A day at the pharmacy.

Beware the spinal trap.

2009-07-29T13:27:00.000+01:00

As part of the Keep Libel Laws Out of Science campaign here is the article at the centre of the BCA's libel case against Simon Singh. Some practitioners claim it is a cure-all, but the research suggests chiropractic therapy has mixed results – and can even be lethal, says Simon Singh

You might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that "99% of all diseases are caused by displaced vertebrae". In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.

In fact, Palmer's first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.

You might think that modern chiropractors restrict themselves to treating back problems, but in fact some still possess quite wacky ideas. The fundamentalists argue that they can cure anything, including helping treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying - even though there is not a jot of evidence.

I can confidently label these assertions as utter nonsense because I have co-authored a book about alternative medicine with the world's first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.

But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.

In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.

Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: "Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck."

This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Edzard Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.

If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

This is an edited version of Simon Singh's Guardian article from April 2008, for which he is currently being sued for libel by the British Chiropractic Association. We have published it as part of a coordinated campaign to demonstrate that bringing legal proceedings against a science writer will not close down free debate. You can learn more by visiting the Keep Libel Laws Out of Science campaign.

So much pandemonium caused by so small a thing.

2009-05-03T18:17:00.000+01:00

How can something as minute as H1N1 influenza cause so many problems?

Ebay?

2009-05-01T08:33:00.002+01:00

Is it time to put these chaps on Ebay?

Pandemic Flu?

2009-04-28T11:07:00.004+01:00

Hat-tip New Humanist magazine

Good to see the homoeopaths helping with a cure for Pandemic flu.

"At present we do not have a nosode, i.e.a remedy made from the disease material. However, we do have existing remedies which have been used successfully over many years to treat all stages of flu. These are effective and safe for everyone from babies to the elderly.
Our advice regarding Swine flu is that your best protection against disease comes from looking after your health generally and taking simple common-sense preventative measures. There are a number of vitamin and mineral supplements and herbal remedies that will help to boost the immune system. These can be viewed on our website Home Page, select Newsletters, then WINTER ALERT for more information."

"At present" suggests that research is being carried out. How does that work? Do they need to find something that makes your nose run and eyes hurt? How about a ridiculously dilute onion tincture. Hey, right first time, I'm good at this.

Nice to see the old "boost the immune system" chestnut being promoted again too. I have a pile of Tamiflu, I think I wil stick with that.

Levonelle Advert

2009-04-28T11:06:00.000+01:00

Quite an interesting advert for Levonelle which is shortly to be advertised on the television in the UK. The only problem is it does not mention the price (£26 in my pharmacy, about 38 USD)

Obviously, the patient can choose to get it from their doctor instead, at no cost to themselves. I suspect most people in the target age-range are going to be unable to pay, or not want to pay. It's a good tool to have in one's therapeutic armoury but I cannot see it flying off the shelves. (Unlike Alli which is flying off the shelves, and then down the toilet!)

131 Viagra

2009-03-17T16:10:00.000Z

This is what 131 Viagra 100mg looked like shortly before I destroyed them. These were returned by one patient who did not want them. Even though he did not use them he still ordered them from his doctor every single month! Why did he do this? Well, in the United Kingdon people over the age of sixty, people on limited incomes and people with certain illnesses pay exactly zero towards their medications.

This results in horrendous wasteage. People do not, in general, value things that they get for free. Total cost to the NHS of this one episode? Approximately £800! ( 1122 USD)

I suppose I should be thankful that they were returned and not given way to friends, sold or kept in a cupboard. [and yes, I really did destroy them and did not take them home with me.]

Happy New Year

2009-01-01T21:53:00.000Z

Happy New Year everybody.

Nine Lessons and Carols for Godless people

2008-12-23T18:26:00.005Z

Robin Ince hosted the evening of science readings, comedians and music. The music wasn’t all to my taste but Jarvis Cocker went down very well with the crowd with “They said there’ll be snow at Christmas.” This he picked for its mean-spirited lyrics.

Simon Singh gave an interesting talk about his book on the Big Bang and also his argument with Katie Melua about the lyrics to her song “Nine million bicycles” . Obviously we aren’t 12 billion light years form the edge. Simon didn’t mention the trouble he was having with the British Chiropractic Association, presumably for legal reasons. Hopefully the case will be resolved very soon, it should be very interesting to follow.

The comedians were a mixed bunch. The event lasted for three hours with each act getting, I think, eight minutes. So, there were a lot of performer of variable quality. Some excellent, some okay and some not to my taste at all. I have seen Mark Thomas a fair few times and he did much of the same material that I had seen previously. Stewart Lee is always worth seeing live and did some very funny material asking whether the sale of Pope John Paul II lollipops increased or decreased after his death.. Ricky Gervais got a very good reception but seemed to offend people by making a joke about raping an old woman. Personally, I thought it was amusing and his logic was impeccable. But there was an audible sharp intake of breath.
Dara Ó Briain has a science degree and doesn’t have much time for alternative medicine. His proposal to put nutritionists, psychics and homeopaths in a burlap bag and then hit them with a stick caused great applause. He also pointed out that whilst dietician is a protected title (as is pharmacist in the UK) anybody can call himself or herself a nutritionist in the UK. (Hence, the pseudoscientific mumbo-jumbo written by nutritionists in every UK newspaper)

The highlight for me was Professor Richard Dawkins. Mr God Delusion himself. He read three extracts from his work including an interesting and humbling piece from “Unweaving the Rainbow” Dawkins has a voice that reminds me of Professor Yaffle from Bagpuss, but it is a very sonorous one and I could listen to him for hours.

Ben Goldacre gave an impassioned speech about his legal battle with Matthias Rath. Rath sued Goldacre and The Guardian over articles in which Goldacre criticised Rath’s peddling of vitamin pills for the treatment of HIV and AIDS. A chapter in Goldacre’s book “Bad Science” was cut due to ongoing litigation. This has since been dropped by Rath who now owes The Guardian about £500,000 in legal fees.

Tim Minchin was also amazing, ending the show with a nine minute beat poem, “Storm.” It sounds horrendous but it was actually incredibly moving and inspiring.

It was a very interesting evening and a rational celebration of Christmas. Considering the room was largely full of atheists, it was not particularly anti-religion. More anti-woo and pro- evidence-based medicine.

Never have I seen so many geeks and nerds in one room. As Robin Ince said “This is our time!”

Merry Christmas

Lactose Intolerance

2008-12-15T18:26:00.000Z

Don't we all love lactose intolerant patients? ;)

Oliver Postgate

2008-12-09T19:06:00.001Z

Sadly Oliver Postgate, creator of Bagpuss, teh Clangers, Ivor the Engine and many more childrens programmes died today, aged 83.

So, I have been reliving my youth and spending the day watching classic episodes of Bagpuss such as the "The ship in a bottle" episode or my personal favourite, "The Mouse Mill." I really wanted there to be a chocolate biscuite factory, but sadly it was all a fraud.

And when Bagpuss was asleep,

All his friends were asleep.
The mice were ornaments on the mouse organ.
Gabriel and Madeleine were just dolls.
Professor Yaffle was just an old wooden bookend in the shape of a woodpecker.
Even Bagpuss himself, once he was asleep, was just an old, saggy cloth cat,
Baggy, and a bit loose at the seams,
But Emily loved him

Nothing evokes my memories from thirty years ago more than that passage.

BNP list

2008-11-24T17:20:00.002Z

Oh dear, the leaking of the BNP membership list has caused a rumpus. Not least for Wikileaks. It didn't take very long to find the list online.

I searched for our local postcode. I was thinking maybe there would be one or two in my local area. Nope, I was wrong, very wrong. A quick search found over twenty. I especially liked the names that had labels added such as actor;teacher,discretion required;singer,etc. Is there a "What skills do you have?" section on the application form? I cannot imagine a situation where a singer would be useful-a charity Christmas record for whites-only?

I did recognise a few of my patient's names on the list. Ten or fifteen maybe. I am guessing they too must have joined by accident, or for research. Some are the type of people one would imagine-lumbering oafs with Bulldog tattoos and shaven heads. Some look almost normal. Most of them were over sixty. A couple of them came in last week and, from their demeanour, I am guessing that they still have no idea that anybody with the time, and inclination, could find out their political proclivities. Then again, maybe they are the sort of people who would be proud to be members?

I guess it shouldn't be a great surprise that some of my big, fat customers are big, fat racists.

Engage with Grace

2008-10-28T10:32:00.000Z

From here.

Acomplia

2008-10-23T20:20:00.001+01:00

Oh well, another one bites the dust. Looks like all of those fat people will have to start eating sensibly and do some exercise. Yeah, sure! Heavy bones are such a burden in life.

All aboard

2008-10-21T20:27:00.002+01:00

"There's probably no God. Now stop worrying and enjoy your life." I couldn't agree more. More on this story here and here. Feeling generous, then make a donation here.

More information on British Humanist Association here.

Personally, I'd pay even more to see Richard Dawkins driving it around London.

All aboard......ding,ding.

Donated so far- £ 89,842.18

Pregnancy test

2008-10-14T15:43:00.001+01:00

Now this appeals to my geeky nature.

The process starts off like most pregnancy tests. You pee on a stick, specifically the absorbent test strip at one end. But everything's different after that first step. Remove the cap from the other end of the stick (cleverly provided to keep you from accidentally contaminating the wrong end) to reveal the USB connector. Pop it in your computer. The power from your USB port starts the electrospray ionization process, creating a spectrograph of the various masses for your analysis.

You don't actually get to see the spectrograph yourself. The mass analysis happens inside the device. And p-Teq's device only analyzes for specific chemical makeups, so you don't have to worry about this thing busting you for that "poppy seed bagel" you had yesterday. The mass spectrometry software on the device comes with several sequenced hormones, including hCG (human Chorionic Gonadotropin), hCG-H (hyperglycosylated hCG - for detection before your first missed period), and LH (luteinizing hormone - for detection of your most fertile days). I like the fact that it does all three. After all, if you're not pregnant and you wanna be, you need to know if now's the time to be gettin' it on.

While most home tests can detect a level of 15-50 mIU/mL of hCG, the enhanced methodology of the USB Pregnancy Test Kit can detect 5-50 mIU/mL, and will show you the exact concentration via its friendly onscreen interface. In addition, the LCD display on the device itself will light up and show you the symbol of a baby, no baby, or multiples and your Estimated Delivery Date based on the concentration of hCG, hCG-H, and LH in your urine. So you can clear your calendar in advance.

After you're done reviewing your test results, just pop the device out of your computer and change the test strip. The display will remain lit for five minutes and then automatically power off.

Even my patients who don't know what positive and negative mean would be able to use this. Well, if they stopped buying lottery cards and bought a PC instead.

British Chiropractic Association suing Simon Singh!

2008-08-17T13:23:00.002+01:00

As mentioned here, the British Chiropractic Association has issued a writ against Simon Singh. Note that they haven't issued a write againt the Guardian, who published the piece, but instead the author that wrote it. I guess they are adhering to Mark Twain's maxim of "never pick a fight with someone who buys their ink in barrels". I've read Singh and Ernst's book, "Trick or Treatment" and it's a cracking read. It should be read by all those who recommend alternative treatments to patients.
Sadly, even pharmacists can go over to the dark side. This week's edition of the increasingly lamentable Pharmaceutical Journal contains a letter from the Superintendent Pharmacist of the Royal London Homeopathic Hospital. Guess what, she thinks homeopathy works. What a shocker! She also suggests that there is solid evidence that it works. The studies that she references include one published in that well known academic journal, "Journal of Alternative and Complementary medicine" (2005;5:793-798) This is the same, sack-of-shit paper where the amazing results were merely those self-reported by patients. I feel better when I see a nice cleavage, but unfortunately I cannot get that on prescription. It's that level of research.

Anyway, here is my copy of Simon Singh's original article:-

This is Chiropractic Awareness Week. So let's be aware. How about some awareness that may prevent harm and help you make truly informed choices? First, you might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that, "99% of all diseases are caused by displaced vertebrae". In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.

In fact, Palmer's first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.

You might think that modern chiropractors restrict themselves to treating back problems, but in fact they still possess some quite wacky ideas. The fundamentalists argue that they can cure anything. And even the more moderate chiropractors have ideas above their station. The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.

I can confidently label these treatments as bogus because I have co-authored a book about alternative medicine with the world's first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.

But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.

In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.

Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: "Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck."

This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Professor Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.

Bearing all of this in mind, I will leave you with one message for Chiropractic Awareness Week - if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

·Simon Singh is the co-author of Trick or Treatment? Alternative Medicine on Trial

www.simonsingh.net

Look out for Ralph

2008-08-04T20:44:00.000+01:00

Wheelchairs

2008-07-24T20:21:00.000+01:00

Come on, it's okay to laugh. You would have to be pretty dozy to drive into a trench that big. Pensioner wheelchair users are the bane of my life. Half the people I know that use them are purely lazy, with no need for them besides liking to sit on their arses all day. Plus, they are a hazard- no tax, no insurance and myopic pensioners driving them around at 8mph. This old codger doesn't even know she has crashed. Look at that vacant expression, the blank, "You have only given me half of my medication" stare. Also note she isn't even trying to help herself, just waiting for someone else to lend a hand and prevent her from having to use her brain.

I'm kidding, I love old people really. Thanks for posing grandma, you are the best. Be safe, don't Zopiclone and drive.

Mobile phones

2008-05-29T21:09:00.006+01:00

Is it me or are people becoming increasingly rude in their use of mobile phones? I've toyed with the idea of buying some signs for the pharmacy such as this or this. However, I doubt that this would convince my thick-skinned customers to shut the hell up. Glaring at them does not work and putting their prescription to the back of the queue does not work either. It is hard enough to juggle three jobs, answer the phone, check a dosage without listening to some half-witted drivel. I've never overheard a half-way interesting conversation.

Anyway, I found an answer here.

"The Y300 triple system jammer is similar to the Y300 dual model, except that this Y300 triple includes 3G jamming too. This model is only available from us and will take care of your jamming requirements as more and more 3G networks are created over the next few years. The Y300 comes in 2 models, one for GSM and the other for the Americas/Canada. Each transmitter outputs 3 Watts, the total output is 9 Watts. If you want a cell phone jammer to last into the future, then this is the one to buy"

That should do the trick nicely. Now, when I get frustrated, I can simply switch it on and cut off their stream of inanity. How much fun will that be?

Don't shoot the pharmacist.

2008-05-29T19:43:00.002+01:00

A movie about pharmacists? The trailer looks good, it shows a few situations not dissimilar to those I have faced in the pharmacy.

More info here. It's just been released in the USA, so, if at all, it'll probably be out in the UK in a few months. If not then I'm afraid I'll have to reach for my favourite torrent site, or buy it on Region 1 DVD.

At least the pharmacist is an improvement on those two fictional pharmacists-Ned Flanders of "The Simpsons" fame, and Mort Goldman from "Family Guy"

Facebook

2008-04-22T16:32:00.002+01:00

Okay MrHunnybun (or as near as I could get) is now on Facebook here. So, come and befriend me (especially if you play Scrabulous too)

Pharmacy Numberplates

2008-04-22T10:14:00.004+01:00

I'm not a big fan of personalised number-plates like these. Each to their own, I suppose. But £3500?! I am not sure I would want my neighbouts to know I worked in a PIIMCY and that I was a CIIMST.

The Last Lecture

2008-04-21T13:48:00.003+01:00

I have recently finished reading "The Last Lecture" by Randy Pausch. It is a book I would recommend to anyone-it's touching and inspirational without being sentimental. It's also possible to download the video of "The Last Lecture" through iTunes

Randy was given three to six months to live. This was, er, six months ago. At the time of reading the book I was not aware of his current status, but he has a blog. There he posts his news and lab results for those of us, in his own words "keeping score at home." It was whilst perusing this blog that I found a post mentioning these very cool-looking pill-bottle designs. It looks as if these were designed for Target in the United States.

The bottles stand on their caps and have a large flat surface that enable a large font to be used. If you have your pharmacy-geek head on then follow the link to his blog, click on the photograph of his meds and work out his meds regime from the photograph.

We don't have anything similar to this in the United Kingdom, at least where I work. We just have boring old plastic pots with clik-lok lids. I think this design would be a lot more useful for patients. I understand that a lot of dispensing is done from bulk in the US, rather than from calendar packs. Anyone know why? Do you all just like counting tablets by hand, or by mechanical counter?

Next time I am in the US I am going to see if I can find a Target and buy/barter for some of these containers.

Wallpaper

2008-04-20T21:45:00.005+01:00

I recently bought a roll of wallpaper that was used in Damien Hirst's restaurant Pharmacy. Unfortunately the restaurant shut down before I got a chance to eat in it.I did get to go to the auction at Sotheby's where the contents of the restaurant were auctioned for eleven million pounds!

Obviously the small amount of paper I have is not enough to wallpaper any room larger than a room in a dolls house. So, what to do with it? I guess I could unfurl it every now and again and look at the pictures of tablets. Or, possibly, have it framed and hang it in my study.

It contains a weird selection of drugs, some from the United Kingdom and some presumably from the United States. I'm not sure how they chose which dosage forms to use in the wallpaper. What they could obtain photographs of maybe?

Inside my patient's heads

2008-03-30T19:25:00.003+01:00

This is my estimate of the inside of many of my patient's minds. They stand there and seem to be looking at me. But, no-one is at home. "One tablet daily, does that mean I take one in the morning and one at night?"

Grr