Sunscreens – Are You Buying Them Right?

Sunscreens – Are You Buying Them Right?

I read a very interesting research paper yesterday –published in the prestigious New England Journal of Medicine (read here- http://www.nejm.org/doi/full/10.1056/NEJMp1504912) - detailing the current research trends in melanoma – a skin cancer condition. And the research paper in passing touched upon something of interest to all of us- namely how effective were sunscreens in preventing skin cancer. Now the two commonest skin cancer types are Carcinomas and Melanomas. A melanoma (often called a malignant melanoma because it spreads so easily and so fast) is a cancer of the melanin pigment producing cells of our body. Melanin is the protein which gives us our skin colour- dark or fair and and also protects us from the radiation of the sun- in effect its a natural sunscreen. Dark skinned people have an abundance of melanin pigment in their skin naturally and require lesser quantities of sunscreen to protect their skin, while fair skinned people with less melanin get tanned and sun burnt easily and also have more instances of getting skin cancer- melanomas. So with that small introduction let me get onto the meat of the matter.

 Sunscreens as we all know are classified as over the counter cosmetic products which do not need a doctors prescription. But we must remember that cosmetic companies make certain tall claims regarding sunscreens and their effects touting them as wonder drugs as they contain certain chemicals which, in effect prevent skin-tanning, anti-aging etc. Now the American Food and Drug administration has specified certain guidelines for sunscreens based on recent research

1)    Anything less than SPF- 15 is no use for cancer prevention but can only be used for anti-tanning- so this means the FDA has now effectively barred anything which uses less than 15-SPF.

2)    Anything above SPF-50 has been shown to be useless for skin protection- which means that more than that is an overkill and unnecessary.

3)    Both cream and liquid based sunscreens work equally well when applied as a coating- but all of them last for only 90 mins to 120 mins for single application- which means you are protected for one and a half to two hours only with a single application. So covering up exposed areas with adequate clothing becomes important for long term prevention. And there goes my dream of ogling at all those bikini clad beach babes.

4)    Any sunscreen which only protects against UV-A is not effective as anti-cancer but only for anti-tanning. Hence check out for the sunscreen prevents both UV-A  and also UV-B rays from affecting the skin. So only broad-spectrum sunscreens prevent  skin cancer while others are just for the beach.

5)    Ingredients like  ecamsule and enzacamene come under banned substances – no longer safe and effective and hence check out that you are using a product which no longer contains these.

6)    And finally remember that background radiation exists even indoor- so anything which promises anti-aging should protect your skin all the time and not just under direct sun exposure.

So these few pointers should help you choose the best sunscreen for avoiding skin cancer and not be taken in by the tall claims made by cosmetic companies.

Communist Medicine In A Capitalist World

Communist Medicine In A Capitalist World – The Evidence Based Medicine Conundrum

Any casual reader of history or anyone at all with any general knowledge know that the discredited philosophy of communism and its paramount creation the soviet empire were both destroyed because both economically and even with common sense it beggars belief that decisions can be made in central committees and by fiat be implemented in all places and in all situations without a single thought for local conditions or differences. Crops to be sown, fertilizers to be used and harvesting times were all imposed on farmers from afar by fat-cat bureaucrats sitting in distant Moscow committees who thought they knew better than the local farmers born and bred up on their lands for generations. The result was total collapse of the agriculture sector and widespread famines everywhere in Russia. Production quotas and processes to be implemented in factories led to so many shoddy products that anyone who was just anyone at all in Soviet Russia preferred to use imported products for everything from shavers to ovens.  Rule by distant committee was comprehensively proved to be the stupidest idea to have ever been invented by the human race and believe me we as a species have made many, many more such mistakes.

So if I now told you that the same discredited theory of communism is now being touted as the only way to practice medicine what would you say? I kid you not- search evidence based medicine on the internet and you would find plenty of laudatory articles as the way to go for practicing medicine as per modern protocols. But read past the platitudes and rule by central committee is exactly what you would find.  And just because the committee distributing it is the internet itself it finds its greatest advocates on the net who tout it as the only way to go and not as one more way as it really is. Now enough with all the historical references and let me start explaining what evidence based medicine really is all about.

Sometime in the last decade of the last century (the 1990’s anyone?) there arose a new system of medicine called evidence based medicine. As with everything else when it was first introduced the intentions were noble and its advocates were sincere and it was definitely a step forward to the future. Doctors everywhere welcomed it because it seemed to offer a way forward during those times when doctors most need help- decision time. Evidence based medicine involved putting up the results of large scale clinical trials on the net to help doctors everywhere follow those same guidelines in their treatment for their own patients. It showed what worked or what didn’t work to others who were hard pressed to make difficult clinical decisions in real time. As such it definitely was a step forward. It even helped simplify which drugs to prescribe or which not to. For instance many of the old time doctors used to rely heavily on antibiotics where were popular during their heydays often not realizing that such antibiotics were no longer active due to an effective resistance built up by bacteria continually exposed to the same drugs for so long. Hence evidence based medicine pushed the medical fraternity into discarding old, tried and tested beliefs and adopting newer treatments. And that’s when things started going wrong.

When the popularity of evidence based medicine picked up worldwide big pharma was as usual right there to swing things in their favor. They started sponsoring the large clinical trials needed to get their evidence – often using low cost outsourcing firms in under developed countries where patients signed up for medical trails for a pittance- and used the results of such biased trials to push heavily in favor of their own drugs which had been used in such trials. Other drugs, even tried and tested ones didn’t stand a chance because all the latest evidence (sponsored of course) freely available on the net pointed towards such and such drug – as the only one with enough evidence available to show it worked. If a doctor wished to use any other drug which he felt could be equally effective he stood in grave risk of being taken to court by the patient for not following “internationally accepted standards of care available on the net”. Which led to all the doctors falling in line cowed by threatened medical malpractice suits and patients reading up the results of such biased trials on the internet and demanding of their doctors the same treatment that dr.google recommends.

If to take an example you have constipation and I as your doctor want to recommend to you a single plantain (local banana) every night and you go on the net and read that florida oranges grown in glass rooms in chilly Alaska when given to 5000 people led to 4000 people rushing to their toilets every morning and you quote that study to me and demand that I prescribe only Florida oranges to you- imported straight from Alaska- then I have no choice except to write a prescription of the same. Because I or anyone else for that matter have no evidence at all that bananas work, forget the fact that every single individual we know all around us for thousands of years have used bananas to evacuate their bowels. There is no large clinical trial for local bananas- no one paid money to large groups of people to eat a banana and shit in the morning and hence no evidence for banana which makes it a false treatment under the evidence based medicine guidelines and if despite this I want you to eat a banana, god help me, I would end up losing my license for practicing medicine- for not asking you to eat imported Florida oranges which might beggar you with just one months treatment cost. And this is the literal truth and I am not exaggerating. The costliest drugs are the ones which drug companies prefer to send for large clinical trials by recruiting thousands of patients. Hence when the results come out its the same costly drugs which become the default treatment option worldwide and any doctor who differs is branded a witch doctor for not following the evidence. Individuality has been stamped out and creativity rooted out in the name of the evidence based medicine fad.

Just like communists used to prescribe their guidelines from a central committee for everything, evidence based medicine has a central treatment guideline which every doctor has to follow to save their own skins or woe to them. Such evidence gathered in distant populations does not take into account individuals or their idiosyncrasies. Medicine is not an exact science and most prescriptions are based on informed guesses but that doesn’t mean that in the name of standardization a one size fits all variety of medicine becomes the only way to practice. The evidence based medicine fad has been taken to such ridiculous levels that surgeons who often make small incremental advances in surgery by trying out newer and innovative surgical techniques on individual patients cannot publish their results anymore as case reports and case series- which are about smaller groups of patients – are increasingly being not published or downright derided in favor of larger clinical trials. Surgeons are being forced to fall in line with the same efficiency as robots and an individual surgical technique (even surgical flair) is being eliminated in favor of standardization.

The day is not far off when patients can print off their own prescriptions off the internet from a published list of symptoms to treat themselves and a doctor (or a middleman) becomes superfluous to medicine. Is that a step forward? Or will it lead to more chaos? Based on the history of communism I am very skeptical of the future of evidence based medicine as it is now. But I can’t speculate on what the next medical fad will be. Will evidence based medicine escape the stranglehold of big pharma and sponsored clinical trials and evolve into something more inclusive and egalitarian taking into account individual knowledge. Or will it act the monolith and seem impregnable till it suddenly implodes on its own like communism did? Only time will tell.

A Medical Whodunit? And A Cautionary Tale

A Medical Who-dunit? Or A Cautionary Tale

This post starts as a medical mystery and ends as a cautionary tale and a general advice column. But before I get to telling you my cautionary tale let’s talk semantics first. When you say you are sick or ill what does that mean? It merely means you have a set of aches or pains or complaints which you go show to a doctor and then he hears them/sees them/checks them and tells you that you are "suffering" from such and such a disease. The Annals Of Internal Medicine has a pithy description of this:

"Illness is what you have, when you go to see a doctor. Disease is what you have, when you come out of seeing a  doctor" 

 So even the American academy of internal medicine agrees that a disease is just a name applied to a group of likely symptoms very similar to those named in a book somewhere. You might have that disease or you might not. It requires, usually, more investigations to confirm or deny. Everything else is an educated guess. Sometimes the only way to confirm that the disease is indeed what you have is to start the treatment and observe. If the prescribed medicines work for you and you get relief from your symptoms (or illness) you are considered cured of your disease. If not, then the process starts again, right from the investigation stage.

But is this all there is to health? Mere absence of any symptoms or illness or disease? If you say No then you are right. And the World Health Organization agrees with you too. The WHO says health is

"Not mere absence of disease,

But Physical, Mental and Emotional well-being"

If you read that again you can see that health is a very simple concept of wellbeing in everything and even a little emotional turmoil is considered sickness. But this fact is not easily accepted by our society for when someone complains of emotional turmoil what does society say to him or her? Chin up, be brave, ride it out, accept it, move on, it happens to everybody. All these platitudes merely cover up the fact that society does not accept anything other than physical pain as illness and visible symptoms as disease.

Say for instance one of you constantly misses his train to work every day because the trains are late or overcrowded or canceled at the last minute and this causes constant emotional turmoil. Would you consider that man as a sick man because of his emotional suffering? Or say someone suffers under impossible work conditions, long hours, bad superiors, unappreciative colleagues and work involving unthinking drudgery, causing daily emotional turmoil in daily work. Would you consider that person as sick and accept that his work which has made him sick? Or would you say that as long as he is able to work normally he is healthy?

And the answer to that question is exactly the cautionary tale I am about to tell you.

The other day I had a call over from a ward to attend a patient who had been admitted for occult blood in the oral cavity. To translate it into normal English, the patient had woken up from sleep to find blood in his mouth and had rushed to the hospital to get admitted saying he was vomiting blood. Now the reason for bleeding into the mouth without any obviously visible injury (like being punched) may range from cancer to tuberculosis and to everything in between. But under the keep it simple stupid principle the most obvious reason to rule out was gum disease or gingivitis as it’s known medically.

The reason for this is that gingivitis (gum disease) is widespread and almost every one of us has at some stage or the other has had it with or without us knowing about it. And its also one of the most easily curable of diseases. You just have to brush with the right tooth paste (preferably an imported one) and gum disease disappears. Or so says the omnipotent doctors (practicing in America or Britain) who act in Television commercials (seen the Sensodyne Ad? Parodontax Ad?). But nothing in life is that simple, especially infections involving bacteria or viruses is not. It’s an almighty hell of a battle inside our body daily- us trying to fight off the bacteria which are trying to live off us.

So even the best brushing with a will - diligent brushing ten minutes a day/three times a day (including nights) might not prevent gum disease. Because, for one thing, the bacteria in the mouth cannot all be eliminated with brushing them away - they can hide in other places like tongue, tonsil and throat and come back again. For another, bacteria develop resistance fast and using the same toothpaste with same medications in it for a long time means the bacteria are no longer affected by the toothpaste's antibacterial action. And finally we come to the one reason no one talks about- stress. Emotional stress or mental stress has an enormous role to play in our body’s immune system and stress can make us weak and easy prey for bacterial infections.  

And so when the patient had complained of blood in the mouth and after they had checked out and dismissed all the frightening diseases (like cancer) first, the attending postgraduate students had diagnosed the patient as suffering from the common disease of gingivitis or gum disease and having told the patient to brush properly had closed his case file and marked him for discharge the next day. But someone else had decided at the last minute that an expert opinion is needed and asked for a consultant's all-clear before finally closing the file.

And that’s how I ended up being summoned to check out the patient, the last thing pending before they sent the patient home. Which was quite a lucky thing for him as events turned out, for I cracked the real case which the others had dismissed so easily as obvious. But i will get to that. When i first entered and saw the patient i read the case notes top to bottom. But I was not satisfied with the reason given there of the blood being due to gum disease. It seemed too obvious and easy a solution and my Sherlock Holmesian instincts were aroused.

Something prompting my subconscious, I examined the patient again trying to find some other reason till at last I found it on the roof of the mouth. This is an area which normally nobody bothers about so someone had missed it when admitting the patient. But on the roof of the mouth there were many small bleeding spots called purpura from which blood was dripping into the patient’s mouth. And intrigued by this finding when I checked his blood test results again, I found that his blood levels were dangerously low. 

I arranged for blood substitutes and drugs to increase his hemoglobin levels- under the treat first and ask questions later policy and then sat down to talk with him. I slowly got him to loosen up and drew out the following. He told me that he was a police constable in the traffic department and his work consisted of standing still in one spot all day long. And consequently when he came home after the day's work he had severe leg pains and cramps and couldn’t get to sleep easily but spent tossing and turning half the night. He had visited a local doctor who had prescribed him sleeping tablets to help him go to sleep.

It was at this juncture that I made the connection. I asked him the name of the drug and it was as I had suspected. I asked him how for how long the doctor had told him to take it and how long he had continued to take it. The patient confessed that the doctor had specified that it was to be taken for only ten days but the patient had kept the prescription and automatically renewed it himself from the medical shop and had been taking the drug for months continuously. And there was the reason. Some drugs have dangerous side effects when taken long term, especially drugs prescribed for sleeplessness, which can cause bone marrow depression and consequently reduced production of blood cells.

So there was the case in a perfect link -the reason for the patients bleeding in the mouth was a drug overdose, which had caused reduced blood levels, which had caused increased bleeding tendency, which had caused purpura in the palate, which had caused blood to drip into the mouth, which had frightened the patient and brought him to the hospital on a complaint of vomiting blood. Voila. Elementary my dear Watson. Case Closed, I take a bow.

And all this was because the patient had been stressed enough in his job to need sleeping tablets every day. So should we blame this man’s condition on his stupidity in taking a medicine daily for many months without telling anybody? Or should we blame it on the stress on his life which drove him to take it like that? Which is the real culprit here- the medicine or the stress? If we can go back and read the WHO advice again which I have quoted above- it says that health is not just absence of disease but wellness in everything - physical, mental and emotional. So the emotional sickness of a stressful job can really cause you ill health and make you develop un-looked for diseases. And that is the cautionary tale I wanted to share with you.

One final thought to leave with you- self-diagnosis and especially self-medication is playing with fire. And that’s putting it diplomatically. 

It Takes As Long As It Takes

It Takes As Long As It Takes

They say that doctors make the worst patients. But what they fail to add is that doctor’s relatives come a close second. Case in point is at my mom. A couple of days ago my mother had to be admitted to the hospital for a cholecystectomy, or in normal English, a gall bladder surgery to remove her gall bladder which had become blocked with gall stones. Like all patients my mom had plenty of questions and as the doctor we had chosen for her surgery being a hot-shot surgeon who didn’t communicate much to the patient’s I had to bear the brunt of the questioning. Here’s a sample:

Mom: Is this a good doctor?

Me : well, I guess so. I talked to some friends and colleagues and they recommend him as having the best success rate. 

Mom : so you guarantee he is good?

Me : well, you know, I cannot guarantee anything, even the best doctors have an off-day and things can be bizarre during the simplest surgeries but yours is pretty much a straightforward procedure, so we don’t have to worry much about the doctor.

Mom: don’t you know anything about this? Aren’t you a doctor too?

Me : of course I know a little about this – but only the theory part. And yes I am doctor too, but I am not this kind of doctor, my specialty is different. Not all doctors know everything.

Mom : aren’t all doctors supposed to know everything about diseases? Like for emergencies?

Me : yes of course – for emergencies, like there was  a plane crash in the Sahara desert and there is no other doctor for 3000 miles around, then I suppose I can do something about it. But right now we are in a big city in a big hospital with the best doctors treating you- so I will let the experts work on you and stay out of it.

Mom: will you be there? I mean watching inside?

Me : I would love to, but I would rather not. No surgeon will like it when someone else comes and stands beside them to observe them. especially if it’s a relative of the patient. They get nervous and we don’t want that do we? We want him relaxed and concentrating on your surgery alone and not on me. Besides each hospital has different policies and they usually never allow any stranger, including docs inside the operation theatre.

Mom: how long will this take? Is this a big surgery or a small one?

Me : it’s the smallest of surgeries. You should be done by an hour or so. But we don’t know what the doctor prefers – whether he prefers to work fast or slow. So depending on his technique the timing may change. We can’t say right now how long it will take- just make a guess.

Mom: ok how long will take for me to get well?

Me : the minute the thing is out of your body- you are getting well.

Mom : that’s not what I meant. Getting well from the surgery I mean.

Me : hmmm, like all wounds it takes about a week’s time after the surgery – for the wound to become strong enough to no longer need the stitches. But it might take a month to get back its full strength again. Why do you bother about that? Let it take as long as it takes. 

And on that note we ended our conversation. Sitting along with my mom in the hospital room while she rested - for my dad who is alternating with me, has gone home to change before coming back- I was bored out of my skull and thought I would write something for my blog to pass the time. It was either that or to play stick tennis again on my mobile phone and I am frankly getting fed up of the number of time that federer keeps beating me that I am sorely tempted to delete the game. And so arose this blog post composed of a view from the other side- the patients’ side. Watch out for more hospital updates in the coming days.

Stem Cell Shenanigans

If you have read Huck Finn (Mark Twain’s novel?), you would probably remember that famous passage near the end of the novel where tom sawyers in reply to Huck’s questioning will say “but what is the fun in doing anything the easy way? Intentionally making it harder to do is the only way to enjoy doing it” I agree with Tom Sawyer, although Huck does have some choice abuse for him, it’s more fun to reach around your head to touch your nose, rather than touch it directly. All my life, I have followed this simple dictum of toms to squeeze more fun out of life, out of even the mundane everyday things by adding a little bit of spice and novelty to it. Case in point, my recent fun time at the most boring of events- a scientific conference dedicated to stem cell research. If you thought scientist were all (mostly) stuffy, old (bald) males, who talk to each other in incomprehensible jargon, you are right, they are and they do.  But occasionally, into that small and exclusive club of super minds, someone like me gatecrashes. And what do I do? I milk them for all the fun I can get.

Anyway to start at the beginning, I spent the last couple of days, in a stem cell conclave of India’s best and brightest minds working in stem cell research. And I forgot to add, India’s most boring too. Besides being entirely male dominated filed, there was not a single good looking female to time pass with. I was bored out of my skull, after just the morning/pre-lunch session on day one and was wondering how much more I could stand of this till I either escaped or got some diversion or other to pass the time. And the only way I could get some harmless fun was to look out for some unfortunate innocent to troll. And as luck would have it, I got both my wishes rolled into the one, in the guise of pretty trainee journalist from the Asian College of Journalism, (the journalism school run by the Hindu newspaper group?) who had been sent out to that conference to write an article on it. She and I seemed to zero in on each other like guided rockets and after just a few minutes of pointed questions from her, I picked up the fact that she had absolutely no clue about what was going on in there. She had not done her homework and to turn up to a stem cell conference blindly and start understanding the advanced discussions going on in there, would have challenged the genius of an Einstein. And this girl was clearly not up to that level. Perfect opportunity for me to have some fun, I reasoned and launched into her. 

She had picked up a few words of jargon from the morning session and to show that she could talk the talk she let loose with something about how the cells culture together? And that was my cue. I launched into the thickest jargon I could think of at the spur of the moment in explaining to how two stem cells which are fated to meet each other, are drawn near, meet, mate and multiply on a Petri dish. And how it always breaks our heart to separate them into different culture tubes. I could see she was not swallowing this wholly, but hey she stood around for more than ten minutes listening to all of this without moving away or calling me on it and finally I burst out into laughter. I mean, I couldn’t take it anymore. I apologized to her for pulling her leg and as a sign of my contrition offered to get her the soup (from the lunch line) which she had missed by listening to my interesting take on stem cell proliferation. And I offered her my card to call me later if she needed any sound bytes or authentic info on stem cell research and I promised that I wouldn’t play the same prank on her twice. Something else maybe, but not this again.

And then in the afternoon it was time for our presentation. Remember what I told earlier about doing things different? Well, that’s what I did. For a start, if you have seen any scientific presentations, you would have seen serious faced men, impeccably dressed in suits go up there, stand (hide) behind the lectern and deliver their lecture like schoolmasters lecturing students. Me? I went the opposite way. I removed my impeccably tailored suit jacket (yes, I was suited up all morning…and need I say it? I looked awesome in a suit), rolled up my shirt sleeves, loosened my tie, unbuttoned the top button, borrowed a remote to help me change the slides and shunning the corner, for when I used to dance, my instructor Archana Ma’m used to tell me “use the stage, the depth, the length, use it fully” and remembering her training, I did indeed use that stage- I owned it, I was everywhere, in the face of the audience, making my point. Although the Strict professorial types in the audience might not have liked it much, I really woke them up with my PPT slide’s (sample- opening credit included) and had them all staring avidly at the screen.

So that was the highlight of my weekend and to come back to the opening Para where I talked about having fun everywhere? A stem cell conference would be the last place anyone can look to have fun and it challenged even my ingenuity to squeeze a little fun out of it. But that’s the beauty of it; you can look for fun in even the most boring of places if you loosen up your inhibitions. We can’t all be climbing Everest every day or go bungee jumping as part of work. We have to wake up in the morning, head to our routine jobs daily and anything done routinely is sure to get boring pretty soon, so the only solution is to change our attitude (if we can’t change what we are doing) and look to have a little fun- here, there, everywhere. If life gives you lemons, squeeze it to the pips to make juice. And that’s my motto to live life by. What’s yours?