Thursday, May 31, 2007

BrainPOP and Educational Films About Asthma, Allergies and the Immune System

Yahoo has an interesting item about an immunologist, Dr. Avraham Kadar, who has set up BrainPOP, a company that produces online, animated shorts about asthma, allergies, the immune system and a variety of other topics.
Visit BrainPOP and join teen-robot duo Tim and Moby for a plane ride on which a seemingly innocent bag of almonds prompts an in-depth discussion of allergies. Viewers learn about the physiology of an allergic reaction, the role of the immune system, the different types of allergens and the symptoms, diagnosis and treatment of allergies. Additional BrainPOP films tackle related subjects like asthma and the immune system itself.

For allergic little ones in grades K-3, there's a BrainPOP Jr. film on the subject as well. Find out why Moby has cupcake frosting all over his metal face at BrainPOP Jr.. There, he and leading lady Annie explain the basics of allergies in terms this age group can relate to. Interactive games and activities supplement the film's lessons.
There is a time-limited offer on free access to the films. Log-in information expires June 7:

Username - Journalist

Password - Allergies

I have no connection with this company or anyone associated with it: I do not know anyone who has used or recommended these films. I like the fact that they have close-captioned the films.

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R4's Allergic Reactions Was Spotty and Irritating in Parts

A young boy and his dog in a position of prayer
And please let Shinga find some decent coverage of allergy issues before she explodes.

A valued correspondent has been kind enough to send me a partial transcript of Radio 4's recently broadcast Allergic Reactions. The clinical experts were interesting but the reporter repeated the cliched investigations that do nothing to educate or to inform the debate: consequently, judging by the reactions and comments, he has achieved very little. Allergic Reactions was (sadly) spotty and irritating in parts - I could say that it probably seemed like a good wheeze at the time but that is probably going too far.

Allergic Reactions (BBC Radio 4 Tues 22 May, 8pm, reporter Matthew Hill)

Partial transcript

Beginning of broadcast: Prof. Gideon Lack and Dr. Pam Ewan provide an overview of the current inadequate NHS service for allergies and allergic diseases.

[06.25] A mother describes the uncertainties and difficulties in obtaining an accurate diagnosis. Her one year-old son had an allergic reaction to fish which is even more worrying than normal because her son has eczema and asthma; as such, the boy has hit the trifecta for multi-system allergies and needs high-quality, careful, medical management.

The mother's apprehensions and fears were not allayed when she took her son to A&E following the allergic reaction to fish and the Senior House Officer (as the grade then was) examined the child and suggested a diagnosis of hydrocephalus and defended that diagnosis in the face of the mother's frank disbelief.

[07.00] Dr. Ewan provided an overview of the lack of adequate provison at all levels in the NHS.
The lack of provision is at a series of levels, first of all in primary care. GPs are not well informed about allergy at all, but particularly about food allergy and that is because they are not trained in it. So GPs have gained knowledge by self learning or self interest, then if a GP wishes to refer to a specialist he will have a problem finding a specialist because there is a very small number of these.
[07.35] Another chilling case history of a little boy, William, in NE England. William was known to have peanut allergy. For some unclear reason, the General Paediatrician decided that it would be appropriate to check if he still had an allergic reaction by setting up an open challenge with peanut. In an account that must have dropped ice-water down the back of parents in a similar position, the challenge was conducted in a hospital (as per the guidelines) but without constant observation/monitoring.

As the amount of peanut was incrementally increased, William's mother was more and more convinced that he was showing signs of an allergic reaction. The nurse discounted the mother's observations and refused her request to terminate the test, arguing that William was just anxious and that abandoning the test would mean having to repeat the stress at a later date.

The subsequent events were wretched and resulted in anaphylaxis. William was in a life-threatening condition and taken to HDU; nobody could tell the mother whether or not William was expected to survive (thankfully, he did).

[09.35] Dr. Ewan reveals that both the Royal College of Physicians and even the Department of Health itself have warned there are not enough specially trained doctors: there are only six specialist centres in the UK. Despite the recommendations and reports, there are only 7 trainee allergy consultants at present, although the recommendations called for 40.

[10.17] Prof. Lack provides further detail on just how poor NHS allergy provision is in the UK. E.g., there are 5 paediatric allergy specialists in the UK; the comparable figure for Germany is 500 allergy specialists.

[10.34] There was some discussion of private tests which, by default, because of the poor NHS clinical provision, tend to be offered by CAM therapists. Prof. Lack was sufficiently concerned about this that he conducted a survey of the allergy advice parents have received before they attended his paediatric allergy clinic.
We found almost 50% had received alternative health care advice about allergies before coming to see us. I would say that of the children who come to our clinic at least 10% and possibly up to 20% have received unsound advice; these children will face nutritional problems.
Martin Hill presents a case study of Carol who was so desperate that she went to her local health food store for a Vega food allergy/intolerance test. She was advised to give up milk and she did - for 6 months. However, the symptoms didn't go away and, on past experience, there seemed to be little point in returning to consult her GP. Later in the programme, about 12:36, Carol reveals that her problems were related to undiagnosed coeliac disease; she obtained her diagnosis while she was pregnant. While she had been avoiding milk, Carol had unwittingly consumed more cereals, and these had exacerbated her gut problems.

At about 12:30, MH talks to Dr. Joe Unsworth, who is a clinical immunology consultant with a special interest in allergy, about the dangers of eliminating dairy without appropriate dietary supervision and guidance on other sources.

[14:58] Martin Hill introduces a disproportionately long section that deals with the YorkTest foodscan test for food intolerance. He does the horribly cliched split test by taking two samples at the same time and submitting them under different names.]
There is one test available via the internet that does sound very scientific [sound effects of conducting a YorkTest foodscan 42]. YorkTest labs claim their food intolerance test has been found to relieve symptoms in a wide variety of conditions by identifying problem foods and avoiding them. I decided to put it to the test. I ordered 2 kits and then sent back two samples…42 foodscan test…suggested on the website for children and people with restricted diets. Costs £125 [more sound effects].
The samples came back with different results so Martin Hill arranged to meet John Graham, the chairman of YorkTest labs to discuss the results.
John Graham (JG): We’d like to explain what we do.

Martin Hill (MH): I’m Martin Hill, I was the patient. It was my blood that was taken and there’s my result [I should avoid cow’s milk and rotate wheat]. Same blood, same day, same test, Martin Redfern [my alias], [I should avoid] cow’s milk, no mention of wheat.

JG: OK, so what we’d like to do now is send it off to the lab, investigate it properly. I’ll be able to respond shortly
[17:20] Dr. Gill Hart can be heard giving a presentation in the background]

[17:50] Alistair ?, the lab manager arrives and presents the raw data from the original lab tests. He reports that the results for the two samples, in arbitrary units, were: Milk – Martin Hill 12.9, Martin Redfern 10.4; Wheat Martin Hill – 5.4, Martin Redfern 5.2.

Personal note: For the remainder of this YorkTest segment, the discussion was disappointingly irrelevant and the quality was poor. Neither MH nor JG displayed much understanding of the issues; this entire segment failed on so many fronts that it was neither informative nor educational. I will put some comments in where I can't help it but for the most part, this nonsense speaks for itself.

It would have helped enormously if they had explained that they had measured the levels of IgG for particular foods; YorkTest had presumably established the levels in (say) U/ml, and they had mapped these to their scale of 0-4, where 4 is 'very reactive' or similar. I would like to know the measurements that map to the sensitivities and this section of the programme would have been clearer if they had announced where MH's results were on the 0-4 scale.
MH: So, John, your saying they’re quite similar, the results.

JG: Yes, as you can see [for] the results in 42 foods mentioned, 41 produced identical results. One produced a result that isn’t identical and that is very close to a zero result or a treat with caution result. My advice to you in both cases would be to do nothing other than to seek to avoid the one food you have a positive reaction to.
OK, my silence didn't last long. With respect, we know that 2 results were not identical; we don't know any such thing about the others. We just know that we didn't get the figures because they were not around the boundary level where they acquired any degree of significance. They may or may not have been identical.

This would have been an ideal point at which to discuss whether or not YorkTest's foodscan is recognised by the appropriate pathology services in the UK and what the normal lab. tolerances are for variation in the results of split tests. It is difficult to confirm this, but I'm told that the usual permissible variation is 10%.

I would like to point out that there was an almost 20% variation in the measurement of IgG levels for cows milk and a negligible difference for wheat. It isn't at all clear whether the difference in the cows milk was written off because it didn't affect the category on the sensitivity scale, but somehow the negligible variation in the wheat measurement crossed some threshold of significance.

I'm also losing the will to persevere because MH hasn't stated, clearly and simply, that he does or does not have any clinical symptoms that might indicate that he does have intolerance to cows milk.
MH: But there was a difference in [the] advice I got from your nutritionist. One test; no milk. The other [test results, I'm advised] no milk and rotate wheat…so you don’t think that’s an issue?

JG: You contacted a nutritionist and you haven’t got anything wrong with you…Correct?

MH: She rang me back…as part of the package you get a free consultation. In that consultation she was giving the different advice on what foods to have. On the one hand [the outcome of one test profile recommends that I] don’t have cow’s milk, on the other hand [the outcome of a separate test on the same blood sample recomends that I] don’t have cow’s milk and also rotate wheat.

JG: I can only repeat myself. You’ve got 41 foods which are identical and you’ve got one result where it’s marginal if you should rotate the food or just not do anything with it. When you look at our booklet you will see that you should seek to avoid the one food and…treat with caution the other food. [Presumably the former is milk and the latter is the wheat.]

MH: The treat with caution advice I don’t think was clear in what I was sent...

JG: Could we examine that document and try and establish whether that is clear?
JG reads the YorkTest booklet that was sent out with the test results, noting the advice to eliminate foods with high number reactions first. There is some background chatter in which MH is objecting that he wasn't told to treat the wheat result with caution and Dr. Hart chips in that that is (possibly) implied by the instruction to "rotate". You will not be surprised to learn that neither Dr. Hart nor JG succeeds in clarifying the issue.
MH: It doesn’t specifically say "treat with caution".

JG: No, but that is a problem of nomenclature, it is something actually that [is flagged] in our quality control procedures at the moment...to look exactly at the wording we offer. And we can show you evidence of that…today, because the proposal has been made that we should change from ‘rotate’ to ‘treat with caution’.
This discussion is really not improving. Both participants are missing the broader issue that it may be wholly inappropriate to hand out dietary advice that is based on borderline measurements and categories, when those lab results are not interpreted by a skilled clinician who has examined the client and taken a decent medical history.
JG: What you’re dealing with is a very sensitive area right at the centre of all this…the difference between a slight positive result that may have some significance to one person or…no significance to another person.
Seriously people, would it cause you deep distress to clarify whether you are still whittering on about the borderline wheat result? In yet another journalistic cliche, MH pulls out a variation on the "Won't somebody think about the children?!?" card.
MH: But if you’re advising…some of your patients are children, presumably...

JG: Yes.

MH: If you’re advising parents to cut down a lot on the wheat when that is a marginal grey area as you admit in your test…isn’t that a long way to go?

JG: If you look carefully at what we say…eliminate highest food first…concentrate on that. For a marginal [result] seek to rotate or treat with caution. I think we make that very clear...
End of 1st YorkTest segment. Martin Hill reports that he was concerned that avoiding milk products and rotating wheat would be difficult. He decided to take his results to Registered Dietitian Catherine Collins and paediatric dietitian Susan Durham-Shearer. Martin Hill expresses concern that the YorkTest nutritionist had a 2 year diploma in nutrition and that her advice was that he should exclude all dairy products for 3 months, and consume wheat products, 2-3 times per week.

Catherine Collins gave an overview of the core food groups and the difficulties that people can encounter when they are accustomed to a typical UK diet and need to obtain calcium from non-dairy sources. She debunks a piece of advice that is a source of irritation to me: the one where people tell you that you can obtain calcium from eating tinned fish - which is true if you eat the bones, but how many people do?

Martin Hill mentions that he had a IgG test for food intolerance. Catherine Collins explains that your IgG levels reflect the foods that you eat and that your highest levels may reflect the foods that you eat more frequently.

Finally, Martin Hill raises a nagging issue.
MH: The key question is: Can YT distinguish between IgG levels in people without food intolerance and people with food intolerance?
Martin Hill gives an overview of the Gut paper that is frequently cited as clinical evidence and validation by YorkTest (I have previously discussed the Gut paper). He discusses the paper and its findings with Dr. Ewan (PE) who thinks that the significance of the paper's findings are overplayed.
PE: The so-called active or treatment group avoided milk and wheat and it’s well known that milk and wheat are the commonest foods to cause flare-ups…in IBS. So if you remove those, there is a good chance there will be some improvement in those patients but that does not mean it was anything to do with test results; it was not related to IgG antibodies.
Martin Hill put these criticisms to JG who put on a surprising show of bluster that was embarrassing: he seemed to deprecate Dr. Ewan's opinion and knowledge without even attempting to lay a foundation for his criticism. He also glossed over a major issue that Dr. Ewan raised; namely whether the level of IgG antibodies is relevant in the diagnosis of food intolerance.
JG: One criticism we can’t do anything about…elevated antibodies in healthy humans (i.e. they exist). Another one is the systemising of the dietary change because, as you say, you are quite right, it is considered that some foods are more allergenic than others. So we have to give very careful thought to when we change a person’s diet and do the randomising of it that the other – sham – diet would be as difficult for the patient to adhere to...

MH: So, does that mean your Gut Study was flawed?

JG: No, no, every effort was made to do that...

MH: But you’re using…the Gut paper…

JG: Surely one would if…

MH: But that paper, according to experts we’ve spoken to, is flawed.

JG: I know but I’m sorry but the duty of these so-called experts is to produce another paper to demonstrate that [the Gut] paper is flawed and not just to write in with their comments. [My emphasis.]

MH: But to advise that children…

JG: We always advise [people] to see your doctor. We are not in the business of trying to alter young people’s diets...
I have to point out that the foodscan 42 test used to be recommended for use when testing children. As it is, in many places that advertise the foodscan tests, the advice is that they should only be used on children over the age of 2 (see Health Products for Life) so it does seem to me that this is part of their business. JG responds to MH's child card with his own emotive claims.
JG: When these parents come to us they’re desperate, beside themselves. Terrible colic, IBS, diarrhoea, skin complaints, seeing doctors…[They]don’t get better…desperate…[They're] not getting better through conventional medicine...

MH: Should we be considering excluding whole foods until the evidence is better?

JG: Our advice is to consider excluding foods with the highest levels of antibodies…

MH: Your paper says about 75% of people who buy your product show improvement but this is based upon them reporting…how much credibility can you give that?
It is not at all clear whether they are discussing the Gut paper or the more recent published audit of customer satisfaction.
JG: By itself it’s quite a useful piece of indicative information…What we don’t know is [how much of those results should be attributed to the] placebo effect…or regression to mean effect...
Martin Hill than gives an overview of John Graham's contention that some of the tests that are ordered by 'conventional allergists' may result in false positives. This is true but the specificity etc. of these tests is known; and good clinical allergists only ever interpret test results alongside an examination and thorough clinical history. I fail to understand John Graham's point here or why he thinks that a direct-to-consumer lab test is comparable to a test that is conducted and interpreted by experts but I'm not getting any younger and my hair is starting to fall out.

Dr. Unsworth agrees that test results alone are problematic; he emphasises that the best way to diagnose allergy or intolerance is to take a good clinical history before testing.

Martin Hill then discusses YorkTest's collaboration with academic researchers to establish the normal ranges of IgG measurements. He mentions small pilot studies from a London hospital that have just been presented as a poster at a conference in Washington, DC. MH assures us that Dr. Anton Emmanuel (AE) (one of the researchers) has some interesting findings.
AE: What we found is that patients with [inflammatory bowel disease] who report greater sensitivity to food also tend to have highest levels of IgG in their blood. [However], patients with Crohn’s disease seem to have an inverse relationship…the more foodstuffs they report sensitivity to, the lower the IgG count, whereas in ulcerative colitis there is a much more direct relationship. We wonder whether there is some sort of gut permeability problem in Crohn’s...
Martin Hill discusses the findings and questions Dr. Emmanuel on whether these results in people with serious bowel conditions are sufficiently powerful to convince him that YorkTest can predict food intolerance in anyone?
AE: IgG measurement is a strength and a weakness…it reflects exposure in the past…The weakness is that it doesn’t tell us anything about recent exposure. What we need is a normal range [of values].

So, can you say, 'My level was Y in March, [I] went on the diet, now it’s Z?'. Unfortunately we can’t do that. These tests are done with artificial reference points. I think the IgG test is very broadbrush. If you use it as the sole basis on which to alter your diet…that is folly. I’m sure no-one would ever suggest that. Whatever you do has to be allied to input from a physician or dietitian…but [IgG] does open our eyes to something we have ignored [the relationship between diet and symptoms]…It illustrates a trend but needs to be fine tuned. [My emphasis.]
Martin Hill does not comment on the fact that what Dr. Emmanuel calls "folly" is actually happening: IgG results are being used as the sole basis on which people are advised to change their diets and people are doing this without input from a physician or dietitian (a nutritionist does not necessarily count for this purpose). Hill reveals that YorkTest has since informed him they are withdrawing the foodscan 42 test, and changing the language in their booklets from ‘rotate’ to ‘treat with caution’.

The remainder of the programme reverts to the extraordinary difficulty people have in accessing allergy services on the NHS. Despite his clear clinical signs, the little boy with the fish allergy was not referred to an allergy clinic for 4 years and waited all that time for a diagnosis of multi-system allergic disease.

Dr. Ewan explained that she and her colleagues are asking for central funding for trainee specialists but control has been devolved to the local PCTs and resources are being used inefficiently because funding allergy trainees would save the NHS money.
The big problem there is that they are strapped for cash so that there is no way PCTs are going to be able to fund a new consultant or a new trainee post...

The NHS are spending money on allergy patients, but it is in a sense wasted because patients, if they are not properly diagnosed, are somewhere in the system being ill. They are either having acute reactions coming into A&E, there are hospital admissions, there is very good data showing a rise in hospital admissions.

They are frequently attending their GPs with continuing illness. They are using a lot of drugs - now all that is a cost to the NHS and our argument is that a small investment in training more specialists which would enable both the specialist sector and primary care to develop would be actually a cost saving.
Prof. Lack, Drs. Ewan, Unsworth and Emmanuel were interesting although some of those speakers must be weary of repeating the same warnings about the inadequate NHS provision of allergy services. The case studies were interesting but the segment about the YorkTest was profoundly irritating.

Allergy and allergic diseases are distressing and have a remarkable impact on people's quality of life. The BBC did not serve its listeners well by offering them this programme. Listeners both deserve and need better coverage.

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Thursday, May 24, 2007

Are GPs Being Nibbled to Death by Ducks? Part 1

Ducks with a disembodied hand
I've been in Wales, attending a wedding and staying with friends. I knew that my friends weren't online but they promised me that neighbours had already agreed that I could use their connection. I'll draw a veil over the attempts and say that a Windows 95 system with negligible memory and something like a 56K dial-up connection don't play nicely with anything (it seems that they don't use the internet as such - the children are dotted about in India and Africa and they use the modem for faxes).

There were medics from several countries at the wedding. There were several points of interest that will probably make it into a series of posts. One frequently recurring theme was that most of them felt that their professional autonomy was being eroded. Some of the GPs and family physicians mentioned that they spent a disproportionate amount of time on the telephone, justifying prescribing decisions to pharmacists and HMOs (Dr. Rob Lambert posted on a similar theme: American (Dysfunctional) Medicine). Others spoke of the difficulties that they encountered when asked for a course of treatment by a patient with a condition that could not be readily confirmed by a clinical test or had been discounted by a 'within bounds' test result; examples were:
  • parents who wanted children to be tested for environmental allergies and toxicities
  • patients with test results indicating normal thyroid function who requested a trial with thyroid hormones for sub-clinical hypothyroidism
  • CFS/ME where a patient asked for long-term antibiotics to treat Chronic Lyme Disease (infection with Borrelia Burgdorferi)
  • asthma that is brittle and non-responsive to standard drugs where a patient asked for a combined antibiotic protocol (CAP) to treat either mycoplasma pneumoniae or chlamydia pneumoniae
  • Multiple Sclerosis or Rheumatoid Arthritis where the patient was also requesting a CAP to treat c. pneumoniae and other infectious agents.
In some cases, the doctors rejected the treatment requests because they did not believe in the diagnosis that they were asked to treat, e.g., vaccine-induced heavy metal poisoning, sub-clinical hypothyroidism or Chronic Lyme Disease. In other cases (like the asthma or MS), several of them were interested in the proposed mechanism of action and were sympathetic to the rationale underpinning the proposed treatment, but felt that they could not do it because they doubted that it would stand up to a Bolam standard where actions may be justified if they are reasonable according to the prevailing body of medical opinion (Dr. Crippen has written that in many ways NICE is the new Bolam).

Both in the UK and various other countries, there are doctors who are known for being, e.g., Lyme Literate or willing to run tests for or treat the conditions such as environmental illness, CFS/ME, thyroid or adrenal problems or controversial diagnoses that cause much frustration for some GPs and patients. Both in the UK and elsewhere, these doctors are being investigated by their licensing bodies or equivalent. Some of the UK doctors have survived various hearings but closed their practices because it is difficult/impossible to obtain insurance to cover GMC Hearings and they couldn't afford to fund a future defence.

Several people at the wedding discussed the case of Dr. Sarah Myhill, a local private GP who is in just that position. Five years ago, she was scheduled to have a GMC Hearing but it was cancelled without further explanation. However, because of the Hearing that didn't happen, she couldn't obtain insurance against future Hearings and she is now scheduled for a GMC Hearing, later this year. She is asking her patients to help fund her defence.
The complaints against me are all from doctors who do not like my style of practice. No patient has been harmed or even put at risk. The three patients involved have all refused to have their medical records used against me, but their "anonymised" records have been taken anyway by the GMC against their desires and without their permission.
The merits or de-merits of Dr. Myhill's practice and the complaints against her were not under discussion. There seems to be some unhappiness about the way in which the GMC gathers its evidence and runs its Hearings. However, a number of the doctors felt that it is a strong indicator that they could not consent to an non-standard test or treatment protocol without running the risk that a colleague might use it as the basis of a complaint. I have no idea whether or not they are being over-sensitive and hyper-cautious or merely prudent in a climate where they feel that their decisions are being consistently second-guessed or questioned. It was plain that a number of them felt that compromising their therapeutic autonomy was not always in the best interests of the patient.

I don't know if GPs are being nibbled to death by ducks but I have two anecdotes from my own family (privacy waiver given). My husband is on a trek to Everest Base Camp. As part of your own medical kit, you are advised to ask your doctor to prescribe a courses of three antibiotics in case you develop a UTI, or pick up a GI or chest infection; if you are not on a medical trek where people are monitoring your physiology, you might also discuss whether you will take along acetazolamide to prevent or mitigate the symptoms of Acute Mountain Sickness.

The GP's first objection was that she would need to contact the Primary Care Trust (PCT) to obtain a policy decision on prescribing take-along antibiotics. After that, she wanted to speak with the medical advisors to the trek because she wanted to know why they couldn't prescribe the antibiotics. The medical advisors argued that although they had extensive physiological data on my husband and a medical history (largely consisting of the word, 'No'), they did not have his medical records and would not know of any pre-existing allergies or adverse reactions. She then explained to them and my husband that even if she were to write the prescription for the antibiotics, she believed that the local pharmacists would refuse to fill it without documentation from the trek company and in the absence of a policy statement from the PCT.

Following these messy discussions, matters took a turn for the worse when the GP checked my husband's negligible medical records and realised that, apart from routine and travel vaccinations, he has never been prescribed any medication, including antibiotics. She expressed concern at the prospect of authorising the use of a medication under those conditions and then asked my husband to phone her if he were to fall ill and need a prescription. My husband pointed out that although satellite phones are good, and ignoring the logistical problems relating to time zones, he wasn't sure that this would be practical when he was on the trek as there wouldn't be a local pharmacy.

We didn't obtain a decision from the PCT before my husband departed. The trek organisers agreed that this was a set of circumstances where the trekkers would be surrounded by an unusual degree of medical and clinical expertise and one of the expedition doctors would dip into the team's own store of antibiotics etc. if my husband were to need them.

I have a condition that includes loss of balance, nausea and dizziness amongst its symptoms. I used to have a prescription for a daily medication to reduce the number of episodes and an as-needed medication that would act as an anti-emetic if I did have an episode. Medication 1 doesn't prevent all the episodes, medication 2 didn't always work because you might be sick after you took it etc. Nonetheless, medication 2 was helpful when it did work; not least because it is easier to persuade someone to put you into a taxi or on a train home, even if you are unable to walk unaided, if you are not actually being sick.

Some time last year, my GP's practice had a medication review. I don't know who carried out this review, but 'somebody' decided that I could no longer have both of these drugs. My ENT consultant provided a letter to support the prescription of both drugs and my GP was sympathetic but decided that she would no longer prescribe medication 2. I have no doubt that some medication reviews are useful (Dr. Crippen discusses this in his Tuesday entry) but this one had a significant impact on my day-to-day activities.

Not everybody has this option but I'm now seeing a consultant privately. Not only do I have a private prescription for medication 2 for use as needed but we're about to try a treatment protocol that is popular in the US but not commonly used in the UK. I wish that I could have done either of these with the full cooperation of my GP. My GP possibly wishes that she wasn't subject to so much oversight by others or so apprehensive about being nibbled to death by ducks.

For more information about the images used in the illustration, click on it or visit Flickr.

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Wednesday, May 16, 2007

Recall of Emergency Asthma Care Pack, Asthma UK

Asthma UK recently launched its Emergency Asthma Care Pack but needs to recall it because there is a potentially serious error in the guide. If you received a hardcopy of the pack, please destroy it. If you received a CD, please return it (details below).

There is an IV dosage error on page 14, table five. The dose of IV Salbutamol should read 250 micrograms (mcg) not 250 milligrams (mg) as stated. Administering the incorrect dose of Salbutamol might result in a serious, possibly fatal, consequence for some patients.

Asthma UK is reviewing its procedures in order to prevent anything similar happening again.

Understandably, Asthma UK is amending the packs and CDs, and this means that they will not be filling orders for the Emergency Asthma Care Pack until they are confident that everything has been amended. Everybody who received a CD will be sent a correct version and a correct version of the Emergency Asthma Care Pack will be available to download in the near future.

1. CDs should be returned free of charge, to Freepost RLUR-HJUK-JCEE, Asthma UK, Summit House, 70 Wilson Street, London, EC2A 2DB

2. Any copies of the Emergency Asthma Care Pack from the Asthma UK website should be destroyed.

3. Any hardcopies of the Emergency Asthma Care Pack should be destroyed.

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Monday, May 14, 2007

Oil Seed Rape, Fashionable Demon or Time to Break Out the Pitchforks and Torches?


Judging by recent stories about oilseed rape, it is either the latest victim of fashionable demonology (wheat, gluten, dairy) or it is justly reviled and past time for the allergy-bedevilled villagers to take up the pitchforks and torches.

Against a backdrop on an increase incidence of hayfever in the UK, it is a little dispiriting that the stories contain a strong whiff of superstition alongside the science. Two representative accounts are, The rape of spring: Health concerns over crop (Independent) and Teacher forced out by oil seed rape (This Is London).

Oilseed rape is highly visible, its vast gharish swathes do not blend gracefully into the usual british landscape of colours: its vibrant coloration catches the eye, its cloying scent seems to swamp all others. If you're looking for an obvious scapegoat for crimes against your nose, eyes and upper-airways, then oilseed rape couldn't be a more noticeable culprit. If this were a detective story, then oilseed rape would be discovered at the crime scene, looking self-consciously guilty, fingerprints and DNA strewn about the scene along with incriminating documents that provide evidence of motive.

The article in This Is London describes the plight of Peter Hallam who is forced to flee from his home to the refuge of a hotel, 45 miles away because of his "severe allergic reaction to the oil seed rape fields surrounding his house". Except, it is not at all clear that Peter Hallam is allergic to oilseed rape. It seems that the diagnosis of allergy is based upon Hallam's personal conviction (Dr. Ben Goldacre recently commented on the unreliability of intuition):
The doctor couldn't know for sure what was causing it but I'm certain.
Based on his personal certainty, Hallam and his partner call for research and a general alert, "the general public should be made aware of the danger of these oil seed rape".

However, there is no indication that oilseed rape is more dangerous than any other plant. According to a BMJ commentary on the research, there is no clear evidence that oil seed rape affects health adversely:
the [MRC] report shows that there is evidence of health effects associated with the cultivation of oilseed rape but no convincing evidence that rape is a cause of widespread disease or ill health in the general population...

Only in Britain has oilseed rape been suspected by the public of causing ill health effects. In other rape growing countries, such as France, Germany, Denmark, and Canada, no such public concern against oilseed rape exists.
The Independent reports the opinion of prominent scientists. Professor Pamela Ewan, consultant allergist at Addenbrookes Hospital, said:
The amount of allergy to rapeseed is very low. People think they are allergic to it because of its bright colour and powerful smell when they are really allergic to other pollens that they can't see. There could be some adverse reaction to the volatile chemicals the plant produces. But I think the perception is much greater than the reality. Grass pollen is by far the most potent cause of hayfever in Britain.
There is a strong case for requesting a referral to a clinical allergist if you suspect an allergy to oil seed rape. A clinical allergist will be able to distinguish a reaction to oilseed rape from allergy to grass pollen. In combination with a thorough clinical history, a negative allergy test can liberate someone from the expense and inconvenience of unnecessary allergen avoidance. If there is allergy, then the allergist can provide guidance on the most appropriate and effective avoidance techniques and medication.

A clinical allergist can also advise somebody on whether there is evidence that indicates that they do not have a clinical response to a specific allergen (e.g., oil seed rape) but exhibit symptoms when they are exposed to that allergen along with additional allergens at the same time. If somebody does exhibit a reaction threshold, then an allergist can give advice on whether it is possible to reduce the allergen load by avoiding one or more of the allergens to which they are sensitised (it may not be the most obvious one). If selective avoidance is practical then it might be possible both to reduce symptoms and the need for pharmacotherapy.

The Independent piece acknowledges that:
[o]thers take a less rigorous approach to the science, preferring to emphasise sufferers' reported experience. Muriel Simmons, spokeswoman for the charity Allergy UK, said: "Rapeseed very rarely triggers an allergic response, but it may be an irritant"...

"I think it is worrying that we are seeing the yellow tide advancing and the number of fields turned over to rapeseed spreading. Whether it is affecting the immune system or not is irrelevant - it is making a lot of people feel very uncomfortable."
It is difficult to argue the case for funding further research into oilseed rape if there are strong indications that the prejudice against it may be unfounded. This reported attitude is rather more indicative of the pitchforks and torches approach than the scientific approach that one might expect from somebody representing "the leading medical charity for people with allergy".

Oh misery me! mecum omnes plangite!

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Sunday, May 13, 2007

Paediatric Grand Rounds Wants Your Post, Please

Mock-up cover for Standing Baby magazineYes, it is out with the begging bowl, as I shamelessly rattle the post collection bag and ask you for your contributions to Paediatric Grand Rounds. As you can see from the magazine cover, we are open to conventional and more off-beat topics.

The next edition of the PGR will be hosted by Ami at Ami Chopine's blog. Ami asks that you send submissions to
ami (at) geekatplay DOT com
by May 19th.

Ami has a theme but does not intend to hold us hostage to it:
I’ve decided to give this one a casual topic. Casual, because I certainly won’t keep anyone out who submits a post that doesn’t fit with it. But maybe a topic can inspire thoughts that will turn into posts.

The topic is:

The role of the doctor in the child’s life and/or the role of the child in the doctor’s life.
Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

For more information about the image used in the illustration (from Tedsblog), click on it or visit the detail on Flickr.

Friday, May 11, 2007

Reducing Hayfever Symptoms: Abusing My Damehood to Recommend Something That Is Not Evidence-Based

Buff microfibre tube, laid flatIt seems that Dr. Clark Bartram of Unintelligent Design has granted me a damehood. I have just learned of my enoblement to Dame Shinga Salisbury Shingashire. I shall follow in the fine tradition of people who abuse honours by recommending something for which I have absolutely no evidence-base although I feel its truthiness.
Stephen Colbert's "truthiness"...describes things that a person claims to know, without regard to evidence, logic, intellectual examination, or actual facts.
I realise that it would fully round out my abuse if I were to have a financial or other interest in my recommendation but, sadly, I don't, not even indirectly, no matter how upstream or downstream you look. Nonetheless, I hope that the lack of any conflict of interest doesn't detract from the magnitude of the complete lack of evidence that I have for my recommendation.

I should also admit that I have no part in the essence of the idea which is no more than a variation of reducing hayfever symptoms by covering-up to reduce your exposure to pollen or other airborne irritants. It's not so much standing on the shoulders of giants as coming-up with a re-tread of something your grandmother probably told you along with every advice leaflet that you've ever read on the topic of hayfever. This idea, should, of course, only be implemented alongside your useful self-care measures and medication programme.

Baby wearing a Baby Buff in babuschka styleDrumroll please for my damp squib of a recommendation. When you are outdoors and likely to be exposed to pollen, wear wraparound glasses and a Buff or something like it. The Buff is a soft, flexible, microfibre tube that comes in sizes for infants, children and adults: consult the website for a guide to the many ways in which a Buff can be worn.

If you have long hair, and you wear your Buff so that your hair is completely covered, inside the tube; if you carefully remove the Buff when you go indoors, then you have brought less pollen into your home. You may also find that you are less likely to exposure yourself to the pollen trapped in your hair when you fall asleep, and you may reduce the amount of pollen that you transfer to your pillow, bedding, soft furnishings in general.

Other people might consider wearing the Buff in Ninja or Biker style. In both of these the nose and mouth are covered. The fabric of the Buff can filter out some of the larger pollens or airborne irritants. For people who need a finer degree of filtration, I recommend that you wear the equivalent of a silk mask inside your Buff. You might be able to purchase a silk mask that fits over your nose and mouth or stitch together a suitably-sized pad: you need 8 layers of silk to filter out the smaller sizes of pollen, but silk is so fine that this doesn't make the pad at all bulky. If you are familiar with the pollens that irritate you, you can look up their sizes in this handy pollen guide. If you are in tree pollen-hating mode, feel free to sing The Silvicide Song: Cut Down the Trash Trees to the tune of Hava Nagila but always remember Charlotte Mew's injunction, "Hurt not the trees" (hat-tip to The Laundress for both the song and poem).

I do, of course, recommend that you should nose-breathe wherever possible, because this will filter and humidify your air intake. If you are wearing a Buff over your nose and mouth, this may feel a little odd at first, and there may be a feeling of increased nasal resistance (particularly if you are also using the silk pad), but most people adapt to this. If you wear a Buff when you are exposed to pollen and irrigate your nose regularly, then I feel that you are reducing your exposure to airborne irritants and may lessen your hayfever symptoms.

You should, of course, exercise sensible caution, when persuading a child to try out this arrangement. Some children can't bear the feeling on anything on the head or face, others see it as a variation on a Spiderman costume-it can be hard to predict. I know that there is an ample variety of pollution and pollen masks available for purchase, but I've shied away from recommending mask-wearing to people in the UK because, well, it's the UK. People might think it ill-mannered to say anything to you, but there would definitely be raised eyebrows. I look upon my recommendation as a half-way house between no protection and Carole White (Julianne Moore's character) in Safe. She and the other characters looked alien and alienated as they trundled around, wearing masks, dragging portable oxygen tanks, afraid of modern life and convinced that they had multiple environmental allergies.

I was emboldened to make this evidence-free recommendation because, not only have I become a dame (courtesy of Clark Bartram), but Christine Barry has published a paper in which she calls for us to cast off the tyranny of RCTs and the shackles of conventional evidence and stand up for our rights to interpret evidence using different modalities and outcomes until we find a result that we like. I am indebted, both to the author and the reviewers who accepted her paper, for the profound observation:
There is no such thing as The Evidence, just competing bodies of evidence.
I credit this with my realisation that it would be pointless to wish for laboratory testing to demonstrate the filtering power of a Buff or Buff plus silk mask or patch when I could just assert my autonomy and state that I feel that they do, which is an essential part of truthiness. My feelings must be a form of evidence and it would be disloyal of me to disown them by demanding proof from a testing laboratory.

Pros of the recommendation: it might reduce your hayfever symptoms. Whatever happens, you will have a piece of headgear that many people have found useful and that you could, in a pinch, gift to someone else. It will be unbelievably easy to disguise yourself in public should you spot someone that you wish to avoid.

Cons of the recommendation: it might not work for you. It might work for you but you can't get used to the sense of nasal resistance. The price: it will cost you whatever is the price of the one that you buy. You might have to stitch together your own silk filtration pad. Your children might cry if they unexpectedly see you wear a Buff Ninja-style. If your child insists on wearing a Buff all the time, you will never again be able to say, "You've got liar written all across your forehead". Your baby might look so unbelievably cute that you take an album of photographs to show everybody; s/he will hate you for this in years to come. You may be the subject of security alerts if you attempt to enter a public building with your face completely concealed.

P.S.: I'm well on the road to recovering from the salmonella: rational service will be resumed at some point.

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Wednesday, May 09, 2007

Greater and Earlier Incidence of Hayfever among Children in UK

Mosaic of itchy, troublesome noses: some nose-pickingThere have been lots of advance warnings in the UK about the likelihood of widespread hayfever earlier this year; we have been advised that there will be an earlier onset to the pollen season than usual. It seems that these warnings were appropriate as there are reports of a doubling in sales of hayfever remedies and higher than usual numbers of people, between the ages of 5-44, who are experiencing eye problems.
In the week ending 24 April, figures show that NHS Direct was receiving on average 150 calls a day from people with these hay symptoms, which is a rise of all calls to NHS Direct from 0.7% to 1.5%.

The most likely cause of this is increased pollen from trees like the Silver Birch, Oak and Plane trees brought on by the recent warm sunny weather. Commenting on this Helen Young, Executive Clinical Director/Chief Nurse for NHS Direct said:

"It's unusual to see this number of people calling us this early in the year with hay fever symptoms. June and July is the usual time when people are suffering from an allergic reaction to pollen from grasses. Our figures show that the most affected group is 5 - 14 year old children.
The linked article advises readers to consult a pharmacist about over the counter medications to alleviate symptoms. It also contains some standard pollen avoidance advice:
  • stay indoors and keep doors and windows closed when the pollen count is at its highest
  • if appropriate, wear wraparound sunglasses
[Edited: Dr. de Asis offers further guidance on allergen avoidance.] Regular readers will not be surprised to learn that I also advise the use of nasal irrigation to:
  • remove allergens
  • soothe the outraged tissues
  • reduce the severity of the symptoms.
If your young child develops hayfever symptoms alongside eczema then it is advisable that you should consult your GP as this may indicate the development of multisystemic allergic responses that may need careful medical management.

For more information about the images used in the illustration, click on it or visit the detail on Flickr.

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Monday, May 07, 2007

Paediatric Grand Rounds 2.2 Is Up!

Star - text is Paediatric Grand RoundsMoreena of The Wait and The Wonder is our host for Paediatric Grand Rounds 2.2.

Moreena's compilation contains a number of entries from parents, exploring their experience from hope to grief. Many of the posts are moving. Elsewhere, we have Dr. Flea discussing whether paediatricians are unsuited to general practice because they are accustomed to looking after sick rather than healthy children and, thankfully, general practice is mostly about the latter.

There are some controversial posts (such as Signout in which she vents about why some people have children when they can't look after them) and dowright weird - I'd never heard of the pump and dump until Dr. Clark Bartram described it (hint, it's not a dance step).

All in all, I commend PGR to you.

Our next host is Ami Chopine who is inviting us over for PGR hospitality on May 20.

Dr. Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

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Friday, May 04, 2007

A GP Homeopath in BBC's Doctors, A Bold Idea or Mainstream Anti-Science?

Skit on Prince Charles support for CAM as anti-elitistA few weeks ago I complained about the depiction of tonsillitis as a life-threatening illness for children in BBC's daytime medical drama, Doctors. I thought that I'd shrugged off how annoying medical dramas can be when I learned that this same drama is about to feature a GP Homeopath.

I was profoundly irritated at first and then wondered if I were jumping the gun. After all, I don't know how they will handle the storyline and homeopathy is available on the NHS in the UK. Back in January, an interesting paper in the British Journal of Clinical Pharmacology revealed that 60% of the 323 of the surveyed doctors' surgeries in Scotland prescribe homeopathic or herbal remedies (there was also an intriguing analysis of the demographics of the people who obtained these prescriptions and the conditions for which they were prescribed: mostly the very young or female adults; mostly 'lifecyle' conditions). Whatever I think of homeopathy, perhaps it is not entirely unreasonable that a medical drama should cover homeopathy as part of the NHS (for the first time in the UK, as far as I know-please tell me if I'm wrong).

Coincidentally, the widely-esteemed Prof. Michael Baum has just published an anti-homeopathy piece in a newspaper that is notorious for its support of CAM and extravagant reporting of medical issues:Homeopathy is worse than witchcraft - and the NHS must stop paying for it. In true Baum brimstone style, we learn:
Homeopathic companies are making a fortune marketing placebos. Yet, despite this, last September, the Medicines and Healthcare Products Regulatory Authority approved the marketing of homeopathic remedies for 'self-limiting conditions' (these are conditions which should improve by themselves) - even if there is no evidence of their efficacy.

This scares me. Homeopathy is to medicine what astrology is to astronomy: it's witchcraft - totally barmy, totally refuted, and yet it's available on the NHS. For while homeopathic medicine is not toxic, its use as an alternative to conventional medicine can, in fact, cause serious harm...

The majority of homeopathic physicians are nice, kind people and they're not stupid.

They will claim homeopathy is a complementary therapy, not an alternative to medicine. But how does homeopathy complement other medicine? Bogus potions aren't complementary, they are a deception and provide false hope.
Just to provide some further context as to what is happening about NHS provision of homeopathy in the UK, Prof. David Colquhoun of UCL's Dept. of Pharmacology, is calling for public support for the closure of Tunbridge Wells Homeopathic Hospital.

Back to the medical drama, as far as I can tell, the background to the storyline is that the female GP has always been interested in 'alternative' things. Some time ago, she had a brief research fellowship (or similar) in Australia to allow her to study traditional medicine (not otherwise specified). For various reasons, she has decided that she wants to practise as a GP Homeopath. It is not clear whether she has decided that she is experienced enough to declare herself competent to be a homeopath or if she has actually qualified in the subject (I'm overlooking the issue of the content of homeopathy degree courses because it is possible for GPs to take a one year course through continuing education credits to qualify as a homeopath). She has written articles about undisclosed subjects related to complementary medicine for un-named publications: some of these seem to have been in local newspapers, other newspaper articles seem to be about the fact that she was published elsewhere.

After declaring her intention, the partners in the practice asked her to make a presentation to make her case. At this point I was interested. I wondered if they were going to ask her about the evidence base for homeopathy or its remedies. I wondered if they were going to ask her if she is going to prescribe homeopathy or isopathy (a distinction I only learned about during an odd evidence session to a House of Lords enquiry but apparently it is isopathy rather than homeopathy that has failed in clinical trials that were supposedly about homeopathy). I wondered if they were going to ask about the distribution of the workload and how she was going to fit a full homeopathic profile history taking etc. into the standard 7 minutes appointment. What would be the implications for the other partners? Is there a compounding homeopathic pharmacist in the local area (possibly harking back to my homeopathy v. isopathy enquiry). So, I decided not to pre-judge the way in which the storyline was handled but to tape the day of the presentation and see what happened.

Dramatic personae for the presentation (descriptions, as supplied by my neighbour)
Dr. Joe - practice partner. For the purposes of this vignette, a crusty, sneering rationalist who disdains 'new age' stuff.
Julia - practice manager and partner. Has made many questionable judgment calls in the past but for purposes of this is supposed to represent sound business sense and open mind.
Dr. Nick - newly made-up to partner. Previously reprimanded by GMC for something or other involving inappropriate care for asthma patient leading to death. Possibly here because he has previously been in conflict with Joe and may be more likely to vote with anyone who irritates him.
Dr. George - salaried doctor in the practice. Has always been pro the 'alternative'. Has declared herself as ready to be a GP Homeopath.

Broadcast Tuesday April 30, 2007. Any transcription errors and emphases are mine. I have put in readings and actions where they seemed necessary. I have offset some comments in the dialogue.

Dr. George: How do we treat someone with sciatica? We send them away with painkillers. They present with an upset stomach. It's the same thing, "There's the prescription. Take it to your local pharmacy".

Dr. Joe: What's wrong with that?

Dr. George: Well...the problem with modern medicine is that we're treating the symptoms and not the whole patient.

Dr. Joe: But if we're taking away the pain...

Dr. George: That's fine in the short term, Joe. But sometimes the pain comes back and sometimes it presents itself in an entirely different way. We haven't solved the underlying cause of the real problem.

Dr. Nick: So you want to take a more holistic approach.

Dr. George: Well, I think we need to because I think we're failing our patients.

Dr. Joe: But I don't hear many complaints. [Disingenuous, somewhat exasperated.]

Dr. George: [Very exasperated.] Don't take my word for it, Joe. Just look at the hundreds of thousands of people every year who are so disenchanted by the NHS they seek the services of a complementary therapist. One of the increasing number of complementary therapists. The key word here is complementary. What I'm proposing is that we offer the very best of modern medicine alongside traditional remedies, some of which have been successfully used for thousands of years. That way we are serving our patients better because we are offering them choice and well and truly bringing The Mill [the name of the medical centre] into the 21st century.
I was badly confused at this point as I'd thought that she was only introducing homeopathy. However, here it seems that she may be referring to acupuncture and aboriginal remedies. I have no idea who is to provide the acupuncture or where she will obtain the ingredients for aboriginal remedies and who is to compound them. Nonetheless, I do regard it as classic that these ancient and traditional remedies will bring The Mill and, by extension, the NHS, into the 21st century.
Julia: That's very impressive. Well done, George.

Dr. Joe: Yes. The presentation was top-notch. However, I do have a few questions...

[Cuts to some unrelated scenes. Presumably, during this time most of the questions in which I would have been interested were asked because they certainly are not fully addressed in what follows.]

Dr. George: I'm suggesting that we start by offering acupuncture and homeopathy.

Dr. Joe: What do you mean, start? Do you mean that this is going to be some sort of creeping process? That eventually the asthma clinics and ante-natal classes are going to have to make way for some sort of aboriginal folk remedy? [Sneering 'woo'-ish tone to last 3 words with accompanying Twilight Zone finger gestures.]

Dr. George: [Peeved and irritated.] I'm suggesting that we react to what our patients want. If there is a demand for alternative remedies then why aren't we offering them.

Julia: Well, there does seem to be a demand. I mean I'm still getting phone calls from people wanting to join our list and it's all down to George's articles.

Dr. Joe: But these therapies that you're talking about. How many of them have undergone any kind of rigorous scientific testing?

Dr. George: What-and that's the only way to prove a treatment works?

Dr. Joe: In my book - yes.

Dr. George: [Still seated, hand on hip.] Joe, this isn't some kooky scheme that I thought up on the way into work. I've put a lot of effort into this. And I won't have it dismissed by some close-minded cynic.
Because we didn't see the presentation perhaps I shouldn't judge, but "What - what can you possibly have thought up to get round the problems of those meta-analyses that show that homeopathy doesn't work, unless this character is also resorting to the "It was isopathy that was trialled" defence".
[Gets up from seat, on high horse, gives dismissive hand wave.] Do you know-Actually, do you know what? If you're not interested then maybe I'll take my services elsewhere-to a practice that has a little bit more imagination.

[Storms out of room and slams door.]

Dr. Nick: Do you think she was serious?
Sadly, here he is referring to her threat, rather than her lack of an adequate response to Dr. Joe's question about the scientific testing.
Julia: Well, I know George can be a little emotional at times, but, yeah, I think she was serious.

Dr. Joe: Then maybe we should call her bluff. Threatening to resign if you don't get your own way I think is tantamount to blackmail.

Julia: OK. Let's compromise. Why don't we give George's idea a trial run and see if any of the patients are interested?
I'm not clear here whether she thinks that clinical evidence and efficacy are irrelevant when compared to a business idea that will attract patients. However, if The Mill's lists are already full and (previous plot according to my helpful neighbour) they've recently lost another GP, how are they going to take on more patients?
Dr. Joe: Why waste time and money setting up something that patently is not going to work?

Dr. Nick: It's not what her research has suggested.
Again, this seems to be about the business angle, whereas the Joe character is trying to discuss the clinical efficacy.
Julia: Look, I know there's a certain amount of risk involved but if we didn't take risks sometimes, The Mill would never have been created in the first place.

Dr. Joe: And I would not have contemplated joining you if I had known that after one year the whole practice was considering such a radical change.

Julia: OK. There's only one way to decide this. Let's take a vote.

[Unrelated scenes. Dr. George is summoned back to the room.]

Julia: As we couldn't agree, we thought that it only fair to put your proposal to the vote. And I'm happy to say that we've decided to implement your plans. On a trial basis. And we'll have an assessment after six months. See where we go from there.

Dr. George: I don't believe it.

Dr. Nick: It was a very persuasive presentation.

Dr. George: I know, but still...Thank you. Thanks Julia.

Julia: It'll mean a lot of extra work for you.

Dr. George: Well that's alright. It'll be worth it. Cheers, Nick.

Dr. Nick: It's only what you deserve.

Dr. Joe: [Somewhat sourly but playing the game.] Well done. [Leaves room.]

Dr. George: You won't regret it.

[Unrelated scenes. Cut to Dr. Joe's room. Dr. George knocks on door.]

[Preamble]

Dr. George: I'm presuming that the vote wasn't unanimous.

Dr. Joe: I made my position quite clear. Unfortunately, the others disagreed.

Dr. George: I just want the opportunity to prove that I'm right.

Dr. Joe: I'm entitled to my opinion. Look, I've worked hard to establish a good reputation and I don't want to see that ruined by being associated with a practice that is turning into, I don't know, a kind of Midlands version of Glastonbury [Woodstock with mud, wholefoods, CAM and various 'alternative lifestyle' trappings].

Dr. George: This isn't going to be some kind of hippy-dippy set-up. It'll be extremely professional.

Dr. Joe: So you say. I can not support something which encourages patients to turn their backs on scientifically-proven treatment.
Interestingly, both Prof. Baum (as above) and Orac (and again for Orac) relate instances where they say a patient with breast cancer has rejected advice in favour of other therapies.
[Dr. George turns away in disgust.]

Well, let's face it. You and I are never going to see eye to eye.

Dr. George: So, what? You're gonna try and ruin this for me?

Dr. Joe: I won't need to. There are so many things that can go wrong with your scheme all I have to do is sit back and wait for everything to implode and just hope it doesn't bring down The Mill with it.
It is very difficult to sympathise with the rationalist voice in this set-up when he is being played as unbearably patronising and self-satisfied. This may be a neat way of shorthanding the CAM v. NHS medicine debate but it is horribly simple and doesn't address the evidence issue.
[Dr. George has been shaking her head in disbelief.]

[Unrelated scenes. Dr. George is having celebratory drink in bar with her husband.]

Dr. George: I did my presentation today and if I do say so myself, I was brilliant. I was business-like, professional, answered all the questions and guess what...
What, when did the business-like professional bit happen? Also, why did I see the slamming-out-of-office bit rather than answering of the questions?
They've given me the go-ahead. Complementary therapies will finally come to The Mill. I think I've made an bit of an enemy of Joe but I'm sure I'll get round him once he sees the therapies working.
Well, I suppose that it depends on your baseline for your selected conditions. Will the 'therapies' work if they cost less than the present NHS offerings or if patients like them more? When did this character do this huge amount of work into putting together this baseline? How will the practice review progress in 6 months if there is no baseline?
[Transcript ends.]

So there you have it. The one attempt to ask about the evidence led to the remarkable anti-science riposte and a fauxrious storming off. Offhand, I can't decide whether that exchange or the claim about the remedies that have been successfully used for "thousands of years" bringing The Mill/the NHS into the 21st century is the most outlandish.

I have no idea when acupuncture was added into the mix. I have no idea whether the homeopathy will be restricted to self-limiting conditions or if all conditions will be fair game. It may be interesting or infuriating to see how this develops. Will there be a pro-homeopathy, pro-science stance or an attempt at neutrality that attempts to present them as equivalent? Sadly, given the credulous nature of much mainstream media, I am not optimistic. My pessimism on this matter is summed up by the comments on Prof. Baum's article which can be captured in one sentence from one poster, "Though my comment will only be recorded as anecdotal, it is a fact!."

Flickr artist Tom Morris offers a skit of Prince Charles talking about complementary and alternative medicine.

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Food Poisoning

My husband is off to Nepal on Saturday as part of the Caudwell Xtreme Everest medical expeditions. Word back from others who have completed the trek is that everyone takes around 1000 photographs. Possibly as a pre-emptive and defensive move against being shown these photographs, friends have been inviting us to dinner before my husband's departure.

After one recent dinner, I developed food poisoning. I've had the full works. Fortunately, my husband hasn't had so much as a gippy tummy. With any luck, this bodes well for his ability to withstand the usual bugs that bedevil trekkers on these trips.

Anyway, I can drink fluids again and the muscle aches are slackening off. And, it's given my husband practice in taking a fast pulse (they need to record pulses etc. during the trek).