

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

Up To Date?

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

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

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

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

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

Political Correctness

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

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

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

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

Clarity

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

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

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

In Conclusion

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

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

I've said this before, and I'll say it again: why would you continue to use an abacus when calculators exist, and are proven to have a better record at getting the right answer?

 

Evidence-Based Ambridge

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

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

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

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

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

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

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

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

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

And as for herbal arnica? there's also no evidence that it works, although there is a little bit of prior plausibility, in that some of the chemicals in the arnica plant have an anti-inflammatory and anti-platelet action. There is, however, no information on how clinically significant these actions are, and whether rubbing a bit of cream into an area would get these potentially useful chemicals to the right place in any meaningful amounts.

Let's not forget that bruises are self-limiting. They go away of their own accord (and probably at the same pace), regardless of whether or not you rub some gunk into them. herbal arnica isn't risk free: the cream can cause  contact itchiness, dry skin, and rash. Orally, arnica can be pretty nasty stuff, even causing coma and death in extreme cases. 

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

Blowing a raspberry

Imagine there is a door in front of you. There is a person standing next to the door:

"Hey there, pudgy, do you want to be thin and beautiful without having to do any exercise at all? All you have to do is hand me some cash and step through that door there."

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

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

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

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

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

But before you step through the door, you take a moment to consider what might be behind it.  You don't know, and the person telling you to go through the door doesn't know what's in there either. No one has studied what's behind the door. There are no photos and  no videos of what's in there. All you have is this person's word that it is safe, and it will work. 

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

  1. Nothing. Its just a room. You go through the door, and nothing happens. You don't lose any weight, but you have lost your money. 
  2.  It works. You step through the door and emerge as a smiling, happy, beautiful, skinnier you. You quickly run home to find some horrible grey tracksuit so you can smugly show everyone how marvellous you are now you're skinny.
  3.  Something harmful is in there. Maybe there is a big pile of dog poo right behind the door, and you are destined to step in it, which will be mildly unpleasant for you. Or the door could be perched on top of a cliff, below which is a mesh of razor blades that will cut you into little pieces. Worse than that, perhaps Piers Morgan is through there.

Do you step through the door? 

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

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

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

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

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

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

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

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

Hxxx


The Ultimate Christmas album for the Existentially Wounded

"It's why, it's why we hang lights so high
and gaze at the glow of silver birches in the snow
Because of the dark, we see the beauty in the spark
We must be alright  if we could make up Christmas night"
-Tracey Thorn, Joy. 


Now, I'll admit that at this time of year, I can get rather annoying.

I love Christmas, I really do. I'm often to be found wearing antlers and tinsel. I put my decorations up at the first opportunity humanely possible, and start on the mince pies in September. This year, I excitedly bought myself a Lego advent calendar, despite the incredulity of the guy behind the counter in the shop. I also have snowman hoodie which yes, I shall wear out in public.

As a child-free, cynical, atheist adult, it might seem like this is a hard time of year to enjoy. And, to be honest, you're probably right. It would be a whole lot easier to throw in the towel and grumble about how commercial it all is, and how I just wish it was over and done with and everything can go back to normal. But I refuse to give into this, and put quite a bit of effort into maintaining my child-like delight at the festive season.

Obviously, its nothing to do with god. And don't get me wrong, I love the presents too (dear parents, if you are reading this, please do take note that I shall never be too old for Lego). But my desperation to enjoy this time of year runs somehow deeper than all that. I don't need to link it to religion, nor do I need to experience it through a child or partner. Christmas reminds me of my own, hard-won personality.

For me, it is about traditions. And these traditions, as they shift and change slightly each year, somehow reinforce my own self to me. Back in what now seems like a lifetime ago, my ex-husband and I took joy in forming new traditions together at this time of year. It was a way of reinforcing ourselves as a couple unit, of forging our own little family ways. Small things, like buying a new special decoration for the tree each year, came to mean a lot to us.

When my marriage broke down on Boxing Day 2010, I had to start again. Everything I had known up until that point fell apart, and my hopes and dreams, which I had been carrying like a shield all my life, shattered in a matter of hours. I had to begin again from scratch, and it was often the smallest of things that seemed to make all the difference to me.

The next year, my new, empty Christmas tree seemed somehow symbolic of how I had to start to collect some traditions of my very own. These traditions would belong to me, and me alone. I started picking up little decorations here and there, and now I have a rather lovely collection of bits and pieces to adorn my home with. And I've done the same with traditions: baking certain things at certain times, (including my beloved Christmas pie), drinking startlingly strong fruit wine in a particular pub on Christmas Eve with my friends, seeing Rare Exports at the cinema, taking part in a gingerbread contest, and many others. Some of us even go so far as to throw ourselves into the freezing North Sea on Boxing Day which not only washes away any vestiges of hangover cobwebs, but also distracts me from the awfully sad memories I would otherwise be thinking about.

Winter is a dark and often terrifying time for many of us. Dark mornings and dark nights make it easy for the sadness and emptiness to creep in. Getting home to a cold, dark, empty, one-bedroomed flat can start to feel like a failure. But then I pop on the tree lights, and I have something to focus on, some little pinpricks of hope that, in the end, the world is full of good people, and I will be able to spend some quality time with those who I love most- my friends and my family. And I will have an excuse to fill my flat with sparkly things, and wear glitter eyeliner.

Christmas is, to me, an acknowledgement that times will be dark and hard ahead, but that I will get through those times, with the help of those around me. It reminds me of how far I've come, and how proud I am of myself. It reminds me of all the good I have found in the world, of all the little bits of help I have gotten from the most unexpected sources, of all the new people I have met and the pride I have in my oldest friendships. If humankind has the presence of mind to plonk a huge celebration in the middle of the darkest season (even if they have done so on the pretence of a god I don't believe in), then that's fine by me, and I shall do my damnedest to make sure I embrace it with gusto.

I love the standard Christmas songs. I'll dance about to a bit of Slade with the best of them. But the saccharine jingle bells of most of the tunes you'll find on Now Thats What I Call The Ultimate Best Ever Christmas Tunes In World... Vol 3 don't seem to quite catch the nuances of the festive season for me. I've only come across a few songs which do, and I have collected them here for your auditory pleasure. I'm keen to know of more, so if you have any you would like to recommend, please do let me know, either in the comments, by email, or by tweeting me (@SparkleWildfire). What I would like to do is create a playlist of genuinely good, beautiful songs that evoke both the joy and the darkness of Christmas.

Joy by Tracey Thorn.
Tracey Thorn's (of Everything But The Girl fame) Christmas album Tinsel and Lights, which she released last year, was a total revelation to me. Its a gorgeous, calming album which hits just the right pitch of melancholy and joy for this time of year. I think this song says it all really.

Snowglobe by Dean Owens.
I saw Dean play at the Tyneside Cinema just before that fateful christmas of 2010. This is a lovely, sad little song about having depression or mental health issues over Christmas time. It serves as a reminder that mental health issues don't instantaneously resolve over the festive period, and that this time of enforced happiness can be extremely hard for many.

December Will Be Magic Again by Kate Bush
You may already know by now that I absolutely adore Kate Bush. Even the title of this song is poignant. This song has the same theme to me as Joy: its about using tradition to cover the darkness of the winter.

Winter by John Smith
This is simply the best, most beautiful song about the baby Jesus that I have ever heard. I first saw John play as support for John Martyn, and I have since seen him live several times and been reduced to tears by him. I absolutely adore his voice. I don't mind that this is a song about the nativity: to me it is a song about a story, and I just love how plaintively he sings that "I was there" line.

A Christmas Fable by The Selecter
I love a bit of ska. I've spent a full day agonising over which song to go for from this single. Then it occurs to me: its a double A-side, so I can legitimately have both. The songs are supposed to symbolise the light and dark sides of christmas, so they're pretty perfect for my playlist. Skank 'Til Christmas is all about letting your hair down when everything else in life has gone to shit (I love the references to the current financial situation), whilst a Christmas Fable is about a rather distressing family breakdown on Christmas day.

River by Madeleine Peyroux & K.D. Lang
A cover of this track also appears on the aforementioned Tinsel and Lights album. Thanks to the ever marvellous Ian Robinson (@eyeswideshut75) for suggesting it.

White Wine in the Sun by Tim Minchin
Thanks to Steve Haigh for reminding me of this. There's so much truth and humour in this gorgeous little tune, and it really sums up a good old family Christmas.

The Atheist Christmas Carol by Vienna Teng
This is just gorgeous.Thanks to Jackie (@Jackpot73- one of those new people so I am so thankful for having met this year) for

Silent Night/ 7 O'clock News by Simon and Garfunkel
Pretty self explanatory.

Love is All We've Got by Paul Fisher
I have loved Paul's music since the first time I saw him at a folk night when I was still underage drinking. I can remember being completely astounded by the noises that were coming out of this guy on the tiny stage upstairs in the Egypt Cottage pub. Turns out he has made a beautiful, gorgeous, poignant Christmas song this year which I will be listening to over and over.

Candle Song 3 by Mojave 3.

Tar Barrel in Dale by Rachel Unthank and the Winterset
Another one suggested by the lovely Jackie. A New Year's song about a Northumberland tradition. This year has been so cruel to so many of my friends and people I know, so I listen to this hoping that the new one brings those who I love some luck.

Hxxx

P.S. Here's my Sparkle Wildfire Top Festive Tip for the year: mulled wine liquid soap might seem like a good idea in the shop, but its really not. You end up smelling like a wino.

The Tale of the Pencil Woman

She used to visit us in waves. We wouldnt see her for a few weeks, then it would be up to three times a day, every day, for a week. First, it was pencils, so she became known as The Pencil Woman.

She would ask us each time if we sold pencils. We would reply that we didn't. She would smile a lovely, lopsided grin, and say oh yes she remembered now, silly her.

One day a rep came round, and in his catalogue we noticed some pencils. We ordered them in. 

She came in and asked for pencils. We told her that yes, we did have some in stock now. We sold her one, and off she went. 

She came back the next day, and asked if we sold pencils. We must have looked a bit confused, as we knew we had told her where they were yesterday.

 

"Oh yes, I remember now. I bought a pencil, but you see, its my son. He's an artist and he draws all the time, and he had ran out of pencils so I gave him mine. Now I need a pencil."

 

This started happening a lot. Always the same story. We laughed about it because we didn't know what else to do.

The next time we saw her was about three weeks later. She asked if we sold reading glasses. We showed her where they were, on the counter. She selected some, paid her 99p, and off she went. She came back the next day and asked if we sold glasses.

"Oh yes, I know I just bought some, but you see its my son. He needs glasses for when he is drawing, and he has taken my pair because he lost his. So now I need another pair. "

She would sometimes return just an hour later, and say exactly the same. She would come in when we were really busy with prescriptions, and sometimes we would be impatient with her.

One morning, we sold her a pink, flowery pair of glasses, joking that her son wouldn't want to steal those ones. She was back in for more in the afternoon. 

There were various other sundries that she cycled through.

Then one day she asked for aspirin. I asked her all the questions, and she Said she wasn't taking any other medicines etc. She said she just like to keep them in the house in case she got a headache. So I sold her them.

The next day she came in and asked for aspirin.

"Well its my son you see. He had a headache too (probably because he does so much drawing) so he took the pack of aspirin to  work with him so now I need one for me."

The same thing happened over and over again. I tried to question her more and more, but without accusing her of lying I couldn't get anywhere. I tried to have long chats with her, to find out her name, and who her doctor was. She told me she wasn't registered with a doctor and she didn't like going to see them.

I was worried. She was obviously forgetting that she had bought aspirin, and buying more. The son was a clever cover story, for the times when she could see the pity in our faces. One day, she came in for aspirin again and I saw a large bruise on her hand. She said she didn't know where it had come from, it just appeared one day. I asked her to promise me that she would see a doctor. She held my hand and said she would and how sweet I was.

If she was forgetting that she had bought the aspirin, was she forgetting when she had taken the aspirin. Was the bruising because she was bleeding because of taking too much aspirin?

I asked our delivery driver to ask around when he was out and about, to see if anyone knew her. We asked in the local shop and pub if anyone knew her name or address so I could look her up on our records and see who her doctor was. No luck. Everyone knew her, but no one knew her name.

One day, a woman came in with some medi-boxes that had been dispensed from another pharmacy. She said she had found them in her mum's house, but her mum had plenty of boxes, so could we dispose of them. I did so, and just happened to glance at what was in there. It was some Alzheimer's drugs. I didn't think anything else of it.

The same woman rang the pharmacy a few days later, to ask something about her health. She said she was feeling really run down, as she was finding it hard to work full time and look after her mother who had dementia. Something clicked, and I asked her to describe her mother to me. It might have sounded like an odd question to her, but she described the pencil woman. What happened next might have been a breach in confidentiality, but I told her about the aspirin, and the bruising, and how I had been worried about selling it. I figured yes, I had broken confidentiality, but the pencil woman was in danger if I didn't.

Her daughter told me the story. It started with tins of soup. She had cupboards and cupboards full. Then it was loaves of bread, which went mouldy, and the daughter had to clean out her whole kitchen. There were tears, and I had absolutely no idea what the right words to say were.

We still used to see her. When she came in to ask for aspirin, I told her that her daughter had been in to get her some and would see her later. I had agreed this line with her daughter. It was a little white lie that saved her from more embarrassment, and kept her a little safer.

I still think about her a lot, especially now my own Grandma is approaching the upper end of the moderate stage of Alzheimers. I think of all the times we were impatient, or didn't have time to stop and chat. I wonder what her story was, and what she had done when she was younger. I wonder about all the tales she might have had to tell, and how many of them are lost.

I wonder where she is now, if she is still alive. I wonder how her son and daughter are coping. 

I think of the embarrassment and terror in her eyes when she was telling us about how its her son, you see.

Today is Dementia Awareness Day. I think of The Pencil Woman.

Pharmacies, pharmacies, everywhere.

"Phew, I tell you what, I can't move for pharmacies these days. They're everywhere I turn, and I can't walk down a street these days without tripping over multiple green crosses. Everywhere you go its pharmacy here, pharmacy there, pharmacies everywhere"- No-one, ever.

And yet, apparently there are too many of the blighters, according to some pharmacy leaders. About 3,000 too many, give or take. Funnily enough, I beg to differ. And here's why.

I have worked in two newly-opened pharmacies in my career. In each, I was inundated with customers wandering in and telling me how lucky they were to have a pharmacy in their area. In one, the residents of the local area had campaigned for years to get their own pharmacy. Within months, the pharmacy was busy and the delivery service was thriving- and this was in a very small pit village.

We weren't, however, busy enough to justify a second pharmacist. This meant that I-despite good, efficient staff- would have to work many a late night-for no extra pay or lieu time- just to keep my head above water. The pharmacy closed at 5.30pm. I was regularly there until 10.30pm on a Thursday night, dispensing and checking prescriptions to make sure we were clear for Friday morning so that we could get all the prescriptions done and delivered in time for the weekend. This was just to keep on top of the day to day dispensing and didn't take into account any of the routine business things I had to do, like writing SOPs, Business continuity plans, finances, etc etc etc as a pharmacy manager. The pharmacy opened at 9am. I would turn up at 7:30am (again, unpaid) to get the till float done, prescriptions counted etc before we opened.

Its not that my time management or organisation was bad. It was just the sheer volume of work that needed to be done. I got away lightly- one of my fellow pharmacists in a different branch was known to be still at work at 2am at least once a week, just to keep afloat.

This was a few years ago now, but I locum fairly regularly and I still see busy pharmacies, with staff working flat out to get their work done as efficiently as possible. Not that much seems to have changed. What I don't see is empty, quiet overstaffed pharmacies filled with bored staff who have nothing  to do.

One day, the managing director for the company came round, and had a go at me because I hadn't been doing enough Medicines Use Reviews (MURs). Now, I was initially enthusiastic and excited about MURs. I couldn't wait to sit down with patients and get my teeth into providing a good quality service.

But I just couldn't do it. I didn't have time to do as much training, preparation, and CPD as I wanted to, and as a result I was nervous of doing MURs. What didn't help was the fact that, throughout each one, a large part of my brain was taken up with worries about how many prescriptions were piling up in the dispensary, when I wanted to give the patient my full attention. Each 15-20 min slot I spent in the consultation room with a patient meant I was behind with prescriptions- and because most of mine were deliveries, this had a huge knock on effect on the delivery drivers, and ultimately, the patients, who would then ring up in a panic wondering why their medicines hadn't been delivered by the usual time, putting us even further behind schedule. Thus began a vicious circle, worsened by my own constant feeling that I was so thinly stretched I just wasn't able to do enough justice to every aspect of my work. I'm by no means a perfectionist, but I like to do things well, and the fact that I just didn't have the resources to do so constantly played on my mind.

I ended up frustrated at my own inadequacies and inability to get on top of the situation, stressed to breaking point, and incredibly disheartened. I'd even go so far as to admit that resentment started creeping in too. I know I'm not alone here, and suspect that the majority of community pharmacists have felt this way. 

MURs are just one example of a service of course. In the year and a bit I worked at that pharmacy, we started doing MURs, morning after pill, over 50 men's health checks, diabetes screening, a minor ailments scheme, smoking cessation schemes, and a weight management scheme, amongst others. I was desperately swimming against a tidal wave of more and more jobs to do in the same amount of time.

Each time I read a pharmacy magazine like Chemist + Druggist, there seems to be yet another call from yet another pharmacy body or the other for pharmacists to be involved in delivery of yet another service. And my heart sinks, because I wonder just how on earth this is supposed to fit in with all of the other jobs that need doing.

Now, I'll admit that I haven't read the Now or Never report from the Royal Pharmaceutical Society commission (on account of being a cash-strapped non-member pleb). Nor have I kept up to date with the response to it on social media, blogs etc (on account of a fairly severe bout of anxiety-induced apathy over the last few days). With that in mind, though it still seems to me that the following metaphorical conversation is going on:

Pharmacy leaders: "And, and, and, you would be really good at delivering all these new services, so you should start doing that."

Pharmacist (from underneath a large pile of prescriptions that need checking, in between phone calls, and being called to the counter to speak to patients): "Yeah, I probably would be good at that. And I would love to do it, if only I had time."

Pharmacy leaders: "Good, well that's settled then. We'll pay you less for dispensing, but because you'll be doing all these services that will definitely be okay because you'll make up the money elsewhere."

Pharmacist (desperately attempting to gulp from a cold cup of tea to avoid dehydration): "Erm, right. Sorry, I need to go and talk to a patient now hold on... right, sorry, I'm back, what were you saying again? oh hang on, that's the phone ringing, I'll just have to get that..."

Pharmacy leaders: "We're so pleased you're co-operating. Oh, and by the way, we've decided there's too many pharmacies, so we're going to close all the ones near you, so you'll be getting more prescriptions to do, and more customers."

Pharmacist: "hang on, whaa- yes Mrs Brown, your prescription will only be a couple more minutes"

Pharmacy leaders: "Great! so to summarise, that's more prescriptions, more customers, more services, less pay. See you later!" (flounces off)

Pharmacist: "What in the hell just happened?... No no, Mr Smith, its okay, I don't need to see your haemorrhoids again, thank you"

Strategic decisions and the bigger picture are all very well, but at the end of the day they are just words if the people at the front line aren't able to deliver the vision because they are already overloaded. To me, it feels like new ideas, new visions and new services are bandied about by the top level folk, but what they neglect to do is look at the minutiae and check how the "little people", the folk on the ground are doing and what they think about any changes.

The realities of life on the shop floor are, in my mind, not conducive to delivering the sorts of services that the profession is calling for, unless there is a huge overhaul in how pharmacies are staffed, funded, and managed. And given that, in these austere and pressured times, everything possible is being done to reduce costs, pare down staffing, and maximise profits, I just cannot see the sort of situation in which we can do all of these things to the best of our abilities well panning out in real life. Yes, great changes in the direction of the profession need to come from the top, but they also need to come from the pharmacists behind the counter in the little pharmacy in the tiny pit village too.

The only way that I would have been able to deliver MURs in my pharmacy to the standard and quality that I so desperately wanted to acheive would have been to have had a second pharmacist present. And the only way a second pharmacist would have been present was if they had been paid. And the only way the company would have paid for a second pharmacist would have been if they were absolutely, just short of gunpoint, forced to.

I'd like to suggest that before the profession starts excitedly waving its hands and shouting "ME ME ME!!" to every available service going, we take a step back and decide whether or not we can actually deliver it, given everything else we also have to do. That enthusiasm is great, but if we can't follow it up with actions, we will end up an all-talk and no substance sort of profession.

So, in summary: are there too many pharmacies? No, although there might be the odd street or village which has more than its fair share. To be honest its a moot point. What's a more important question is: "what can we do to support pharmacists and improve the quality of services in the pharmacies we've got?"

H xxx